(iii) Vitamins.

Vit A - Conversion of Carotene to Vit A is inhibited by low thyroid states, and may cause yellow pigmentation. It controls uptake of Iodine into the thyroid gland. Deficiency also reduces TSH

Vit B Riboflavin, Niacin, Pyridoxine play a role in thyroid hormone manufacture.

VitC & VitE - Deficiency has been shown to cause hyperplasia at cellular level in the thyroid. Clearly, part of the management of hypothyroidism requires some dietary advice; the provision of iron and vitamins and other minerals is simple and obvious.

2. Genetic Thyroid Failure.

This will have become apparent soon after birth; but may not be obvious cretinism. A sickly child, with poor weight gain, frequent infections, lethargy, or oddly enough, hyperkinesia, and is a candidate for genetic poor thyroid function. Thyroid replacement is mandatory as early as possible.

3. Pituitary Failure.

This is a more common problem than is recognized, and apart from its specific clinical features, it may be a cause of secondary hypothyroidism. The pituitary may have a genetic deficiency, when it will have been probably recognized early. Not uncommon is Sheehan’s Syndrome, resulting from major trauma from accidents or surgery. Adenomas of the pituitary may cause pressure atrophy and / or abnormal hormone outputs. But the pituitary may be involved in the general multiple deficiency state, and more specifically in low thyroid states. This partial failure in hypothyroidism may well be a cause of low TSH, so that a vicious spiral may slip into being. The danger of a low or normal TSH in this situation being misinterpreted when thyroid function tests are carried out is quite clear. In this situation, correction of the thyroid state will bring benefits to the pituitary; and may explain why some patients on thyroid replacement therapy begin to need lesser doses as time passes. Correction of the thyroid deficiency is clearly necessary; but adrenal insufficiency, considered in more detail later, as a consequence of lowered ACTH output, may require cortisone and Dehydroepiandrosterone (DHEA) in addition.

4. Thyroid Surgery.

This is undertaken as a treatment for pathology of the thyroid itself, or as a treatment for over-activity, discussed below. Thyroid cysts, adenomas or carcinomas are necessarily removed by surgery; and it is sometimes necessary to remove goiters where the size is causing respiratory or oesophageal embarrassment. Hashimoto’s disease may come into this category.

Replacement by thyroid hormone is an obvious consequence.

5. Treatment of previous thyroid over-activity, by surgery or I131 ablation.

Grave’s disease is widely treated, where medical methods are deemed unsatisfactory, by partial thyroidectomy, or Radioactive Iodine ablation. This is often unsatisfactory, since it is very difficult to get it right. Either too much is removed or destroyed; (in which case replacement therapy is a permanent necessity) or too little, and it may have to be done again.

For such patients, replacement therapy is an obvious no-option requirement.

6. Major Surgery

Most particularly in this context comes cholecystectomy and hysterectomy. Many doctors are aware that women may suffer weight gain and loss of well being after this surgery; and this will be found to be due to early loss of thyroid function. Replacement therapy is required.

7. Tonsillectomy.

Quite why in adults, tonsillectomy may result in slow running down of thyroid function is not clear, but may be the result of interruption of the blood supply. The present writer has noted a number of cases of young adults misdiagnosed as M.E sufferers in this situation. Replacement therapy provides a most satisfactory return to normal.

8. Major Trauma

Major road traffic accidents, and surgical accidents are known to precipitate thyroid and/or pituitary insufficiency. In this category have been noted the major psychic trauma of certain life events. Replacement indicated, with regard given to pituitary/adrenal function.