FEATURE ENDOCRINOLOGY 027 “Are you feeling tired, depressed or nervous?
Are you experiencing unexplained weight gain or weight loss?”
Normal changes or alarming symptoms after delivery? Are you becoming more sensitive to heat or cold?
WHAT IS POSTPARTUM THYROIDITIS? Thyroiditis is a general term that refers to inflammation of the thyroid gland. Postpartum thyroiditis is a painless inflammation of the thyroid gland that usually occurs within a year after a woman gives birth. Postpartum thyroiditis occurs in approximately 5-10% of women after they deliver a baby. The incidence can be greater in certain high-risk populations (for example, women with positive antithyroid antibodies).
WHAT IS THE CLINICAL COURSE OF POSTPARTUM THYROIDITIS? The classic description of postpartum thyroiditis includes thyrotoxicosis or hyperthyroidism followed by hypothyroidism. Not all women demonstrate evidence of going through both phases; approximately 1/3 of patients will manifest both phases, while 1/3 of patients will have only a thyrotoxic or hypothyroid phase. In the usual first phase (hyperthyroidism) the thyroid gland is damaged and releases too much thyroid hormone (T3 and T4) into the blood. The thyrotoxic phase occurs 1-4 months after delivery of a child, and lasts for 1-4 months. When the level of these hormones goes up in the blood it causes the metabolism to speed up. Symptoms can include:
Sudden and unexplained weight loss Tiredness/fatigue Palpitations Tremors Sweating Sensitivity to heat Feeling nervous and irritable Anxiety/emotional lability Insomnia
Since these symptoms are often attributed to being postpartum and the stress of having a new baby, the thyrotoxic phase of post-partum thyroiditis is often missed. In some patients, the hyperthyroid phase will be associated with significant damage and scarring to the thyroid as a consequence of the inflammation, and hence the hyperthyroid phase will be followed by the development of hypothyroidism. Patients presenting in the hypothyroid phase generally will often become
symptomatic 4-8 months after delivery, but are occasionally asymptomatic. With a low level of thyroid hormone, the metabolism slows down.
Many women with hypothyroidism have a goiter that causes swelling in the front part of the neck. Other symptoms of hypothyroidism can include: Unexplained weight gain Feeling tired or fatigued Depression Dry skin and brittle nails Hair loss Sensitivity to cold
Constipation Puffy face Hoarse voice Most women will have return of their thyroid function to normal within 12-18 months of the onset of symptoms. However, about one out of five develops permanent hypothyroidism within three to four years. They require life-long treatment with thyroid hormone. If left untreated, hypothyroidism can cause serious problems (e.g., heart disease) and rarely death. It is important to remember that the symptoms of both hyper and
hypothyroidism can be non-specific, and many women with a new baby have fatigue, inability to lose weight, aches and pains, and emotional lability, even in the absence of thyroid dysfunction. Although thyroid dysfunction can clearly influence emotional lability and mood at any time, the vast majority of women with post-partum thyroiditis will not experience major depression as a result of the thyroid inflammation. Patients who develop an episode of postpartum thyroiditis are at increased risk of developing this problem again. Hence, these patients should be monitored after childbirth, with a TSH level periodically to detect the development of thyroid dysfunction.
WHAT CAUSES POSTPARTUM THYROIDITIS? The exact cause is not known but it is believed to be an autoimmune disease very similar to Hashimoto’s thyroiditis. In fact, these two disorders cannot be distinguished from one another on pathology specimens. As in Hashimoto’s thyroiditis, postpartum thyroiditis is associated with the development of anti-thyroid (anti-thyroid peroxidase, anti-thyroglobulin) antibodies. Women with positive antithyroid antibodies are at a much higher risk of developing postpartum thyroiditis than women who do not have positive antibodies. It is believed that women who develop postpartum thyroiditis have an underlying asymptomatic autoimmune thyroiditis that flares in the postpartum period when there are fluctuations in immune function.
WHAT ARE THE RISK FACTORS FOR DEVELOPING POSTPARTUM THYROIDITIS? You are at greater risk of developing postpartum thyroiditis if you have: Autoimmune disorders (such as Type 1 Diabetes Mellitus) Positive anti-thyroid antibodies (risk correlates with antibody levels, the higher the antibody the higher the risk) History of previous thyroid dysfunction History of previous postpartum thyroiditis (20% of women will have recurrence of thyroiditis with subsequent pregnancies) Family history of autoimmune thyroid disorder (Graves’ disease or Hashimoto’s thyroiditis)
HOW IS POSTPARTUM THYROIDITIS DIAGNOSED? Diagnosis depends on the phase of the disease and is based on your symptoms and laboratory tests, including: Levels of thyroid hormones (T3 and T4) in the bloodstream
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