Internal use only by approved personnel. Unpublished Work © 2019 Beacon Hospital. All rights Reserved. In Strict Confidence.

Common Thyroid Problems in Women Tip and Tricks

Dr Carla MoranConsultant Endocrinologist

1. New Thyrotoxicosis – what to do

2. Hypothyroidism – Tips

3. Pregnancy issues

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Topics

New Thyrotoxicosis - Causes

Graves’ disease

Cause Notes/Clues Treatment

Thyroid Nodule(s)

Thyroiditis

F>M20-50 y.oFHxPrevious GDGoitre +/-Eye disease

Antibodies to TSH Receptor

Anti-Thyroid Drugs (ATD)

Course 18monthsTrial off: 50% relapse

Later RAI/Sx

One or more autonomous thyroid nodules

OlderF>MNodular gland +/-

ATD….but…Never remitsRAI > Surgery

Inflammation - Viral - Post-partum

Recent viral illnessNeck pain High ESROR post-partum (<6m)

Later….

Thyrotoxicosis (Graves’ disease)

20-30 pmol/L 30- 40 pmol/L > 60 pmol/L

Carbimazole

40-60 pmol/L

10mg od

FT4 level

20mg od 20mg bd 20mg tds

Side effects Rash – use anti-histamine, usually goes in few days Birth Defects – not common, but advise not to conceiveLiver abnormalities rare Agranulocytosis –

STOP medication if:• Sore throat• Flu-like illness• Mouth ulcers• FeverHave FBC within 24 hours – if normal WCC, restart

Thyrotoxicosis (Graves’ disease)

20-30 pmol/L 30- 40 pmol/L > 60 pmol/L

Carbimazole

40-60 pmol/L

10mg od

FT4 level

20mg od 20mg bd 20mg tds

Side effects Rash – use anti-histamine, usually goes in few days Birth Defects – not common, but advise not to conceiveLiver abnormalities rare Agranulocytosis Advice

Advice/Bits EyesStop smokingEnsure in sinus rhythmConsider beta blocker (propranolol 10mg tds – 20mg tds)

Repeat TFTs 4-6 weeks; if FT4 mid range or lower*, halve carbimazole dose

Repeat TFTs 4-6 weeks; if FT4 mid range or lower*, halve carbimazole dose

*TSH stays low!!!

TSH remains high on thyroxine 1. Check administration is correct

• First thing in morning• On empty stomach• Do not eat or drink anything other than water for at least 30 mins• Some medications require further time spacing; calcium, iron, sevelamer,

cholestyramine (at least 2 hours) 2. Increase dose by 25mcg daily 3. Repeat TSH in 6-8 weeks 4. Consider anti-TTG (even if no symptoms) 5. If remains high, refer - we sometimes do a thyroxine absorption test

Hypothyroidism

Tips• No need to repeat TPO antibodies if previously positive (EVER!)• No need to reduce thyroxine dose if TSH normal and FT4 high• If misses dose, can take double next day

Hypothyroid Women on Thyroxine – Pregnancy

Prior to conception

Trimester 1

Trimester 2 & 3

Post-partum

Check TSH; aim TSH 2.5mU/L or lower; check q3mInform pt to increase dose by 25mcg od if + test

Positive Test: PATIENT should increase thyroxine by 25mcg daily

Check TSH; aim TSH 2.5mU/L or lower

Repeat TSH every 4 weeks

Check TSH once per trimesterTarget TSH 3.0mU/L or lower

Reduce thyroxine to pre-pregnancy dose if well controlled

preconception

If not, reduce by 25mcg and repeat TSH 6 weeks post-partum

Post partum thyrotoxicosis

Beta blockade& ReassuranceNO ATDs!

Thyroxine if severeor prolonged

Trial off thyroxine at 1 year?Can recurAnnual TSH;

at risk of hypothyroidism

Graves’ disease vs Post-Partum Thyroiditis; Rx beta blocker and Check TRAbTRAb + = Graves disease

Rx carbimazole lowest dose (up to ~ 25mg per day is OK with breastfeeding)

TRAb Neg = PPTDynamic changes in thyroid status

Months62 4

Key points

Thyrotoxicosis:• Most likely to be Graves disease• Patients should be seen within 2 weeks • Don’t be concerned about starting carbimazole; just remember about agranulocytosis &

Repeat thyroid function in 4-6 weeks and adjust meds

Useful website: Hypothyroidism • Administration of thyroxine important • When planning pregnancy, or during pregnancy, aim

for TSH </=2.5mU/L & check q4 weeks in T1

• If checking any antibody; check TRAb

Post-Partum Thyrotoxicosis • TRAb helpful • Likely to be PPT; treat symptomatically • PPT patients at risk of later hypothyroidism

Referral Information Beacon Outpatients Phone (01) 293 8669Fax (01) 293 8654

outpatientsclinic@beaconhospital.iecarla.moran@beaconhospital.ie

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