Hypothyroidism - secondary

Primary and secondary hypothyroidism

Thyroid gland

Definition:
Secondary hypothyroidism involves decreased activity of the thyroid caused by failure of the
pituitary gland.
Alternative Names:
Pituitary hypothyroidism
Causes, incidence, and risk factors:
The thyroid gland is an important organ of the endocrine system, located in the front of the neck
just below the voicebox. The thyroid secretes the hormones thyroxine (T4), triiodothyronine
(T3), and calcitonin, which control body metabolism and regulate calcium balance.
The secretion of T3 and T4 by the thyroid is controlled by an endocrine feedback system
involving the pituitary gland and the hypothalamus (structures in the brain). Lowered levels of
these thyroid hormones result in increased levels of pituitary and hypothalamic hormones. The
reverse is also true -- when levels of the thyroid hormones rise, pituitary and hypothalamic
hormones fall back. This helps keep levels appropriately balanced.
Since the thyroid gland is regulated by the pituitary gland and the hypothalamus, thyroid
disorders may result not only from defects in the thyroid itself but also from the disruption of the
control system in these other organs.
Thyroid disorders caused by overproduction of thyroid hormones are called hyperthyroidism,
and underproduction of these hormones is known as hypothyroidism.
The cause of secondary hypothyroidism is failure of the pituitary gland to secrete thyroid
stimulating hormone (TSH). This is usually caused by a tumor in the region of the pituitary.
Rarely the cause is an infiltration of the pituitary by inflammatory cells from the immune system
or foreign substances (such as iron in hemochromotosis).
Hypothyroidism may cause a variety of symptoms and can affect all body functions. The body's
normal rate of functioning slows, causing mental and physical sluggishness. Symptoms vary
from mild to severe. The most severe form is called myxedema, which is a medical emergency
and can lead to coma and death.
Risk factors for secondary hypothyroidism include being over 50 years old, being female, and
having a history of pituitary or hypothalamic dysfunction.
Symptoms:

Early symptoms:

Weakness
Fatigue

Cold intolerance

Constipation

Weight gain

Depression

Joint or muscle pain

Brittle fingernails

Coarseness, thinning of hair

Late symptoms:
Slow speech
Dry, flaky skin

Thickening of the skin

Puffy face, hands, and feet

Decreased hearing

Thinning of eyebrows

Hoarseness

Menstrual disorders
Signs and tests:
A physical exam usually reveals a small thyroid gland. Vital signs (temperature, pulse, rate of
breathing, blood pressure) reveal a slow heart rate, low blood pressure, and low temperature.

A chest x-ray may reveal an enlarged heart.

Laboratory tests to determine thyroid function include:

Free T4 test
Total T3

Serum TSH -- Results are generally low in secondary hypothyroidism because the
pituitary is damaged. However, normal or even high values may be seen.

Additional laboratory abnormalities may include:

Increased cholesterol levels

Increased liver enzymes

Increased serum prolactin

Low serum sodium

Low blood glucose

A CBC that shows anemia

Deficiency or excess of other pituitary hormones

Imaging will include an MRI of the pituitary to look for a tumor.

Treatment:
The purpose of treatment is to replace the deficient thyroid hormone. Levothyroxine is the most
commonly used medication. The lowest dose effective in normalizing thyroid function is used.
Life-long therapy may be necessary. Medication must be continued even when symptoms
subside.
After replacement therapy has begun, report any symptoms of increased thyroid activity
(hyperthyroidism), such as restlessness, rapid weight loss, and sweating.
A high-fiber, low-calorie diet and moderate activity will help relieve constipation and promote
weight loss if weight was gained during the time when thyroid activity was low.
In individuals with accompanying hypoadrenalism, steroid replacement must be instituted before
thyroid replacement is begun.
In patients who have hypothyroidism caused by a pituitary tumor, surgery may be required.
However, surgery may not cure the hypothyroidism, and thyroid replacement will still be
needed.
Myxedema coma is treated by intravenous (IV) thyroid replacement and steroid therapy.
Supportive therapy of oxygen, assisted ventilation, fluid replacement, and intensive care nursing
may be indicated.
Expectations (prognosis):
With early treatment, return to the normal state is usual. However, relapses will occur if the
medication is not continued. Myxedema coma can result in death.
Complications:
Myxedema coma, the most severe form of hypothyroidism, is rare. It may be precipitated by an
infection, illness, exposure to cold, or certain medications.

Symptoms and signs of myxedema coma include:

Unresponsiveness
Decreased breathing

Low blood pressure

Low blood sugar

Below-normal temperature

Other complications include:

Heart disease
Infertility

Miscarriage in pregnant women

Adrenal crisis, if thyroid replacement is begun prior to steroids in hypoadrenal patients

Calling your health care provider:
Call your health care provider if signs of hypothyroidism are present, or if chest pain or rapid
heartbeat occur.

Call your provider if restlessness, rapid weight loss, sweating, or other symptoms occur after
beginning treatment for this disorder.
Call your provider if headache, visual loss, or breast discharge occur.
Prevention:
This condition may not be preventable. Awareness of risk may allow early diagnosis and
treatment.
Review Date: 8/6/2004
Reviewed By: Aniket R. Sidhaye, M.D., Division of Endocrinology and Metabolism, Johns
Hopkins University School of Medicine, Baltimore, MD. Review provided by VeriMed
Healthcare Network