Hashimoto’s thyroiditis

Definition: What is Hashimoto’s thyroiditis?

Hashimoto's thyroiditis is an autoimmune disease that leads to hypothyroidism as it progresses.

The immune is reacting against its own body, leading to chronic inflammation and destruction of the thyroid gland, which is accompanied by a loss of function of the organ in its later stages.

The disease is particularly common in middle-aged women.

Overview of the causes for Hashimoto’s thyroiditis

The exact cause for the development of Hashimoto's thyroiditis is not clear. In general, with an autoimmune disease, i.e. a disease in which the immune system attacks the body's own structures, antibodies are formed, which in this case are against the thyroid gland. As a result, the immune cells, known as lymphocytes, are activated, causing inflammation and eventually leading to the destruction of the tissue.

Several factors contribute to the development of Hashimoto's thyroiditis and are being discussed nowadays. These include genetic factors, as the disease tends to run in families. Additionally, certain hormones, such as estrogens, are known to contribute to the development of Hashimoto's thyroiditis.

Furthermore, environmental factors like infections, stress and deficiencies seem to also play a part in the onset of Hashimoto's thyroiditis.

In addition, excessive iodine intake could be significant in genetically predisposed individuals, and a variety of autoimmune diseases are more likely to occur together in Hashimoto's patients, such as celiac disease (gluten intolerance) or type 1 diabetes mellitus.

Typical symptoms for Hashimoto’s thyroiditis

The disease is often asymptomatic in the early stages and patients do not experience any symptoms.

In some cases, the thyroid gland may initially become hyperactive (hyperthyroidism), which is caused by the destruction of hormone-containing cells whose contents are released in uncontrolled amounts. This transient hyperthyroidism is also known as hashitoxicosis.

The symptoms of this include a feeling of restlessness, nervousness, rapid heartbeat (tachycardia) and cardiac arrhythmia, tremors, increased blood pressure, increased sweating, hair loss, weight loss and diarrhea.

In the course of the disease, a goiter may develop.

The inflammation leads to an enlargement of the thyroid gland, which can progress without symptoms, or cause symptoms such as a feeling of pressure in and around the throat, difficulty swallowing or shortness of breath.

In the later stages of the disease, patients usually develop an underactive thyroid (hypothyroidism), as the functional thyroid tissue has been destroyed by the inflammatory reaction of the patient's own immune system. Frequently, this leads to connective tissue remodeling and scarring of the thyroid gland. This means that the important thyroid hormones T3 (triiodothyronine) and T4 (thyroxine) can no longer be synthesized or can no longer be synthesized in sufficient amounts.

Symptoms of hypothyroidism include fatigue, lack of concentration, lethargy, a slow heartbeat (bradycardia), weight gain and constipation.

Individuals with this condition often experience cool, dry skin, an increased sensitivity to cold, and reduced sweating. They may also have noticeable hair loss, with hair becoming dry and brittle. In some cases, they exhibit Hertoghe's sign, characterized by thinning of the hair at the outer edges of the eyebrows. Neurologically, these individuals might show a slowing and weakening of muscle reflexes. Hypothyroidism can initially clinically resemble depression or even dementia.

Myxedema may also occur, which is a swelling of the skin and makes it appear dry and doughy. This can particularly be noticed on the eyelids, hands, feet and lips. Due to the swelling of the vocal cords, it can even alter the voice, and speech may be rough and slow.

Menstrual cycle and fertility disorders can occur as part of hypothyroidism.

Hashimoto's thyroiditis often progresses gradually and is only recognized and diagnosed at a later stage due to its sometimes unspecific symptoms.

Diagnosis: How does a doctor diagnosis Hashimoto’s thyroiditis?

The doctor can generally identify irregularities such as a goiter, a slowed heartbeat or weakened muscle reflexes through a physical examination. Furthermore, the patient should be carefully questioned about all physical and psychological complaints, as the symptoms of Hashimoto's thyroiditis can be varied and diverse.

A blood test can be used to diagnose hypothyroidism if the disease is manifest. The thyroid hormones T3 (triiodothyronine) and T4 (thyroxine) are measured, and reduced levels indicate hypothyroidism.

However, especially in the early stages of the disease, it is also possible that both T3 and T4 are still within the normal range.

Furthermore, TSH (thyroid-stimulating hormone) levels are measured in the blood. This hormone is secreted by the pituitary gland, which stimulates the thyroid gland and thereby activates the production of thyroid hormones, particularly if there are low levels in the body.

This means that TSH levels are typically elevated with an underactive thyroid caused by Hashimoto's thyroiditis.

As previously mentioned, hyperthyroidism may initially be present.  Blood tests carried out at this time may show a decrease in TSH and an increase in T3 and T4 levels. It is therefore important to monitor patients with ongoing or changing symptoms.

Moreover, autoantibodies are searched for in the blood. TPO (thyroid peroxidase) antibodies (present in around 90% of patients) or thyroglobulin antibodies (present in around 50% of patients) are frequently found in Hashimoto's patients.

Another diagnostic tool is an ultrasound examination. Chronic Hashimoto's thyroiditis often shows a shrunken thyroid gland, although an enlargement (goiter) is also possible in the case of acute inflammation. In most cases, the ultrasound reveals a hypoechoic, inhomogeneous tissue structure.

Only rarely is a thyroid scintigraphy necessary for the diagnosis.

A microscopic tissue examination is also possible to confirm the diagnosis, for which a small amount of thyroid tissue is taken directly through the skin of the neck using a thin needle. A marker of inflammation is a significantly increased number of white blood cells.

Which therapy and treatment options are available? 

At present, it is not possible to cure Hashimoto's thyroiditis.

In the case of existing hypothyroidism, L-thyroxine tablets must be taken lifelong to replace the missing thyroid hormones.

The treating doctor will explain in detail how exactly and in which doses the medication should be taken.

Should a patient not have hypothyroidism yet, no action needs to be taken for the time being. It is, however, necessary to regularly check the thyroid levels in the blood.

Removal of the thyroid gland can be beneficial, especially if the thyroid gland is enlarged (goiter), and accompanied by symptoms such as the sensation of a lump in the throat, difficulty swallowing, or shortness of breath.

In severe complications of Hashimoto's thyroiditis with for example encephalopathy or myxedema coma, treatment with anti-inflammatory medication (such as cortisone) may be indicated.

What effect does Hashimoto’s thyroiditis have on fertility?

Thyroid hormones T3 and T4 play a crucial role in maintaining normal fertility. They influence various factors, including the regularity of the menstrual cycle, ovulation, and libido.

Hashimoto's thyroiditis with hypothyroidism is frequently associated with irregular menstrual cycles, missed periods, hormonal fluctuations and a reduced sense of libido, especially in younger patients. This can make it more difficult to conceive normally if the patient wishes to have children. There is also an increased risk of miscarriage in Hashimoto's patients.

In fact, hypothyroidism is only often first diagnosed in otherwise healthy patients when they are unable to conceive.

Nevertheless, pregnancy is still entirely possible. It is important to investigate the cause of the hypothyroidism and treat it accordingly. In the case of existing Hashimoto's thyroiditis, the medication with L-thyroxine is adjusted to a specific dosage and continuous monitoring is crucial.

The medication should be continued during pregnancy, and the dose is adjusted to suit the different metabolic situation. Regular monitoring is essential, as the need for thyroid hormones changes during pregnancy.

Pregnant women are normally recommended to take additional iodine, but whether this is the case for an individual Hashimoto's patient should be clarified with the treating doctor.

Which values are elevated in Hashimoto’s thyroiditis?

There are various values that are noticeable in Hashimoto's thyroiditis and can be measured in the blood. These include the thyroid hormones but also specific antibodies. The following is an overview of the possible variations in Hashimoto's patients.

Thyroid hormones:

In the beginning, Hashimoto's thyroiditis can be accompanied by an overactive thyroid (hyperthyroidism):

• TSH (thyroid-stimulating hormone) is decreased
• T3 and T4 are increased

In the course and later stages, an underactive thyroid (hypothyroidism) commonly occurs:

• TSH is increased
• T3 and T4 are decreased

Antibody detection:

In Hashimoto's patients, autoantibodies are very often found, which are directed against the body's own structures and cause an important part of the immune reaction against the organ. The disease involves antibodies against components of the thyroid cells that are important to produce thyroid hormones.

• Thyroid peroxidase antibodies (TPO antibodies) positive (approx. 90% of patients)
• Thyroglobulin antibodies (Tg antibodies) positive (approx. 50% of patients)

When diagnosing antibodies, it is crucial to consider the patient's complete clinical picture and all examination results together. This is because certain antibody types can also be found in other thyroid conditions, such as Graves' disease.

Which specialists and clinics treat Hashimoto’s thyroiditis?

Hashimoto's thyroiditis is a disease of the thyroid gland, and therefore falls into the medical specialty of endocrinology (the study of internal glands and hormones). Endocrinologists specialize in internal medicine and can either work in private practice or in a clinic.

There are also specialized centers dedicated to thyroid diseases, including their diagnosis and treatment, which offer significant benefits for patients with Hashimoto's. Additionally, fertility clinics often collaborate with expert endocrinologists to provide comprehensive care.

Anyone in need of a doctor would expect the best possible medical care for themselves. Therefore, patients are looking for the most suitable clinic for their needs. Since this is not an objective decision and a respectable doctor would refrain from claiming to be the best, patients must trust the experience of a doctor.

We can help you find an appropriate expert for your condition. All the doctors and clinics listed have undergone extensive review and have been verified by us for their outstanding expertise in the field of Hashimoto’s thyroiditis. They are looking forward to and are ready to address your questions and treatment requests.