Transcribed by Joseph Schwimmer

Organ Systems Lecture #43 Physiology of the Thyroid Gland

4/28/14


Dr. Joel Schiff - Ok , so Thursday you had Dr. Lopez and she gave you the whole story about the cells involved
in the endocrine system, at least most of them, and you get an overall view of most of the endocrine pathways
although not some of them. Because most of them involve a sort of hypothalamic/pituitary control feedback
operation where basically from the hypothalamus you get some sort of releasing hormone which acts on the
pituitary, the tropin cells where tropes, trophs if you prefer, I prefer tropes, which then release some sort of a
tropin. And this acts on some sort of gland which secretes some sort of hormone, and basically theres a
negative feedback sort of thing here, and in most cases to here, so that the secretion of this hormone is
regulated by this negative feedback loop.
And so this is your fundamental overall outline for all of these hormones that are regulated through the
hypothalamic pituitary access. And of course this pathway is the portal system. You have capillaries in the
hypothalamus, capillaries in the anterior pituitary and a vein or venule that carries the blood from one to the
other. Then of course these capillaries drain into the systemic circulation. Otherwise how would they reach
their target glands?
And so what weve got here is a whole number of systems that operate this way, including the first two topics
that Im gonna be going over today, the first hour will be thyroid, and the second hour will be the adrenal
cortex. And in the case of the thyroid, what youve got here is the hypothalamus releases thyrotropin releasing
hormones, or TRH, which tells the cells, the thyrotropes in the pituitary to release thyrotropin which is also
TSH, for thyroid stimulating hormone. Nowadays thyroptropins used mainly in textbooks. Humans, well maybe
not the humans who write textbooks, humans generally say TSH. However, the T is TRH is thyrotropin. And the
gland in this particular case is the thyroid. You know where the thyroid is. I mean, you guys know more than
most physicians about head and neck anatomy, right? And the fact that these thyroid hormones are
synthesized follicles which then transport the thyroid hormone along with the protein thyroglobulin out into
the extracellular, outside follicle space, where its picked up by the capillaries and ends up in the circulation.
And the major hormones produced by the thyroid are T4 and T3. And Im not gonna start drawing chemical
diagrams, but theyre in the handout, the lecture points that I posted. The interesting about this is you get a
mixture being secreted by the thyroid about T4 or T3 or something approximating that. They act their
peptide, they act on receptors in cells where T3 is much stronger hormone than T4. Its a stronger agonist on
the receptors. So for all intents and purposes this is the major hormone in terms of getting things done but
most of what is secreted is T4. That leads to an interesting situation because for the most part a lot of what
you get, 3/4 of what you get is T4, but your liver, as this travels through the circulation, is able to convert it to
T3. Why would it do that? Why have this strange sort of situation? Thats because the liver, and the cells in the
liver, the hepatocytes, sense in a way the amount of thyroid hormone activity traveling through the
circulation, which is a mixture of T3 and T4 where the T3 counts more because its a stronger hormone. And if
the liver sense that you need more hormone activity what happens is that it converts some of the T4 into the
T3 which is a stronger hormone, if not it doesnt, if its fine with the current mix, with the current amounts of
hormone, then this conversion doesnt take place. There is also, however, another hormone, called reverse T3.
If you look at the diagram on the handout you see there are two, for the structure of the thyroid hormones,
what youve got is a sort of is two saturated, two benzene rings connected by an ether bond, right? And here
you have a carboxy, and an amine, sort of a peptide sort of thing, because this is tyrosine, and this is derive by
connecting together two molecules of tyrisene, and youve got your OH there. And it then attaches iodines,
one, two, three, four, ok? Thats T4. Its called tetraiodothyronene, tetra means four, iodo means there are
four iodines. If theres one less, lets take away one of these two. Does it matter which one I take away? No.
because these are single bonds around the ether thing, so this can flip or rotate freely. So it doesnt matter
which one I take away. If you take away one of the ones further from the carboxy or amine groups, you end up
with T3, let me not leave this label here, let me associate this with this with nothing here, with one of these
gone, is T3, ok? Thats stronger than T4 which has T4 iodines. On the other hand if you were to take away one
of these two from T4, which liver can do, thats called reverse T3. Because you have ring, ether, ring, and so
on. And youre left with one here, and both of these fellows so in other words instead of taking away one of
these, you take away one of these, thats called reverse T3, as opposed to T3, thats a weaker hormone than
T4. In other words, in terms of hormone activity, T3 is greater than T4, which is greater than reverse T3. So the
net effect is you secrete just T3 and T4, mostly T4, but the liver can then, either increase the amount of
hormone activity by converting some of the T4 to T3, or it can decrease the level of hormone activity by
converting some of the T4 into the weaker form, reverse T3.
Of all of these hormones, only T4 plays a part in the feedback control. T3 does not. So, the pituitary
thyrotropes, and whatever cells are involved in secreting TRH in the hypothalamus, they have a very specific
receptor for thyroid hormone that only response to T4, and not to T3, whereas throughout the rest of the
body, the receptors such as they are respond to T4 or T3 or reverse T3, and respond better, BEST with T3. So
obviously theres some sort of difference in the hormone receptor up in the pituitary and the hypothalamus.
In any case, youve got this.
And theres a negative feedback loop, and the secretion of T3 and T4 is doing absolutely fine. What does it do?
Whats the function of the thyroid hormones? Well, for the most part they step up metabolic rate. Even while
youre just sitting around doing very much of nothing, listening to me for example, not very great exertion,
you have your cells constantly carrying out various reactions, maybe to a certain extent in your brain, but
when youre learning, but throughout your body your cells are doing their standard running up a down
escalator to maintain homeostasis, if nothing else, thats whats referred to as basal metabolism, just the
baseline of what you have to do to maintain homeostasis. And the other thing that you have to remember, is
that all of these reactions that are involved in having your body do anything, including basal metabolism,
involves formation of ATP from metabolic pathways, and breakdown of ATP into phosphate.
Now, lets go back to a couple of fundamental truths in chemistry. Reactions only go downhill, if you want
them to go spontaneously, and from an energy point of view. So whatever you start out with, your substrate
turns into a products, lets say you have an enzyme somewhere. The total free energy in the product will be
less than the free energy in the substrate. If theyre equal then the two things will be equal and there wont be
very much movement along that pathway. In order for a reaction to go it has to go downhill. You put a ball on
a flat table itll hang around. You put a ball on a sloped table itll roll downhill. Same sort of thing. So by
definition, and this is your second law of thermodynamics, reactions only go when theyre inefficient, because
youre starting off with this much energy, you end up with this much energy. What happened to the other
energy, which of course by the first law of thermodynamics is conserved. Energy is conserved. And the answer
is, it becomes heat. So youre body generates heat which keeps you at 37 degrees when its only 27 degrees in
this room. Plus, if youre actually doing physical work, moving muscles, that involves generating heat as well,
because these reactions, again, only go when theyre downhill, that is, when theyre inefficient. Thyroid
hormones increase metabolic rate. If you have a deficiency in thyroid hormones your metabolism, or
metabolic pathways will slow down. So, if you are hyperthyroid, chances are your body temperature will be
above 37 degrees Celsius. If youre hypothyroid, chances are your body temperature will be a little lower. But
a more practical point of view, if you go into a cold room, you can readily increase metabolism to generate
more heat to keep your body temperature from going down. If you enter a hot room you can turn down your
metabolism a bit to generate less heat, so you dont keep heating up. Well be getting to that in a couple of
weeks under body temperature regulation, thermoregulation.
The other thing is the effect on the nervous system. The thyroid increases the level of activity of your nervous
system making you startle-able. Youre nervous, youre anxious, youre twitchy, and if theres a sudden noise,
youre easily startled. The classic I dont know how many people nowadays, youve all gotten a taste of I love
Lucy ever watched the Andy Griffiths show, set in the town of Mayberry where he was the sheriff, and he
had a deputy played by Don Knotts, who was the textbook example of hyperthyroid. He was thin, high
metabolic rate, large appetite, couldnt gain weight, stayed thin because of the high basal metabolic rate,
driven by the thyroid hormones. And, one interesting symptom of hyperthyroidism is referred to as
exophthalmos eyes bulging out. And this apparently happens because of the hypertrophy of the fat pads of
the back of your literally pushed the eyeball forward. The people who are hyperthyroid, so are nervous,
large appetite, high body temperature, thin, startle-able. The people who are hypothyroid have too little
thyroid hormone activity tend to be mentally sluggish, physically sluggish, dont have much of an appetite but
still gain weight. And also have an interesting symptom called myxedema, which is, the skin feels thicker,
thats partly because theyre gaining weight, subcutaneous fat, but its dry. The edema part refers to the
thickness part of the skin. But the skin is very dry less sweating. Why less sweating? Low body temperature,
or low standard of body temperature. So they dont sweat very much because theyre not producing very
much heat because of the lack of metabolism. The other symptom of hyperthyroidism I referred to is,
exophthalmos. Ex meaning to project outward. And the ophth- referring to eyes.
But in most people, the thyroid equilibrium, the thyroid balance is maintained properly by these negative
feedback loops. However, a number of ways in which this very nicely engineered feedback regulation of
thyroid hormone can go astray. And thats one of the things were gonna see as we discuss endocrinology, is
that the best laid plans, developed over billions of years of evolution. As bobby burns said gangafte glay.
One thing you need, for example, is iodine to make thyroid hormone. Your thyroid gland has a very efficient,
very effective iodine transport mechanism. It glums up most of the iodine in your body, assuming you have
some, brings it to the thyroid to be used to make thyroid hormone. Nothing else that your body synthesizes,
involves iodine. Right now, 99.9% of your iodine is in your thyroid. What if you ate a diet that didnt supply
enough iodine, or didnt supply any iodine? Well, lets just say not enough. Decreased iodine input. What will
happen? Well, your thyroid cant produce T4 and T3. So you have low T4, low T3. What T4 you make, your
liver is trying to do its best by converting it to T3, and that little bit of iodine is recycled and eventually picked
up by the thyroid, its trying hard, so you probably end up with a lot more T3 than T4 in your circulation.
Theres a lack of T4. What does T4 do? Its negative feedback. So with low T4 you dont get the negative
feedback on the pituitary, so TSH levels go up.
Now these tropic hormones, TSH is thyrotropin and anything that is a tropin, these tropic hormones, some
books say trophic. Probably the books written before 1950. The tropic hormones basically send two messages
to their target glands .one is maintain yourself, or grow. And second is, secrete whatever youre supposed to
secrete. After all, thats its job, its stimulating, its called thyroid stimulating hormone, it stimulates the
thyroid to produce more T4 and T3, and at the same time, in the particular case of the thyroid, one of the
messages it carries is to grow, sort of live long and prosper. So the TSH goes way up, the thyroid cant make
its hormones, but what it certainly can do is grow. And so what you end up developing here is large growth of
the thyroid, hypertrophy of the thyroid. And thats referred to as goiter. And basically what it looks like is an
enlargement of the thyroid gland. Sometimes midline, sometimes off to one side, sometimes wrapped around
the neck, depends how extreme it is. Looks like youve got a half a cantaloupe plasted onto the front of your
neck .these can get large. Now, interesting side point of this, in parts of the world, where you do get your
iodine? Iodize salt. Your basic salt out of a salt mine doesnt have much iodine, if any. We chemically add some
iodine to it. So theres some sodium iodide in with the sodium chloride. Thats enough if you salt your food.
Or, theres plenty of iodide as well as chloride in seawater. So, if you eat fish, you eat seafood, youre probably
getting iodine. If you eat seaweed, youre getting plenty of iodide. All of these are readily available nowadays.
But lets go back a few hundred years. People who lived near the ocean, or near the Mediterranean, or any
body of water where there might be fish or seaweed growing, were fine. But people who lived up in the Alps,
lets say, and did not have a ready source of iodine from seawater or fish or seaweed or other plant stuffs that
came from seawater, they had a chronic deficiency of iodine. Now, as bad as a deficiency of iodine can be in
an adult, its absolutely necessary for the development of a nervous system. So a fetus, a newborn, a young
child who is faced with an iodine deficiency, will have mental problems, because the nervous system does not
develop properly in the absence of iodine. You need something to keep that metabolism going. Second, there
ill be problems/defects in bone growth. So you end up with let me just put a list here mental defect or
brain nervous system defect/deficiency in growth, bone growth. This can lead to dwarfism, which is different
from what we referred to pituitary dwarfism. Its not a politically correct word, ok. But, pituitary, most little
people thats their choice of preferred word have a deficiency in growth hormone, which is secreted by the
anterior pituitary, and Im sure Dr. Lopez went through that to a certain extent. Theyre normally
proportioned. The ratio of head size to body size is normal. Theyre just shorter for the most part. The people
who, in development, fetal growth, have a deficiency in iodine, have missing bones in the wrists and ankles,
have particularly short long bones, so that proportioned to the body, the head appears large. There are
deficiencies in mandibular growth, things like that. These people were first discovered in the area thats now
Switzerland in the 17
th
century by people travelling across Europe from the coastal areas of the
Mediterranean, and they were referred to as cretins, which is a word that has a very interesting etymology.
And the syndrome is referred to as cretinism, Ill toss out the etymology, I cant resist. When these people
were discovered, short stature, mental defect, slow metabolism, goiter, so the body is sort of generally
deformed. The immediate reaction of the good people who found them was, are they human? And much
more specially, when you consider whats going on in the 17
th
century, and this is the major subset of are
they human, do they have souls? In other words, can they be Christian? Cretian Christian is the origin of
the word cretin. Because it was somewhere at the papal level decided that they do indeed have souls, and
thus could be hounded by missionaries. Ok, this is what happens with a defect of iodine in the diet.
Something else can go wrong. What you can sometimes get is a pituitary adenoma. An adenoma is a tumor
that secretes something. In other words, an overgrowth of one of the trophic cells in the pituitary, that
secretes a particular tropin in excess, and is not regulated by feedback. So you can have a thyrotropin secretin
adenoma, that secretes TSH in excess. And is not subject to the feedback inhibition by T4. So youve got lots of
TSH, which stimulates the thyroid to secrete and grow. So you have high T4 and T3 and the thyroid is
stimulated to grow so you have a goiter. Ok.
What else could go wrong with this, with this feedback? There are a couple of things that are actually results
of autoimmune processes and they have sort of opposite effects. Autoimmune means that youre producing
antibodies to something of yourself. Normally your immune system is supposed to leave you alone and only
kill the strangers. But one thing that can go wrong is referred to as Graves Disease. And what happens in
Graves disease is your body, your immune system produces an antibody that binds to has affinity for binds
to the TSH receptors on the thyroid. Remember, TSH from the pituitary normally stimulates the thyroid. So the
thyroid has TSH receptors. In Graves disease what happens is you have an immunoglobulin an IgG that binds
to TSH receptors and stimulates them. It acts as if it were TSH. SO the thyroid says lots of TSH coming in, even
though there isnt necessarily. So what happens? The thyroid thinks its getting lots of TSH coming in so it
grown, well call that, just write goiter. And the thyroid secretes lots of T4 and T3. High T4, high T3. The high
T4 specifically inhibits the normal pituitary production from the normal thyroid troves from TSH. So TSH is low.
But your thyroid thinks theres lots of TSH because of that immunoglobulin. So the person with Graves
disease is HYPERthyroid and has a goiter. The person with the iodine deficiency is HYPOthyroid and has a
goiter. So a goiter is not diagnostic of whether your person is hyper or hypothyroid.
And theres one other common screw-up, fairly common. And its referred to as Hashimotos Thyroiditis, in
Hashimotos Thyroiditis, which has a genetic component, its an autoimmune problem. And I happen to know
its a genetic component, because I have, or had, at one point 17 first cousins on my mothers side with not
one working thyroid among the 18 of us. Hashimotos Thyroiditis is an autoimmune attack on the thyroid
itself, which initially causes a bit of inflammation of the thyroid, but then destroys it. So lets see what
happens. Is there goiter? Theres an inflammation, inflammatory enlargement that from the outside,
contemporarily looked like a goiter, but its not really a goiter, its an inflammatory enlargement, and its
temporary, because eventually all that thyroid tissue is destroyed. So, a goiter-brief swelling. That brief can
mean a year or two by the way, but its not a goiter.
And then what? Well the thyroid is destroyed, so you have no T4, no T3 and therefore what happens with that
feedback loop? You have no inhibition of the pituitary or the hypothalamus, so you end up with very high TSH
levels. But, so what? What does TSH do? It stimulates the thyroid, but there is no thyroid! So, bottom line,
these people are HYPOthyroid; these people are HYPERthyroid, these people, sorry, HYPER, these are HYPER.
These people are hypothyroid. Hyper, hyper, hypo.
A HYPOthyroid state such as this, well if it happens during development, its too late, too late to fix it. But if it
comes on in adulthood, because you suddenly decide youre going on some weird exotic Zen macrobiotic diet,
and eat nothing but rice, which doesnt, and you dont sprinkle a little iodine salt on it. If it comes on in
adulthood this can be treated by simply adding iodine to your diet. This hypothyroid state cant be treated by
adding on iodine to the dies because theres no thyroid to use the iodine. What you have to treat it with, is
synthetic T4. So the treatment here, T4 has a fairly long body life, its not digested, or broken down, or
destroyed for a couple of day. So basically, its orally ingested and it survives the stomach, T4 tablets can be
given on a once a day, or even once every other day dosing regimen. And, takes care of everything.
What if you need a little more thyroid activity for some particular task? Well, your liver can convert that T4 to
T3. All of the other pathways are still perfectly intact. So basically there are four major the first one, the
deficiency of iodine in the diet is relatively unusually nowadays. The pituitary adenomas also have an
interesting additional symptom that can sometimes narrow down the diagnosis very well.
Do you remember when Dr. Lopez gave you the or did she? Im trying to remember from her powerpoints.
Did she give you the anatomy well youve had it somewhere along the line of the pituitary? Pituitary, bone
underneath stella turcica. If youre looking at the base of the brain, looking up at the bottom, right? Heres
your brain. A couple of eyes here, the optic nerves cross, or partly cross at the chiasm. Some fibers go back
this way, and some fibers cross over, depending on whether youre looking at the medial or lateral hemi-
retina. Dr. Jeong did that in neuro. Your pituitary is hanging down right about there, with the stella turcica
under it. If theres a tumor in the pituitary, its gonna grow. Wheres it gonna go? Its got bone around it! So,
the only way it can expand is to push up and slightly anterior, which means it presses on the optic chiasm. So if
you have a pituitary adenoma, and youre gonna see that again when I discuss adrenal cortex and a few other
things. The pituitary enlarges, it presses on the optic chiasm, and can interfere with axonal conduction. Which
axons are actually crossing over at the optic chiasm? Remember, the lateral hemi-retinas, which look at the
central medial visual fields, their axons go around, make a U-turn, and go back in the optic nerves, in the optic
tract. Same thing here, this one make a U-turn and goes that way. The medial hemi-retinas which look at the
lateral visual fields, theyre the ones that cross. And theyre the ones that are gonna be pressed on by a
growing pituitary. So what does that do? In terms of your visual fields, you see here just fine. But the lateral
visual field which corresponds to the medial hemi-retina, those pathways are being pressed on by the pituitary
tumor. So a person with a pituitary adenoma such as this, will in addition to all the other symptoms, have
whats referred to as tunnel vision. Because he can only see the medial visual fields. Anything out to the sides,
which would project only onto the medial hemi-retina, doesnt get through. Because those action potentials
are trying to cross the chiasm and cant because theres something pressing on the chiasm preventing action
potential propagation. So whenever you see, specifically tunnel vision thats a loss of lateral visual fields on
both sides symmetrically, you have to suspect the pituitary tumor. So this is very often the first complaint from
the patient, I can only see straight ahead, Im losing my peripheral vision, check the endocrines
Ok, so, so much for the thyroid, next hour is adrenal cortex. Why dont we take 5.