CHAPTER 19
Thyroid dysfunction
Colin M. Dayan  •  Onyebuchi E. Okosieme  •  Peter Taylor
CHAPTER OUTLINE
INTRODUCTION  373
NORMAL THYROID PHYSIOLOGY  374
The thyroid gland  374
Biological actions of thyroid hormones  374
Synthesis, storage and release of thyroid
hormones  375
Iodine and thyroid hormone synthesis  376
Transport of thyroid hormones
in blood  376
Free hormone hypothesis  376
Entry of thyroid hormone into tissues  377
Thyroid hormone deiodination and regulation
of extrathyroidal T3 production  377
Catabolism of thyroid hormones  377
Nuclear action of thyroid hormones  377
Control of thyroid hormone synthesis and
secretion  378
Extrathyroidal factors that may affect thyroid
function  379
THE EVALUATION OF THYROID
FUNCTION  382
Clinical evaluation of thyroid status  382
In vitro tests of thyroid activity and
pituitary–thyroid status  383
Measurement of thyroid stimulating
hormone  383
Free T4 and free T3 measurements  383
Methods for measuring free thyroid
hormones  383
Validity of commercial methods for free
hormone analysis  383
Nomenclature of free thyroid hormone
assays  384
Total T4 and total T3  384
Selective use of thyroid function tests  384
INTRODUCTION
Thyroid hormones are essential for normal growth,
­development and metabolism, and their production is
tightly regulated through the hypothalamic–pituitary–
thyroid axis. Thyroid disease is common, particularly in
women, with a prevalence in the community of 3–5%.
With the exception of iodine deficiency, which affects
millions of people worldwide, diseases that directly
Interpreting results of thyroid function tests  385
Common situations in which TSH results may
be misleading  385
Reference ranges and significant
changes  385
Miscellaneous tests  386
Autoantibodies to thyroidal antigens  386
Imaging the thyroid  387
HYPERTHYROIDISM 388
Clinical features  388
Causes of hyperthyroidism  389
Hyperthyroidism or non-thyroidal
illness?  394
HYPOTHYROIDISM  394
Clinical features  394
Causes of hypothyroidism  396
Treatment of hypothyroidism  397
THYROIDITIS  398
Thyroiditis producing
hyperthyroidism  398
Hypothyroidism resulting from Hashimoto
thyroiditis  399
Other forms of thyroiditis  399
Hypothyroidism and the postpartum
period  399
NEOPLASIA  399
Diagnosis  399
Treatment  400
Tumour markers  400
SYNDROMES OF RESISTANCE TO THYROID
HORMONES  400
SCREENING  401
affect the thyroid gland are the most common causes
of thyroid dysfunction. Pituitary disease and the use of
­certain drugs that alter thyroid hormone synthesis or me-
tabolism can also give rise to thyroid dysfunction. Any
severe illness can produce abnormalities in the r­ esults of
thyroid function tests that resolve as the patient’s i­llness
improves. Once diagnosed, thyroid disease is usually eas-
ily treated, with an excellent long-term outcome for most
patients. This chapter outlines thyroid physiology and the
373