Insomnia


Insomnia

Overview

Insomnia or sleeplessness is a common sleep disorder, which affects millions of people across the world. People with insomnia have difficulty in falling asleep, staying asleep, or both. The National Institute of Health estimates that nearly 30% of world population suffers sleep disruption and nearly 10% among them have daytime sleeping.

Insomnia can impair psychosocial functioning and quality of life. Getting enough sleep is an important aspect of healthy lifestyle. An adult person needs at least 7 to 8 hours of sleep in a day. However, sleep patterns change with age. For instance, older adults may sleep less at night and take frequent naps during the day. Lack of sleep makes a person feel tired, depressed, and irritable. It also decreases concentration and reduces the ability of a person to perform his or her daily activities. Insomnia is associated with mood swings, irritability, and anxiety. It also increases the blood pressure and risk of chronic diseases such as diabetes.

Every person experiences occasional episodes of insomnia that come and go without causing any serious problems. But, for some people, the episodes of insomnia last for months or years and have a significant impact on the quality of life. Based on the duration of illness, insomnia is classified into two types- acute or short-term insomnia and chronic or long-term insomnia. Acute insomnia is brief and occurs due to stressful events or depression. In most of the cases, it resolves without any treatment. Chronic insomnia lasts for more than three months. It is caused due to environmental changes, unhealthy sleep habits, changes in lifestyle or due to other chronic illness.

Insomnia is primarily diagnosed based on the sleep history of a patient. Polysomnography is a type of sleep study, which is performed only in patients with sleep disorders such as periodic limb movement disorder (PLMB) or obstructive sleep apnea (OSA). The treatment for insomnia includes a combination of medications, behavioral or psychological therapies, and lifestyle modification.

Causes

Insomnia is often caused due to an underlying disease or condition. Some of the most common causes of insomnia are:

  • Pain: Acute physical pain such as a toothache, abdominal pain and so on causes sleep disturbance until the inflammation and pain subside.
  • Poor Eating Habits: Overeating or eating a big meal late at night impairs metabolism. It also disrupts the sleep-wake cycle and causes insomnia.
  • Travel and Jet Lag: Traveling from one time zone to another alters the body’s normal circadian rhythm and causes temporary insomnia.
  • Changes in Work Shift: Changes in work shift causes short-term insomnia in some people as they need time to re-adjust their body clock.
  • Stress: Some people fret or worry about insignificant matters and lose sleep. However, it is natural to worry over a recent event or an unexpected incident, but it should not affect the quality and quantity of sleep.
  • Anxiety and Depression: Anxiety or depression affects sleep and causes insomnia.
  • Biological Causes: Biological changes such as aging affect the sleep pattern. Older people tend to have lighter sleep and wake up more often in the night.
  • Hormonal Changes: Hormonal imbalances cause difficulty in sleeping especially in the females during pregnancy and menopause. These changes are usually caused due to changes in the estrogen levels.

Medical Conditions

Certain medical conditions that interfere with sleep are:

  • Asthma
  • Arthritis
  • Heartburn
  • Hyperglycemia
  • Hyperthyroidism
  • Prostate disease
  • Angina or chest pain
  • Congestive heart failure
  • Chronic fatigue syndrome
  • Hypoglycemia due to diabetes
  • Chronic obstructive pulmonary disease
  • Acid reflux or gastroesophageal reflux disease
  • Restless leg syndrome: Restless leg syndrome is a disease of the nervous system characterized by an unpleasant or burning sensation in the legs. It causes the individual to move the legs unnecessarily. The unpleasant sensation may keep the person aroused from sleep.
  • Sleep Apnea: Sleep apnea is associated with difficulty in breathing while sleeping. It causes awakening in the middle of sleep.
  • Medications: Medications such as antidepressants, anti-hypertensives, and anti-asthma drugs can interfere with sleep and cause insomnia.
  • Excess intake of caffeine, nicotine, and alcohol: Caffeine and nicotine act as central nervous system stimulants. Consuming the products rich in caffeine and nicotine late in the evening disrupts sleep and causes insomnia. Alcohol often causes an awakening in the middle of the night by preventing deeper stages of sleep. However, the effect of these substances varies from one person to another.
  • Lack of physical activity: Lack of physical or social activity can cause insomnia.

Depending on the duration and cause, insomnia is classified into multiple types. Some of them are:

  • Acute Insomnia: It is characterized by a brief episode of difficulty in sleeping caused due to stressful events in life or due to depression. It often resolves without any treatment.
  • Chronic Insomnia: It is a long-standing sleep disorder characterized by trouble falling asleep or staying asleep at least three nights per week for three months or longer. It may be caused due to a long-term history of sleeping disorders.
  • Comorbid Insomnia: It is caused due to other medical condition such as arthritis or back pain, which makes it difficult to sleep.
  • Onset Insomnia: It is characterized by difficulty falling asleep at the beginning of night.
  • Maintenance Insomnia: It is characterized by an inability to stay asleep. People with maintenance insomnia wake up during the night and have difficulty returning to sleep.

Symptoms

Insomnia itself is considered as a symptom of other medical conditions such as chronic anxiety or depression.

Some of the common complaints associated with insomnia are:

  • Difficulty maintaining sleep
  • Trouble falling asleep at night
  • Tending to fall asleep during the day
  • Feeling tired and lethargic during the day
  • Waking up not feeling recharged or refreshed
  • Feeling weak or tired even after a night of sleep
  • Awakening relatively earlier than the desired time
  • Nighttime awakenings or waking up several times at night

Sleep deprivation or insomnia impairs the normal functioning of the body and can cause serious effects on health. These include:

  • Heart disease
  • Tension headaches
  • Low energy levels
  • The decrease in attention span
  • Poor memory and recall
  • Poor focus and concentration
  • Lack of coordination and errors
  • Lack of proper motivation
  • Poor performance at work or in school
  • Inability to perform simple daily tasks
  • Difficulty socializing with others
  • Low immune functions
  • Constant worrying and fretting
  • Signs of gastrointestinal problems
  • Anxiety and depression
  • Feelings of moodiness and irritability

Risk Factors

  • Age: The elderly have a higher risk for insomnia due to lifestyle changes such as lack of physical activity, increased health problems, and increased use of medications. The body clocks of older people are disturbed and this may interfere with their desired sleep time. In general, older individuals have lesser deep sleep, more sleep fragmentation, and use a large number of medications, all of which increases the risk of insomnia.
  • Gender: Women are at a higher risk for insomnia than men due to hormonal changes occurring during puberty, pregnancy, postpartum period, or during the menopausal transition and after menopause.
  • Lifestyle Changes: Poor lifestyle such as engaging in shift work, smoking or using other tobacco products, alcohol consumption or drinking beverages containing caffeine in the afternoon or evening, and exercising close to bedtime impairs sleep habits and increases the risk of insomnia.
  • Medications: Medications such as steroids, theophylline, phenytoin, levodopa, and selective serotonin reuptake inhibitors increase the risk of insomnia.
  • Mental Health Conditions: Patients with depression, substance abuse, anxiety, and other medical conditions such as heart disease, musculoskeletal disorders, gastrointestinal conditions, endocrine disorders, chronic renal failure, and neurological disease have a risk of insomnia.

Diagnosis

Insomnia is primarily diagnosed by the history of a patient. Some of the assessments and investigations that a doctor may conduct to diagnose insomnia are discussed below:

Sleep History: Initially the doctor collects the sleep history of a patient for evaluating primary insomnia. It helps the doctor to follow a structured approach to diagnosing insomnia. Sleep history consists of a general description of the disorder such as its duration, severity, variation, and daytime sleep patterns based on the patient experiences and the information given by the patient.

Medication History: Various medications such as phenytoin and lamotrigine, beta-blockers, antipsychotics, selective serotonin reuptake inhibitors (SSRIs) or monoamine oxidase inhibitors (MAOIs), and non-steroidal anti-inflammatory drugs (NSAIDs) such as indomethacin, diclofenac, naproxen, and sulindac causes insomnia. So, the doctor will check if the patient is taking any of these medications.

Sleep Diary or Sleep Log: A sleep diary helps to identify maladaptive sleeping habits of a patient such as taking naps or spending excessive time in bed (more than 8 hours). The patient is instructed to write his daily experiences and sleep pattern in the diary. It helps keep track of compliance with behavioral interventions and response to treatment.

Sleep and Psychological Rating Scale: Epworth Sleepiness Scale (ESS) rates the chance of dozing while a person is doing any of the following activities:

  • Sitting and reading
  • Watching television
  • Sitting inactively in a public place
  • Traveling for an hour without a break
  • While lying down to take rest in the afternoon
  • Sitting and talking to someone for a long time
  • Sitting quietly after lunch without having alcohol
  • While waiting at a traffic signal in a car

Each of the above factors is rated on a 4-point scale as follows:

  • 0 – no chances of dozing;
  • 1 – slight chances of dozing;
  • 2 – moderate chances of dozing; and
  • 3 – high chances of dozing.

If an individual scores more than 16, it indicates daytime sleepiness.

Physical examination and Medical History: A general physical examination will be conducted, and patient’s medical history will be reviewed to know if the individual has conditions such as chronic obstructive pulmonary diseases (COPD), asthma, or restless leg syndrome that may disturb sleep.

Blood Tests: Blood tests are conducted to know if the patient has hormonal disorders such as thyroid diseases, iron deficiency anemia, or vitamin B12 deficiency which causes insomnia.

Polysomnography:  It is considered the gold standard for measuring sleep in patients with chronic insomnia. Electroencephalogram (EEG), electrooculography (EOG), electromyography (EMG), electrocardiography (ECG), pulse oximetry, and airflow are used to detect a variety of conditions like periodic limb movement disorder, sleep apnea, and narcolepsy. These tests also help to monitor and record the pattern of brain waves, breathing, heartbeat, and eye movements in an individual.

Actigraphy: It helps to measure the physical activity of an individual. It is a portable device, which a person has to wear on the wrist. Data recorded can be stored for weeks and then downloaded into a computer. Sleep and wake time can be analyzed by analyzing the movement data. Reduced sleep and wake time are recorded in patients with insomnia.

Treatment

Treatment of insomnia mainly aims at treating the underlying medical condition or psychological problems. Identifying maladaptive behaviors that worsen insomnia helps the patients to develop a healthy lifestyle and eliminate insomnia. The treatment includes a combination of cognitive-behavioral therapies and medications.

Cognitive-Behavioral Therapies

  • Stimulus Control Therapy: Stimulus control therapy suggests the actions that will trigger sleep. Some of the actions which help to trigger sleep are:

    Going to bed only when feeling sleepy

    Use the bedroom only for sleeping

    Maintain a regular waking time in the morning regardless of the duration of sleep in the previous night

    Avoid daytime napping

    Exercise regularly at least 20 minutes in a day 4-5 hours before going to bed

    Avoid drinking caffeinated beverages such as tea, coffee, soft drinks etc., later than the afternoon

    Avoid placing high-intensity lights, temperature, noise, etc. in your bedroom

  • Sleep Restriction: Sleep restriction therapy consists of restricting the amount of time spent in bed. It helps to prevent excessive daytime sleepiness and promotes early onset of sleep.
  • Relaxation Therapies: Relaxation therapies such as progressive muscle relaxation and biofeedback techniques reduce arousal. Attention focusing procedures such as imagery training reduce pre-sleep cognitive arousal. These methods reduce sleep disturbance in patients with stress.
  • Cognitive Therapy: Cognitive therapy seeks to alter wrong beliefs and attitudes about sleep in a person.
  • Sleep Hygiene Education: Sleep hygiene education helps to develop a healthy lifestyle by practicing good diet and exercise. It teaches methods to reduce environmental factors such as light, noise, temperature, and mattress that may disrupt sleep.
  • Behavioral Intervention: It helps the patients to adopt good sleep hygiene and to eliminate behavior incompatible with sleep, such as lying in bed and worrying.

Medications

Medications helps to alleviate insomnia by correcting the hormonal imbalance and treating the underlying psychological disorders.

Some of the medications used for the treatment of insomnia are:

  • Benzodiazepines
  • Zopiclone
  • Zolpidem
  • Zaleplon
  • Eszopiclone
  • Ramelteon
  • Tricyclic antidepressants (TCAs)
  • Trazodone
  • Antihistamines

These medications are usually prescribed for a short period (2 to 3 weeks). Long-term use may cause addiction, impair coordination, balance, or mental alertness.

These medications are contraindicated in patients who are allergic to them, history of drug abuse, or have untreated sleep apnea. They are not safe for pregnant or lactating women.

Prevention

Insomnia can be prevented by developing better sleeping habits. Some of the good sleeping habits are listed below:

  • Sleep only when you feel tired.
  • Drink a glass of warm milk before going to bed.
  • Make sure your bedroom is quiet and dark.
  • Keep your bedroom at a comfortable temperature.
  • Do not exercise just a few hours before going to bed.
  • Use the bedroom only for sleeping and sexual activity.
  • Avoid eating large meals or drinking a lot of water in the evening.
  • Avoid taking caffeinated drinks such as coffee and tea, or tobacco late in the day
  • Follow regular sleep and wake cycle even on the weekends. It helps the body develop a sleep schedule.
  • Avoid reading, watching TV, or worrying in bed as these can cause sleep disturbances
  • Avoid taking a nap for more than 30 minutes. Do not take frequent naps and do not nap after 3:00 p.m.
  • Take a warm bath before going to bed or read a novel or a story for 10 minutes every night before bed.

FAQs

Can insomnia be life-threatening?

Acute insomnia is not a life-threatening condition. But, secondary insomnia caused due to obstructive sleep apnea can be life-threatening. Remember insomnia itself is not the problem, but the cause of the insomnia is dangerous and can be life-threatening.

What is jet lag?

Jet lag is a temporary imbalance of the body’s normal circadian rhythm, which is caused by high-speed air travel through different time zones. It disrupts the biological clock of the body changes its pre-set orientation towards day and night. Therefore, the person may experience fatigue and sleepiness at odd hours, irritability and various other functional disturbances.

Does sleeplessness go away on its own without taking any treatment?

Yes, transient or acute insomnia caused due to stressful events of life goes away after the stressful phase is over. Persistent or chronic insomnia needs medical treatment.

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Hypothyroidism: Causes, Symptoms, Risk Factors and Treatment

Hypothyroidism: Causes, Symptoms, Risk Factors and Treatment

Overview

The thyroid gland produces thyroid hormones & it is situated below Adam’s apple in the lower part of the neck. The gland is present around the windpipe (trachea) & it has a shape similar to a butterfly – formed by two wings (lobes) & attached by a middle part (isthmus). The thyroid gland produces thyroid hormones by using iodine & most of it is available from the diet through foods like bread, seafood & salt. The two thyroid hormones that are produced by thyroid gland are thyroxine-tetra-iodothyronine or T4 & tri-iodothyronine or T3. T3 accounts for 1% & T4 accounts for 99% of thyroid hormones. Both are released into the blood after being secreted by the thyroid gland.

The most biologically active form of hormone is T3. Once T4 is released into the blood from the thyroid gland, T4 is converted into T3, & this active hormone affects the metabolism of cells. When thyroid hormone production slows down, the body’s processes also slow down & change. Hypothyroidism will affect various systems of the body.

Hypothyroidism or underactive thyroid is a condition in which the thyroid gland will not produce enough of thyroid hormones. Women, above 60 years of age, usually end up with hypothyroidism. Hypothyroidism causes an imbalance of chemical reactions in the body. If enough thyroid hormone is not produced in the bloodstream, the body’s metabolism slows down. Typical signs of an underactive thyroid are tiredness, weight gain & a feeling of depression. In the early stages, its symptoms are rare, but if left untreated, hypothyroidism leads to a number of health-related problems like heart disease, obesity, joint pain, infertility. It is a quite common condition affecting all age groups & races. However, women, especially older women are more prone to develop hypothyroidism than men.

Thyroid function tests help to diagnose hypothyroidism. Treatment with synthetic thyroid hormone is usually simple, safe & effective. There are no preventive measures for an underactive thyroid. An underactive thyroid is either caused due to the immune system attacking the thyroid gland & causing damage to it or by damage to the thyroid that occurs during some treatments for an overactive thyroid or thyroid cancer.

Both men & women can be affected by an underactive thyroid, but it is most common in women. In the western countries, it affects fifteen in every thousand women & one in a thousand men. Children can also develop an underactive thyroid.  Around one in 3,500-4,000 babies are born with an underactive thyroid known as congenital hypothyroidism. The babies are screened for congenital hypothyroidism by taking blood spot test when the baby is about five days old.

Causes

The common causes of hypothyroidism are

  • Hashimoto’s thyroiditis
  • Thyroid destruction (from radioactive iodine or surgery)
  • Lymphocytic thyroiditis (which may occur after hyperthyroidism)
  • Medications
  • Pituitary or hypothalamic disease
  • Severe iodine deficiency

Hashimoto’s thyroiditis

An inherited condition known as Hashimoto’s thyroiditis is the most common cause of hypothyroidism. Dr. Hakaru Hashimoto described this condition in 1912 & is therefore named after him. In Hashimoto’s thyroiditis, the thyroid gland is enlarged goiter and the ability to make thyroid hormones is reduced.  Hashimoto’s is an autoimmune disease in which the body’s immune system attacks the thyroid tissue. This condition is genetic & runs in families. Women are 5 to 10 times more affected when compared to men. The antibodies to the enzyme, thyroid peroxidase (anti-TPO antibodies) are increased in this condition.

Lymphocytic thyroiditis following hyperthyroidism

Inflammation of the thyroid gland is known as thyroiditis. As the inflammation is caused by a lymphocyte, a type of WBC cells, the condition is known as lymphocytic thyroiditis. It affects 8% of women after their delivery. In these patients, first, the hyperthyroid phase where excessive amounts of thyroid hormone are produced by the inflamed gland, followed by a hypothyroid phase that lasts up to six months. Most of the women return to normal state of normal thyroid function, but some remain in the hypothyroid state.

Thyroid destruction secondary to radioactive iodine or surgery

When hyperthyroid condition (such as Graves’ disease) patients receive radioactive iodine, they have very little of functional thyroid tissue after treatment.

The likelihood of this depends on some factors including the dose of iodine given, along with the size & the activity of the thyroid gland. If there is no significant activity of the thyroid gland six months after the radioactive iodine treatment, it is usually assumed that the thyroid will no longer function adequately. The result is hypothyroidism. Similarly, removal of the thyroid gland during surgery will be followed by hypothyroidism.

Hypothalamic or Pituitary disease

If for some reason the pituitary gland or the hypothalamus are unable to signal the thyroid & instruct it to produce thyroid hormones, a decreased level of circulating T4 & T3 may result, even if the thyroid gland itself is normal. If this defect is caused by pituitary disease, the condition is called “secondary hypothyroidism.” If the defect is due to hypothalamic disease, it is called “tertiary hypothyroidism.”

Pituitary injury

A pituitary injury may result from brain surgery or if there has been a decrease in blood supply to the area. In case of a pituitary injury, the TSH that is produced by the pituitary gland is deficient & blood levels of TSH are low. Hypothyroidism results because the thyroid gland is no longer stimulated by the pituitary TSH. This form of hypothyroidism can hence be distinguished from hypothyroidism that is caused by thyroid gland disease, in which the TSH level becomes elevated as the pituitary gland attempts to encourage thyroid hormone production by stimulating the thyroid gland with more TSH. Usually, hypothyroidism from pituitary gland injury occurs in conjunction with other hormone deficiencies, since the pituitary regulates other processes such as growth, reproduction, & adrenal function.

Medication

Medications which are used to treat an overactive thyroid may cause hypothyroidism. These drugs are Methimazole (Tapazole) & Propylthiouracil (PTU). The psychiatric medication, lithium (Eskalith, Lithobid), is also known to alter thyroid function & cause hypothyroidism. Interestingly, drugs containing a significant amount of iodine such as amiodarone (Cordarone), potassium iodide (SSKI, Pima), & Lugol’s solution can cause changes in thyroid function, which may result in low blood levels of thyroid hormone.

Severe iodine deficiency

Iodine deficiency in the diet causes severe hypothyroidism. It affects 5% to 15% of the population. It is seen in areas like India, Zaire, Chile, Ecuador. Severe iodine deficiency is also seen in mountain areas like the Himalayas & the Andes. Iodine deficiency is rarely seen in the United States due to the addition of iodine bread & table salt.

Symptoms

The signs & symptoms of hypothyroidism vary depending on the severity of the hormone deficiency. It will often take some years to develop hypothyroidism. At first, a person may barely notice the symptoms of hypothyroidism, such as fatigue & weight gain, or person may simply attribute them to getting older. But as the metabolism continues to slow down, more obvious signs & symptoms develop.

Signs & symptoms may include:

  • Fatigue
  • Increased sensitivity to cold
  • Constipation
  • Dry skin
  • Weight gain
  • Puffy face
  • Hoarseness
  • Muscle weakness
  • Elevated blood cholesterol level
  • Muscle aches, tenderness, and stiffness
  • Pain, stiffness or swelling in your joints
  • Heavier than normal/irregular menstrual periods
  • Thinning of hair
  • Slowed heart rate
  • Depression
  • Impaired memory

When hypothyroidism is not treated, signs & symptoms can gradually become more severe. Constant stimulation of the thyroid gland to release more hormones may lead to an enlarged thyroid (goiter). Also, the person may become more forgetful, thought processes may become slow, or a feeling of depression might arise.

Advanced hypothyroidism, also known as myxedema, is rare, but when it occurs, it can be life-threatening. Signs & symptoms include low blood pressure, decreased breathing, decreased body temperature, unresponsiveness & even coma. In extreme cases, myxedema can be fatal.

Hypothyroidism in infants

Although hypothyroidism most often affects middle-aged & older women, anyone can develop the condition, including infants. Initially, babies born without a thyroid gland or with a gland that doesn’t work properly may have few signs & symptoms. When newborns do have problems with hypothyroidism, they display the following issues:

  • Yellowing of the skin & whites of the eyes (jaundice) – in most cases, this occurs when a baby’s liver cannot metabolize a substance called bilirubin, which usually forms when the body recycles old or damaged RBCs.
  • Frequent choking
  • A large & protruding tongue
  • A puffy appearance to the face

As the disease progresses, infants are likely to have trouble feeding & may fail to grow & develop normally. They may also have:

  • Constipation
  • Poor muscle tone
  • Excessive sleepiness

When hypothyroidism in infants is not treated, even mild cases can lead to severe physical & intellectual disabilities.

Hypothyroidism in children & teens

In general, children & teens who develop hypothyroidism have the same signs & symptoms as adults do, but they may also experience:

  • Reduced growth, resulting in short stature
  • Delayed development of permanent teeth
  • Delayed puberty
  • Poor mental development

Risk Factors

Hypothyroidism can affect anyone, but increased risk is observed in:

  • Women older than 60 of age
  • Presence of autoimmune disease conditions
  • The family history of thyroid disease
  • Patients with rheumatoid arthritis or lupus, a chronic inflammatory condition
  • Treatment with radioactive iodine or anti-thyroid medications
  • Radiation to the neck or upper chest
  • Have had thyroid surgery (partial thyroidectomy)
  • Have been pregnant or delivered a baby within the past six months

Diagnosis

Hypothyroidism can be suspected in patients with fatigue, cold intolerance, constipation & dry, flaky skin. A blood test is needed to confirm the diagnosis.

If hypothyroidism is present, the blood levels of thyroid hormones can be measured directly. They are usually found decreased. However, in early hypothyroidism, the level of thyroid hormones (T3 and T4) may be normal. Therefore, the main tool for the detection of hyperthyroidism is the measurement of the TSH, the thyroid-stimulating hormone. TSH is secreted by the pituitary gland and if a decrease in thyroid hormone happens, the pituitary gland reacts and produces more TSH & the blood TSH levels encourage production of thyroid hormone.  This increase in TSH can precede the fall in thyroid hormones by months or years. Thus, the measurement of TSH should be elevated in cases of hypothyroidism.

However, an exception exists. If the decrease in thyroid hormone is actually due to a defect of the pituitary or hypothalamus, then the levels of TSH are abnormally low. As noted above, this kind of thyroid disease is known as “secondary” or “tertiary” hypothyroidism. A special test, known as the TRH test, can help distinguish if the disease is caused by a defect in the pituitary or the hypothalamus. This test requires an injection of the TRH hormone & is done by an endocrinologist (hormone specialist).

The blood work mentioned above confirms the diagnosis of hypothyroidism but does not point to an underlying cause. A combination of the patient’s clinical history, antibody screening & a thyroid scan can help diagnose underlying thyroid problem more precisely. If a pituitary or hypothalamic cause is suspected, an MRI of the brain & other studies may be done.

Treatment

An underactive thyroid (hypothyroidism) is usually treated by taking daily hormone replacement tablets called levothyroxine. Levothyroxine replaces the thyroxine hormone when the thyroid does not make enough.

Initially, the patient will have regular blood tests to adjust the correct dose of levothyroxine. The patient is started with a low dose of levothyroxine, which would be increased gradually, depending on the patient’s body response. Some people begin to feel healthy soon after the beginning of treatment, while others do not notice an improvement in their symptoms for several months.

Once the patient takes the correct dose, he/she usually will have a blood test once a year to monitor the hormone levels.

If blood tests suggest an underactive thyroid, but no symptoms are noted, or only mild symptoms are seen, the patient may not need any treatment. In these cases, the general physician will usually investigate the hormone levels for every few months & prescribe levothyroxine if the patient develops symptoms.

Taking Levothyroxine

If the patient has prescribed levothyroxine, one tablet at the same time every day is usually taken. The patient usually takes the tablets in the morning, although some people prefer to take them at night.

The effectiveness of the tablets can be altered by other medications, supplements or foods, so they should be swallowed with water on an empty stomach, & should avoid eating for 30 minutes afterward. If the patient skips taking a dose, the dose should be taken as soon as the patient remembers.

An underactive thyroid is a lifelong condition, so the patient usually needs to take levothyroxine for the rest of the life.

Side Effects

Levothyroxine does not usually have any side effects because the tablets simply replace a missing hormone.

Side effects usually occur if the patient is taking too much levothyroxine. It can cause problems including headaches, sweating, chest pain, vomitings & diarrhea.

Combination Therapy

Combination therapy (using levothyroxine & triiodothyronine (T3) in combination) – It is not routinely used because there is insufficient evidence to show that it is better than using levothyroxine alone (monotherapy).

In most cases, suppressing thyroid-stimulating hormone (TSH) using high dose thyroid replacement therapy should be avoided because it carries a risk of causing adverse side effects, such as atrial fibrillation (irregular and abnormally fast heart rate), strokes, osteoporosis, & fracture.

However, this type of treatment may sometimes be suggested in cases where a person has a history of thyroid cancer & there’s a significant risk of it reoccurring.

Underactive thyroid & pregnancy

It is necessary to treat an underactive thyroid before pregnancy. If the patient is pregnant or trying to become pregnant & have hypothyroidism. They may refer to a specialist for treatment & monitoring during the pregnancy.

Prevention

The common cause of hypothyroidism is Hashimoto’s thyroiditis, which cannot be prevented. Although hypothyroidism cannot be prevented, some symptoms of the disease need to be watched for, so that it can be treated properly. Some patients who are at high risk of having hypothyroidism but do not have symptoms can be tested to see whether they have mild, or subclinical, hypothyroidism.

  • Stop smoking
  • Exercise daily and maintain fit conditions
  • Reduce stress
  • Filtered water should be used for drinking, water containing fluoride will worsen the risk of thyroid problems.
  • Iodine content consumed should be moderate otherwise it may lead to other health problems.
  • Avoid foods containing excess fat

FAQs

Where is the thyroid gland located?

The thyroid gland is situated below Adam’s apple in the lower part of the neck. The gland is present around the windpipe (trachea) & it has a shape similar to a butterfly – formed by two wings (lobes) & attached by a middle part (isthmus).

What are the hormones secreted by the thyroid gland?

The two thyroid hormones that are produced by thyroid gland are thyroxine-tetra-iodothyronine or T4 & tri-iodothyronine or T3. T3 accounts for 1% & T4 accounts for 99% of thyroid hormones. Both are released into the blood after being secreted by the thyroid gland.

What are the signs and symptoms of hypothyroidism?

Signs & symptoms may include:

  • Fatigue
  • Increased sensitivity to cold
  • Constipation
  • Dry skin
  • Weight gain
  • Puffy face
  • Hoarseness
  • Muscle weakness
  • Elevated blood cholesterol level
  • Muscle aches, tenderness, and stiffness
  • Pain, stiffness or swelling in your joints
  • Heavier than normal/irregular menstrual periods
  • Thinning of hair
  • Slowed heart rate
  • Depression
  • Impaired memory

4) What are the risk factors for hypothyroidism?

Risk Factors

  • Hypothyroidism can affect anyone, but increased risk is seen in:
  • Women older than 60 of age
  • Presence of autoimmune disease conditions
  • The family history of thyroid disease
  • Patients with rheumatoid arthritis or lupus, a chronic inflammatory condition
  • Treatment with radioactive iodine or anti-thyroid medications
  • Radiation to the neck or upper chest
  • Have had thyroid surgery (partial thyroidectomy)
  • Have been pregnant or delivered a baby within the past six months

5) When to take levothyroxine drug for hypothyroidism?

Taking levothyroxine

If the patient has prescribed levothyroxine, one tablet at the same time every day is usually taken. The patient usually takes the tablets in the morning, although some people prefer to take them at night.

The effectiveness of the tablets can be altered by other medications, supplements or foods, so they should be swallowed with water on an empty stomach, & should avoid eating for 30 minutes afterward. If the patient skips taking a dose, the dose should be taken as soon as the patient remembers.

An underactive thyroid is a lifelong condition, so the patient usually needs to take levothyroxine for the rest of the life.

What are the Signs & Symptoms of HIV?

What are the Signs & Symptoms of HIV?

Symptoms of HIV vary from one Individual to another. If you are sexually active and you think may have been exposed to HIV,  it is important to get tested. Here we present some common symptoms of HIV. Most of the people initially suffer from flu-like a symptom which is your body’s natural response to the virus, also known as ‘seroconversion’ period.

It’s crucial to identify at this time if HIV is the cause, as your viral load is very high which greatly increases the risk of passing it on. And the only way to confirm is by getting tested.

1st Symptom: Fever

First symptoms of HIV, is fever, usually accompanied by other mild symptoms, such as fatigue, swollen lymph glands, viral hepatitis c, and a sore throat. At this stage, the virus is circulating into the bloodstream and starting to replicate in huge numbers. When it happens, your immune system induces an inflammatory reaction.

2nd Symptom: Fatigue and headache

Once the inflammatory response is generated by your compromised immune system, it can cause you to feel tired and lethargic. Sometimes, it can make you feel breathless while walking. Fatigue is seen as both an early and later symptom of HIV.

3rd Symptom: Lymph nodes Swelling, Muscle Pain and Joint pains

Lymph nodes, being part of the immune system, protect your blood by getting rid of bacteria and viruses. When there’s an infection, the lymph nodes tend to get inflamed. These lymph nodes are located in your armpit, groin, and neck, which can result in aches and pains in these areas.

4th Symptom: Skin Rash

In the early or late stages of HIV seroconversion, Ache , skin rashes can occur. In a few cases, the skin rash can appear like itchy, pink breakouts, bowens disease.

5th Symptom: Nausea, vomiting, and diarrhea

Large number of people experience digestive system problems, as a symptom of the early stages of HIV. In the early and later stages of HIV, symptoms like nausea, vomiting, and diarrhea  can also appear as the result of an opportunistic infection. It is important to stay hydrated. Severe diarrhea and not responding to usual therapy is an indication of HIV.

6th Symptom: Sore throat and dry cough

Sore throat is commonly seen in HIV Infected Persons. Severe dry cough that lasts for weeks to months without seeming to resolve,  is a typical symptom in HIV patients (even with antibiotics and inhalers).

6th Symptom: Night Sweats

In many patients,  night sweats are seen during the early stages of HIV. In later stages, Night Sweats can be even more common and are not related to exercise or the temperature of the room.

As you can see most of the early symptoms of HIV are very non-specific and can occur in many other infections too.If you are at high risk of being infected with HIV, such as having unprotected and multiple partner sex, intravenous drug use, shared needles and other such unsafe practices, you should get tested for HIV.

HIV testing is vital to ensure a proper diagnosis for such a vast array of symptoms. If you feel you’ve been exposed to HIV, or if you have an active sexual life with casual partners, it is important to get tested whether you have symptoms or not, as soon as possible. If the above symptoms persist or continue it is better to consult with best gastroenterologist for immediately for advice.

What is Hernia? Its Types, Causes, Symptoms and Treatment

What is Hernia? Its Types, Causes, Symptoms and Treatment

Headache

Headache

Epilepsy

Epilepsy

Endocarditis

Endocarditis

Overview

Endocarditis is termed as inflammation of the inner lining of the heart valves and heart chamber called endocardium. This condition usually occurs when fungi, bacteria or other germs from others parts of your body, such as the mouth, are spread through blood circulation and then attach themselves to the damaged regions in the heart. It can cause life-threatening complications by damaging your heart valves if it is not treated immediately. This condition can be treated by means of antibiotic medications and in some cases, surgery may be required.

Since there are numerous ways to develop this condition, your medical practitioner might not be able to identify the exact reason that caused endocarditis. However, individuals at higher risk of endocarditis generally have artificial heart valves, damaged heart valves, mitral valve repair or other heart ailments.

Causes

Endocarditis occurs when germs from other parts of the body enter the blood flow, reach the heart, and attach themselves to the damaged heart tissue or abnormal heart valves. In most cases, certain types of bacteria are the cause, while in some cases, fungi or other microorganisms may also cause this condition.

Generally, your immunity prevents dangerous bacteria from entering the bloodstream. Even if harmful, bacteria can make its way to the heart, they may pass through without triggering an infection. However, harmful bacteria that exists in your throat, mouth or any other part of your body like your gut or skin can at times cause serious infections like endocarditis.

Organisms that trigger endocarditis might enter your blood circulation through:

  • A Medical Condition Or infection– Bacteria may pass from an infected region of the body, such as a skin sore. Apart from this, other medical issues like sexually transmitted infections, gum disease or certain intestinal ailments like inflammatory bowel disease can also provide bacteria a chance to enter your blood circulation.
  • Everyday Oral Activities – Oral activities such as brushing your teeth daily may cause your gums to bleed. Gum bleeding enables bacteria to enter your bloodstream, especially if your gums and teeth are not healthy.
  • Catheters – It is another way for bacteria to enter your body. A catheter is a thin tube that your medical practitioner uses it to remove fluid from the body. If the catheter is in place for a long period, then there is a higher chance for bacteria to enter the blood circulation.
  • Illegal Intravenous (IV) Drug Use – Contaminated syringes and needles are a cause of concern for those individuals who use illegal intravenous (IV) drugs such as cocaine or heroin. People, who use these kinds of drugs repeatedly, do not have access to unused, clean syringes or needles.
  • Needles Used For Body Piercing and Tattoos – The bacteria can also enter your blood circulation by means of needles used for body piercing or tattooing. This can also trigger endocarditis.
  • Certain Dental Procedures – A few dental procedures may cause cuts in your gums, which allows bacteria to transmit through your bloodstream.

If the lining surface of your heart (endocardium) is rough, then bacteria can easily stick to the endocardium. If you have damaged, faulty or diseased heart valves, then you are at high risk of developing endocarditis.

Endocarditis Symptoms

Endocarditis may come up suddenly or slowly, based on the type of germs that are causing the infection, and depending on whether if you have any cardiac ailments. Endocarditis symptoms can differ from one person to another.

Here are some of the common symptoms of endocarditis:

  • Fatigue
  • A changed or new heart murmur, which is the heart sound made by blood passing through the heart
  • Swelling in the legs, abdomen or feet
  • Night sweats
  • Bacterial endocarditis
  • Aching muscles and joints
  • Abnormal heartbeat
  • Shortness of breath
  • Flu-like symptoms like chills and fever
  • Chest pain when you breathe

Endocarditis can also give rise to symptoms that are rare. These include:

  • Unexplained weight loss.
  • Softness in your spleen, which is an abdominal organ present on the left side of your body just under your rib cage that is key to immunity.
  • Blood in urine, which you will be able to see or your doctor may find out when he/she analyses urine using a microscope.
  • Jane way lesions, which are red spots on the palms of your hands or on soles of your feet.
  • Osler’s nodes, which are red, tender spots under the skin of your toes or fingers.
  • Petechial, which are red spots or tiny purple on the whites of your eyes, on the skin or inside your mouth?

Diagnosis

There are several factors, which makes your doctor to suspect endocarditis. Diagnosis of endocarditis is generally based on numerous factors rather than a single symptom or a positive test result.

Your doctor may ask you to undergo several tests in order to make a positive diagnosis. These include:

  • Blood Culture –This test is conducted to find out the presence of any fungi or bacteria in your bloodstream. It is perhaps the most important test your medical practitioner will conduct.
  • Echocardiogram – It uses sound waves to generate images of your heart when it is beating. This test is generally used for checking signs of infection. In order to diagnose endocarditis, your doctor may use a transthoracic echocardiogram or transoesophageal echocardiograms.
  • Transthoracic Echocardiogram – In this type of test, sound waves are aimed at your heart from the transducer (a wand like device) held on your chest to generate video images of your heart movements. This test enables your doctor to check for any signs of damage, or infection and also observe the structure of your heart.
  • Transesophageal Echocardiogram – This is another type of echocardiogram that your doctors may conduct in order to get a closer look at your heart valves. This test can help your medical practitioners to get detailed images of your heart.
  • Electrocardiogram (ECG) – This test is not particularly conducted to diagnose endocarditis. ECG can show your specialist if there is something affecting the electrical activity of your heart. While conducting an ECG, sensors are attached to your arms, legs, and chest. These sensors can detect your heart’s electrical activity. This test is performed to compute the duration and timing of each electrical phase in the heartbeat.
  • Chest X-Ray – Using the images produced by the chest X-ray, your doctor will be able to view the condition of your heart and lungs. These images also help your doctor to see if endocarditis has caused any heart enlargement, or if there are any signs of any infection.
  • MRI or CT scan – Depending upon the condition, your doctor may advise you to undergo an MRI or a CT scan of your chest, brain, or other parts of your body. It enables your doctor to analyse if the infection has spread to these areas.

Treatment of Endocarditis

In most cases, endocarditis is effectively treated by means of antibiotics. At times, surgery may be required to fix damaged heart valves and clean up any remaining signs of the infection.

  • Antibiotics

Doctors may recommend intravenous antibiotic therapy in case if your endocarditis is caused due to bacteria. You may have to take antibiotics until the time your infection is treated effectively. You will get these in a hospital for a minimum period one week until you show some signs of progress. Upon discharge from the hospital, you will have to continue antibiotic therapy as recommended by your doctor. Later on in your treatment, you may switch to oral antibiotics. Antibiotic therapy usually takes up to six weeks to complete.

  • Heart valve surgery

Damaged heart valves or prolonged infective endocarditis caused by endocarditis may require surgical treatment to correct. It is done to remove any scar tissue, dead tissue, debris or fluid build-up from infected tissue. The surgical procedure may also be required to remove or repair your damaged heart valve and substitute it with either animal tissue or man-made material.

Prevention

Undergoing regular dental check-ups and maintaining good oral hygiene can help minimize the build-up of any bacteria in your mouth and prevent it from entering into your bloodstream. By doing this, you will be able to reduce your risk of developing endocarditis from an oral injury or infection. If you have gone through a dental treatment that was followed up with antibiotics, then ensure to take your medicines as prescribed.

If you have a history of heart surgery, congenital heart disease, or endocarditis, stay alert for the signs and symptoms of endocarditis. Take special care of unexplained fatigue or persistent fever.

you should also avoid:

  • Illegal  drug use
  • Tattoos
  • Body piercings
  • Any unsterile procedure that may allow germs to get into your blood

Risk Factors

If you have a healthy heart, there is less chance for you to develop endocarditis, but it is still possible. The germs that trigger any infection have a tendency to stick to and proliferate on surgically implanted or damaged heart valves, or on endocardium that has a rough surface.

Individuals at greater risk of endocarditis are those who have:

  • Congenital Heart Defects – Your heart may be more susceptible to infection if you were born with certain types of heart ailments like an abnormal heart valve or irregular heartbeat 
  • Artificial heart valves – There is a high possibility that germs will stick to an artificial (prosthetic) heart valve when compared to a normal heart valve.
  • Damaged Heart Valves – Certain health issues like infection or rheumatic fever can harm or scar one or more of your heart valves. This can make them more susceptible to endocarditis.
  • A History of Endocarditis – Endocarditis can damage heart valves or tissue that increases the risk of recurring heart infection.
  • A History of Illegal Intravenous Drug Use – Those who inject illegal drugs are at higher risk of developing endocarditis. There is a high possibility that the needles used to inject illegal drugs can be contaminated with the bacteria.

ECZEMA

ECZEMA

Dementia

Dementia

What are the First Signs of Conjunctivitis?

What are the First Signs of Conjunctivitis?

Conjunctivitis is popularly known as Pink Eye. It is an irritating condition in which the white part of the eyeball and the inner part of the eyelids get inflamed. This inflammation makes the blood vessels more visible and also affect the sclera of the eye. It gives the eye a pink or reddish color. Conjunctiva is the thin layer of cells that covers the front of your eye muscles

The main causes behind the pink eye or Conjunctivitis include Viruses, Bacteria, Allergens, Irritants which infects or irritates the eye and eyelid lining. However, it is difficult to determine the exact cause of Conjunctivitis pink eye because of its signs and symptoms.

Symptoms of Pink Eye

The first symptom of pink eye is a pink or red shade in your eyelids and the area of your eyes that is normally white. However, the symptoms may vary depending on specific conditions. You need to consult a healthcare provider if you experience:

  1. Eye redness – Because of the inflammation and blood vessels enlargement in the conjunctiva.
  2. A discharge –The cells present in the conjunctiva produce mucus and the tiny glands that produce tears become overactive and produces more water and mucus resulting in discharge

Firstly, only one of your eyes may get affected. However, the symptoms affect both of your eyes within a few hours. 

Infective Conjunctivitis

Viruses can infect the conjunctiva and are most common. Bacterial infections are less frequent. Infections are very contagious and can easily pass from one person to another person or from one infected eye to the uninfected eye.   

During  infective conjunctivitis, you may sense:

  1. A burning sensation in your eyes
  2. A feeling of grit in your eyes
  3. Eye Cancer
  4. A sticky coating on the eyelashes
  5. Discharge from eye
  6. An enlarged lymph node (gland) in front of the ear

Allergic Conjunctivitis

Allergic conjunctivitis is a form of conjunctivitis which is susceptible to irritation from allergens like pollen or mold spores, especially in the hay fever season. Allergic conjunctivitis is quite common.

During allergic conjunctivitis, you may have:

  1. Itchy eyes
  2. Eyes become irritated
  3. Small blood vessels widen in the conjunctiva
  4. Painful and sensitive to light
  5. Eyelids may puff up
  6. Burning sensation

You may also experience some other symptoms such as sneezing and a runny or blocked nose which may be experienced at certain times usually from early spring into summer. 

Conclusion

Conjunctivitis is a very irritating condition that causes pain. A right medication from your doctor can cure this inflammation. Get the right medical attention for conjunctivitis, if you think that you are at risk of this ailment.

 In most cases, pink eye is a  mild condition that goes away even without treatment. However, it is important to see a healthcare provider to get the proper diagnosis and care with the best ophthalmologist in India.