BBC: Low [thyroid] hormone levels in pregnancy linked to hard birth

Expectant mums who are low in a hormone made by the thyroid gland in the neck are more likely to struggle in labour, findings suggest.

Not only are these labours generally longer and harder, they are also more likely to end in an assisted delivery with forceps, ventouse or a Caesarean.

The article talks about abnormal positioning of the infant prior to birth and information on problems for the infant during development, also, if the mother's thyroid hormones are off. 

To read the whole article: Low hormone levels in pregnancy linked to hard birth

Central Hypothyroidism: A Cushing's Disease problem, too

Since approximately 80% of Cushing's Disease/Syndrome is caused by a pituitary adenoma, other hormones produced by the interaction of the hypothalamic-pituitary-adrenal (HPA) axis are often deficient. This includes thyroid-stimulating hormone (TSH).

Primary hypothyroidism is often detected by elevated TSH values. This is due to the normal feedback-loop of the HPA axis. Central hypothyroidism (CH), however, is not typically detected by measuring TSH which is low due to a disruption of the pituitary's stimulus and is not produced as needed. The most common cause is a pituitary adenoma.

In Mechanisms Related to the Pathophysiology and Management of Central Hypothyroidism, the authors state, "Given that the prevalence of pituitary adenomas in the general population is greater than 10%, the true prevalence of CH might be much higher than that reported". When speaking of the method of measuring TSH levels alone, they say this "approach works, however, only if the hypothalamic-pituitary-thyroid axis is normal. Conversely, the strategy of first-line TSH measurement can miss patients with CH."

The authors give a very nice synopsis of the HPA axis' role in thyroid regulation and function. The diagrams are well-done, also. In Table 1, the causes of CH are listed:

Table 1. Causes of Central Hypothyroidism

Cause	Congenital	Acquired
Classic causes
Space-occupying lesions (brain or pituitary; pituitary adenoma, craniopharygioma, etc.)	Yes	Yes
Radiation	No	Yes
Vascular disease (Sheehan syndrome, etc.)	Yes	Yes
Nonclassic causes
Traumatic brain injury or subarachnoid hemorrhage	No	Yes
Drug-induced (bexarotene, carbemazepine, etc.)	No	Yes
Growth hormone therapy	No	Yes
Infection (lymphocytic adenohypophysitis, lymphocytic hypophysitis)	No	Yes
Set point diseases (infant's born to mothers with inadequately controlled Graves disease, etc.)	Yes	No
Genetic mutations	Yes	No
Idiopathic	Yes	Yes

CH usually appears concurrently with other hormone deficiencies. "Hormone deficiencies were seen for luteinizing hormone/follicle-stimulating hormone (LH/FSH) in 85% of patients, growth hormone in 65%, adrenocorticotropic hormone (ACTH) in 62%, TSH in 60%, antidiuretic hormone in 23% and prolactin in 15%."

The authors also detail non-classic causes of CH, including genetic mutations. With one familial case inheritance was determined to be autosomal recessive. Interestingly, the values of TSH measured varied by assay with one mutation.

The researchers make a case for using free T4 and free T3 to determine CH while levels of TSH have no diagnostic value. They also indicate that although the "nocturnal surge of serum TSH level has been used to assess CH, this approach is still controversial. MRI could be required for most suspected cases of CH to detect origin of hypothalamic or pituitary disorders."

Treatment is much the same as for any hypothyroidism. Levoxythyroxine is the first line of treatment. They also carefully point out the following:

Deficiencies of hormones other than TSH should be considered before starting
treatment. When ACTH deficiency is also present, glucocorticoid therapy should
be started at least 1 week before initiation of levothyroxine to avoid increased
consumption of cortisol and worsening of the ACTH deficiency, which can
induce crisis. (emphasis mine)

An algorithm was developed for treating CH sufferers. Interestingly, this does not show using any form of T3, although there are folks who do not convert forms of T4 to the needed T3. They do empasize, however, the importance of achieving "free T4 in the upper end of the normal range rather than within the middle or lower values".

On a positive note for those who have or will undergo pituitary surgery, they authors conclude, "Surgery is reported to lead to an improvement in anterior pituitary function in approximately 35% of patients with pituitary adenoma and CH."

Masanobu Yamada, Masatomo Mori (2008). Mechanisms related to the pathophysiology and management of central hypothyroidism Nature Clinical Practice Endocrinology & Metabolism, 4 (12), 683-694 DOI: 10.1038/ncpendmet0995

Vitamin D and the thyroid gland...

Many of us who deal with Cushing's and its aftermath have low vitamin D. We know there is a relationship with the endocrine system and vitamin D just from the sheer numbers of us who deal with the combination. Now there is some research which ties vitamin D with the thyroid. It appears a vitamin D deficiency may result in new or worse autoimmune hyperthyroid problems.

Endocrinology published online (October 16) a study done by Alexander Misharin, et al, of the UCLA school of Medicine in LA . In the introduction, the authors state:

It is now well-recognized that, in addition to its role in skeletal homeostasis, vitamin D plays a role in both innate and adaptive immunity (reviewed in 1). The vitamin D receptor is expressed on monocytes and activated lymphocytes (2) and the biologically active metabolite of vitamin D [1,25 dihydroxyvitamin D3, 1,25(OH)2D3] is a potent modulator of T cell responses (3). Because of this activity, the immunological effects of vitamin D have been the subject of intense investigation in animal models of autoimmune disease.

However, the authors had a "surprise" conclusion:

The continuing hyperthyroid state in vitamin D deprived BALB/c mice could not be attributed to any immunological difference (as described above)...For these reasons, it seems likely that persistent hyperthyroidism can only be attributed to a difference in the sensitivity to TSAb of the thyroid in BALB/c mice on deficient vitamin D diet.

Although the research was done on mice, "vitamin D may have similar effects in humans".

A. Misharin, M. Hewison, C.-R. Chen, V. Lagishetty, H. A. Aliesky, Y. Mizutori, B. Rapoport, S. M. McLachlan (2008). Vitamin D deficiency modulates Graves' hyperthyroidism induced in BALB/c mice by thyrotropin receptor immunization Endocrinology DOI: 10.1210/en.2008-1191

Recent Advances in Neuroendocrine Imaging Lead to Improved Diagnosis

Imaging is critical in the diagnosis and care of neuroendocrine disorders. The exponential growth of technology has improved techniques and engineering with medical imaging. In turn, this has affected the effectiveness of these tools.

Neuroendocrine tumors and lesions are found on multiple endocrine organs. Imaging of the pituitary, adrenal, thyroid and parathyroid glands are discussed in this article with perfusion metrics as a basis for evaluation. The MRI is touted as the most recent advance in imaging due to the comparison of sequences (pulse versus standard).

Pituitary imaging using 3 T-based MRI with three-dimensional anisotropy contrast is a relatively new approach to determining cavernous sinus invasion with a pituitary tumor. Dynamic MRI imaging is valuable when imaging microadenomas of the pituitary. 3T imaging with MRI increased the localization of small lesions/tumors, and both approaches are more accurate for patients with mild/episodic hypercortisolism. The value of CSS and IPSS are also discussed.

The addition of perfusion MRI aids in the evaluation of prolactinomas and the effectiveness of the treatment with dopamine antagonists. This, in turn, allows more informed decisions with respect to surgical intervention.

A similar protocol is used for patients with acromegaly caused by growth hormone-secreting tumors and who are treated with octreotide.

The newest addition to the evaluation of the adrenal glands is the the use of "MIBG, Octreotide or PET". This is key to avoidance of a bilateral adrenalectomy due to the lack of localization of an ectopic source of ACTH.

Chemical shift imaging is also being used to determine adrenal hyperplasia and tumors. This technique is based upon the "slightly differing resonant frequencies of protons in water and fat in an external magnet field." Hyperaldosteronism, a cause of hypertension, is one diagnosis that has been improved by this. Perfusion metrics are used with these techniques to improve accuracy in diagnosis.

In addition to the normal use of MRI, CT and ultrasound in the evaluation of the thyroid and parathyroid glands, the author talks about the increased use of PET-CT in the treatment of differentiated thyroid carcinomas with patients where conventional whole body scanning did not work. Perfusion imaging of the thyroid using (FAIR)-true fast imaging with steady precession (FISP) sequence is noted as a possible alternative for evaluating thyroid nodules. The same techniques are suggested for parathyroidism.

The author suggests the use of MRI with neuroendocrine disorders is still young, and there will be improvements over time.


Keogh, B.P. (2008). Recent advances in neuroendocrine imaging. Current Opinion in Endocrinology, Diabetes & Obesity, 15(4), 371-375.

Oh, my sore Cushie bum....but the view is gorgeous!

As my British friends would say, "Oh my aching bum!" I think too much sitting is as hard on the body as too much walking or running. I tried to walk a lot yesterday in between my flights (and oh, I had the time...as you read yesterday), but sitting for 5 hours straight is just hard on a body.

It sure is nice here where I am. Breezy and low 70's. I'm actually sitting by the pool right now and FREEZING! The sun feels good, but I may have to go get my polar fleece blanket. I don't lack in insulation, so what is it that keeps me so cold? The only time I got warm (not hot) yesterday was when I was wearing my jacket and lugging my wannabe-a-totebag purse along with my laptop and hoofing it through the terminal. And that was short-lived because as soon as I stopped, I was cold again.

I guess I need to go get bloodwork done to check my free T3 and free T4 levels so my endo can figure out what's going on there. The last time I had them checked my endo had to increase my Levoxyl dosage. And my anti-TPO was up, again. I know I freeze with AI, but that's a different kind of cold. It's a cold-from-the-inside-out chill. The bloodwork will have to wait 'til I get back home, though!

My suite where I'm staying is beautiful! This part-time job has its perks, that's for sure. I have two bedrooms and bathrooms, a living area with dining area, full kitchen with stainless steel appliances, LCD TV, wireless internet, and an empty refrigerator. Oops...that last one doesn't sound like a perk, does it? HA! Nah, I could get a cab and go get stuff to stock it or the staff here will go for me, but several of us are going out to eat tonight, so why bother? Plus, I ordered from a local restaurant who delivers last night and got a half-a-chicken (smallest plate they had!) with steamed veggies and a salad and ate the leftovers for lunch today. There is breakfast served for all the guests, so I'm covered. I'll be wined and dined all week. Who needs food? (Oh, I brought my coffee...I'm 'tic'lar!)

So, I sound like I'm bragging, but trust me, I'm not. I really, really enjoy this, and I love what I do to earn it. I get to meet and work with people from all over the world, plus I get to teach something I love: database design and programming. That keeps it from being a "job". And there have been some very tough times in my life where I was wondering how I was going to feed myself and my girls. You know what I mean. So, I know I've been blessed with this "not-a-job" and I'm thankful.

I have a spare bedroom...who's coming to visit? The view is gorgeous.

Traveling as a recovering Cushie....

The first section below was written yesterday while I was traveling. I have more to add after it.

Yesterday:

Can you tell I'm stuck at a major airport waiting on another flight out? Argh..... I managed to make the short leg with no problems, but our destination was covered in fog and backed up. Long story short version: Missed my connecting flight.

I'm so proud of myself. Why? I didn't need a ride, or any help, navigating either airport. Last year at this time, that was not true, although I was much better than during the previous trip! No wheelchairs, no hitching a ride on the glorified golf carts, no sitting down halfway down one terminal while trying to get to the main hub and to another. Nope...I walked it all, lugging my laptop and big purse-wannabe-a-tote-bag-a-ma-jiggee. Now, I wasn't as fast as some, but I DID IT!!

Hey, no stress dosing today, either! Not yet, anyhow. I'm feeling a little nauseous, but part of that is due to the fact I didn't get any time to eat until a few minutes ago. I think I'll be ok. No pains, no swelling (!!!!!) today, and most of all, no anxiety.

The little puddlejumper I came in on was about 3/4 full. I mention that because it has a bearing on my meandering tale. I was at the exit door on the right, and was supposed to have a seat mate. The other set of seats across from me was facing me, and there were two folks assigned to those two seats. The funny thing (and it really was funny) was that we were the 4 of the larger folks on the plane. There were others with probably the same size, but the logistics of the 4 of us was beyond hilarity. 4 of us sitting together.

Well, the flight attendant (FA), without being a bit rude, realized the situtation. Mind you, I wasn't complaining. The lady beside of me was, though. And her butt was bigger than mine. The dear lady across from me was a novice flyer (more about her later), and the gentleman beside of her was not. However, he was very uncomfortable. He was at least 6 feet tall, and at least 350 pounds.

FA started moving folks around. But she didn't move the four of us, first. She said to one young man, "Honey, if you want to go sit with your grandmother, you can." He went. She moved another person beside a friend/business partner so they would be
together. Then she moved the gentleman who was in our group of 4 with a "There will be more room for you to stretch out over there." The lady beside of me never quit complaining. Finally, FA looked at the complaining lady (CL) and said, "There
is a set of empty seats. Take your pick."

Mind you, our flight was all of 38 minutes long. I could handle it if CL could. Don't tell me FA was trying to balance the plane. There were plenty of folks on there as big as the 4 of us. They just didn't have to sit with another one who was their size. FA
was marvelous, though. She had a wonderful sense of humor and was very courteous the whole time.

Back to the lady who was flying the first time. She was Cushie. Love her heart. She
had all the signs and symptoms. And I didn't bring my cards with me! YIKES! She didn't have email, her purse was stowed and she couldn't remember her own (new) cell phone number. My purse was stowed, I had no way to write anything. When we landed, I decided I'd write down some info for her and hand it to her. I wanted to be
tactful, but I also wanted to help her.

It wasn't to be. When we landed, she had 15 minutes to catch her next flightand they whisked her away on a golf cart. Me, I had all the time in the world............. I didn't see her again. I'm so sad. She was such a nice, sweet, lady. I hope someone, somewhere will help her.

Today:

Things didn't go quite as smoothly as I'd hoped. The nausea got worse before I got on my 5 hour flight, I got very cold and shakey, and my head was hurting. While walking to get to my gate, I lost my balance and a dear, elderly lady stopped and asked me if I was ok. I said yes. I was not. I did have it together enough to know to take some cortef. Which I did. And ibuprofen for my head. That and a bottle of juice really did help, though, and by the time I boarded the plane I was ok. Not great, but ok. I got a great seat, though! Exit row seating! Stretch my short legs out seating! No getting up to let folks out seating!!

I don't know about y'all, but those airplane seats do not fit me right. I'm too short. My head hits the wrong spot, my spine is out of whack, and the small of my back is not touching anything. So, I have to grab a pillow, use a blanket, my jacket and whatever else I can find to "adjust" so I don't get the headache (a worse headache this time) and the backache. Still, once I do that, my seat cuts into the back of my legs. Yes, I'm short. I need a footstool to prop my feet on.

And yes, I get cold. I've learned to fly with enough clothes layered to handle that. And a trusty, small blanket that fits in my wannabe-a-totebag purse .

Soooooooooo, I read a whole book on the flight ("Protect and Defend" by Vince Flynn), did umpteen leg, ankle, and foot stretches, slept a couple of times, listened to my mp3 player, and chatted with the nice young man from Russia sitting beside me. He was reading one of Dan Brown's older novels ("Angels and Demons") and we discussed his books for a while, and then some others we'd both read.

Once I made it to my destination, I was tired. Very tired. At that point, I'd been up and going for 20 hours. That was tough for me. I know it's not for some of you reading this, but it was for me. My muscles ached from head to toe and I was bone-tired. When I got to baggage claim, I think someone must have realized this because a nice USAirways gentleman was standing there with my one big piece of luggage! I could have kissed him! The other luggage was just starting to be unloaded. I don't know how/why he had mine, but I didn't care. (I think the FA I had on the long flight had something to do with it. I helped her out with change and such, and she and I had a good conversation, too.)

I love my luggage, btw. It's an e-bag called the "Mother Lode", and it's so easy to pack, versatile, easy to roll and great for a Cushie without much muscle strength. I can't deal with two pieces of luggage. I can't handle it. I can strap my laptop case to it when I roll through the airport.

Speaking of luggage....you know that the new regs allow only one piece 50 pounds or under or you have to pay extra. Since my ticket was booked before July 9, I didn't have to pay the $15 fee for checking that one piece. When the dear man wrestled my luggage on the scale, it was moving between 49 and 51 pounds. Finally, it came to rest. 50.00 pounds. ON THE DOT! The fellow looked at me...looked back at my luggage....looked at me...."I have NEVER had a piece of luggage hit the fifty-dot-oh-oh exactly before." I never batted an eyelash. "That's what you call great packing, isn't it?"

(Added note: Man, am I ever sore today!)