A 35-Year-Old Soldier With Galactorrhea and Amenorrhea

Ranjodh Singh Gill, MD

Disclosures

May 24, 2021

Discussion

This case is typical of primary hypothyroidism caused by Hashimoto thyroiditis (chronic autoimmune thyroiditis), as suggested by the patient's family history of hypothyroidism, elevated TSH level, low FT4 level, and positive anti-TPO antibody titer. Hashimoto thyroiditis is the most common cause of primary hypothyroidism in both male and female adults. Like other autoimmune diseases, it has a strong familial tendency and has a female preponderance. Other causes of primary hypothyroidism include thyroidectomy, thyroiditis, and radiation to the neck.

Characteristic laboratory findings in primary hypothyroidism are low FT4 and elevated TSH levels. Other common laboratory abnormalities are elevated cholesterol and prolactin levels and elevated anti-TPO antibody titers. Reduced hepatic clearance raises cholesterol levels, and an increase in thyrotropin-releasing hormone (TRH) leads to a rise in the level of prolactin. Once the diagnosis of primary hypothyroidism is confirmed, further testing (eg, anti-TPO antibody measurement) is usually not required, except in specific settings, such as before conception in women or during pregnancy.

Primary hypothyroidism is commonly associated with fatigue, weight gain, dry skin, and constipation. Some patients may have periorbital puffiness, peripheral nonpitting edema, and a delay in the relaxation phase of deep tendon reflexes, depending on the severity of the disorder. Thyroid enlargement may be present, or the thyroid gland may be absent, depending on the etiology. Some patients may have vitiligo, alopecia areata, or other features of concurrent autoimmune diseases.

Hypothyroidism is treated with thyroid hormone replacement in the form of levothyroxine. The dose can be estimated on the basis of body weight, at 1.6 µg per 1 kg of weight. In young patients, the full replacement dose can be given at the start of treatment. However, in patients with very severe hypothyroidism; older adults; and those with underlying heart disease, such as ischemia and/or arrhythmias, levothyroxine should be started at a low dose and then escalated every 2-3 weeks to the optimal dose, as tolerated by the patient.

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