REPRODUCTION AND THE THYROID

Rista Silvana

Pembimbing : Dr. dr. Kms Yusuf Effendi, Sp.O.G, Subsp F.E.R

1 | BIOLOGY SCIENCE PRESENTATION

 NORMAL THYROID PHYSIOLOGY

 Plasma iodide enters the thyroid under the

influence of thyroidstimulating hormone (TSH), the
anterior pituitary thyrotropin hormone.
.
 These iodinated compounds are part of the
thyroglobulin molecule, the large (660 kDa) protein
that is stored in the thyroid follicle and serves as a
depot for thyroid hormones

2 | BIOLOGY SCIENCE PRESENTATION

 NORMAL
THYROID
PHYSIOLOGY
 Approximately 70% of thyroid hormones
are bound to thyroxine-binding globulin
(TBG), which, therefore, is the major
determining factor in the total thyroid
hormone concentration in the circulation.
3 | BIOLOGY SCIENCE PRESENTATION
The metabolic rate is determined to
a large degree by the relative
production of T3 and RT3.
 Estrogen increases the TRH receptor
content of the pituitary; hence, the TSH
response to TRH is greater in women than
in men and greater in women taking
estrogen-progestin contraceptives
 THYROID FUNCTION
TESTS
Free Thyroxine (FT4)
 The free T4 level has a different range of
normal values from laboratory to laboratory but
is usually 0.8–2.0 ng/dL

Total Thyroxine (TT4)

 The total thyroxine, both the bound portion to
TBG and the free unbound portion, is measured
by displacement assays, and, in the absence of
hormone therapy or other illnesses, it estimates
the thyroxine concentration in the blood.
4 | BIOLOGY SCIENCE PRESENTATION
 THYROID
FUNCTION TESTS
Free Thyroxine (FT4)
 The free thyroxine index is calculated
from the TT4 and the T3 resin uptake Thyroid-Stimulating Hormone
measurements. This test has been  TSH (also called thyrotropin) is
replaced by the free T4 assay measured by highly sensitive assays
Total T3 and Reverse T3 using monoclonal antibodies, usually in
 However, in most clinical a technique that uses two antibodies, one

circumstances, they add little to what is directed at the α subunit and one directed

learned by the free T4 and TSH at the β subunit of TSH.

measurements.

5 | BIOLOGY SCIENCE PRESENTATION

  Autoantibodies that compete with TSH for
THYROID its receptor are collectively known as TSH

FUNCTION TESTS receptor autoantibodies (TRAb) and

include thyroid-stimulating

TSH Receptor, Thyroid Peroxidase, and immunoglobulin (TSI) and thyrotropin-

Thyroglobulin Autoantibodies binding inhibitory immunoglobulin (TBII).

 TRAb test is a binding assay that detects both

TSI and TBII; it can be used instead of TSI
 Detectable concentrations of anti-TPO
assay for most applications, as long as the
antibodies are observed in most patients
results are interpreted in the clinical context.
with autoimmune thyroid disease (e.g.,
Hashimoto thyroiditis, idiopathic
myxedema, and Graves disease).
6 | BIOLOGY SCIENCE PRESENTATION
 Radioactive Iodine Uptake Scan
THYROID FUNCTION the thyroid gland is the only tissue that utilizes iodine,

TESTS radioisotopes of iodine can be used as a measure of

thyroid gland activity and to localize activity within
the gland.

The Laboratory Evaluation

 If the initial TSH is low, especially less than
0.08 μU/mL, then measurement of a high T4
will confirm the diagnosis of
hyperthyroidism.

7 | BIOLOGY SCIENCE PRESENTATION

 HYPOTHYROIDISM
 Hypothyroidism increases with aging and is more
common in women.
 8 Up to 45% of thyroid glands from women older than
age 60 show evidence of thyroiditis
 Hypothyroidism is frequent enough to warrant
consideration in most older women, justifying screening
even in asymptomatic older women.
 Women be screened with the TSH assay every 5 years
beginning at age 35, then every 2 years beginning at age
60, or with the appearance of any symptoms suggesting
hypothyroidism
8 | BIOLOGY SCIENCE PRESENTATION
  Myxedematous infiltration can produce enlarged, cystic
ovaries. 12 The increase in cholesterol is due to impaired
LDL-cholesterol clearance secondary to a decrease in

HYPOTHYROIDISM cell membrane LDL receptors. The mechanism for this

LDL effect is attributed to a thyroid response element in
the LDLreceptor gene.
 Amenorrhea can be a consequence of
hypothyroidism, either with TRH-induced
increases in prolactin or with normal prolactin
levels.
 Other clinical manifestations of hypothyroidism
include constipation, cold intolerance,
psychomotor retardation, carpal tunnel syndrome,
and decreased exercise tolerance.

9 | BIOLOGY SCIENCE PRESENTATION

 DIAGNOSIS OF HYPOTHYROIDISM
Subclinical Hypothyroidism  Women, and increases with age, affecting up to

 In early hypothyroidism, with undetectable 20% of women over age 60

symptoms or signs, a compensated state can be  Subclinical hypothyroidism, about 2–5% each
detected by an elevated TSH (greater than the year will become clinically hypothyroid with
upper limit of the normal range of 0.45–4.5
03 low T4 concentrations.
μU/mL) and normal T4 (called subclinical
hypothyroidism).
 Subclinical hypothyroidism is present in 4–
8.5% of U.S

10 | BIOLOGY SCIENCE PRESENTATION

 DIAGNOSIS OF
HYPOTHYROIDISM
Treatment of Hypothyroidism

Mixtures of T4 and T3,
such as desiccated thyroid,
provide T3 in excess of
normal thyroid secretion.
Because of a risk of coronary heart disease in older
women, the initial dose should be 25–50 μg/day for 4
weeks, at which time the dose is increased by 25 μg
daily every 4 weeks according to the clinical and
biochemical assessment.
Recovery of the hypothalamicpituitary
axis usually requires 8 weeks at which
time the TSH and free T4 levels can be
measured.

11 | BIOLOGY SCIENCE PRESENTATION

DIAGNOSIS OF
HYPOTHYROIDISM
Evaluation of Therapy
When the patient appears clinically euthyroid, evaluation of
TSH levels will provide the most accurate assessment of the
adequacy of thyroid hormone replacement. The goal is to
maintain the TSH in the lower half of the normal range,
between 0.45 and 2.0 μU/mL. 7,31 Thyroid hormone
requirements decrease with age.
12 | BIOLOGY SCIENCE PRESENTATION
A patient being treated with thyroid
hormone should be evaluated once every
year with the TSH assay, and each patient
should consistently remain on the same
levothyroxine product. If the TSH level is
low, then the free T4 should be measured
to help adjust the thyroxine dose. 32 The
full response of TSH to changes in T4 is
relatively slow; a minimum of 8 weeks is
necessary between changes in dosage and
assessment of TSH
 HYPERTHYROIDISM Hyperthyroidism affects 1.3% of adult US
population, 14 and its two primary causes are
Graves disease (toxic diffuse goiter) and

How Genetics Plummer disease (toxic nodular goiter).

Shapes Who We In postmenopausal women, symptoms are often

concentrated in a single organ system, especially
Are the cardiovascular or central nervous system.

The triad of weight loss, constipation, and loss of

appetite, suggesting gastrointestinal malignancy,
occurs in about 15% of older patients with
hyperthyroidism.

13 | BIOLOGY SCIENCE PRESENTATION

 HYPERTHYROIDISM
Diagnosis of Hyperthyroidism

 The diagnosis of hyperthyroidism requires laboratory

testing.
 A suppressed TSH (below 0.4 μU/mL) with a high T4
or a high T3 confirms the diagnosis.
 Graves disease is associated with the presence of
TRAb.
 The measurement of TRAb in all patients with
hyperthyroidism is important in order to confirm a
The scan will indicate whether the patient has a diffuse
diagnosis of Graves disease.
toxic goiter, a solitary hot (functional) nodule, or a hot
nodule in a multinodular gland.

14 | BIOLOGY SCIENCE PRESENTATION

 HYPERTHYROIDISM
Subclinical Hyperthyroidism
 Therefore, TSH levels less than 0.1
 TSH levels can be suppressed to 0.1–0.5
μU/mL should be treated to avoid
μU/mL by general illnesses and drugs such as
glucocorticoids, dopamine, and bone loss and atrial fibrillation in
anticonvulsants; however, this suppression older women, or in those at risk for
does not extend below 0.1 μU/mL. osteoporosis and heart disease.

15 | BIOLOGY SCIENCE PRESENTATION

  There are multiple objectives
of therapy: control of thyroid

HYPERTHYROIDISM hormone effects on peripheral

Treatment of Hyperthyroidism tissues by pharmacologic

blockade of beta-adrenergic
receptors, inhibition of thyroid
gland secretion and release of
thyroid hormone, and specific
 Important to ensure that a woman is
treatment of nonthyroidal
not pregnant before treatment with
systemic illnesses that can
radioactive iodine, and pregnancy
exacerbate hyperthyroidism or
should be postponed for several
be adversely affected by
months after treatment.
hyperthyroidism.
16 | BIOLOGY SCIENCE PRESENTATION
 OSTEOPOROSIS AND
EXCESSIVE THYROXINE
 In addition, total and ionized calcium increase in
hyperthyroid women, leading to increases in serum
phosphorus, alkaline phosphatase, and bone Gla
protein (osteocalcin), a marker of bone turnover.
 The net effect of excessive thyroid hormone is
increased bone resorption and a subsequent decrease
in bone density—osteoporosis
 Both premenopausal women and especially
postmenopausal women receiving thyroxine with
TSH levels to ensure that levothyroxine doses are
“physiologic.”
17 | BIOLOGY SCIENCE PRESENTATION
 THYROID NODULES

There are four major types of

primary thyroid carcinoma:
Surgical excision of nodules can
papillary, follicular, anaplastic,
result in vocal cord paralysis,
and medullary.
hypoparathyroidism, and other
complications.
18 | BIOLOGY SCIENCE PRESENTATION
THE THYROID GLAND In response to the metabolic demands of pregnancy, there is an increase
in the basal metabolic rate (which is mainly due to fetal metabolism),
AND PREGNANCY iodine uptake, and the size of the thyroid gland (caused by hyperplasia
and increased vascularity).

The increase in thyroid activity in pregnancy is accompanied by a marked increase in the circulating levels of TBG in response to
estrogen; therefore, a new equilibrium is reached with an increase in the bound portion of the thyroid hormone.

19 | BIOLOGY SCIENCE PRESENTATION

 HYPOTHYROIDISM IN
PREGNANCY
 Women with thyroid antibodies have a significant risk of
becoming hypothyroid as pregnancy progresses and also an
increased risk of postpartum thyroiditis
 TSH should be monitored monthly and again in the
postpartum period, and dosage should be adjusted to keep the
TSH level in the lower half of the normal range, less than 2.5
μU/mL in the first trimester and less than 3.0 μU/mL in the
rest of pregnancy

20 | BIOLOGY SCIENCE PRESENTATION

 HYPOTHYROIDISM IN PREGNANCY
Fortunately, infants with congenital
Thus, there is a relatively high
hypothyroidism have low T4 and high
incidence of postpartum thyroiditis
TSH concentrations easily detected in
(5– 10%), 1–6 months after delivery
blood, and early high-dose treatment Most women can be successfully
(most commonly at 3 months),
before 3 months of age is usually treated with thioamide drugs
manifested by either hyperthyroidism
associated with normal mental propylthiouracil and methimazole,
or hypothyroidism, although usually
development, while persistent which are equally effective for
transient hyperthyroidism (lasting 1–2
impaired mental performance has pregnant women.
months) is followed by
been observed in long-term follow-up
hypothyroidism
studies.

Newborn Screening for Postpartum Thyroiditis Postpartum Thyroiditis

Hypothyroidism

21 | BIOLOGY SCIENCE PRESENTATION

 THANK YOU

22 | BIOLOGY SCIENCE PRESENTATION