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Clinical Review Fortnightly review

Controversial aspects of thyroid disease

BMJ 1999; 319 doi: (Published 02 October 1999) Cite this as: BMJ 1999;319:894
  1. F W F Hanna, consultant endocrinologist (,
  2. J H Lazarus, consultant physicianb,
  3. M F Scanlon, professorb
  1. a Department of Medicine, Prince Charles Hospital, Merthyr Tydfill, Cardiff CF47 9DT
  2. b Department of Medicine, University Hospital of Wales, Cardiff CF4 4XN
  1. Correspondence to: F W F Hanna
  • Accepted 12 May 1999

The thyroid gland controls the metabolic rate of many organs and tissues Underactivity and overactivity of thyroid function represent the commonest endocrine problems, have widespread manifestations, and often require long term treatment. Therefore, all practising clinicians have to be aware of thyroid physiology and the consequences of dysthyroidism.

Summary points

Simplifying the treatment regimen for thyroid disease is the most important way of improving patient compliance

All solitary thyroid nodules should be examined by fine needle aspiration; the technique may also be helpful in multinodular goitres if carcinoma is suspected

Subclinical hyperthyroidism is defined as suppressed concentrations of thyroid stimulating hormone with normal serum thyroxine and triiodothyronine concentrations

In subclinical hyperthyroidism the incidence of atrial fibrillation increases as thyroid stimulating hormone concentrations decrease, and in postmenopausal women bone mineral density may also be slightly reduced

Smoking increases the risk of both Graves' disease and Graves' ophthalmopathy


We have chosen topics in thyroid disease of interest to clinicians in both primary and secondary care: compliance, because it remains a challenge to all clinicians; and subclinical thyroid disease and the effect of amiodarone on thyroid function because they are interesting and evolving topics. We have also addressed some aspects of Graves' disease that have recently generated interest. Our sources included papers from Medline as well as discussions from recent national and international endocrinology meetings.

Box 1 —Causes of increased thyroid stimulating hormone concentrations with adequate thyroxine replacement dose

  • Poor compliance

  • Malabsorption

  • Influence of pharmacological agents:

Reduced absorption



Ferrous sulphate

Aluminium hydroxide

Reduced conversion of thyroxine to triiodothyronine


Compliance with treatment

Management of thyroid disorders usually requires prolonged, and often lifelong, courses of treatment. Hence adequate compliance is needed to achieve and maintain euthyroidism. The sensitive assay for thyroid stimulating hormone has advantages over assays for thyroxine, triiodothyronine, and free thyroxine, and both the free thyroxine index and older versions of the thyroid stimulating hormone radioimmunoassay. The sensitive assay helps to differentiate normal concentrations of thyroid stimulating …

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