The thyroid is the central gland of our metabolism. It dictates how fast or slow our body processes energy.
Its hormones have several roles throughout the body, depending on the tissue. That’s why hypothyroidism has a wide array of signs and symptoms.
We usually see hypothyroidism in women. Only 3.7% of the population in the United States is diagnosed with hypothyroidism. Most of them are women in a male to female ratio of 1:4.
The disease is more common in developing countries, especially those with a low intake of iodine. That’s because iodine is required for thyroid hormone production and fundamental for thyroid function (1).
As we age, hypothyroidism becomes more common, as well as goiter, thyroid nodules, and other abnormalities. That’s why up to 20% of older men and women have a form of hypothyroidism.
According to the Framingham study, this condition can be found in 5.9% of older women and 2.4% of older men. Thus, the statistics clearly show an increase in the prevalence of hypothyroidism in men, especially after highlighting the change in male to female ratio from 1:4 to almost 1:2 (2).
But what is hypothyroidism, and how do males experience this ailment? In this article, we’re reviewing the most critical aspects of this ailment, including the diagnostic steps and tests and the available treatment options for males with hypothyroidism.
What is hypothyroidism?
Hypothyroidism is an endocrine disorder of the thyroid gland that results in abnormally low thyroid hormone levels. All over the world, one of the most common causes of primary hypothyroidism is an insufficient intake of iodine. It may also result from the treatment of an overactive thyroid (hyperthyroidism).
Other causes include an autoimmune hypothyroidism problem known as Hashimoto’s thyroiditis. But in most cases, an adequate intake of iodine solves or significantly improves the patient’s condition.
There is also secondary hypothyroidism. In these cases, the gland produces enough thyroid hormone, but TSH does not correctly stimulate its release. Thyroid Stimulating Hormone (TSH), also known as thyrotropin, is released by the pituitary. This hormone triggers the release of thyroid hormone. But it is sometimes the pituitary that fails to produce enough of this hormone.
We can also talk about tertiary hypothyroidism. Thyroid Stimulating Hormone triggers Thyroid Hormone release. But TSH release should also be triggered by another hormone called Thyrotropin-Releasing Hormone (TRH). This hormone is released by the hypothalamus, reaching the pituitary and causing TSH release. Tertiary hypothyroidism would be an insufficient TRH release with a normal pituitary and thyroid hormone (3).
Another form is congenital hypothyroidism, thankfully a rare condition. It only affects one in every 4000 newborn babies. The cause is a congenital problem in the thyroid gland, usually due to a maternal iodine deficiency. If nothing is done to treat this condition, it will cause cognitive problems in children. However, once detected, it can be successfully treated without consequences.
Symptoms of hypothyroidism in men
There is no single presentation of hypothyroidism. Some patients do not display any symptoms, or they are very mild and easy to neglect. In other cases, patients enter into a severe condition known as myxedema coma.
They may even have a multisystem organ failure as a consequence of severe hypothyroidism. This is because the thyroid hormone is essential for every cell in the body.
Thus, hypothyroidism has several effects on every organ and body system. The most common symptoms of hypothyroidism in men are listed below (3, 4):
- Low energy levels: Some hypothyroidism patients experience fatigue, lethargy, or a continuous sensation of exhaustion. They often feel muscle weakness and do not fully recover after a full night’s sleep.
- Sleepiness: Despite having a good night’s sleep, hypothyroidism patients experience daytime drowsiness and sleepiness. They may even fall asleep or have difficulties to stay focused and awake.
- Depression and other emotional changes: These patients often experience emotional liability and mood swings. Depression is a common problem in this ailment, as well as anxiety and other psychiatric problems.
- Cognitive impairments: Their low energy levels also reflect in the brain. Patients often report forgetfulness, difficulty to concentrate, and impaired memory and cognition.
- Unintentional weight gain: The metabolic rate of these patients is lower, and their metabolism slows down. Thus, they do not consume as many calories and tend to gain weight.
- Slow heart rate: Besides slow metabolism and weakness, these patients also have a slow heart function. The heart pumps with reduced force, and in severe cases, it can lead to heart failure.
- Muscle and joint pain: These symptoms go along with muscle weakness, especially in severe cases.
- Nerve entrapments and paresthesias: Patients often experience tingling in the extremities and other nerve-related symptoms. There is a higher prevalence of nerve entrapment syndromes in this group of patients.
- Low appetite levels: Despite the weight gain, patients usually have lower appetite levels. Gastric emptying is slower than usual, and patients feel less hungry.
- Constipation: Similarly, patients experience slower bowel movements and a predisposition to constipation.
- Cold intolerance: Body heat regulation is affected, and there’s a reduction in thermal energy formation. As such, patients become intolerant to cold weather.
- Dry skin: Sweat glands and sebaceous glands also slow down their function. Thus, patients have decreased sweating and dry skin.
- Hair loss: The hair cycle does not function as it should, and the skin changes above contribute to hair loss.
One of the causes of hypothyroidism is an autoimmune thyroid disease known as Hashimoto thyroiditis. It is more common in women, but some men also have this problem. In that case, the following symptoms add up to the problem (3, 4):
- A lump or a sense of fullness in the throat
- Thyroid enlargement
- Sore throat or neck pain
In the physical exam, doctors may also find other cues and warning signs (3, 4):
- Periorbital puffiness
- Slow movements and slow speech
- Dull expression
- Jaundice or pallor
- Brittle hair
- Low systolic and high diastolic blood pressure
- Slow heart rate, sometimes with a pericardial effusion
The diagnosis of thyroid-related conditions is easier in severe hypothyroidism. But most patients do not reach this condition and have a borderline problem. In these cases, it is often necessary to run several tests and make comparisons.
The signs and symptoms listed above are only useful to suspect hypothyroidism. We can’t merely point to the thyroid gland just because a patient feels a lump in the throat and is lately gaining weight. The diagnosis should be made with one or more of the following tests (4, 5):
- TSH levels: They are measured in the blood to screen for primary hypothyroidism. Normal ranges are between 0.4 and 4.2 mIU/L. However, they can vary according to the patient’s age, stress levels, health, and weather. Levels above the normal range should be evaluated with further tests.
- Total, free, and bound T4 and T3 levels: This test is usually performed when serum TSH levels are not normal. T4 levels are generally more important for hypothyroidism diagnosis. It can be measured as free or bound T4 depending on its relationship with carrier proteins. There is usually a high level of TSH in primary hypothyroidism and a low level of free T4. But we can also have subclinical or mild hypothyroidism when TSH is high and free thyroid hormones are normal. T3 levels usually decrease as the disease progresses, as opposed to an early stage of the disease.
- Antithyroglobulin and anti-thyroid peroxidase: They are also known as Anti-Tg and Anti-TPO. These are antibodies against the thyroid gland or thyroglobulin. They are useful to understand the cause of the disease, and it is usually ordered only once. No follow-up will be required for patients with a positive result.
- TRH stimulation test: This test was formerly used to evaluate the hypothalamus and pituitary function. However, it is now possible to reach accurate conclusions with TSH and T4 levels alone.
- Other blood tests: In diagnosed patients, doctors need to follow up on a few blood values. For example, a complete blood count to rule out anemia, blood chemistry to check on creatinine levels, transaminases, creatinine kinase, and a lipid profile to detect hyperlipidemias. In patients with high TRH levels, prolactin levels should also be considered.
- Imaging studies: One of the most useful screening studies is the ultrasonography of the thyroid gland. This exam is helpful to detect Hashimoto disease or another structural change in the thyroid.
- Fine needle aspiration biopsy: When a structural change is found in the ultrasound or physical exam, patients will probably need a fine-needle aspiration biopsy. These are useful to evaluate a suspicious thyroid nodule. It is mainly performed in patients with a family history of thyroid cancer or previous neck irradiation. These exams can also detect autoimmune thyroiditis and chronic inflammation of the gland.
The goal of hypothyroidism treatment is to reverse the symptoms and slow down the progression of the disease. These patients should receive thyroid hormone replacement. This is achieved with exogenous thyroid hormone (levothyroxine).
It is administered daily in a constant dose, which should be adjusted over time. The dose should start as one-fourth of the final dosage in older adults with heart problems. Then, the dosage begins to increase slowly every 4 or 6 weeks.
Patients often experience significant benefits after 5 days of therapy. They are more evident after the fourth week. Even after the patient feels better, TSH levels may still be too high for months. Thus, symptomatic adjustments should be made initially, and only 8 weeks later should doctors consider TSH levels to make dosing changes. When the problem is the pituitary or hypothalamic gland, T4 levels should guide the dose adjustment (3, 5).
When the dose of levothyroxine to achieve therapeutic goals is very high, doctors should rule out a gastrointestinal problem such as H. pylori infections. Testosterone and synthetic androgens can alter the patient’s dosage recommendations. Thus, if you had low testosterone and your doctor prescribes androgens, you might need a new dose adjustment of levothyroxine. The same happens if you start using carbamazepine, phenobarbital, sertraline, rifampin, or phenytoin.
After achieving the goal with a completely stable dose, patients should continue monitoring every year. They should also report any overtreatment symptoms (palpitations, tachycardia, nervousness, sleeplessness, tremors).
But what about subclinical hypothyroidism? When patients do not have signs or are very mild, some doctors recommend treatment while others do not. Aggressive treatment is not required in any case, but the recommendation of starting treatment depends on the risk factors and other comorbidities of the patient.
On the other hand, patients who develop severe problems such as myxedema coma should be hospitalized. They need to be tested for adrenal insufficiency, cardiac disease, and other conditions. People at an advanced age have a higher chance of cardiac complications in these cases.
Throughout this time, it is appropriate for patients to maintain an adequate intake of iodine. 150 µg is usually a reasonable daily intake for male adults, and 50-120 µg is traditionally recommended for children. It is also recommended to be cautious in contact sports to prevent injury because they tend to have generalized hypotonia and a higher risk of ligament tears (3, 4, 5).
Hypothyroidism is an endocrine disease affecting our serum levels of thyroid hormone. There is insufficient thyroid hormone due to an underactive thyroid gland (primary hypothyroidism), the pituitary gland (secondary hypothyroidism), or the hypothalamus (tertiary hypothyroidism).
This thyroid disease causes a slow-down of the metabolic rate and affects other body functions. Thus, slow heart rate, sluggish thoughts, weight gain, and fatigue are likely thyroid dysfunction symptoms. However, the only way to diagnose a thyroid disorder is through blood tests such as TSH and T4. Other tests may also be useful, such as antibodies and imaging tests to detect hypothyroidism and other thyroid conditions.
The most useful thyroid medication is levothyroxine, which acts as hormone replacement therapy. The dose should be adjusted until reaching the patient’s therapeutic goal, and after that, he should continue monitoring his condition every year or as instructed by the doctor.