Information on Diabetes and Endocrine disorders
Diabetes Mellitus
Diabetes mellitus commonly referred to as diabetes is a disease characterized by high blood glucose levels.
Criteria for the diagnosis of diabetes
1. A1C(previously known as HbA1c) ≥6.5%.
or
2. Fasting Plasma Glucose ≥126 mg/dl (7.0 mmol/l).
Fasting is defined as no caloric intake for at least 8 h.
or
3. Two-hour plasma glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT.
The test should be performed using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.
or
4. In a patient with classic symptoms of hyperglycemia (frequency of urination, increased thirst and apetite) or hyperglycemic crisis, a random plasma glucose ≥200 mg/dl (11.1 mmol/l)
In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing.
Type 1 diabetes – results from beta cell destruction, usually leading to absolute insulin deficiency
Type 2 diabetes – results from a progressive insulin secretory defect on the background of insulin resistance
Other specific types of diabetes due to other causes, e.g., genetic defects in beta cell function, genetic defects in insulin action, diseases of the exocrine pancreas (such as chronic panreatitis), and drug or chemical-induced diabetes (such as in the treatment of AIDS or after organ transplantation)
Gestational diabetes mellitus (GDM) – diabetes diagnosed during pregnancy
Prediabetes – Before people develop type 2 diabetes, they almost always have “prediabetes”—blood glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes. There are three different tests your doctor can use to determine whether you have prediabetes:
• The A1C test
• The fasting plasma glucose test (FPG)
• The oral glucose tolerance test (OGTT)
10 Must Know Facts for Diabetics
1. Diabetes is a chronic and lifelong disease. Diabetes can be controlled but cannot be cured.
2. Diabetes usually remains asymptomatic. But it causes silent damage. Elevated blood glucose levels cause damage to major organs of the body like heart, kidney, eyes, nerves, blood vessels, etc. So get yourself treated for diabetes even if you are not having any problems.
3. Classic symptoms of increased thirst, urination and appetite along with weight loss occurs with high blood glucose (>200mg/dL). A lesser elevation in blood glucose, as already mentioned, remains asymptomatic but should never be ignored.
4. Those with diabetes need to follow dietary restrictions and lead a healthy life style.
5. Those with diabetes usually need medicines for control of blood glucose on a long term basis. Do not take/change medicines on your own; follow your doctor’s advice.
6. Type 1 diabetes is treated with insulin. Stopping insulin can have grave consequences like diabetic ketoacidosis. Ask your doctor about ketone bodies if you are a type 1 diabetic.
7. Type 2 diabetes is usually treated with oral medicines. A type 2 diabetes patient with very high blood glucose can be transiently treated with insulin. Use of insulin for a few days in such a situation does not make your body dependent on insulin. Insulin might be required on a long term basis because the oral medicines are unable to lower your blood glucose.
8. Hypoglycemia is a complication of treatment of diabetes. Please ask your doctor about symptoms of hypoglycemia and its management. Some of the medicines can cause side effects. Discuss with your doctor if you are having any problem from the medicines prescribed to you. The damage done from high blood glucose is however much more than side effects of medications.
9. Following a regular lifestyle and sticking to your meal timings is very essential. One of the most common cause of variation in blood glucose is changes in timing or quantity or quality of meals.
10. Blood glucose and HbA1c should be monitored regularly as per the instruction of your doctor. Long term complications of diabetes include heart disease, retinopathy (damage to retina), nephropathy (kidney disease), neuropathy (damage to nerves), diabetic foot and so on. All patients with diabetes should be screened annually for these problems. Contact your doctor for even apparently minor problems.
Hypoglycemia
Hypoglycemia is a condition that occurs when your blood sugar (glucose) is too low. Blood sugar below 70 mg/dL is considered low but poorly controlled diabetes can have symptoms of hypoglycemia at higher blood glucose levels.
Hypoglycemia: When & How?
• Delaying or skipping meals or when you do not eat enough food.
• Wrongly taking excess dose of medicine or insulin
• Wrongly timing insulin/ medication with meal.
• Unaccustomed physical activity or exercise
• Alcohol intake.
• Vomiting / other illness (e.g. Fever), kidney disease.
How to recognize?
• Abnormal hunger, feeling restless without food.
• Blurry vision, dizziness, headache.
• Fast or pounding heartbeat – palpitation, shaking or trembling.
• Sweating, tingling or numbness of hands and legs.
• Tiredness or weakness, acting aggressive, feeling nervous, unclear thinking.
Danger Signs: Very low blood glucose may cause one to faint, have a seizure or become unconscious.Hospitalize immediately for administering intravenous dextrose.
What to do?
• If there is ready access to glucometer check blood glucose or move onto next step.
• Add 4 teaspoons of glucose or sugar to a glass of water and drink it immediately (other options: honey, fruit juice, glucose biscuits)
• If symptoms still persist or blood glucose is still low after 15 mins, take additional 4 teaspoons of glucose or sugar in a glass of water.
• Take a snack (2 slices of bread or 1 apple or a glass of milk) to prevent recurrence of hypoglycemia.
• If hypoglycemia occurs while travelling, take any available sweet drink or food.
• Try to find out the reason which might have caused hypoglycemia. Most common reason is irregularity in your meals. If hypoglycemia occurs in spite of a normal routine talk to your doctor.
Preventive Tips:
• If blood glucose level before exercise is less than 100 mg/dL, take a light snack (a piece of brown bread, or a glass of milk or an apple).
• Carry some snacks (biscuits, lozenges) while going for exercise.
• Ask your doctor or nurse if you need a bedtime snack (e.g. a glass of milk) to prevent low blood sugar at night.
• Eat meals at regular intervals, and balance extra exercise with extra food or lower your insulin dose by consulting your doctor.
• Call a local emergency number if hypoglycemia does not improve after basic corrective steps.
• Always carry some identification of you being a diabetic as it will help others identify the problem in case of emergency.
• Ask your doctor about usage of glucagon injection.
Diabetic Ketoacidosis
Diabetic ketoacidosis (DKA) is a medical emergency that can occur in people with diabetes. It occurs when the body cannot use sugar (glucose) as a fuel source because there is deficiency of insulin. Fat is used for fuel instead. Byproducts of fat breakdown, called ketones, build up in the body. Ketone bodies are acidic in nature and their accumulation shifts the pH of blood towards acidic range.
By definition DKA is characterized by the triad of
1. Uncontrolled hyperglycemia (high blood glucose)
2. Metabolic acidosis
3. Increased total body ketone concentration
Causes and Risk Factors
DKA results from the combination of absolute or relative insulin deficiency and an increase in counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone). Most patients with DKA have type 1 diabetes; however, patients with type 2 diabetes are also at risk during the stress of acute illness such as trauma, surgery, or infections.
Common causes or precipitating factors
• Omission of Insulin dose
• Inadequate insulin dose
• Infections
• Heart attack
• Stroke
• Use of drugs like steroids, antipsychotic drugs, phenytoin, etc.
• Can be first manifestation of type 1 diabetes
• Previously blockage of continuous insulin pumps (unlikely with modern pumps)
When to suspect?
Usually occurs in the setting of uncontrolled blood glucose (the person might complain of history of polyuria, polydipsia and weight loss in the preceding days).
• Blood glucose is usually more than 250 mg/dL
• Infections in persons with type 1 diabetes
• Vomiting and abdominal pain
• Dehydration
• Rapid breathing
• Fruity odour in breath
• Extreme fatigue and drowsiness – can progress to coma
Common clinical features
• Low blood pressure
• Increased pulse rate
• Increased respiratory rate
• Dry skin and mouth
• Mental status can vary from full alertness to profound lethargy or coma
Treatment
The goal of treatment is to correct the high blood sugar level with insulin. Another goal is to replace fluids lost through urination and vomiting.
Most of the time, the person will need to go to the hospital, where the following will be done:
Insulin replacement
Fluid and electrolyte replacement
The cause of the condition (such as infection) will be found and treated
Someone with diabetes may be able to spot the early warning signs and make changes at home before the condition gets worse. It is important to stay in close touch with the doctor.
Early warning signs
Loss of appetite, nausea and vomiting, abdominal pain, fatigue
Early corrective changes at home (Only to be underatken in close consultation with the doctor)
• Check blood glucose with glucometer
• Check urine ketones with dip stick
• Increase water intake
• An additional dose of short acting insulin can be injected in consultation with the doctor
Diabetic Kidney Disease
Diabetes is the most common cause of kidney failure, accounting for nearly 44 percent of new cases. The chance of developing kidney failure can be prevented to a large extent by control of blood glucose (sugar). People with kidney failure undergo either dialysis, an artificial blood-cleaning process, or transplantation to receive a healthy kidney from a donor. It has been found that high blood pressure and high levels of blood glucose increase the risk that a person with diabetes will progress to kidney failure.
The Course of Kidney Disease
Diabetic kidney disease takes many years to develop. In some people, the filtering function of the kidneys is actually higher than normal in the first few years of their diabetes. Over several years, people who are developing kidney disease will have small amounts of the blood protein albumin begin to leak into their urine. This first stage of CKD is called microalbuminuria. The kidney’s filtration function usually remains normal during this period.
As the disease progresses, more albumin leaks into the urine. This stage may be called macroalbuminuria or proteinuria. As the amount of albumin in the urine increases, the kidneys’ filtering function usually begins to drop. The body retains various wastes as filtration falls. As kidney damage develops, blood pressure often rises as well.
Overall, kidney damage rarely occurs in the first 10 years of diabetes, and usually 15 to 25 years will pass before kidney failure occurs. For people who live with diabetes for more than 25 years without any signs of kidney failure, the risk of ever developing it decreases.
Diagnosis of CKD
People with diabetes should be screened regularly for kidney disease. The two key markers for kidney disease are eGFR and urine albumin.
eGFR. eGFR stands for estimated glomerular filtration rate. Each kidney contains about 1 million tiny filters made up of blood vessels. These filters are called glomeruli. Kidney function can be checked by estimating how much blood the glomeruli filter in a minute. The calculation of eGFR is based on the amount of creatinine, a waste product, found in a blood sample. As the level of creatinine goes up, the eGFR goes down.
Kidney disease is present when eGFR is less than 60 milliliters per minute.
Urine albumin. Urine albumin is measured by comparing the amount of albumin to the amount of creatinine in a single urine sample. When the kidneys are healthy, the urine will contain large amounts of creatinine but almost no albumin. Even a small increase in the ratio of albumin to creatinine is a sign of kidney damage.
Kidney disease is present when urine contains more than 30 milligrams of albumin per gram of creatinine, with or without decreased eGFR.
Effects of High Blood Pressure
High blood pressure, or hypertension, is a major factor in the development of kidney problems in people with diabetes. Both a family history of hypertension and the presence of hypertension appear to increase chances of developing kidney disease. Hypertension also accelerates the progress of kidney disease when it already exists.
Blood pressure is recorded using two numbers. The first number is called the systolic pressure, and it represents the pressure in the arteries as the heart beats. The second number is called the diastolic pressure, and it represents the pressure between heartbeats. In the past, hypertension was defined as blood pressure higher than 140/90. Recent recommendation suggests that people with diabetes keep their blood pressure below 130/80.
Hypertension can be seen not only as a cause of kidney disease but also as a result of damage created by the disease. As kidney disease progresses, physical changes in the kidneys lead to increased blood pressure. Therefore, a dangerous spiral, involving rising blood pressure and factors that raise blood pressure, occurs. Early detection and treatment of even mild hypertension are essential for people with diabetes.
Preventing and Slowing Kidney Disease
Blood Pressure Medicines
Scientists have made great progress in developing methods that slow the onset and progression of kidney disease in people with diabetes. Drugs used to lower blood pressure can slow the progression of kidney disease significantly. Two types of drugs, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), have proven effective in slowing the progression of kidney disease. Many people require two or more drugs to control their blood pressure. In addition to an ACE inhibitor or an ARB, a diuretic can also be useful. Beta blockers, calcium channel blockers, and other blood pressure drugs may also be needed.
Examples of ACE inhibitors are enalapril, lisinopril and ramipril, which doctors commonly prescribe for treating kidney disease of diabetes. The benefits of these drugs extend beyond its ability to lower blood pressure: it may directly protect the kidneys’ glomeruli. ACE inhibitors have lowered proteinuria and slowed deterioration even in people with diabetes who did not have high blood pressure.
Examples of ARBs are losartan, telmisartan or olmesartan, which have also been shown to protect kidney function and lower the risk of cardiovascular events.
Any medicine that helps patients achieve a blood pressure target of 130/80 or lower provides benefits. Patients with even mild hypertension or persistent microalbuminuria should consult a health care provider about the use of antihypertensive medicines.
Moderate-protein Diets
In people with diabetes, excessive consumption of protein may be harmful. Experts recommend that people with kidney disease of diabetes consume the recommended dietary allowance for protein, but avoid high-protein diets. For people with greatly reduced kidney function, a diet containing reduced amounts of protein may help delay the onset of kidney failure. Anyone following a reduced-protein diet should work with a dietitian to ensure adequate nutrition.
Intensive Management of Blood Glucose
Antihypertensive drugs and low-protein diets can slow CKD. A third treatment, known as intensive management of blood glucose or glycemic control, has shown great promise for people with diabetes, especially for those in the early stages of CKD.
The human body normally converts food to glucose, the simple sugar that is the main source of energy for the body’s cells. To enter cells, glucose needs the help of insulin, a hormone produced by the pancreas. When a person does not make enough insulin, or the body does not respond to the insulin that is present, the body cannot process glucose, and it builds up in the bloodstream. High levels of glucose in the blood lead to a diagnosis of diabetes.
Intensive management of blood glucose is a treatment regimen that aims to keep blood glucose levels close to normal. The regimen includes testing blood glucose frequently, administering insulin throughout the day on the basis of food intake and physical activity, following a diet and activity plan, and consulting a health care team regularly. Some people use an insulin pump to supply insulin throughout the day.
A number of studies have pointed to the beneficial effects of intensive management of blood glucose. Also studies conducted over the past decades have clearly established that any program resulting in sustained lowering of blood glucose levels will be beneficial to patients in the early stages of CKD.
Dialysis and Transplantation
When people with diabetes experience kidney failure, they must undergo either dialysis or a kidney transplant. Currently, the survival of kidneys transplanted into people with diabetes is about the same as the survival of transplants in people without diabetes. Dialysis for people with diabetes also works well in the short run. Even so, people with diabetes who receive transplants or dialysis experience higher morbidity and mortality because of coexisting complications of diabetes-such as damage to the heart, eyes, and nerves.
Good Care Makes a Difference
People with diabetes
• Should have their health care provider measure their A1C level at 2 to 4 times a year. The test provides a weighted average of their blood glucose level for the previous 3 months. They should aim to keep it at less than 7 percent.
• Work with their health care provider regarding insulin injections, medicines, meal planning, physical activity, and blood glucose monitoring.
• Have their blood pressure checked several times a year. If blood pressure is high, they should follow their health care provider’s plan for keeping it near normal levels. They should aim to keep it at less than 130/80.
• Ask their health care provider whether they might benefit from taking an ACE inhibitor or ARB.
• Ask their health care provider to measure their eGFR at least once a year to learn how well their kidneys are working.
• Ask their health care provider to measure the amount of protein in their urine at least once a year to check for kidney damage.
• Ask their health care provider whether they should reduce the amount of protein in their diet and ask for a referral to see a dietitian to help with meal planning.
Points to Remember
• Diabetes is the leading cause of chronic kidney disease (CKD) and kidney failure.
• People with diabetes should be screened regularly for kidney disease. The two key markers for kidney disease are estimated glomerular filtration rate (eGFR) and urine albumin.
• Drugs used to lower blood pressure can slow the progression of kidney disease significantly. Two types of drugs, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), have proven effective in slowing the progression of kidney disease.
• In people with diabetes, excessive consumption of protein may be harmful.
• Intensive management of blood glucose has shown great promise for people with diabetes, especially for those in the early stages of CKD.
Diabetic Neuropathy
Long term high blood glucose (sugar) levels can cause damage to the nerve fibers and give rise to various manifestations of diabetic neuropathy.
The diabetic neuropathies are heterogeneous with diverse clinical manifestations.
They may be focal or diffuse.
Most common among the neuropathies are chronic sensorimotor distal symmetric polyneuropathy and autonomic neuropathy.
Why is it necessary to undergo evaluation for diabetic neuropathy?
1) Nondiabetic neuropathies may be present in patients with diabetes and may be treatable.
2) A number of treatment options exist for symptomatic diabetic neuropathy.
3) Up to 50% of DPN may be asymptomatic and patients are at risk for insensate injury to their feet.
4) Autonomic neuropathy and particularly cardiovascular autonomic neuropathy is associated with substantial morbidity and even mortality.
Diabetic Peripheral Neuropathy
The areas of the body most commonly affected by diabetic peripheral neuropathy are the feet and legs. Nerve damage in the feet can result in a loss of foot sensation, increasing the risk of foot problems. Injuries and sores on the feet may go unrecognized due to lack of sensation. Hands and upper limbs can also get affected in later stages.
Symptoms of diabetic peripheral neuropathy may include:
• Tingling
• Numbness (severe or long-term numbness can become permanent)
• Burning (especially in the evening)
• Pain
In most cases, early symptoms of diabetic peripheral neuropathy will become less when blood sugar is under control. Medications can be taken to help control the discomfort if needed.
Diabetic autonomic neuropathy
Major clinical manifestations of diabetic autonomic neuropathy include resting tachycardia (incresed heart rate>100/min), exercise intolerance, orthostatic hypotension (lowering of blood pressure on standing), constipation, gastroparesis (delayed gastric emptying), erectile dysfunction, sudomotor dysfunction (dry or moist skin), impaired neurovascular function, and potentially autonomic failure in response to hypoglycemia.
Cardiovascular autonomic neuropathy (CAN), may be indicated by resting tachycardia (>100 bpm) or orthostasis (a fall in SBP >20 mmHg upon standing without an appropriate heart rate response); it is also associated with increased cardiac event rates.
Gastrointestinal neuropathies (e.g., esophageal enteropathy, gastroparesis, constipation, diarrhea, fecal incontinence) are common, and any section of the gastrointestinal tract may be affected. Gastroparesis should be suspected in individuals with erratic glucose control or with upper gastrointestinal symptoms without other identified cause. Constipation is the most common lower-gastrointestinal symptom but can alternate with episodes of diarrhea.
Diabetic autonomic neuropathy is also associated with genitourinary tract disturbances. In men, diabetic autonomic neuropathy may cause erectile dysfunction and/or retrograde ejaculation. Evaluation of bladder dysfunction should be performed for individuals with diabetes who have recurrent urinary tract infections, pyelonephritis, incontinence, or a palpable bladder.
Diabetic Foot Care
How to take care of your feet ?
Diabetes can be dangerous to your feet – even a small cut can produce serious consequences. Diabetes may cause nerve damage that takes away the feeling in your feet. Diabetes may also reduce blood flow to the feet. Contact your doctor for even minor problems.
Inspect your feet daily. Check for cuts, blisters, redness, swelling, or nail problems. Use a magnifying hand mirror to look at the bottom of your feet.
Wash your feet, use water at normal temperature or lukewarm (not hot!) water. Keep your feet clean by washing them daily.
Be gentle when bathing your feet. Wash them using a soft washcloth or sponge. Dry by blotting or patting, and carefully dry between the toes.
Moisturize your feet – but not between your toes. Use a moisturizer daily to keep dry skin from itching or cracking. But DON’T moisturize between the toes – that could encourage a fungal infection.
Cut nails carefully. Cut them straight across. Don’t cut nails too short, as this could lead to ingrown toe nails.
Never treat corns or calluses yourself. Visit your doctor for appropriate treatment.
Wear clean, dry socks. Change them daily.
Avoid the wrong type of socks. Avoid tight elastic bands (they reduce circulation). Don’t wear thick or bulky socks (they can fit poorly and irritate the skin).
NEVER use a heating pad or hot water bottle for your feet. If your feet get cold at night, wear socks.
Shake out your shoes and feel the inside before wearing. Remember, your feet may not be able to feel a pebble or other foreign object.
Never walk barefoot. Not even at home! Don’t smoke. Smoking restricts blood flow in your feet.
Get periodic foot exams. Seeing your doctor on a regular basis can help prevent the foot complications of diabetes.
Use proper footwear. Ask your doctor about what type of footwear you require.
Pituitary disorders
Disorders of pituitary hormone excess
Growth hormone excess – Results in gigantism and acromegaly
Hyperprolactinemia or high prolactin levels –
Common causes are prolactinoma (prolactin secreting tumor), other tumors in
pituitary region, some medicines, hypothyroidism, etc.
Cushing’s disease results from excess adrenocorticotrophic hormone (ACTH)
secretion. The patient develops features of steroid hormone excess as ACTH
drives the adrenal gland to secrete excessive amount of steroids.
Other disorders of hormone excess like TSH secreting pituitary tumor are very
rare.
Disorders of pituitary hormone deficiency
Growth hormone deficiency results in short stature in childhood. Adult growth
hormone deficiency is detrimental for general well being, heart and bone health.
Secondary hypothyroidism is a rare cause of thyroid hormone deficiency resulting from inadequate secretion of thyroid stimulating hormone (TSH) from the pituitary.
Secondary hypoadrenalism results from deficiency of adrenocorticotrophic hormone (ACTH) secretion.
Hypogonadism results from deficiency of LH and FSH, the pituitary hormones responsible for gonadal (ovary and testis)
development and its functioning.
Pituitary Tumors
Non-functioning pituitary tumors are the ones which do not secrete any active hormonal components.
Functioning pituitary tumors are those which secrete hormones as already discussed in disorders of pituitary hormone excess.
Pituitary Inflammation
Lymphocytic hypophysitis is an autoimmune inflammatory condition of the pituitary commonly occurring after pregnancy.
Tuberculosis and other infections can also affect pituitary.
Thyroid Disorders
Hypothyroidism
Hyperthyroidism
Goiter
Thyroiditis
Thyroid malignancy
Iodine deficiency disorders
Hypothyroidism
Hypothyroidism is a condition in which the thyroid gland does not make enough thyroid hormone.
Causes, incidence, and risk factors
The thyroid gland is located in the front of the neck just below the voice box (larynx). It releases hormones that control metabolism.
Hypothyroidism, or underactive thyroid, is more common in women and people over age 50.
The most common cause of hypothyroidism is thyroiditis. Swelling and inflammation damage the thyroid gland’s cells. Causes of this problem include:
• An attack of the thyroid gland by the immune system
• Cold or other respiratory infection
• Pregnancy (often called “postpartum thyroiditis”)
Other causes of hypothyroidism include:
• Certain drugs, such as lithium and amiodarone
• Congenital (birth) defects
• Radiation treatments to the neck or brain to treat different cancers
• Radioactive iodine used to treat an overactive thyroid gland
• Surgical removal of part or all of the thyroid gland
• Sheehan syndrome, a condition that may occur in a woman who bleeds severely during pregnancy or childbirth and causes the destruction of the pituitary gland
Symptoms
Early symptoms:
• Hard stools or constipation
• Increased sensitivity to cold
• Fatigue or feeling slowed down
• Heavier menstrual periods
• Joint or muscle pain
• Paleness or dry skin
• Sadness or depression
• Thin, brittle hair or fingernails
• Weakness
• Weight gain
Late symptoms, if left untreated:
• Decreased taste and smell
• Hoarseness
• Puffy face, hands, and feet
• Slow speech
• Thickening of the skin
• Thinning of eyebrows
Signs and tests
A physical examination may reveal a smaller-than-normal thyroid gland, although sometimes the gland is normal size or even enlarged (goiter). The examination may also reveal:
• Brittle nails
• Coarse features of the face
• Pale or dry skin, which may be cool to the touch
• Swelling of the arms and legs
• Thin and brittle hair
Lab tests to determine thyroid function include:
• TSH test
• T4 test
Other tests that may be done:
• Cholesterol levels
• Complete blood count (CBC)
• Liver enzymes
• Prolactin
• Sodium
Treatment
The purpose of treatment is to replace the thyroid hormone that is lacking. Levothyroxine is the most commonly used medication.
• Doctors will prescribe the lowest dose possible that relieves your symptoms and brings your blood hormone levels back to normal.
• If you have heart disease or you are older, your doctor may start you on a very small dose.
• Most people with an underactive thyroid will need lifelong therapy.
When starting your medication, your doctor may check your hormone levels every 2 – 3 months. After that, your thyroid hormone levels should be monitored at least every year.
Important things to remember when you are taking thyroid hormone:
• Do NOT stop taking the medication when you feel better. Continue taking them exactly as your doctor prescribed.
• If you change brands of thyroid medicine, let your doctor know. Your levels may need to be checked.
• What you eat can change the way your body absorbs the thyroid medicine. Talk with your doctor if you are eating a lot of soy products or are on a high-fiber diet.
• Thyroid medicine works best on an empty stomach and when taken 1 hour before any other medications.
• Do NOT take thyroid hormone with fiber supplements, calcium, iron, multivitamins, aluminum hydroxide antacids, colestipol, or medicines that bind bile acids.
While you are taking thyroid replacement therapy, tell your doctor if you have any symptoms that suggest your dose is too high, such as:
• Palpitations
• Rapid weight loss
• Restlessness or shakiness
• Sweating
Myxedema coma is a medical emergency that occurs when the body’s level of thyroid hormones becomes very low. It is treated with intravenous thyroid hormone replacement and steroid medications. Some patients may need supportive therapy (oxygen, breathing assistance, fluid replacement) and intensive-care nursing.
Expectations (prognosis)
In most cases, thyroid levels return to normal with proper treatment. However, you must take thyroid hormone replacement for the rest of your life.
Myxedema coma can result in death.
Hyperthyroidism
Hyperthyroidism is a condition in which the thyroid gland makes too much thyroid hormone. The condition is often referred to as an “overactive thyroid.”
Causes, incidence, and risk factors
The thyroid gland is an important organ of the endocrine system. It is located in the front of the neck just below the voice box. The gland produces the hormones thyroxine (T4) and triiodothyronine (T3), which control the way every cell in the body uses energy. This process is called metabolism.
Hyperthyroidism occurs when the thyroid releases too much of its hormones over a short (acute) or long (chronic) period of time. Many diseases and conditions can cause this problem, including:
• Getting too much iodine
• Graves disease (accounts for most cases of hyperthyroidism)
• Inflammation (thyroiditis) of the thyroid due to viral infections or other causes
• Noncancerous growths of the thyroid gland or pituitary gland
• Some tumors of the testes or ovaries
• Taking large amounts of thyroid hormone
Symptoms
• Difficulty concentrating
• Fatigue
• Frequent bowel movements
• Goiter (visibly enlarged thyroid gland) or thyroid nodules
• Heat intolerance
• Increased appetite
• Increased sweating
• Irregular menstrual periods in women
• Nervousness
• Restlessness
• Weight loss
Other symptoms that can occur with this disease:
• Breast development in men
• Clammy skin
• Diarrhea
• Hair loss
• Hand tremor
• High blood pressure
• Itching – overall
• Lack of menstrual periods in women
• Nausea and vomiting
• Pounding, rapid, or irregular pulse
• Protruding eyes (exophthalmos)
• Rapid, forceful, or irregular heartbeat (palpitations)
• Skin blushing or flushing
• Sleeping difficulty
• Weakness
Signs and tests
Physical examination may reveal:
• High systolic blood pressure (the first number in a blood pressure reading)
• Hyperactive reflexes
• Increased heart rate
• Thyroid enlargement
• Tremor
Subclinical hyperthyroidism is a mild form of hyperthyroidism that is diagnosed by abnormal blood levels of thyroid hormones, often without any symptoms.
Blood tests are also done to measure levels of thyroid hormones.
• TSH (thyroid stimulating hormone) level is usually low
• T3 and free T4 levels are usually high
This disease may also affect the results of the following tests:
• Cholesterol test
• Glucose test
Treatment
Treatment depends on the cause and the severity of symptoms. Hyperthyroidism is usually treated with one or more of the following:
• Antithyroid medications
• Radioactive iodine (which destroys the thyroid gland and stops the excess production of hormones)
• Surgery to remove the thyroid
If the thyroid must be removed with surgery or destroyed with radiation, you must take thyroid hormone replacement pills for the rest of your life.
Beta-blockers such as propranolol are used to treat some of the symptoms, including rapid heart rate, sweating, and anxiety until the hyperthyroidism can be controlled.
Expectations (prognosis)
Hyperthyroidism is generally treatable and only rarely is life threatening. Some of its causes may go away without treatment.
Hyperthyroidism caused by Graves disease usually gets worse over time. It has many complications, some of which are severe and affect quality of life.
Complications
Thyroid crisis (storm) is a sudden worsening of hyperthyroidism symptoms that may occur with infection or stress. Fever, decreased mental alertness, and abdominal pain may occur. Immediate hospitalization is needed.
Other complications of hyperthyroidism include:
• Heart-related complications including:
• Rapid heart rate
• Congestive heart failure
• Atrial fibrillation
• Increased risk for osteoporosis, if hyperthyroidism is present for a long time
• Surgery-related complications, including:
• Scarring of the neck
• Hoarseness due to nerve damage to the voice box
• Low calcium level due to damage to the parathyroid glands (located near the thyroid gland)
• Treatments for hypothyroidism, such as radioactive iodine, surgery, and medications to replace thyroid hormones can have side effects.
Female Hormone Disorders
Polycystic Ovary Disease (PCOD)
PCOD, also called polycystic ovary syndrome (PCOS), is one of the most common female endocrine disorders. PCOD is a complex, heterogeneous disorder of uncertain etiology, but there is evidence that this disease is more commonly present in families with diabetes.
PCOS produces symptoms in approximately 5% to 10% of women of reproductive age (12–45 years old). It is thought to be one of the leading causes of female subfertlity and the most frequent endocrine problem in women of reproductive age.
The principal features are anovulation, resulting in irregular menstruation, amenorrhea, infertility, and polycystic ovaries; excessive amounts or effects of androgenic (masculinizing) hormones, resulting in acne and hirsuitism; and insulin resistance, often associated with obesity, type 2 diabetes, and high cholesterol levels. Women with PCOS have a higher chance of developing endometrial cancer. The symptoms and severity of the syndrome vary greatly among affected women.
Non-classic Congenital Adrenal Hyperplasia
Congenital adrenal hyperplasia (CAH) is a group of disorders where the hormone synthesizing machinery in our adrenal gland is defective. The adrenal glands help keep the body in balance by making the right amounts of cortisol, aldosterone, and androgens. The classic form of CAH is rare and results in deficiency of cortisol and aldosterone and excess amount of androgens. People with nonclassic (late-onset) CAH make enough cortisol and aldosterone, but they make excess androgens. Symptoms beginn typically in late childhood or early adulthood. Boys often do not need treatment. Girls usually need treatment to suppress their excess androgens. Manifestations often mimic PCOD but treatment is different.
Hyperprolactinemia
Hyperprolactinemia is a condition of elevated serum prolactin. Prolactin is a hormone produced in the pituitary gland. Its primary function is to enhance breast development during pregnancy and to induce lactation. Secretion is pulsatile; it increases with sleep, stress, pregnancy, and chest wall stimulation or trauma, and therefore must be drawn after fasting. Normal fasting values are generally less than 20-25 ng/mL, depending on the individual laboratory but can also vary for numerous reasons. Elevated prolactin results in oligomenorrhea, amenorrhea, or infertility. Galactorrhea (abnormal milk secretion from breast )is due to the direct physiologic effect of prolactin on breast epithelial cells. Pituitary tumor is one of the causes of elevated prolactin level. It can also be caused by disruption of the normal regulation of prolactin levels by drugs, medicinal herbs and heavy metals. Hyperprolactinaemia may also be the result of disease of other organs such as the liver, kidneys, ovaries and thyroid.
Premenstrual Syndrome (PMS)
PMS refers to a wide range of physical or emotional symptoms that typically occur about 5 to 11 days before a woman starts her monthly menstrual cycle. The symptoms usually stop when menstruation begins, or shortly thereafter. The symptoms can be related to mood changes e.g depression, irritability, anxiety, confusion, social withdrawal, angry outbursts or somatic disturbances e.g breast tenderness, abdominal bloating, headache and swelling of hands and feet. Numerous pharmacologic agents, medical interventions, and complementary/alternative therapies have been tested as potential treatments for PMS. Medicines like selective serotonin reuptake inhibitors (SSRIs) have been approvesd in symptom management of severe PMS. A recent meta-analysis demonstrated that no single SSRI agent was better than another or more effective for PMDD than PMS, but contrary to popular belief, continuous dosing regimens resulted in better symptom control than intermittent luteal dosing.
Adrenal Disorder
1. Cushing’s Syndrome: Most commonly occurs as a side effect of steroid (glucocorticoid) therapy for kidney disease, rheumatoid arthritis, asthma and other respiratory diseases, ulcerative colitis, etc.
Other rare causes are pituitary tumors secreting ACTH (already discussed), ectopic ACTH secretion (most commonly from tumors of lungs), adrenal adenoma and carcinoma.
Symptoms include rapid weight gain, particularly of the trunk and face with sparing of the limbs (central obesity). A common sign is the growth of fat pads along the collar bone and on the back of the neck (buffalo hump) and a round face often referred to as a “moon face.”
2. Adrenal Insufficiency: May result in loss of appetite, abdominal pain, diarrhea, vomiting, profound muscle weakness and fatigue, extremely low blood pressure, weight loss, electrolyte imbalance (hyponatremia and hyperkalemia) and shock. Most common cause is sudden withdrawal of steroids. Other causes are tuberculosis, fungal infection, autoimmune, genetic causes, sepsis, etc.
3. Primary hyperaldosteronism: A condition associated with secretion of mineralocorticoid hormone called aldosterone. Results in resistant hypertension, often associated with hypokalemia.
4. Pheochromocytoma: A tumor of adrenal medulla causing hypertension and paroxysms of headache, palpitation and sweating.
Erectile Dysfunction
Erectile dysfunction (ED), also referred to as impotence, is the inability to attain and/or maintain an erection sufficient for satisfactory sexual intercourse. Sexual dysfunction is a more general term that also includes disorders of libido (sexual urge), orgasmic dysfunction, and ejaculatory dysfunction in addition to the inability to attain or maintain penile erection. A survey showed that 52% of men between the ages of 40 and 70 were affected by erectile dysfunction of some degree.
Population based studies indicate that the best predictors of the risk of ED are age, history of diabetes mellitus, hypertension, medication use, and cardiovascular disease.Advancing age is an important risk factor for ED in men: less than 10% of men younger than 40 years and more than 50% of men older than 70 years have ED.
Among the chronic diseases associated with ED, diabetes mellitus is the most important risk factor. The age-adjusted risk of complete ED was three times higher in men with a history of diabetes mellitus than in those without a history of diabetes mellitus. Fifty percent of men with diabetes mellitus will experience ED at some time during the course of their illness.
Heart disease, hypertension, and hyperlipidemia were associated with significantly increased risk of ED. Cardiovascular disorders, including hypertension, stroke, coronary artery disease, and peripheral vascular disease, are all associated with increased risk of ED. Physical activity is associated with reduced risk of ED.
Several reviews have emphasized the relationship of prescription medications and the occurrence of ED. IThiazide diuretics and psychotropic drugs used to treat depression may be the most common drugs associated with ED simply because of the high prevalence of their use. However, a variety of drugs, including almost all antihypertensives, digoxin, H2-receptor antagonists, anticholinergics, cytotoxic agents, and androgen antagonists, have been implicated in the pathophysiology of ED.
Recent surveys have revealed an association of lower urinary tract symptoms with erectile dysfunction, even after adjusting for age and other risk factors. The presence and severity of lower urinary tract symptoms is an independent predictor of ED. There is growing evidence that the two conditions may be mechanistically linked, because the biochemical mechanisms that regulate bladder detrusor and cavernosal smooth muscle function share many similarities.
The diagnostic evaluation of a man with ED usually includes measurements of hemoglobin, white blood count, blood glucose, blood urea nitrogen (BUN) and creatinine, plasma lipids, and testosterone levels.
If the history, physical exam, and ED questionnaire do not identify any obvious medical concerns needing further workup, then a cost-effective approach is to prescribe a trial of oral PDE5 inhibitor provided there are no contraindications (e.g., nitrate use).
Male Infertility
The World Health Organization (WHO) has defined infertility as the inability of a sexually active couple to achieve pregnancy despite unprotected intercourse during the fertile phase of the menstrual cycle for a period of greater than 12 months. The percentage of couples seeking medical treatment for infertility is estimated at 4% to 17%.
The estimates of prevalence rates of infertility and subfertility depend crucially upon the method used to define these conditions. The WHO definition was based on studies that used time to pregnancy estimations and found the probability of conception to be 20% per cycle or ∼85% to 90% per year. Even among couples who do not conceive within 12 months, 55% have a live birth within the next 36 months. When the duration of infertility exceeds 4 years, the conception rate per month drops to 1.5%.
In 20% of infertile couples, the primary problem resides in the male partner; in an additional 26%, problems reside in both the male and the female partner; thus, the male partner contributes to infertility in about half the couples. The occurrence of infertility substantially affects a couple’s relationship, quality of life, and health care expenditures.
COMMON DIAGNOSES IN MEN BEING EVALUATED FOR INFERTILITY
Diagnostic Category
Incidence (%)
Idiopathic infertility
50-60
Primary testicular failure (chromosomal disorders including Klinefelter’s syndrome, Y chromosome microdeletions, undescended testis, irradiation, orchitis, drugs)
10-20
Genital tract obstruction (congenital absence of vas, vasectomy, epididymal obstruction)
5
Coital disorders
<1
Hypogonadotropic hypogonadism (pituitary adenomas, panhypopituitarism, idiopathic hypogonadotropic hypogonadism, hyperprolactinemia)
3-4
Varicocele[*]
15-35
Other (sperm autoimmunity, drugs, toxins, systemic illness)
5
*
Although varicoceles are observed with higher frequency in infertile and subfertile men than in fertile men, their role and contribution to infertility remains unclear.
Correctable or treatable causes of infertility, such as gonadotropin deficiency and obstruction, are present in only a small number of men, but it is important to recognize them because effective treatment modalities are available. Varicoceles are present in 10% to 30% of men with infertility; their role, if any, in the pathophysiology of male infertility remains unclear. An increasing number of genetic disorders are being implicated in specific abnormalities of germ cell development; in addition, a number of systemic disorders nonspecifically affect spermatogenesis. Of these, Klinefelter’s syndrome and Y chromosome microdeletions are the most prevalent disorders, together accounting for 10% to 20% of patients . Although the prevalence of antisperm antibodies in infertile men is higher than that in fertile men, the mechanisms by which antisperm antibodies cause infertility are unclear.
Diabetes
What is diabetes?
Diabetes mellitus commonly referred to as diabetes is a disease characterized by high blood glucose levels.
What is glucose ?
Glucose is a form of sugar present in the blood. It is the principal source of fuel in human body. Energy in our body is derived from three principal sources: carbohydrate, protein and fat. Carbohydrates constitute the main bulk of our standard diets. Carbohydrates we eat are broken down into glucose.
What is insulin ?
Insulin is a hormone that is produced by the pancreas. If insulin is absent or ineffective glucose accumulates in the blood and blood glucose levels go up.
What happens when blood glucose levels go up?
Accumulation of high levels of glucose in the blood can cause both short term problems (like increased frequency of urination, increased thirst, increased appetite, visual disturbances, and recurrent infections) and long term problems (damage to heart, kidney, retina and other vital organs). Even though there is high level of glucose in the blood that can not be transported with in the cell in deficiency of insulin. The cells are deprived of fuel (glucose) and the cells start malfunctioning.
What are the types of diabetes mellitus and how are they treated ?
Type 1 Diabetes mellitus- Where there is an absolute deficiency of insulin and the patient need to be on life long injections.
Type 2 Diabetes mellitus- There are components of both insulin deficiency and insulin resistance. Can be treated by both oral medicines and injectable insulin.
Gestational Diabetes mellitus (GDM) - Occurs during pregnancy. There is a small chance that diabetes may continue to persist even after pregnancy. Usually it is treated with lifestyle changes and insulin.
Diabetes Mellitus due to other causes- Damage to pancreas (e.g. chronic pancreatitis), drugs (like steroids), etc.
How do I know if I have diabetes or prediabetes?
Doctors can use either the fasting plasma glucose test (FPG) or the oral glucose tolerance test (OGTT) to detect diabetes or prediabetes. Both require a person to fast overnight. In the FPG test, a person’s blood glucose is measured first thing in the morning before eating. In the OGTT, a person’s blood glucose is checked after fasting and again 2 hours after drinking a glucose-rich drink.
How does the FPG test define diabetes and prediabetes?
Normal fasting blood glucose is below 100 mg/dl. A person with prediabetes has a fasting blood glucose level between 100 and 125 mg/dl. If the blood glucose level rises to 126 mg/dl or above, a person has diabetes.
How does the OGTT define diabetes and prediabetes?
In the OGTT, a person’s blood glucose is measured after a fast and 2 hours after drinking a glucose-rich beverage. Normal blood glucose is below 140 mg/dl 2 hours after the drink. In prediabetes, the 2-hour blood glucose is 140 to 199 mg/dl. If the 2-hour blood glucose rises to 200 mg/dl or above, a person has diabetes.
Could I have diabetes and not know it?
Definitely. People with diabetes don’t often have symptoms. In fact, millions of people have diabetes and don’t know it because symptoms develop so gradually, people often don’t recognize them. Some people have no symptoms at all. Symptoms of diabetes include unusual thirst, a frequent desire to urinate, blurred vision, or a feeling of being tired most of the time for no apparent reason.
Who should get tested for diabetes?
If you are overweight and age 45 or older, you should be checked for diabetes. If your weight is normal and you’re over age 45, you should ask your doctor if testing is appropriate. For adults younger than 45 and overweight, your doctor may recommend testing if you have any other risk factors for diabetes or prediabetes. These include high blood pressure, low HDL cholesterol and high triglycerides, a family history of diabetes, a history of gestational diabetes or giving birth to a baby weighing more than 9 pounds.
Prediabetes
What is prediabetes and how is it different from diabetes?
Prediabetes is the state that occurs when a person’s blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. About 10 percent of people with prediabetes develop type 2 diabetes each year over next 3 years.
Is prediabetes the same as Impaired Glucose Tolerance or Impaired Fasting Glucose?
Yes. Doctors sometimes refer to this state of elevated blood glucose levels as Impaired Glucose Tolerance or Impaired Fasting Glucose (IGT/IFG), depending on which test was used to detect it.
What problems can arise from prediabetes?
People with prediabetes are at higher risk of cardiovascular disease (e.g. heart disease, stroke etc.). People with prediabetes have a 1.5-fold risk of cardiovascular disease compared to people with normal blood glucose. People with diabetes have a 2- to 4-fold increased risk of cardiovascular disease. We now know that people with prediabetes can delay or prevent the onset of type 2 diabetes through lifestyle changes.
Why do I need to know if I have prediabetes?
If you have prediabetes, you can and should do something about it. Studies have shown that people with prediabetes can prevent or delay the development of type 2 diabetes by up to 58 percent through changes to their lifestyle that include modest weight loss and regular exercise. The experts recommends that people with prediabetes reduce their weight by 5-10 percent and participate in some type of modest physical activity for 30 minutes daily. For some people with prediabetes, intervening early can actually turn back the clock and return elevated blood glucose levels to the normal range.
What is the treatment for prediabetes?
Treatment consists of losing a modest amount of weight (5-10 percent of total body weight) through diet and moderate exercise, such as walking, 30 minutes a day, 5 days a week. Don’t worry if you can’t get to your ideal body weight. A loss of just 10 to 15 pounds can make a huge difference. If you have prediabetes, you are at a 50 percent increased risk for heart disease or stroke, so your doctor may wish to treat or counsel you about cardiovascular risk factors, such as tobacco use, high blood pressure, and high cholesterol.
Could I have prediabetes and not know it?
Absolutely. People with prediabetes don’t often have symptoms. In fact, millions of people have diabetes and don’t know it because symptoms develop so gradually, people often don’t recognize them. Some people have no symptoms at all. Symptoms of diabetes include unusual thirst, a frequent desire to urinate, blurred vision, or a feeling of being tired most of the time for no apparent reason.
