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Erring on The Side of Caution

Some complains sound fickle. They come across as vain, flippant or downright silly. Like the young girl who wanted to know whether it was the…

Some complains sound fickle. They come across as vain, flippant or downright silly. Like the young girl who wanted to know whether it was the change in her skin care routine that was causing her to have acne breakouts. Duh? Or the middle-aged man who complained about his emerging potbelly that was causing the buttons of his shirt to pop open at work and the cause of much embarrassment. Or the thirty-six-year-old woman who wanted something to make her breasts fuller.

Most times, when we come across such people, we (healthcare practitioners) tend to dismiss them with a kind word or cruelly with a wave of the hand. We put it down to vanity. In this world of uncertainty, inflation, corruption and cancer- is having a potbelly or sagging breasts really that important?

Unfortunately, it is.

Aisha’s* main complaint was a desire to lose weight. She explained to me that over the cause of a few months, she had added a few extra kgs around her abdomen and wished to go back to her former self. She had delivered a baby six months ago and since then, her weight had steadily increased. Aisha was tired all the time and the two previous doctors she had visited had told her the same thing: weight gain was common after pregnancy. Moreover, she had a small baby who demanded to be breastfed all the time. That on its own, was a recipe for fatigue.

Like the other doctors, I wanted to dismiss her, but for the pleading way she looked at me. She looked like any normal thirty-year-old woman who just had a baby- plump and sullen, but healthy. She was expensively dressed with gold rings on her fingers and expertly applied make-up. Her face was pretty and her vital signs appeared OK. Wanting to dismiss her gently, I asked her to do some tests I was sure would be a wild goose chase. In my mind, I wanted her to hurry and leave as I had other more important things to do than listen to her complain about her weight. 66kg. Is that one weight?

I totally forgot about Aisha until she returned three days later with a triumphant look on her face. Apparently, she had asked Dr google about the test results already. Her tests showed that her thyroid hormones were very low. Aisha had hypothyroidism. On looking at her, I realised that I had missed a very crucial sign in my initial assessment. What I had dismissed as a fat neck was actually a diffuse neck swelling; a goitre. A wave of disappointment washed over me and I gave myself a mental knock on the head. I decided to start over again by taking proper history.

Her hair was falling out and she felt cold even during the hot weather. She felt sleepy all the time and struggled to remember names. She suffered from bouts of constipation. Everyone around her felt it was due to the stress of a baby. She told me about her absent periods. What I thought were irregular menstrual periods due to breastfeeding was actually caused by low thyroid hormones. Again, shame washed over my big head. When had I grown so complacent?

Aisha’s initial excitement at having a diagnosis was dampened when we discussed her condition. The thyroid is a funny organ.

“And though she be but little, she is fierce.” 

Every time I want to discuss the thyroid gland to a patient, this line from Shakespeare’s ‘A Midsummer Night’s Dream’ comes to mind. That tiny butterfly-shaped gland in our neck seems to be to blame for why so many of us feel like utter crap: tired. Grumpy. Overweight. 

Roughly 16 million women will, at some point, have a breakdown of the thyroid, which produces hormones that touch every cell and help regulate our metabolisms, our bowels, our brains. More pointedly, one in 10 women will have hypothyroidism, a sluggish gland that doesn’t produce enough hormones to control such functions. Women have it more commonly than men, a ratio of 8:1. Come to think of it, I have never seen a man with hypothyroidism or the opposite, hyperthyroidism. The closest I have witnessed was a man with thyroid cancer.

Diagnosing hypothyroidism is actually simple—a basic blood test determines the amount of thyroid-stimulating hormone (TSH), a substance pumped out by the pituitary gland that regulates thyroid output. And yet, many doctors miss it. 

An estimated 60 per cent of people with the disorder don’t know they have it, because its vague symptoms (fatigue, weight gain, depression, menstrual irregularities, and slower thinking) so closely mimic other disorders or generalized stress that doctors (such as: yours truly) and patients routinely brush them off. Ironically, those same ambiguous symptoms lead droves of women with healthy thyroids to believe they have a problem—and many fight to be diagnosed with a disease they don’t have and are then treated with synthetic hormones they don’t need. 

Wanting to absolve myself, I initiated treatment right away with Levothyroxine and ordered for more tests to know the extent of her goitre. 

Luckily, the ultrasound scan of Aisha’s neck showed that surgery was not an immediate option. Together with an endocrinologist, we mapped out a treatment plan for Aisha and designed an exercise plan for her to lose weight. 

Six months later, she returned to her normal weight and her emotional state and energy levels have mostly returned to normal. Her thyroid levels will continue to be monitored for a very long time.

I learnt a very important lesson that day; which is to never dismiss a patient’s complaint no matter how fickle it may seem. Imagine if I had dismissed her without the tests? Hypothyroidism symptoms are often shrugged off, which can have deleterious results. Left untreated, the condition can raise your bad LDL cholesterol, increase your risk for heart disease and infertility, and in rare cases, lead to a life-threatening condition known as a myxoedema coma. 

So now, when a patient comes to me with silly symptoms like: ‘my right hand looks bigger than my left hand’, I order a bloody Xray for confirmation. Better to err on the side of caution, than be having nightmares about a misdiagnosis and possible death.

This heaven, we must make am.