Under attack.

I was diagnosed with hypothyroidism my freshman year of college. I was seventeen and fatigued in a way that didn't seem entirely related to, let's say ... the vigorous exercise of my freedom from parental oversight and control. I was given medication to artificially replace the thyroid hormones my body wasn't producing, and I didn't ask any questions. What could I have asked? What should I have known to ask, especially in light of the diagnosing doctor's approach, simple and pragmatic: this medication will solve the problem; thus, there is no problem.

What I could I have asked are the questions I have been asking recently. Like, for example, what caused my hypothyroidism? Why is my body not producing enough thyroid hormone? Could this condition have other, related effects on my body? Is there a relationship between this condition and the fecundity of which I am currently, seemingly, exhibiting a lack?

At the first miscarriage-related appointment, I asked the nurse to test my thyroid hormones as well as hCG. The results showed that at the time the pregnancy was lost, my thyroid-stimulating hormone (TSH) levels were high, meaning that despite the medication I was taking, my body was not receiving enough thyroid hormone and thus was trying very hard, and very unsuccessfully, to make itself produce some. (TSH is the hormone that stimulates the thyroid gland to make thyroxine, or T4, the thyroid hormone. If the T4 level is too low, meaning the body is hypothyroidic, the body releases more TSH in an attempt to stimulate the production of T4. If the body has a problem producing T4, the TSH level will remain high.)

I've since read that a TSH level below 2.5 is recommended for women trying to get pregnant – and, of course, stay that way. Mine was 8.31. I asked my gynecologist if there could be a link between that and the miscarriage. "Maybe," she shrugged.

I followed up with my generalist and asked him, too, if there could have been a link. "Maybe," he, too, shrugged.

I understand the shrugs. Really, at that early moment of pregnancy, it could have been anything.

My TSH and T4 levels looked better after an increase in the dosage of thyroid medication. The generalist asked me to return in six weeks for another follow-up, which took place yesterday.

During those six weeks, I spent some of my interminable free time researching hypothyroidism, which I should perhaps have done, oh, half a lifetime ago, when I was first diagnosed. There are two primary causes: the first, a deficiency in the portion of the brain that produces the thyroid hormone; the second, an autoimmune disease in which the body attacks its own self, the thyroid in this situation.

The two can be distinguished by the presence of anti-thyroid antibodies in the blood, which would indicate that the hypothyroidism is caused by an autoimmune problem. While the treatment for both is the same – taking the thyroid replacement medication that I'm currently taking – the implications of each are very different.

When I went to have my blood taken in anticipation of the follow-up appointment, I asked the nurse to test for the presence of these anti-thyroid antibodies in addition to TSH and T4. She wouldn't; it hadn't been pre-authorized, and the doctor wasn't there yet. I waited until he arrived (which luckily happened before I had to resort to having one of these). I explained what I wanted, and the reasons for it. He didn't understand why I didn't already know, why this test hadn't been done before. "It's usually done at the time of initial diagnosis," he told me. 

I found out yesterday that anti-thyroid antibodies are indeed present in my blood. So it's not just hypothyroidism that I have, but also an underlying autoimmune disease, with all these potential related complications: subfertility, infertility, recurrent miscarriage, and other later-term pregnancy complications that I don't really want to think about right now because the first three on that list are enough for the moment. And it's not just that – having one autoimmune disease puts a person at higher risk for others.

Next step: an appointment with an endocrinologist, to take place in two months (I guess he's busy), which leaves me plenty of time to finish Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and Postpartum (available here, for those interested in thyroid issues) and to make myself as informed and as annoying a patient as possible.

Better late than never.