Hypothyroidism

Introduction to hypothyroidism Hypothyroidism, referred to as hypothyroidism, is a syndrome caused by the synthesis, secretion or biological effects of thyroid hormone. The cause is more complicated, more common in primary, followed by pituitary, others are rare. Patients may experience weakness in limbs, decreased endocrine function, hypotension, dizziness, muscle weakness, abnormal body shape, and abnormal breathing. basic knowledge The proportion of illness: the incidence rate of middle-aged and elderly people over 50 years old is about 0.002%--0.004% Susceptible people: no special people Mode of infection: non-infectious Complications: edema, coma, adrenal crisis, osteoporosis

Causes of hypothyroidism

Primary:

Primary (thyroid) hypothyroidism is more common, accounting for about 96% of hypothyroidism. It is caused by the disease of the thyroid itself. According to clinical findings, chronic lymphocytic thyroiditis is caused by taking antithyroid drugs. , hyperthyroidism or thyroid cancer after thyroidectomy, after radioactive iodine treatment, congenital thyroid deficiency or cretinism, tongue thyroid, invasive fibrous thyroiditis, caused by goiter, congenital thyroid hormone production disorders , thyroid metastases and chronic local iodine deficiency caused by.

Secondary:

Secondary (pituitary) hypothyroidism is less common in pituitary disease caused by decreased TSH secretion, such as pituitary tumors, Sheehan syndrome, non-neoplastic selective TSH deficiency, stroke, pituitary surgery or brain Caused by radiotherapy after the pituitary area.

Third sex:

The third (hypothalamic) hypothyroidism is rare, due to the reduction of thyroid-stimulating hormone releasing hormone (TRH) produced by the hypothalamus, resulting in decreased secretion of TSH in the pituitary, such as saddle tumor and congenital TRH deficiency.

First, the cause of the disease

Hypothyroidism (referred to as hypothyroidism) is a group of clinically comprehensive symptoms caused by various factors causing serum thyroid hormone deficiency or resistance, including body metabolism, functional reduction of various systems, and water and salt metabolism. obstacle.

There are many reasons for hypothyroidism. Hypothyroidism for different causes differs from regional and environmental factors (iodine content in diet, thyroid material, genetics, age, etc.), and newborns in many parts of the world. Screening found that one out of every 4,000 to 5,000 newborns had hypothyroidism; the incidence of hypothyroidism in the elderly varies from country to country, generally from 1% to 14%.

The distal end of the thyroid hormone acts against nuclear receptor deficiency, T3 or T4 receptor binding disorders, and post-receptor defects.

Second, the pathogenesis

1, mucinous edema

The liquid containing hyaluronic acid, mucin, and mucopolysaccharide infiltrates in the tissue, causing swelling of the skin under the skin, atrophy of the epidermis, and keratinization; infiltration of the muscle fibers causes degeneration of the skeletal muscle and the myocardium, resulting in necrosis.

2. Thyroid

Due to the different causes, the thyroid gland can be atrophied or swollen. The thyroid follicles and glial parts of the thyroid gland are partially or completely disappeared. The dense and transparent fibrous tissue appears. The thyroid gland is enlarged. The thyroid follicular cells proliferate, hypertrophy and glue. The quality is reduced or disappeared; the thyroid gland of the chronic disease is nodular, the follicular epithelial cells are flat, and the follicles are filled with gelatin.

3, pituitary

The pathology of the pituitary varies with the etiology. The primary hypothyroidism is reduced by the secretion of thyroid hormone, and the feedback inhibition effect on pituitary TSH cells is weakened. The proliferation of TSH cells makes the pituitary gland enlargement, even nodular hyperplasia, MRI or CT. Examination showed that the pituitary gland was enlarged, sometimes misdiagnosed as pituitary tumor, and the pituitary gland of secondary hypothyroidism had corresponding manifestations such as pituitary tumor, pituitary necrosis and atrophy.

Hypothyroidism prevention

1. Regular screening

Screening is recommended every 5 years in the elderly or in people over 35 years of age in order to detect clinical hypothyroidism; especially in pregnant women, infertility and ovulatory dysfunction; and family history or personal history of thyroid disease, Symptoms or physical examination suggest thyroid nodules or hypothyroidism, type 1 diabetes or autoimmune dysfunction and women who wish to have a pregnancy, more screening, for those with mildly elevated TSH with cardiovascular disease; those with TSH 10.0 mU / Patients with L; TPO-A negative patients should be followed closely, generally do not need drug replacement therapy, it is recommended that most patients with hypothyroidism use levothyroxine sodium (L-T4) replacement therapy, especially those anti-thyroid autoantibodies (TPO-A positive).

2, the cause of hypothyroidism prevention

(1) Causes of smear prevention: endemic stagnation, iodine deficiency in pregnant women during embryonic period is the key to the onset, sporadic stagnation, caused by certain autoimmune thyroid diseases caused by pregnant women, clear cause For prevention, take anti-thyroid drugs during pregnancy to avoid excessive doses. Use small doses of thyroid powder and avoid other goiter-causing drugs.

(2) Prevention of hypothyroidism in adults: timely treatment of thyroid diseases that are prone to hypothyroidism, prevention of thyroid disease by hand surgery or hypothyroidism caused by radioactive 131I treatment of hyperthyroidism.

3. Actively prevent the deterioration of hypothyroidism

Early diagnosis and early and effective treatment are the key to prevent the deterioration of hypothyroidism. Early treatment with traditional Chinese medicine can effectively prevent the occurrence of complications, and pay attention to the stimulation of life conditioning to avoid aggravating the disease.

4, to prevent recurrence after hypothyroidism

After the hypothyroidism, the body is still in the conditioning of yin and yang, taking the stage of "flat". At this time, the comprehensive treatment of dietetic medicated diet and other drugs to enhance physical fitness and improve the ability to prevent disease is an important measure to prevent recurrence after illness.

Hypothyroidism complications Complications edema coma adrenal crisis osteoporosis

1, mucus edema coma, is a complication of hypothyroidism and life.

2, prone to infection.

3, excessive treatment of hypothyroidism, can lead to adrenal crisis.

4. Infertility.

5. Long-term excess replacement therapy can lead to osteoporosis.

Symptoms of hypothyroidism Common symptoms Indifferent expression Bradycardia, slow sleepiness, appetite, lack of emotion, apathy, fatigue, libido, chills, facial edema, constipation

The onset is slow, and there are fatigue, fatigue, weight gain, and inability to withstand cold in the early stages. Then sleepiness, slow response, low and thick voice, swollen face, dry skin, hair loss, bloating, constipation, facial yellow, decreased sexual desire, infertility / infertility, menstrual disorders.

The severity of hypothyroidism varies, some patients have no clinical symptoms, and T3 and T4 levels are normal, only TSH levels are elevated, ie subclinical hypothyroidism; some patients present with functional abnormalities in one or more systems; very few patients appear Mucinous edema coma.

1, common clinical manifestations

(1) Skin: The characteristic manifestation of hypothyroidism is mucinous edema, which is characterized by non-recessed edema of the face, anterior, hand and foot. In some patients, the edema is concave, the skin is thickened, rough and dry. Due to thickening of the dermis and epidermis, blood flow is reduced and some patients have anemia, the skin is pale, cold, the secretion of sebaceous glands and sweat glands is reduced, the skin is dry, the hair is dry, thick, brittle, slow growth or stop, hair, eyebrows and limbs Hair loss, finger nail growth slow, thick, brittle.

(2) Cardiovascular system: Decreased thyroid hormone reduces myocardial contractility, slows heart rate, decreases cardiac output, increases peripheral resistance during rest, and reduces blood volume. These hemodynamic changes make pulse pressure difference smaller, cycle time Prolonged, tissue blood supply is reduced, skin blood supply is reduced, making the skin cool, pale and chilly.

Patients with severe primary hypothyroidism have enlarged heart and weak heart sound. This is mainly caused by leakage of protein and aminoglucan-rich liquid into the pericardial cavity. At the same time, the myocardium is also dilated, and pericardial effusion rarely reaches the pericardium. The degree of tamponade, the heart of patients with pituitary hypothyroidism usually becomes smaller.

Angina is rare, but angina or angina may be aggravated during the treatment of hypothyroidism with thyroid hormone. Hypercholesterolemia associated with hypothyroidism may aggravate coronary atherosclerosis.

Electrocardiogram changes include sinus bradycardia, prolonged PR interval, P wave and QRS group low, T wave low or inverted, occasional atrioventricular block, echocardiography suggesting atrioventricular septal asymmetry hypertrophy and The incidence of left ventricular outflow obstruction is high, and the above abnormalities can disappear after appropriate treatment of mucinous edema.

Blood creatine kinase, lactate dehydrogenase levels increased, isozyme analysis showed that creatine kinase, lactate dehydrogenase from the heart.

If you do not combine with other organic heart disease, thyroid hormone can correct hemodynamics, electrocardiogram and serum enzyme abnormalities, and restore the heart size to normal.

(3) Respiratory system: vocal cord thickening caused by hoarseness is more common, some patients found pleural effusion by X-ray examination, but rarely reached the level of dyspnea, severe hypothyroidism, due to mucous edema of the respiratory muscles, and low Oxygenemia and hypercapnia stimulate the role of ventilation, resulting in weakened alveolar ventilation and carbon dioxide retention, aggravating the occurrence of mucinous edema, is a very dangerous manifestation, obstructive sleep apnea is more common, with Correction of thyroid dysfunction, sleep apnea disappeared.

(4) Digestive system: The tongue is often hypertrophied, and the appetite usually declines, but most patients gain weight. The weight gain is caused by water retention in the tissue, the gastric emptying is delayed, the intestinal peristalsis is weakened, causing nausea, vomiting, bloating, constipation, A Ascites rarely occurs in patients, but ascites can occur with pleural effusion and pericardial effusion. The effect of hypothyroidism on intestinal absorption is complicated. Although the absorption rate of various nutrients is slowed down, the peristalsis slows down. The absorption time is longer, the total absorption may be normal or increased, and occasionally the absorption is obviously poor.

Liver function is normal, but transaminase levels can be elevated, probably due to slower clearance, gallbladder enlargement, and contraction.

(5) Nervous system: Thyroid hormone plays an important role in the development of the central nervous system. The lack of thyroid hormone in the fetal period leads to dysplasia of cerebral cortical cells and delayed myelination. If thyroid hormone deficiency is not corrected early in life, the brain The damage will be irreversible. The thyroid hormone deficiency in adults is not serious damage to the nervous system. It is clinically characterized by fatigue, lack of ambition, lack of vitality, anxiety, depression, lack of thinking, slow response, slowing of speech. Memory loss, slow movement, apathy, sleepiness, and slow reflexes.

(6) Musculoskeletal system: muscle spasm, pain, common stiffness, more obvious when the temperature is low, muscle contraction and slow relaxation cause awkward slow movement, slow sputum reflex, thyroid hormone plays an important role in the normal growth and maturation of bone, life Early lack of thyroid hormones causes linear growth to be impeded, manifested as dwarfism, and the limbs are disproportionately shortened relative to the trunk, bone age is significantly behind age, plasma calcium and phosphorus levels are generally normal, calcium may be slightly elevated, infants and adolescents Alkaline phosphatase is often lower than normal, and bone density can be slightly increased.

(7) Hematopoietic system: As the demand for oxygen decreases and the amount of erythropoietin decreases, the number of red blood cells decreases. About 25% of patients with hypothyroidism are anemia, often showing positive cell anemia, due to menorrhagia and iron absorption disorder. Small cell hypochromic anemia can also occur, the total number and classification of white blood cells are normal, and the number of platelets is normal.

(8) urinary system: renal blood flow, glomerular filtration rate, renal tubular reabsorption and secretion function have decreased, urine output decreased, urea nitrogen, creatinine is normal, uric acid can be elevated, may appear mild Proteinuria, the reduction of water discharge from the kidneys and the accumulation of hydrophilic substances in the tissues cause water retention, which increases the overall fluid volume, which is common in hyponatremia.

(9) Reproductive system: Thyroid hormone has effects on sexual development and reproductive function of both sexes. Adolescent hypothyroidism leads to delayed development of puberty. Primary hypothyroidism can lead to precocious puberty and galactorrhea. Adult women with severe hypothyroidism may be accompanied. Loss of libido, no ovulation, improper secretion of progesterone, resulting in persistent proliferation of the endometrium, leading to menorrhagia and menstrual disorders, reduced chances of pregnancy, easy to cause miscarriage, male hypothyroidism patients with low libido, impotence and sperm reduction.

(10) Energy metabolism system: energy metabolism is reduced, heat production is reduced, and the basal metabolic rate is reduced, loss of appetite, chills, protein synthesis and decomposition are slowed down, decomposition is slowed down more, and protein synthesis slows down as bones and Soft tissue growth is slow, oral glucose tolerance test is a low-flat curve, glucose-stimulated insulin secretion reaction is delayed, may be due to slow absorption of glucose in the intestine, slow down insulin decomposition, increased sensitivity to exogenous insulin, the original In patients with diabetes, the amount of insulin should be reduced after hypothyroidism, the synthesis and decomposition of fat are slowed down, and the decomposition is slowed down more. The blood cholesterol, phospholipids, and triglycerides are elevated in patients with primary hypothyroidism, and free fatty acids are decreased.

(11) Water and electrolytes: Patients with hypothyroidism have an overall increase in sodium, while patients with mucinous edema have hyponatremia, partly due to elevated levels of vasopressin; followed by decreased cardiac output and renal vasoconstriction. A decrease in glomerular filtration rate results in a barrier to free water excretion.

2, mucinous edema coma

Mucinous edema and coma can also be called hypothyroidism. It is a critical stage of severe hypothyroidism complicated with multiple system complications caused by various reasons. Although it is not common, its risk is recognized. If it is not diagnosed in time, The case fatality rate can reach more than 50%. This condition often occurs in patients with severe disease-deficient disease, and the patients with severe hypothyroidism who have not been properly treated may be caused by improper use of cold, infection, surgery, anesthetic or sedative. Mucinous edema is unconscious. The age of onset can range from 10 to 90 years old, the majority occurs between 61 and 70 years old, mostly in elderly patients, and 90% of patients coma occur in the cold season, which may be due to age-related adaptation to temperature. Reduced capacity and hypothyroidism caused by insufficient heat production.

The patient showed coma, or first lethargy, and gradually developed into a coma in a short period of time. The prodromal symptoms were mainly intolerable to the cold and fatigue. Usually, fatigue and lethargy were felt several months before the onset of the disease. The disease often has typical hypothyroidism. About one-third of patients have heart enlargement or pericardial effusion, extreme bradycardia, low heart sounds, arrhythmia, and some patients have pleural effusion.

The signs and characteristics of hypothermia mucinous edema coma, body temperature does not rise (below 35 ° C), some patients have body temperature as low as 27 ° C or less, such low body temperature often indicates that the disease has reached the end of the disease, difficult to recover, the patient is slow breathing, severe Respiratory failure can occur, hypoxemia and hypercapnia, bradycardia, decreased blood pressure, muscle relaxation in the limbs, reflexes disappear, some patients have mental disorders such as hallucinations, delusions and disorientation, etc. Constipation, abdominal distension, paralytic ileus and ascites can occur, severe cases of shock and heart and kidney failure, such as diagnosis, rescue is not timely, often life-threatening.

3, subclinical hypothyroidism

This type of patient has neither the symptoms of hypothyroidism nor the signs of typical hypothyroidism. The thyroid hormone in the blood is also in the normal range, and only the TSH in the blood is higher than normal (>4.0 U/L).

Spontaneous subclinical hypothyroidism is more common in the population. The prevalence of subclinical hypothyroidism varies from 1% to 10% worldwide. The highest age and gender characteristics are more than 60 years old. In some reports, the prevalence rate is close to 20%. People who take more iodine are more susceptible to disease. According to whether thyroid antibodies (TPO-Ah and/or Tg-Ah) can be detected in serum, patients are divided into two subtypes. Subclinical hypothyroidism associated with thyroid antibody-positive patients has an increased risk of hypothyroidism, with 5% to 10% of patients developing subclinical hypothyroidism each year from significant hypothyroidism, and thyroid antibody-positive patients may be The autoimmune thyroiditis, the common serum TSH is elevated and the thyroid antibody is negative, the mechanism of its occurrence is still unclear. These patients may have different subtypes of autoimmune diseases that are dominant in T-cell responses. This subtype develops a lower risk of hypothyroidism (about 2% per year).

Because most patients with subclinical hypothyroidism have few or no symptoms, clinically such people are often missed or difficult to diagnose.

4, elderly hypothyroidism

Many symptoms of senile hypothyroidism are easily confused with aging, such as cold, constipation, unresponsiveness, and dry skin.

Examination of hypothyroidism

1. Serum thyroxine (T4) level <52 mol/L (4 g/dl).

2. The T3 uptake test is reduced.

3. FT4 is reduced.

4. Serum triiodothyronine (T3) and rT3 were all decreased.

5, blood TSH> 5.0U / L.

6, thyroid 131I rate reduction, it should be noted that: normal elderly blood T4, T3 and FT4 levels are lower than adults, and T3 and TSH are higher than adults, should be considered in the analysis results.

7, blood lipid changes: blood total cholesterol, triglycerides and low-density lipoprotein cholesterol and apolipoprotein can be increased, high-density lipoprotein cholesterol content changes are not obvious.

8. The oral glucose tolerance test showed a low-level curve.

9. In patients with chronic lymphocytic thyroiditis, the anti-thyroid antibody titer in the blood can be significantly increased.

10, ECG changes: may have low voltage, sinus bradycardia, T wave low or inverted, PR interval prolonged, atrioventricular separation, QT interval prolonged and other abnormalities, myocardial contractility and ejection fraction decreased, left ventricle The shrinkage time is extended.

11, thyroid radionuclide scanning: is the best way to find ectopic thyroid (post-hyoid bone, sternum, mediastinal thyroid, ovarian thyroid, etc.), contralateral thyroid deficiency of the contralateral thyroid due to functional compensation Imaging enhancement, radionuclide scanning also has a certain significance for the functional evaluation of thyroid and thyroid nodules.

12, molecular biology examination: congenital hypothyroidism, the cause of familial hypothyroidism depends on molecular biology, according to clinical needs to choose the appropriate analytical methods.

13. Pathological examination: If necessary, biopsy or needle aspiration can be used to take thyroid tissue or cells for pathological examination to assist diagnosis.

Diagnosis and diagnosis of hypothyroidism

Diagnostic criteria

1. Typical clinical manifestations, signs and laboratory tests.

2, serum TSH increased, serum TT3, TT4, FT3 and FT4 can be reduced, but mainly FT4.

3, serum thyroid peroxidase antibody (TPO-Ab), thyroglobulin antibody (TG-Ab) strong positive suggestive of autoimmune thyroid disease, such as chronic lymphocytic thyroiditis (also known as Hashimoto's disease) and the original Atrophic thyroiditis.

4. The thyroid 131I uptake rate is reduced.

Differential diagnosis

1. Normal thyroid sick syndrome

Some acute or chronic non-thyroid diseases can affect the production or metabolism of thyroid hormone through different ways, clinical manifestations of low metabolism and low sympathetic response, such as cold, fatigue, edema, loss of appetite, constipation, etc., determination of serum T3 And (or) T4 is low, easy to be misdiagnosed as hypothyroidism, simple T3 is called low T3 syndrome, and severe cases can also show low T4, called low T4 syndrome.

When the body is severely thin, chronic hunger, chronic diseases and serious infections, myocardial infarction and other diseases, the activity of 5 deiodinase decreases, while the activity of 5-deiodinase increases, which reduces the conversion of T4 to T3 in the body and increases the conversion to rT3. Hormone determination found T4, T3 decreased, but TSH did not increase, and T3 decreased more obviously. When the primary disease was cured, T4 and T3 returned to normal, which is different from the common clinical primary hypothyroidism. TSH is elevated. In acute myocardial infarction, T3 is reduced by 50% within 3 to 4 days, but TSH is not elevated. When the primary disease is cured, T3 returns to normal, and low T3 syndrome or low T4 syndrome is identified. Important, because their serum T3, T4 decline is a protective measure of the body, artificially added thyroid hormone preparation to increase the body's metabolic rate, will inevitably exacerbate the condition of the primary disease.

2, chronic nephritis

Hypothyroidism patients with pale sodium retention showed pale skin, edema, anemia, high blood pressure and elevated blood cholesterol. Some patients are also associated with urinary protein positive, so they are often considered to be kidney disease, and they are not diagnosed and treated correctly. Nephritis patients with chronic renal insufficiency often show abnormalities in thyroid hormone determination, mainly serum T3 decline, which is the protective response of the body to reduce metabolic rate. Nephritis edema is mostly concave, and hypothyroidism is mostly non-concave. There is serosal effusion in hypothyroidism and nephritis, but the plasma protein of hypothyroidism is normal, and the plasma protein of nephritis is low. In addition to edema, hypothyroidism patients are often accompanied by cold, low appetite, rough skin and slow heart rate. , constipation and other metabolically low performance, and nephritis proteinuria is obvious, as long as the hypothyroidism is considered clinically, laboratory examination is not difficult to differentiate diagnosis.

3, anemia

About 25% to 30% of patients with hypothyroidism show anemia. The causes of anemia are various. Patients with hypothyroidism are more common in women, often with more menstrual flow, longer menstrual period, leading to excessive blood loss, loss of appetite, undernutrition and stomach acid. Lack of anemia is more serious, and anemia is very common in middle-aged women, and it is not taken seriously. Anemia patients are often accompanied by symptoms such as cold, loss of appetite, fatigue, etc., so many hypothyroidism is often misdiagnosed as anemia for a long time. Without accurate diagnosis and treatment, the thyroid hormone with primary hypothyroidism is low, and TSH is elevated. The differential diagnosis is not difficult. 5% to 10% of patients with primary hypothyroidism have large folic acid deficiency. Cellular anemia, when the effect of iron treatment is not good, should consider the possibility of large cell anemia.

4, serous effusion

The cause of serous effusion in hypothyroidism is due to slow lymphatic reflux, increased capillary permeability, hydrophilicity of serosal mucin and mucopolysaccharide, and TSH stimulates adenylate cyclase activity in the serosal cavity. Increase the secretion of hyaluronidase, causing ascites, pericardial effusion, pleural effusion and joint cavity effusion, serous effusion can appear alone, or two or more appear, hypothyroidism occurs in serous effusion Often misdiagnosed as tuberculosis, malignant tumors, uremia, pericarditis and connective tissue disease, hypothyroidism in the serous effusion with high protein content, low cell count, high cholesterol content and immunoglobulin content, treatment of diuretics Insensitive, in patients with unexplained serous effusion, thyroid hormone should be measured, except for the possibility of hypothyroidism.

5, idiopathic edema

The fibroblasts of hypothyroidism patients secrete hyaluronic acid and mucopolysaccharide, which are hydrophilic, block lymphatic vessels, cause mucinous edema, and most of them show non-concave edema. Patients often have symptoms because they are not specific, and they cannot be found for a long time. It is misdiagnosed as idiopathic edema and has a stronger effect on TSH stimulation, especially in women after abortion and childbirth. It is not difficult to identify pituitary adenoma and hypothyroidism by measuring thyroid function. Sometimes hypothyroidism is caused by swelling of the hands and feet, lips Thick tongue, hoarse voice, increased hand and foot, and increased saddle, will be misdiagnosed as pituitary growth hormone secretory tumor, but hypothyroidism patients with normal serum growth hormone levels, hypothyroidism patients are afraid of cold, constipation, slow heart rate and other symptoms It is different from acromegaly, and the hormone measurement can be used for differential diagnosis.

6, pituitary tumor

Long-term hypothyroidism patients, especially children, the pituitary can be increased, sometimes misdiagnosed as pituitary tumors; primary hypothyroidism long-term blood T4 decline, pituitary TSH cells hypertrophy, resulting in increased saddle, some women due to menstruation Disorders and lactation, laboratory tests found that prolactin was slightly elevated, misdiagnosed as pituitary prolactin secretory tumor, patients with hypothyroidism due to elevated TRH, TRH stimulation of prolactin (PRL) effect is stronger than TSH stimulation effect, especially in In some women after abortion and childbirth, it is not difficult to identify pituitary tumors and hypothyroidism by measuring thyroid function. Sometimes patients with hypothyroidism are swollen by hands and feet, with thick lips and thick tongues, hoarseness, increased hands and feet, and increased saddles. Will be misdiagnosed as pituitary growth hormone secretory tumor, but hypothyroidism patients with normal serum growth hormone levels, hypothyroidism patients with cold, constipation, slow heart rate and other symptoms are different from acromegaly, hormone determination can be differential diagnosis.

7, depression

Patients with hypothyroidism occur more frequently in the elderly. With the increase of age, the prevalence of hypothyroidism also increases. The symptoms of elderly patients are not specific, the progress of the disease is slow, and it is not easy to be found. It is cold, dull and loss of appetite. Symptoms such as depression, poor sleep and depression are diagnosed as senile depression. Elderly people with depression should consider the possibility of hypothyroidism. Patients with hypothyroidism who are treated with anti-depression alone cannot achieve satisfactory results.

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