MANAGEMENT OF HYPER AND HYPO –THYROIDISM IN AYURVEDIC PERSPECTIVE

We Ayurvedic practioners are least concerned about thyroid disorders. Most of us think that thyroid disorder is a hard nut to crack and it can be managed only through allopathic interventions. It is high time to formulate an ayurvedic approach to tackle this issue.

In 30yrs of practice I have come across many hypo and hyper thyroidism cases and found some formulations effective in treating the same.

Let us see in brief about the thyroid gland and its disorders

Anatomy of Thyroid Gland

Thyroid is a butterfly shaped endocrine gland situated below larynx and on the sides of trachea, weighing 25gms, measuring 4*3*2cm.

Parathyroid glands are embedded in it.

Important point to be noted here is it has one of the richest blood supply, and in disorders like goiter it can weigh upto 250gms or more.

Synthesis of thyroid hormones

1. Production of thyroglobulin by follicles
2. Storage as colloid form
3. Iodination
4. Degradation of thyroglobulin

Secretion of thyroid hormones

Hypothalamus releases TRH (thyroid releasing hormone)which stimulate Pituitary gland to secrete TSH ( thyroid stimulating hormone) which in turn stimulate Thyroid gland to secrete Thyroxine (T4) and Triiodotyronine (T3)

Clinical biochemistry adult reference ranges

TSH- 0.3-4.0 mU/L

Thyroxine, free(fT4)- 11-25 pmol/L

Thyroxine, free(fT4)- 1st trimester- 11.6-19.2 pmol/L

Thyroxine, free(fT4)- 2nd trimester- 9.3-16.3 pmol/L

Thyroxine, free(fT4)- 3rd trimester- 8.0-15.2 pmol/L

Thyroxine, total (tT4)- 58-140nmol/L

Tri-iodothyronin(T3)-1.2-2.2 nmol/L

Thyroid function test

Total T3 - 0.600-1.800ng/mL

Total T4 - 4.600-11.500microgm/dl

TSH - 0.350-5.500mIU/L

Actions of Thyroid Hormones

Increase cellular oxidation (BMR)

• Increase in protein breakdown
• Increase in turn over of carbohydrates and fats
• Calcium mobilised from bones
• Increased heart rate

We can see that above said functions are more of catabolic in nature. But In intra uterine stage, infancy and in growing stages thyroid act also as an anabolic hormone. So we can say that thyroid is essentially a gland related to metabolism.

Salient Features and Facts of Thyroid Disorders

• 5% of population is affected
• Females are more prone, ratio 8:1
• Females with diabetis mellitus are more prone to develop
• Misdiagnosis (most of us fail to diagnose hypo and hyper thyroidism cases)
• Malignancy
• Role of auto-immunity

We can see that prevalence of thyroid disorders is quite high and females are more prone . .Hypothyroid females are susceptible to develop D.M. and vice versa due to immunological backgrounds. Rheumatoid Arthritis also usually associate due to the same reason.

Various autoantibodies have been detected which play an important role in genesis of thyroid disorders

Thyroid related malignancies are also found considerably

Diseases of Thyroid Gland

• Goiter
• Hypo thyroidism
• Hyperthyroidism
• Thyroiditis
• Tumors

Hypothyroidism :

Insufficient synthesis and secretion of thyroid hormones leads to hypothyroidism.

1. Marked hypothyroidism

a) Cretinism (children)

b) Myxedema (Adults)

2. Mild to moderate hypothyroidism

Hypothyoidism and Heredity

Though there is no reference of heredity,many physicians have found certain families where thyroid stops to secrete for ever.This happens at 3rd or 4th decade

Cretinism :

Infant born to hypothyroid women

Infant born in endemic goiter belt

Infant born to women on ‘antithyroid drugs’ (pregnant women who is on medication for hyperthyroidism if not monitored properly will develop hypothyroidism and baby born will be cretin.

Symptoms of cretinism:

Dull and lethargic

Retarded growth

Large protruding tongue

Broad flat nose

Croky voice

Somnolence ( the baby sleeps upto 18hrs a day)

Constipation

Neurological abnormalities

Myxedema : (in adults)

Symptoms are

Lethargy and somnolence

Slowing of activities

Slowing of mental activities

Depression

Weight gain

Constipation

Hair coarse and dry

Hair Fall

Generalised non pitting odema

Periorbital odema

Puffy face and macroglossia

Intolerance to cold

Heavy menstrual periods

Diabetes Melitus, Arthritis, CVS ailments

Enlarged thyroid

Important points to remember while treating hypothyroidism

• Quite frequent in daily practice
• Diabetic women are more prone
• Often Arthritis coexists with hypothyroidism, and most of us miss hypothyroidism.

Often a middle aged lady with puffines ,recently overweight,lack of energy and having jontpain is a common customer in our day to day practice,and we diagnose the case as a sandhigatha vata one and starts treatments.If we go for thyroid investigation most of such cases turned out to be hypothyroidism to which modern doctors start eltroxin So we should not missdiagnosis

HYPOTHYROIDISM –Management through Ayurveda

In my clinical experience myxedema and cretinism couldn’t be managed through ayurveda. But mild to moderate hypothyroidism with following conditions can be successfully managed.

• Females/males 40 yrs above, normal thyroxine level and elevated TSH

1. Dullness
2. Puffiness
3. Arthralgia
4. Constipation
5. Weight gain
6. Eltroxin dose insufficient,fails to reverse symptoms
7. when patient willing to withdraw ‘ eltroxin’
8. when D.M. etc.follows

In our day to day practice we encounter female patients above 40yrs with symptoms 1-5 taking ‘eltroxin’ , such cases can be effectively managed.

Often we can see that inspite of taking ‘eltroxin’ regularly, patient still has the above said symptoms which cannot be reversed even with high doses , here ayurvedic approach does wonders.

When we go through the symptoms of hypothyroidism we can see the role of dosas and dusyas

Relation with Doshas and dusyas

• Kapha vridhi
• Medo vridhi
• Tamoguna vridhi

Symptoms related to Kapha

• Lethargy
• Somnolence
• Slowing of physical activities
• Slowing of mental activities
• Oedema
• Intolerance to cold
• Weight gain
• Periorbital oedema & puffy face
• D.M, Hyperlipidaemia
• Cardio vascular problems
• Absence of sweating despite heavy activity [    Diagnostic pointer]

Symptoms related to Medas

• Almost all symptoms of kapha vridhi
• Enlarged thyroid

Symptoms related to Tamo Guna

• Lethargy
• Somnolence
• Slowing of mental activities
• Depression

From the above we can conclude that symptamatology of hypothyroidism go hand in hand with Kapha Medo Vridhi and lethargy etc symptoms are due to the dominance of Tamo Guna. There are some symptoms which cannot be included under kapha medo vridhi viz. Constipation, Arthritis [?Adyavatha], Muscle cramps and aches

,Hair fall ( I have seen this as one of the first symptoms in many cases) Heavy menstrual periods. This symptom cannot be categorized under kapha medovridhi

Treatment protocol for hypothyroidism:

• Basic line of treatment to tackle Kapha , Medo vridhi
• Effective proven formulations
• Measures to kindle Jataragni should be our main aim while treating hypothyroidism.

• Upavasa
• Kapha hara food –(rooksha-alpa-katu ahara)
• Udwarthana
• Rooksha sweda
• Vyayama –yogasanas - breathing exercises
• Lekhana vasti
• Vamana , nasya, dhoomapana-(Avasthaanusari)
• Vishishta prayogas-Toyavidhi- Panchakola or Naagara

Upavasa..As jadaragni is set in low and appetite poor patient should be advised to cut supper stick on kaphahara food..Panchakola jalam acts as deepana and pachana .It also relieves menstrual pain

Udwarthana; it has a greatrole owing to its Kaphahara and Medohara property[Trifalachurna best choice]

Rookshasweda; arthralgia and heaviness of body disappears …powder of kulatha,satahwa and methi can be used in kizhi

Yogasanas including suryanamaskar,pranayamas…

Lekhana Vasti;Very effectively controls kaphamedobahulya and over weight[3 to 5 vastis can be employed

• Kapha medohara yogas:

Varunadhi kashaya

Gulguluthikthaka kashya

Kanchanara gulgulu

Kaisora gulgulu

Vyoshadi gulgulu

Gomutra haritaki

Ayaskrithi

Shilajit bhasmam

Shaddharana choornam

Dashamoolaharitaki etc..

LEKHANA VASTI (Su.S.Ci)

• Makshikam 200ml
• Saindhavam 15gms
• Moorchita tailam 200ml
• Kalkam yavanyadi 30 gms
• Triphala kashyam 300 ml
• Dhanyamlam 200 ml
• Yavaksharam 10 gms

LEGHANAVASTI [simplified]

• Trifala kashayam 150ml
• Kulatha kashayam 150ml
• Makshikam 150ml
• Sneham[e.g.pippalyadi anuvasanam] 100ml
• Kalkam-hinguvachadi churnam 30gms
• Lavanam 10gms
• Avapam -yavaksharam 10gms

Lekhana vasti has got sthoulya, kapha,medhohara property and brings up rookshana in system

VARUNADHI GANA is the most effective formulation when kapha medo vriddi, agni mandyam and adya vata symptoms are prominent .

Apathya :

• Snehanam[ tailam internally is okay]
• Abyangam
• Ksheera , dadhi, ghee
• Divaswapnam

Other Approachs:

Some of the veterans of Ayurveda consider concept of Pandu

and Kaphaja Pandu in treating hypothyroidism.

CASE REPORT; A 48 year old advocate came to me with following complaints

Puffiness,arthralgia.,overweight[recently]with lack of energy and somnolence’.[He was a known diabetic]

TFT was done which showed elevated TSH.

He was stared upon with udwarthana and rooksha sweda same day for 14 days8th 10th 12th day given lekhana vasti’matra vasti[3] in between

Varanadi,kanchanaragulgulu,pranada and kanmada bhasma internaly

From 5th day symptoms started receeding.He was totally asymtomatic in 21days.And to my surprise his chronic diabetis also got cure.He contd medicines for 2 months.

And after one year he developed all above which responded promptly to same procedures

HYPERTHYROIDISM

Presenting Symptoms are due to Hyper symphathetic activity and Hyper metabolic states.

Excess of circulating T4 & T3

Etiology:

Graves disease

Toxic MNG (mono nodular goiter)

Toxic adenoma

Symptoms of hyperthyroidism

• Anxiety and irritability
• Tremor and nervousness
• Tachycardia
• Feeling ‘’HOT’’ –heat intolerance
• Voracious appetite
• Fatigue
• Weight loss
• Diarrhoea( I have seen cases of hyperthyroidism presenting with diarrhea as the preliminary symptom)
• Shorter menstrual periods
• Exopthalmus
• Hair loss
• ‘’Sweating’’ ( patients exibit excess of sweating even while sitting in air conditioned rooms while hypothyroid cases have no sweating at all even in heavy activity etc.)
• Disturbed sleep
• Skin - soft and moist

Note: in my clinical practice I have noticed that most of patients say that they like to take umbrella while going out and cant bear sun. while hypo-cases love to warm comforts.

We can relate above said symptoms with Doshas & Atyagni

• Ativridha pitta lakshana
• Vatavridhi lakshana
• Atyagni roga samya

Pitta Symptoms

• Voracious appetite
• Feeling hot
• Sweating
• Diarrhoea
• Irritability—krodha & eersha
• Shorter menstrual periods-Lohita kshaya yoniroga
• Disturbed sleep

Vata Symptoms

• Anxiety , nervousness
• Tremor
• Tachycardia
• Weight loss-Kaphakshaya=vatakopa
• Fatigue

Atyagni –(Bhasmaka)

while going through the samprapti of atyagni (bhasmaka)

we can see that Kapha sosham, Pitta kopam takes place along with Vata anubandha and Stanasamsrayam happens at pachyamanasayam.

Jataragni gets blew up and burns food in no time; if enough food is not provided for the jataragni it burns up dhatus (Oxidative destruction) resulting in Extreme weakness, Thirst, burning sensation all over the body, difficulty in breathing (gasping) kasa, stupor eventually leading to death. Crisis of hyperthyroidism

(Thyrotoxicosis crisis) when left untreated results in death.

Agni :

In classics different aspects of agni is elaborately discussed

‘Aharam agnim pachati doshaan ahara varjita

Dhatun ksheeneshu dosheshu jeevitam dhatu samkshayet’

Agni --- aharam pachat

Agni --- doshan pachati

Agni --- dhatun pachati

Agni --- mrutyum anayati

The first 2 represents the constructive aspect and last 2 stands for the destructive aspects. We can say that the status of agni in hyperthyroidism is a destructive one like a wild fire.

MANAGEMENT

My first encounter with hyper thyroidism cases was in 1980’s.

I treated around 18 cases with the following combination and got symptomatic relief but no permanent cure was noted

Step 1:

• Kashaya – special guloochyadi kashayam ( guloochyadi gana+ sariba, usheera, chandana & satavari)

Step 2:

• Daadimadhi gritha- to be started after 21 days

Through trial and error I updated and revised my approach

Updated approach:

All the measures to bring down atyagni ,vitiated pitta,and controlling vata help to alleviate agony of hyperthyroid patients

Samana measures can easily reverse the burning issues of patients in short span of time.

• Samana therapy

1. Pittahara kashaya… special guloochyadi, guloochyadi,drakshadi,vidaryadi etc

2. Thoyam –sariba,chandana,usheera

3. Ahara vidhi- of athyagni

4. Ghrita – Kalyanakam ( internally long term)- associated complaints like irritability, restlessness,insomnia etc can be tackled with this . Other pittahara ghritas have less effect on the above symptoms.

• Sadya Virechana – optional ( depending on patients condition)

[1] Avipathhy choornam

[2] Ksheera kashyam of Trivrit,Syama

• Special treatment –Talapothichil- [effective in excessive heat and burning sensation , insomnia and exopthalmus (to a little extend) ]. It should be done for 21 days and have to be repeated once in 2 months.
• Snehapaana –(No swedana)
• Virechana in Uthama Mathra

Note :

* Brinjal and Green gram effect:*

When patients were advised to include brinjal and green gram in their diet for specific time period, in most them the elevated thyroid levels came down and relief from symptoms were also noted. This is a folklore practice which need to be proved scientifically. So I advice this diet for maximum 3 weeks only.

ATYAGNI –LINE OF APPROACH IN MAJOR TREATISES

• Main emphasis on food
• Swadu , guru , kapha, medavardhaka
• Mahisha ksheera, dadhi ,ghritha

FEEDBACKS

• Moolakadikashayam
• Hamsapathyadi kashayam
• Nirgundadi oil—for head
• line of treatment of Galaganda

CASE REPORT.

A male of 35 years on neomercasole and propanolol forhyperthyroidism in the last 3 years came to me to switch over to ayurveda.He had exopthalmus also.

He was started with guloochyadi kashayam b.d and kalyanaghritam simultaneously along with bhrimhana food. His neomercasole was withdrawn. From 3rd week propanolol whichwas meant to counter tachycardia was cut.He started responding from 2nd week.After 3 months only kalyanaghrita was maintained.He was advised bhrinjal and greengram food item for aweek every month.

Now 8 months are over .As he is coolie he couldnot be admitted for snehapana etc.

Dilemmas in Management

Alternating hypo and hyper thyroidism do exists in certain patients.

I have seen a diagnosed case from medical college recently.Doctors opined that one lobe shows hyper features while the other vice versa

A middle aged female who has been on neomercasole plus ……othr medicines came with arthragia and severe fatigue.I stopped all her moderndrugs all of asudden and started following medicines.

Varanadi ks ,trifalagulgulggulu,kanmada bhasma and kalyana ghrita hs

Here a combination of hypo and hyper medicines is done.She is on the above medicines and now asymptomatic.

CONCLUSION

Iam fully aware of limitations in my study.Only a selected group of hypo cases falls in to the criteria are benefitted.

Goitres thyroiditis,malignancies are not studied.

Hypo cases once recovered and having no medication for a year or more recurrence has seen.Ahara and vihara suitable to tackle kaphamedovridhi should be continued for a along run

Yet,I wish my humble attempt in this regard may stimulate earnest physicians to come up with newer approaches backed with trials.Even P.G.students can take this subject for research.

(COURTESY APTA AUGUST 2012)