The main causes of hyperthyroidism are:
- Graves' disease
- Non-cancerous growths of the thyroid gland or pituitary gland
- Tumours of the testes or ovaries
- Inflammation (irritation and swelling) of the thyroid due to viral infections or other causes
- Ingestion of excessive amounts of thyroid hormone
- Ingestion of excessive iodine
Graves' disease accounts for 85% of all cases of hyperthyroidism. This is the most common cause of hyperthyroidism and is due to an autoimmune process. Serum IgG antibodies bind to the thyroid TSH receptor stimulating thyroid hormone production, behaving like TSH. These TSH receptor antibodies can be measured in serum.
Yersinia enterocolitica as well as Escherichia coli and other Gram-negative organisms contain TSH binding sites. This raises the possibility that the initiating event in the pathogenesis may be an infection with possible 'molecular mimicry' in a genetically susceptible individual, but the precise initiating mechanisms remain unproven in most cases. Thyroid eye disease accompanies the hyperthyroidism in many cases (see below) but other components of Graves' disease, e.g. Graves' dermopathy, are very rare. Rarely lymphadenopathy and splenomegaly may occur.
Graves' disease is also associated with other autoimmune disorders such as pernicious anaemia, vitiligo and myasthenia gravis. The natural history is one of fluctuation, many patients showing a pattern of alternating relapse and remission; only about 40% of subjects have a single episode. Many patients eventually become hypothyroid.
The symptoms and signs of Graves' disease are:
- Weight loss
- Increased appetite
- Heat intolerance
- Increased sweating
- Frequent bowel movements
- Menstrual irregularities in women
- Goitre may be present
Additional symptoms that may be associated with this disease are:
- Sleeping difficulty
- Clammy skin
- Skin blushing or flushing
- Bounding pulse
- Nausea and vomiting
- Itching all over the body
- Hand tremor
- Hair loss
- Breast development in men
- High blood pressure
- Protruding eyes (exophthalmos)
In the elderly, a frequent presentation is with atrial fibrillation, other tachycardia and/or heart failure, often with few other signs. Thyroid function tests are mandatory in any patient with atrial fibrillation. Children frequently present with excessive height or excessive growth rate, or with behavioural problems such as hyperactivity. They may also show weight gain rather than loss. The clinical signs show an increased heart rate and the systolic blood pressure may be elevated. Physical examination may reveal thyroid enlargement or goitre.
Laboratory tests that evaluate thyroid function:
- Serum TSH is usually decreased
- T3 and free T4 are usually elevated
The treatment of Gravesís disease in modern medicine depends on the cause of the condition and the severity of symptoms. Hyperthyroidism is usually treated with antithyroid medications, radioactive iodine (which destroys the thyroid and thus stops the excess production of hormones), or surgery to remove the thyroid. If the thyroid must be removed with radiation or surgery, replacement thyroid hormones are prescribed. Hyperthyroidism caused by Graves' disease is usually progressive and has many associated complications, some of which are severe and affect quality of life.
Hyperthyroidism in Chinese medicine
From the point of view of Chinese medicine, when confronted with a patient suffering from hyperthyroidism, the first question we should ask ourselves is how we should consider this disease from a Chinese perspective. In other words, we should establish to which Chinese disease hyperthyroidism might correspond to. For example, when treating hypertension we can quite safely say that this disease corresponds to the three Chinese diseases of Headaches, Dizziness and Tinnitus.
The overwhelming majority of Chinese doctors say that hyperthyroidism corresponds to the Chinese disease of Goitre (Ying Bing). I personally disagree with this view because hyperthyroidism does not always present with goitre; as goitre will always indicate Phlegm and it would be wrong to resolve Phlegm in a patient without goitre. Certainly, if a patient suffering from hyperthyroidism does have goitre, it is legitimate to assume that the pathology and treatment methods of Goitre are largely applicable to the treatment of hyperthyroidism.
Drsí Zhu Ceng Bo and Wei Zi Xiao are two TCM doctors who are of the opinion that hyperthyroidism cannot be equated to Goitre. This raises the question of the importance of the integration of a TCM diagnosis with a Western medical diagnosis. For example, it would be wrong to treat a patient for palpitations and tremors (Chinese disease-entities) without investigating whether those two symptoms are due to a dysfunction of the thyroid.
Dr Wei Zi Xiao
Dr Wei Zi Xiao says that hyperthyroidism may correspond to many different Chinese diseases such as palpitations (Xin Ji), insomnia, depression, sweating, tremors, diabetes (Xiao Ke), fever (of internal origin), exhaustion (Xu Lao) and Phlegm.
According to Dr. Wei Zi Xiao, in the treatment of hyperthyroidism it is important to distinguish Fullness from Emptiness and the Root (Ben) from the Manifestation (Biao). He says that the Root is most often a Deficiency of Yin and the Manifestation is full and may consist in Qi stagnation, Blood stasis, Fire or Phlegm. The presence of goitre indicates Phlegm. Dr Wei Zi Xiao says that the three main organs involved in the pathology of hyperthyroidism are the Heart, Liver and Kidney.
As mentioned above, Dr Wei Zi Xiao says that hyperthyroidism cannot be equated with Goitre in Chinese Medicine; he says that hyperthyroidism may correspond to many different Chinese diseases such as palpitations, insomnia, depression, sweating, tremors, etc. In this opinion, Dr Wei differs from most Chinese doctors who equate hyperthyroidism with Goitre (Ying Bing) of Chinese medicine; I personally tend to agree with Dr Wei in thinking that hyperthyroidism corresponds to Goitre only when there is goitre present and many patients suffering from hyperthyroidism, obviously will not have a goitre.
According to Dr. Wei Zi Xiao, the treatment principles for hyperthyroidism are;
Nourish Yin with Sheng Di Huang (Radix Rehmanniae), Dang Gui (Radix Angelicae sinensis), Gou Qi Zi (Fructus Lycii chinensis), Nu Zhen Zi( Fructus Ligustri lucidi), Han Lian Cao (Herba Ecliptae), Tian Men Dong (Radix Asparagi), Mai Men Dong (Radix Ophiopogonis), Bie Jia (Carapax Trionycis), Bai Shao Radix (Paeoniae alba), Ji Xue Teng (Caulis Spatholobi).
Clear Heat in the Heart (palpitations, insomnia, anxiety) with Huang Lian (Rhizoma Coptidis), Shan Zhi Zi (Fructus Gardeniae), Lian Xin (Plumula Nelumbinis nuciferae), Bai Zi Ren (Semen Platycladi)
Clear Heat in the Stomach (thirst and hunger) with Shi Gao (Gypsum Fibrosum), Zhi Mu (Radix Anemarrhenae), Gan Cao (Radix Glycyrrhizae uralensis), Huang Lian (Rhizoma Coptidis), Huang Qin (Radix Scutellariae)
Clear Liver Heat (dizziness, blurred vision, irritability, tremor) with Huang Qin (Radix Scutellariae), Long Dan Cao (Radix Gentianae), Xia Ku Cao (Spica Prunellae), Ci Shi (Magnetitum), Mu Li (Concha Ostreae).
Eliminate stagnation with Chai Hu (Radix Bupleuri), Xiang Fu (Rhizoma Cyperi), Yu Jin (Radix Curcumae), Fu Ling (Poria), Bai Zhu (Rhizoma Atractylodis macrocephalae).
For goitre, Dr Wei Zi Xiao uses Si Qi Tang (Four Seasons Decoction for the Seven Emotions) plus Gui Zhi (Ramulus Cinnamomi cassiae), E Zhu (Rhizoma Curcumae), Chuan Shan Jia (Squama Manitis Pentadactylae), Bai Jie Zi (Semen Sinapis albae), Mu Li (Concha Ostreae).
For exophthalmos he drains Dampness, resolves Phlegm, eliminates stasis and expels Wind using Mu Tong (Caulis Akebiae trifoliatae), Ze Xie (Rhizoma Alismatis), Bai Jie Zi Semen (Sinapis albae), Ban Xia (Rhizoma Pinelliae preparatum), Zhe Bei Mu (Bulbus Fritillariae thunbergii), E Zhu (Rhizoma Curcumae), Chi Shao (Radix Paeoniae rubra), Yi Mu Cao (Herba Leonur)i, Ju Hua (Flos Chrysanthemi), Mu Zei Cao (Herba Equiseti hiemalis), Bai Ji Li (Fructus Tribuli). Finally, he uses Hai Zao (Herba Sargassi) 20-30g per day.
Dr Zhu Ceng Bo
Dr Zhu Ceng Bo thinks that hyperthyroidism cannot be equated to the Chinese disease of Goitre. Dr Zhu distinguishes three main conditions in hyperthyroidism. The first is characterized by Fire of the Liver, Stomach and Heart with manifestations such as propensity to outbursts of anger, feeling of heat, sweating, excessive hunger, weight loss, thirst and insomnia. The second condition is characterized by Liver-Fire invading the Stomach causing manifestations such as thirst, dry mouth, excessive hunger, weight loss, insomnia, palpitations. The third condition is characterized by deficiency of Yin with such clinical manifestations as exhaustion, weight loss, dizziness, palpitations, anxiety, dry mouth, insomnia, a feeling of heat in the evening and 5-palm heat.
Identification of patterns and treatment
Based on the experience of these doctors and partly my own, the following patterns are the most common in hyperthyroidism;
- Liver-Qi stagnation
- Heat in the Liver, Heart and Stomach
- Liver- and Kidney-Yin deficiency with Empty Heat
- Phlegm-Heat in the Liver
Most of the patterns discussed below assume the absence of goitre. If there is goitre with hyperthyroidism, one must resolve Phlegm, soften hardness and dissolve masses with some of the following herbs:
Zhe Bei Mu (Bulbus Fritillariae thunbergii) and Ban Xia (Rhizoma Pinelliae preparatum) to resolve Phlegm. Kun Bu (Thallus Eckloniae), Hai Zao (Herba Sargassi) or Zhe Bei Mu (Bulbus Fritillariae thunbergii) to soften masses. Xia Ku Cao (Spica Prunella), E Zhu (Rhizoma Curcumae) or Huang Yao Zi (Radix Dioscoreae bulbiferae) to dissolve masses.
From the point of view of acupuncture treatment, if there is a goitre the distal points are selected according to the patterns discussed below, but the local points indicates above under Goitre should be added.
1. Liver Qi Stagnation
Hyperthyroidism, beginning stage, nervousness,
restlessness, heat intolerance, fatigue, palpitations, irritability, mental restlessness, depression, moodiness, abdominal distension, menstrual irregularities in women, pre-menstrual tension. Tongue: slightly Red sides. Pulse: Wiry.
Soothe the Liver, move Liver-Qi, calm the Mind, settle the Ethereal Soul.
T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, P-6 Neiguan, L.I.-4 Hegu, Ren-22 Tiantu. Even method.
T.B.-6 Zhigou, G.B.-34 Yanglingquan, LIV-3 Taichong, P-6 Neiguan move Liver-Qi, calm the Mind and settle the Ethereal Soul. L.I.-4 treats the neck area and together with LIV-3, calms the Mind and settles the Ethereal Soul. Ren-22 is a local point to affect the thyroid function.
2. Heat in the Liver, Heart and Stomach
Hyperthyroidism, thirst, excessive hunger, irritability, feeling of heat, weight loss, nervousness, restlessness, fatigue, insomnia, skin flushing, amenorrhoea or heavy periods, itching all over the body, palpitations, exophthalmos, propensity to outbursts of anger, mental restlessness, insomnia, palpitations, blood-shot eyes. Tongue: Red, with redder sides, yellow coating. Pulse: Wiry-Rapid.
Move Liver-Qi, drain Liver-Fire, Heart-Fire and Stomach-Heat, calm the Mind, settle the Ethereal Soul.
LIV-2 Xingjian, LIV-3 Taichong, HE-8 Shaofu, HE-7 Shenmen, ST-44 Neiting, L.I.-11 Quchi, G.B.-13 Benshen, Du-24 Shenting, Du-19 Houding, Ren-15 Jiuwei, SP-6 Sanyinjiao, Ren-22 Tiantu. Even method.
LIV-2 drains Liver-Fire. LIV-3 moves Liver-Qi. HE-8 and HE-7 drain Heart-Fire and calm the Mind. ST-44 and L.I.-11 clear Stomach-Heat. G.B.-13, Du-24, Du-19 and Ren-15 calm the Mind and settle the Ethereal Soul. SP-6 helps to clear Heat and also calms the Mind. Ren-22 is a local point affecting the thyroid function.
3. Liver and Kidney Yin Deficiency with Empty Heat
Hyperthyroidism, mental restlessness, feeling of heat in the evening, weight loss, nervousness, fatigue, insomnia, skin flushing, itching all over the body, palpitations, hair loss, exophthalmos, backache, dizziness, blurred vision, dry eyes, tinnitus, night-sweating. Tongue: Red without coating or partially without coating. Pulse: Floating-Empty. If there is internal Wind: tremor of the hands.
Nourish Liver- and Kidney-Yin, clear Empty Heat, calm the Mind.
Ren-4 Guanyuan, LIV-8 Ququan, SP-6 Sanyinjiao, KI-3 Taixi, LU-7 Lieque and KI-6 Zhaohai (Directing Vessel, Ren Mai), HE-7 Shenmen, Ren-15 Jiuwei, L.I.-4 Hegu with LIV-3 Taichong, Ren-22 Tiantu. Reinforcing method, except on LIV-3, L.I.-4 and Ren-22 which should be needled with even method.
Ren-4, LIV-8, SP-6 and KI-3 nourish Liver- and Kidney-Yin. LU-7 and KI-6 open the Directing Vessel and nourish Yin. HE-7 and Ren-15 nourish and calm the Mind. L.I.-4 and LIV-3 are used if there are hand tremors to extinguish internal Wind.Ren-22 to affect the thyroid function.
4. Phlegm Heat in the Liver
Mental restlessness, feeling of heat, weight loss, nervousness, fatigue, insomnia, skin flushing, itching all over the body, palpitations, exophthalmos, blurred vision, goitre, expectoration of phlegm, thirst, a sticky taste, a feeling of oppression of the chest. Tongue: Red with a sticky-yellow coating. Pulse: Wiry-Slippery-Rapid.
Drain Liver-Fire, resolve Phlegm, soften hardness, dissolve masses, calm the Mind, settle the Ethereal Soul.
LIV-3 Taichong, LIV-2 Xingjian, L.I..-11 Quchi, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-6
Sanyinjiao, Du-24 Shenting, G.B.-13 Benshen, Ren-22 Tiantu. Even method, except on Ren-12 which should be needled with reinforcing method.
LIV-3 and LIV-2 drain Liver-Fire, soothe the Liver, calm the Mind and settle the Ethereal Soul. L.I.-11 clears Heat. Ren-12, Ren-9, ST-40 and SP-6 resolve Phlegm. Du-24 and G.B.-13 calm the Mind and settle the Ethereal Soul. Ren-22 to affect the thyroid function.
First published in NZRA Journal of TCM.