Hashimoto's disease does not have unique signs and symptoms. The disease typically progresses slowly over a number of years and causes chronic thyroid damage, leading to a drop in thyroid hormone levels in your blood. The signs and symptoms, if any, are those of an underactive thyroid gland (hypothyroidism).

The signs and symptoms of hypothyroidism vary widely, depending on the severity of hormone deficiency. At first, you may barely notice any symptoms, such as fatigue and sluggishness, or you may simply attribute them to getting older.

One of the most noticeable symptoms of Hashimoto's Thyroiditis is goiter. Goiter is an enlargement of the thyroid gland. As the thyroid begins to produce less hormones it attempts to compensate and the thyroid gland enlarges. The thyroid gland is found in the area of the neck. Therefore, goiter will be appear as an enlarged bulging area in the neck.

But as the disease progresses, you may develop more obvious signs and symptoms, including:

* Increased sensitivity to cold
* Constipation
* Pale, dry skin
* A puffy face
* Hoarse voice
* An elevated blood cholesterol level
* Unexplained weight gain - occurring infrequently and rarely more than 10 to 20 pounds, most of which is fluid
* Muscle aches, tenderness and stiffness, especially in your shoulders and hips
* Pain and stiffness in your joints and swelling in your knees or the small joints in your hands and feet
* Muscle weakness, especially in your lower extremities
* Excessive or prolonged menstrual bleeding (menorrhagia)
* Depression

Without treatment, signs and symptoms gradually become more severe and your thyroid gland may become enlarged (goiter). In addition, you may become more forgetful, your thought processes may slow, or you may feel depressed.

Your thyroid gland produces two main hormones, thyroxine (T-4) and triiodothyronine (T-3). They maintain the rate at which your body uses fats and carbohydrates, help control your body temperature, influence your heart rate and help regulate the production of protein.

The rate at which thyroxine and triiodothyronine are released is controlled by your pituitary gland and your hypothalamus - an area at the base of your brain that acts as a thermostat for your whole system. The hypothalamus signals your pituitary gland to make a hormone called thyroid-stimulating hormone (TSH). Your pituitary gland then releases TSH - the amount depends on how much thyroxine and triiodothyronine are in your blood. Finally, your thyroid gland regulates its production of hormones based on the amount of TSH it receives. Although this process usually works well, the thyroid sometimes fails to produce enough hormones.

Your immune system's role

Normally, your immune system uses naturally occurring proteins (antibodies) and white blood cells (lymphocytes) to help protect against viruses, bacteria and foreign substances (antigens) that invade your body. Hashimoto's disease is an autoimmune disorder in which your immune system creates antibodies that damage your thyroid gland. The disease causes inflammation of your thyroid gland (thyroiditis), which may impair the ability of your thyroid to produce hormones, leading to an underactive thyroid gland (hypothyroidism). Then, your pituitary gland attempts to stimulate your thyroid gland to produce more thyroid hormones, thus causing your thyroid gland to enlarge (goiter).

Doctors don't know what causes your immune system to attack your thyroid gland. Some scientists think a virus or bacterium might trigger the response, while others believe a genetic flaw may be involved. Most likely, Hashimoto's disease results from more than one factor. A combination of factors, including heredity, sex and age, may determine your likelihood of developing the disorder. Hashimoto's disease is most common in middle-aged women and tends to run in families.

Diagnosis of Hashimoto's disease is based on your signs and symptoms and the results of blood tests that measure levels of thyroid hormone and thyroid-stimulating hormone (TSH). These may include:

* A hormone test. Blood tests can determine the amount of hormones produced by your thyroid and pituitary glands. If your thyroid is underactive, the level of thyroid hormone is low. At the same time, the level of TSH is elevated because your pituitary gland tries to stimulate your thyroid gland to produce more thyroid hormone.

* An antibody test. Because Hashimoto's disease is an autoimmune disorder, the cause involves production of abnormal antibodies. A blood test may confirm the presence of such antibodies.

Histologic Findings

Hashimoto thyroiditis is a histologic diagnosis. Typically, the thyroid gland shows diffuse lymphocytic and plasma cell infiltration with formation of lymphoid follicles from follicular hyperplasia and damage to the follicular basement membrane. Atrophy of the thyroid parenchyma is usually evident. Correlation with the presence of thyroid autoantibodies, namely anti-TPO and also anti-Tg, is helpful for confirming the definite diagnosis.

The treatment of choice for Hashimoto thyroiditis (or hypothyroidism of any cause) is thyroid hormone replacement. The drug of choice is orally administered levothyroxine sodium, usually for life.

o Tailor and titrate the dose to meet the individual patient's requirements. The goal of therapy is to restore a clinically and biochemically euthyroid state. The standard dose is 1.6-1.8 mcg/kg lean body weight per day, but the dose is patient dependent. Both the free T4 and TSH levels are within reference ranges in the biochemically euthyroid state, with the TSH level in the lower half of the reference range.

o Patients younger than 50 years who have no history or evidence of cardiac disease can usually be started on full replacement doses.

o Start patients older than 50 years and younger patients with cardiac disease on a low dose of 25 mcg (0.025 mg) per day, with clinical and biochemical reevaluation in 6-8 weeks. Carefully titrate the dose upward to achieve a clinical and biochemical euthyroid state. Rarely, it may not be possible to achieve a euthyroid state in a patient with baseline cardiac dysrhythmic disease without worsening his or her cardiac status. In such cases, the astute clinician is content to achieve the clinically euthyroid state and to accept a slightly elevated TSH level.

o Elderly patients usually require a smaller replacement dose of levothyroxine, sometimes less than 1 mcg/kg lean body weight per day.

o One popular treatment, moreso among patients than physicians, is the combined use of liothyronine (T3) and levothyroxine in an effort to mimic more closely thyroid hormone physiology. However, of 9 controlled clinical trials, in only one did combined therapy appear to have beneficial effects on the mood, quality of life, and psychometric performance of the patients over levothyroxine alone. Until clear advantages of levothyroxine plus liothyronine are demonstrated, the administration of levothyroxine alone should remain the treatment of choice for replacement therapy of hypothyroidism.

Surgical Care - Indications for surgery

o A large goiter with obstructive symptoms such as dysphagia, voice hoarseness, and stridor from extrinsic obstruction to airflow: Evaluate patients with these symptoms with a barium swallow study and pulmonary function tests, including flow volume loops and a neck CT scan.

o Presence of a malignant nodule, as found by cytologic exam