Postpartum Thyroid Information: Are you an exhausted new mother,
or do you have a postpartum thyroid problem?

by: Laura Cramer
Department of Anthropology
Indiana University of Pennsylvania
Indiana, Pennsylvania 15705

(Disclaimer: Intended for reading by mothers in the postpartum period, to help with identification of fatigue and possible thyroid dysfunction. This information is not a replacement for diagnosis or treatment by a health care professional)

Many new mothers complain of exhaustion and fatigue well after delivery and into the first few months postpartum. This can be related to unexpected stress of caring for a newborn, lack of sleep, or-in some cases-a medical condition involving dysfunction of the thyroid gland. Although there have been a number of studies on this illness (often called postpartum thyroiditis or PPT) and a good deal of others on postpartum fatigue, rarely are both mentioned together. It should be recognized that fatigue is a symptom of thyroid dysfunction and can be treated by your doctor. (These two problems can be related, even though the literature does not explicitly state it.) How can you tell if you are suffering from thyroid dysfunction, and what should you do if this is what you suspect? This article will help you identify common symptoms of fatigue, its relation to thyroid dysfunction, and where to turn if the problem is severe.

Postpartum fatigue: symptoms and prevalence .

First, what is fatigue? How is it different from just being tired? Studies list some common symptoms as: exhaustion, inability to concentrate, difficulty thinking, nervousness, and lack of self-confidence, among others (See Appendix for a list of items used by physicians in diagnosing fatigue). In relation to childbearing women, a commonly held belief in today’s society is that women are almost completely recovered from childbirth after about six weeks. Recent research, however, demonstrates that this is not always the case. In one study, women were found to be more fatigued and less energetic at fourteen to nineteen months postpartum than at six weeks. When evaluating experiences of motherhood among 79 first-time mothers, one researcher found that the most frequent complaint was feeling unprepared for the demands of a newborn and for the level of fatigue experienced. If this sounds familiar to you, the most common recommendation for dealing with fatigue is to take time for yourself. For example, take a bath, listen to music, or exercise-anything to help replenish your state of mind. But what if your fatigue is a symptom of a larger problem? There are ways to recognize this, and important reasons to do so.

Postpartum thyroiditis and the relation to fatigue.

Depending on what article you read or what doctor you talk to, you will either be told that postpartum thyroiditis (PPT) is quite rare or that it is relatively common. Estimates of incidence within the literature vary from 1.9% to 16.7%. Also referred to as postpartum thyroid dysfunction, Stagnaro-Green (2000) writes that it is the most common endocrine-based disorder and varies geographically, ranging from 5% to 10%. In a book entitled Postpartum Survival Guide, however, the authors write that “problems in thyroid functioning are relatively rare postpartum”. To reduce the disparity between these claims, Gerstein reviewed the literature existing at the time and filtered out studies that were biased. The new range he constructed was 3.7% to 5.9%, with the best estimate being 4.9%. More recently, other studies give the rate of occurrence as 2% to 9%.

All of these numbers are meaningful to the researchers who do these studies, but what do they mean for you as a new mother? Is postpartum thyroiditis something a woman in the postpartum period should worry about? If the incidence is taken to be approximately 5%, that is equivalent to one in 20 women who experience thyroid dysfunction after giving birth. This is a significant proportion, making this disease something which should not be considered uncommon. Also, if fatigue is a frequent complaint of new mothers, cases of PPT may (and probably do) go undiagnosed.

Knowing that fatigue is the most frequent symptom of PPT, it can be used as an indicator leading to the observation of other symptoms. It is important to diagnose thyroid dysfunction because it may lead to permanent hypothyroidism in the years following birth and can also be a factor in postpartum depression.

What exactly is postpartum thyroiditis? It is a dysfunction of the thyroid, a gland that regulates the production of certain hormones within the body. After birth, production by the thyroid drops and it may have trouble regulating itself to return to pre-pregnancy levels of production. Another cause of PPT may be the increase in a hormone called prolactin, which is involved with breast milk production and breastfeeding and can cause temporary low thyroid production.

Postpartum thyroiditis has been shown to follow three sequential phases: hyperthyroidism (or thyrotoxicosis), hypothyroidism, and recovery. The first phase, thyrotoxicosis, appears one to three months after delivery. It is also known as hyperthyroidism, in which the thyroid gland works in overdrive to produce more hormone than necessary. During this time, you may have trouble sleeping and be overly anxious. After this, approximately three to six months after birth, a phase of hypothyroidism appears. This is a slowing down of production by the gland, and results in weight gain, sluggishness, and intolerance to cold. Postpartum thyroid dysfunction typically resolves without treatment when the mother’s body goes through a recovery phase and returns to a normal thyroid (euthyroid) state.

This diagram illustrates the rise and fall of the body’s thyroid levels when experiencing postpartum thyroiditis. Levels will differ depending on how many weeks have passed since giving birth. If measured between the eleventh and thirteenth weeks, levels may appear in the normal range. If test results come back as normal during this time, continue to monitor your body for signs of hypothyroidism in the following months. Approach your doctor with any concerns.

Diagnosis of PPT can be difficult if tests are done during the period between the hyperthyroid and hypothyroid state, when levels are within normal range. Some researchers believe that most patients recover spontaneously and no treatment is needed. It is when symptoms are significant and impair daily living that treatment should be considered. Other symptoms of postpartum thyroiditis that you may notice, in addition to fatigue, are goiter, dry skin, constipation, weight gain, and cold intolerance. Goiter is the most common physical sign: it is the painless enlargement of the thyroid gland, located at the base of the throat above the collarbone. In the case of one new mother, noticing this symptom along with realizing her need for excessive sleep were the reasons for seeking treatment from the family doctor. After receiving thyroid hormone replacement therapy, her condition improved and after six months she was able to gradually stop the medication. As this case demonstrates, being able to recognize such symptoms in yourself is an important step to seeking treatment.

Risk factors that have been cited for developing postpartum thyroiditis are:

1) goiter and the presence of antithyroid antibodies (which are detected through a blood test) in the first half of pregnancy,

2) previous occurrence of PPT,

3) family history of thyroid disease, and

4) the presence of insulin-dependent diabetes mellitus.

If you possess any of these risk factors, and therefore a greater chance of developing postpartum thyroiditis, you should be aware of the symptoms and take notice if any of them start to appear.

Symptoms of hypothyroidism

What to do if you think you have a thyroid dysfunction?

Seeking help from the family doctor is the crucial step in helping yourself. If you suspect thyroid dysfunction, but the doctor does not mention it as a possibility, he or she may be one of those who believe the condition is relatively rare. Also, if it is not in the front of his/her mind, she/he will probably not think of it very readily. According to one physician interviewed, the doctor must have a high index of suspicion to diagnose PPT. In light of this information, don’t feel afraid to suggest doing a thyroid test if your fatigue has been persistent or you have noticed other symptoms. Finding out if you are experiencing or have experienced postpartum thyroiditis is important to your health farther down the road: it has been found that 50% of women develop permanent hypothyroidism within five years of having PPT. Others studies found that up to one-third of affected women develop hypothyroidism within two to four years. Also, the recurrence of PPT is as high as 70%. Treatment for PPT varies depending on the stage in which it is found. For hyperthyroidism, your doctor may prescribe medication (probably beta-adrenergic-blocking drug e.g. propranolol or atenolol) to control symptoms. If hypothyroidism is the case, then thyroid hormone replacement therapy is appropriate treatment. Levothyroxine, a thyroid hormone, will be given to you to help regulate your thyroid. If your symptoms are not severe and your doctor does not decide to prescribe medication, keep watch of yourself and your symptoms. If improvement does not occur by one year after giving birth, and you are still feeling fatigued, visit your doctor again to rule out the possibility of permanent hypothyroidism.

Conclusion:

The high prevalence of fatigue among postpartum women is a concern that should not be taken lightly. It can be a symptom of larger medical problems, including postpartum thyroiditis. Considering the fact that some doctors feel PPT is rare, the actual incidence of this condition may be higher than previously believed. Being aware of the symptoms associated with this disease can help you identify a potential problem. If you suspect yourself to be experiencing a thyroid dysfunction, approach your doctor for possible treatment that may improve your life.

Selected Bibliography

Dunnewold, Anne, and Diane G. Sanford. Postpartum Survival Guide.
Oakland: New Harbinger, 1995.

Gerstein, Hertzel C. “How Common Is Postpartum Thyroiditis”
A Methodologic Overview of the Literature.
Archives of Internal Medicine 150 (1990): 1397-4000.

Lazarus, JH. Clinical Manifestations of Postpartum Thyroid Disease.”
Thyroid 9 (1999): 685-9.

Learoyd, D.L., H.Y. Fung, and A.M. McGregor. Postpartum Thyroid Dysfunction.
Thyroid 2 (1992): 73-80.

McVeigh, C. Motherhood Experiences From the Perspective of First-time Mothers.
Clinical Nursing Research 6 (1997):335-48.

Mestman, Jorge H. Postpartum Perinatal Thyroid Dysfunction: Recognizing the Problem.
Medscape Women’s Health 24 July 1997
http://www.medscape.com/medscape/WomensHealth/journal/1997/v02.n07/wh3268.mestman/wh3268.mestman.html

Miller, Laura J., ed. Postpartum Mood Disorders.
Washington DC: American Psychiatric Press, 1999.

“Postpartum Thyroiditis.” American Family Physician 45 (1992): 1901-02.

Pugh, et al. “Clinical Approaches in the Assessment of Childbearing Fatigue.”
Journal of Obstetric, Gynecological, and Neonatal Nursing 28 (1999): 74-80.

Sichel, Deborah and Jeanne W. Driscoll. Women’s Moods. New York: William Morrow and Co., 1999.

Stagnaro-Green, A. Recognizing, understanding, and Treating Postpartum
Thyroiditis. Endocrinology and Metabolism Clinics of North America 29 (2000): 417-30.

Terry, A.J. and W.M. Hague. “Postpartum Thyroiditis.”
Seminars in Perinatology 22 (1998): 497-502.

Troy, N.W. “A Comparison of Fatigue and Energy Levels at 6 Weeks and 14 to 19 Months Postpartum.” Clinical Nursing Research 8 (1999): 135-52.

White, Carolyn. Personal interview. 20 November 2000.

Acknowledgements

The author is grateful to Ms. Carolyn White, BS, RN, Dr. Kim Hatcher, and Dr. John Neale for their time and information provided that helped contribute to the completion of this article. Special thanks to Dr. Laurence Kruckman for his guidance and assistance throughout the writing and editing processes. The views stated within are those of the author and should not serve as replacement for seeking medical advice for health related problems.

Appendix

Fatigue Identification Form (from Pugh, et al. “Clinical Approaches in the Assessment of Childbearing Fatigue.” Journal of Obstetric, Gynecological, and Neonatal Nursing 28 (1999): 74-80.) This list of questions is generally administered by a nurse or doctor to help in determining the level of fatigue within patients. The following items do NOT determine problems but if you are experiencing some of them seek medical attention.

  1. My head feels heavy.
  2. My body feels tired.
  3. My legs feel tired.
  4. I yawn a lot.
  5. My brain feels hot and muddled.
  6. I am drowsy.
  7. My eyes feel strained. (tired)
  8. My movements are rigid or clumsy.
  9. I am unsteady when standing.
  10. I want to lie down.
  11. It’s difficult to think.
  12. I get weary talking.
  13. I am nervous.
  14. I can’t concentrate.
  15. I am unable to get interested in things.
  16. I am apt to forget things.
  17. I lack self-confidence.
  18. I’m anxious about things.
  19. I can’t straighten my posture.
  20. I lack patience.
  21. I have a headache.
  22. My shoulders feel stiff.
  23. My back hurts.
  24. It’s hard to breathe.
  25. I’m thirsty.
  26. My voice is husky.
  27. I feel dizzy.
  28. My eyelids twitch.
  29. My legs or arms tremble.
  30. I feel ill.