Mumbai: Thyroid disorders are highly prevalent in India. Approximately 8.3 – 10.4% or 1 in 10 adults suffer from hypothyroidism, which occurs when the thyroid gland does not produce enough thyroid hormones to meet the needs of the body. This condition is twice as prevalent in women as in men and the condition is common among women of child-bearing age. A 2016 study conducted in nine Indian states across OPD setups assessing prevalence of hypothyroidism in pregnancy with TSH cutoffs < 4.5 found 13.13% of pregnant women to be hypothyroid.  Following trimester-specific TSH cutoffs of <2.5 mIU/L for the first trimester and <3.0 mIU/L for the second and third trimester, as recommended by the FOGSI, ITS & NRHM guidelines, prevalence of hypothyroidism was found to be 44.3%, 32.0%, and 34% in the first, second, and third trimester, respectively.  There is significant regional variation in prevalence, and in Maharashtra, the study showed 17.85% prevalence in Pune and 14% in Nasik.

Abnormal levels of thyroid hormones during pregnancy are associated with increased risk  of complications such as anemia, miscarriages, postpartum bleeding, preeclampsia and placental abruption. The thyroid hormone is critical for normal development of the fetal brain and nervous system and during the first trimester, the fetus depends on the mother’s supply of thyroid hormone, which directly comes through the placenta. Therefore, treating thyroid disorders is important for both maternal and child health, as thyroid disorders significantly increase the risk of adverse birth outcomes such as preterm birth, low birth weight and fetal death. Thyroid hormone is  critical for normal development of the fetal brain and nervous system.

Despite high prevalence of hypothyroidism among pregnant women in India, and the risks that the condition poses, there is low penetration of screening and testing for the condition in pregnant women. Dr. Nandita Palshetkar, President of Federation of Obstetric and Gynecological Societies of India (FOGSI), explains, “Since thyroid disorders present non-specific symptoms such as fatigue, weight gain, constipation etc., they are often difficult to diagnose without testing. In the absence of visible signs and symptoms of thyroid disorders, combined with low patient awareness, thyroid testing tends to be overlooked.”

Detection in the first trimester is particularly important. ITS guidelines recommend that testing should be conducted at the first prenatal visit or at the time of confirmation of pregnancy, and that diagnosis should be based on trimester-specific TSH thresholds. Dr. Shashank Joshi, Secretary, Indian Thyroid Society (ITS), observes, “Late detection not only increases the chance that surgical intervention is required, but it also leads to higher risk of irreversible damage caused by complications. Thus, ITS and FOGSI strongly advocate thyroid screening in the first trimester of pregnancy and in maintaining trimester specific TSH at the upper threshold of 2.5 mI/L in the first trimester and 3.0 mI/L in the second and third trimester for better maternal and fetal outcomes.”

Awareness plays a critical role in the fight against under-detection. Under its campaign, Making India Thyroid Aware (MITA) and in partnership with Abbott India, ITS seeks to drive awareness amongst doctors and patients for early diagnosis and treatment of thyroid disorders amongst women in the age group of 25 to 45 years. Through a range of initiatives driving education among doctors, making Indian women aware of thyroid disorders and facilitating early detection, MITA has reached over 50,000 doctors and 5.6 million patients nationwide since 2011. Recently, Abbott and ITS launched a digital campaign to procure pledges from doctors across India in support of MITA. In recognition of each pledge and to further diagnostic access for underprivileged women, Abbott will donate an equal number of free screening tests to an NGO. More than 8,500 doctor pledges have been received till date.

Dr. Srirupa, Medical Director, Abbott adds, “Abbott is a thought leader in thyroid therapy and has been a knowledge and education partner to ITS to drive awareness of thyroid disorders in India. In the coming year, Abbott, ITS and FOGSI plan to educate another 20,000 physicians and gynecologists, while also driving awareness among 10 million thyroid patients through digital, print and in-clinic initiatives. Combining the skills and resources of multiple stakeholders, this campaign can lead to greater awareness, strengthening of health services and eventually better disease control. With access to the physician and gynecologists bodies to cascade changes swiftly, we can raise awareness through initiatives at scale, ensuring they reach both medical and patient communities.”

Dr. Nandita Palshetkar adds, “When we use trimester-specific cutoffs, the prevalence of hypothyroidism can be as high as 44% in the first trimester. This is also a critical period, as early detection will help reduce the risks to both the mother and the fetus. Given that thyroid disease is asymptomatic, with symptoms such as tiredness, low cold tolerance and weight gain that are commonplace, universal screening is the way forward. Due to a combination of low awareness and the asymptomatic nature of thyroid disease, up to 49% of pregnant women with hypothyroidism may remain undetected and untreated.”

“Thyroid testing is particularly important for three groups of women, namely pregnant women, women suffering from infertility and women with irregular periods.”

Dr. Shashank Joshi adds, “Given how treatable thyroid disorders are, and how widespread they are, there is a need for greater awareness of this condition. One can liken thyroid disorders to an iceberg: what we see as physicians and patients is just the tip of the actual burden and implications of this often hidden and invisible condition. Low awareness results in low penetration of testing on-ground, despite the fact that advances in thyroid testing have made it more accurate, more accessible and more affordable than before.”

“Thyroid prevalence is on the rise. We have seen a surge in cases. The reasons are two-fold. First, awareness is rising, as is access to healthcare services that drive testing of this condition. This means more patients with this condition are being diagnosed, though there is a long way to go. Second, the most common cause of thyroid disorders is autoimmunity, which in turn is often triggered by stress. Thyroid tends to impact women between the age of 18-35, which is the most productive period of their life, as well as the prime reproductive period, because that is also the time when they tend to suffer the most stress.”