Lymphocytic Thyroiditis

Subtypes, Prognosis, and Coping

Lymphocytic thyroiditis is an autoimmune disorder where immune cells attack the thyroid gland and affect the production of thyroid hormone. There is initially a phase of increased thyroid hormone (hyperthyroidism or thyrotoxicosis) followed by a phase of hypothyroidism which may be acute or chronic.

There are multiple subtypes of lymphocytic thyroiditis. This article will cover each subtype in detail.

Subacute Lymphocytic Thyroiditis

Subacute lymphocytic thyroiditis refers to types of thyroiditis that only last a period of a few months or so but do not cause permanent thyroid problems. Subacute lymphocytic thyroiditis can further be subcategorized into silent lymphocytic thyroiditis and painless thyroiditis.

Silent Lymphocytic Thyroiditis

Silent lymphocytic thyroiditis has a defining characteristic of the presence of lymphocytic thyroiditis without pain or tenderness in the thyroid gland. The condition is common in women who have recently given birth and generally starts when a woman is 12-16 weeks postpartum. This type of thyroiditis is common and occurs in about 5-10% of all postpartum women.

The duration of silent lymphocytic thyroiditis is typically only a few months. After this period of time thyroid hormone levels usually return to normal. In rare cases hypothyroidism may become chronic.

Another condition called painless thyroiditis is similar but occurs in men and women who are not postpartum.

Symptoms

  • Thyroid enlargement without pain or tenderness
  • Early symptoms of hyperthyroidism, which tend to be transient, such as heart palpitations, nervousness, weight loss, heat intolerance, diarrhea, and increased appetite
  • Late symptoms of hypothyroidism including cold intolerance, weight gain, constipation, and fatigue

Diagnosis

Silent lymphocytic thyroiditis frequently goes undiagnosed. When a diagnosis is made it typically occurs during the period of hypothyroidism. The diagnosis is made by a physical examination, considering the history of your symptoms and if you are postpartum and by testing blood levels of the thyroid hormones thyroxine (T4), triiodothyronine (T3), and thyroid-stimulating hormone (TSH).

Treatment 

Treatment depends on what phase of the condition a diagnosis is made. During the hyperthyroidism phase a beta-blocker is typically prescribed to manage symptoms but since the condition is transient and lasts only a short period of time more aggressive treatments for hyperthyroidism such as radioactive iodine are not used.

If diagnosis is made during a period of hypothyroidism typically a thyroid hormone replacement medication such as levothyroxine is prescribed. You usually remain on this levothyroxine for about a year at which point the medication is stopped and your blood levels are tested five weeks later to see if the medicine can be discontinued.

Painless Thyroiditis

Painless thyroiditis is another subtype of acute thyroiditis that can occur in both men and women who are not in the postpartum period. Like other types of thyroiditis, there is usually a period of hyperthyroidism followed by a period of hypothyroidism after which a full recovery is often made. However, it is possible to develop chronic lymphocytic thyroiditis after having painless thyroiditis. This condition may also be recurring.

There may be a hereditary component to painless thyroiditis. Also, the use of certain medications, including drugs that affect the immune system such as glucocorticoids or interleukin, may bring on this condition.

Symptoms

  • During a period of hyperthyroidism, lasting two to eight weeks, you may experience weight loss, rapid heart rate, slight enlargement of the thyroid (painless), increased appetite, heat intolerance or diarrhea.
  • You may then have a period of hypothyroidism during which you may experience weight gain, constipation, fatigue, depression, and other symptoms.
  • Approximately half of the people who experience painless thyroiditis also develop a goiter.

Not all people with painless thyroiditis develop hypothyroidism. It is possible to recover after a period of hyperthyroidism.

Diagnosis

A diagnosis is made based on a physical examination, a history of your symptoms as well as your family history of thyroid disease in combination with blood work (thyroid hormone levels and thyroglobulin) and thyroid scintigraphy.

Thyroid scintigraphy is a nuclear medicine test that involves ingesting radioactive tracers or radioactive iodine and then taking pictures of the thyroid to see how the tissue absorbs this material. It can be helpful in distinguishing painless thyroiditis from Graves disease.

Treatment

Thyroid dysfunction in painless thyroiditis is often mild and frequently requires no treatment. If treatment is need during the hyperthyroid phase due to severe symptoms or if you are at risk of developing a heart condition called atrial fibrillation you may be prescribed a beta-blocker.

As with most types of thyroiditis if you require treatment for hypothyroidism you will most likely be prescribed levothyroxine.

Chronic Lymphocytic Thyroiditis

Chronic lymphocytic thyroiditis is also commonly referred to as Hashimoto's thyroiditis or just Hashimoto's disease or even autoimmune thyroiditis. This is the most common cause of hypothyroidism in the United States.

Chronic lymphocytic thyroiditis is an autoimmune disorder (your immune system attacks your thyroid) that tends to be hereditary. It is similar to subacute thyroiditis but the condition lasts much longer. It can affect men, women, and children but is most common in women and more likely to affect people ages 30-50 years.

In chronic lymphocytic thyroiditis the immune system attacks the thyroid causing chronic inflammation of the thyroid gland and permanent damage to the cells which eventually prevents the thyroid from making an adequate amount of thyroid hormones. The result is chronic hypothyroidism.

Symptoms

There may be no symptoms or only very mild symptoms in the early stages of chronic lymphocytic thyroiditis. As time goes on, more and more of the thyroid gland is damaged, less thyroid hormone is produced and more symptoms occur. Symptoms of chronic lymphocytic thyroiditis may include:

  • Fatigue
  • Weight gain
  • Cold intolerance
  • Loss of appetite
  • Constipation
  • Depression
  • Joint stiffness
  • Muscle pain
  • Infertility
  • Changes in the menstrual cycle
  • Dry skin
  • Hair loss
  • Slow heart rate
  • Difficulty concentrating
  • Poor memory
  • Reduced exercise tolerance
  • Goiter
  • Enlarged thyroid

Diagnosis

Your doctor will perform a physical exam including palpating your thyroid for any enlargement or goiter. She will also take a complete health history and note your symptoms as well as any family history you may have of chronic lymphocytic thyroiditis.

If lymphocytic thyroiditis is suspected blood tests that may be ordered include thyroid hormone levels (T3, T4, TSH) and a blood level of thyroid peroxidase (TPO). Thyroid peroxidase is an antithyroid antibody and it's presence usually means that your immune system is attacking your thyroid.

If your doctor thinks you have an enlarged thyroid gland or a goiter further testing such as ultrasound or other medical imaging may be ordered to evaluate the size of the goiter and determine if treatment such as surgery may be warranted.

Treatment

Levothyroxine is the treatment of choice for managing hypothyroidism due to chronic lymphocytic thyroiditis. Your blood levels of thyroid hormone will need to be checked at periodic intervals to ensure that you are on the correct dose of this medication.

It can be most beneficial to find a doctor who is experienced in managing disorders of the thyroid. An endocrinologist is a physician who specializes in these types of disorders.

In rare cases large goiters that make it difficult to swallow or interfere with other bodily functions such as breathing may need to be surgically removed. Small goiters require no treatment and may resolve following treatment with appropriate medication.

Prognosis

While you may achieve a complete recovery in cases of subacute thyroiditis. it may recur every couple of years in some individuals. Chronic lymphocytic thyroiditis is a lifelong condition.

The good news is that with appropriate treatment your thyroid levels can return to normal and your symptoms may completely subside. You will likely have to take a thyroid replacement medication indefinitely and have your blood work checked every now and again to make sure you are on the proper dose of medication.

Coping With Lymphocytic Thyroiditis

Finding the right doctor to help manage symptoms of lymphocytic thyroiditis is imperative when it comes to coping with the symptoms of lymphocytic thyroiditis. Coping can be especially difficult since thyroiditis can often lead to mood disorders such as depression. It is important to discuss these symptoms with your physician and to realize that they often resolve with appropriate treatment.

It may be helpful to join a support group and to be open about your feelings with family and friends. Do not hesitate to seek professional help when necessary.

Fatigue is another difficult symptom to cope with. You may need to reduce the demands on your time and reduce your expectations of things you are able to accomplish in a day in order to cope with a reduced energy level until your thyroid levels normalize. It will be helpful to practice good sleep habits and reduce your caffeine intake in the meantime (caffeine can reduce your quality of sleep leading to even greater fatigue).

Coping with weight gain related to thyroiditis can also be especially challenging, particularly for women. Weight issues often resolve with appropriate levothyroxine dosing. This can take time to achieve however. In the meantime continue eating a healthy diet and exercise on a regular basis. Exercise can not only be helpful in managing weight but in managing other symptoms such as depression and constipation.

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Article Sources

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  2. Burman KD. Painless thyroiditis. UpToDate. Updated May 20, 2019.

  3. American Thyroid Association. Hashimoto's thyroiditis.

  4. Cleveland Clinic. Hashimoto's disease.