Dr. Zeba Hisam (Published in DAWN Magazine on Sunday, June17, 2001) There are certain medical conditions in which the signs and symptoms are very vague. Classical bookish picture is seldom seen in initial stages of the disease. One such disease is Hypothyroidism. There is an astonishing increase of this condition in our country but statistics are not present, nor any research going on to find the reasons. This write-up aims to make people understand this illness. Thyroid gland is situated in the neck in front of the windpipe (trachea). It produces thyroid hormones (Thyroxine T4 and T3) that are required for the metabolism of all the cells in the body. So it has got widespread functions in the body which are affected if the level in blood is either increased or decreased. Its deficiency is termed as Hypothyroidism in which all the bodily metabolisms are slowed down leading to slow mental and physical activity, depressed mood, sleepiness, tiredness, husky voice, weight gain due to fats and calories not being burnt, puffiness, intolerance to cold, etc. Iodine is needed to synthesize thyroid hormones. So Iodine deficiency can also lead to hypothyroidism. God has made an excellent checking mechanism that controls or limits the production via another hormone termed as TSH (Thyroid stimulating hormone) secreted by brain (Anterior pituitary gland). If levels of thyroid hormones are less in blood, TSH is automatically increased to stimulate thyroid gland to make more hormone so the gland becomes increased in size and can be seen as a swelling in front of the neck termed as “Goiter”. If levels are high TSH is decreased automatically to limit the production. In this manner T3 and T4 remain in equilibrium. Releasing or inhibiting factors from a part of brain called hypothalamus controls TSH in turn. If thyroid hormone is less in children, it leads to mental retardation and stunted growth, as normal development of brain and body needs thyroid hormones. Normally we all feel tired and fatigued after whole day’s work but we replenish our energies if we take adequate rest, sleep and healthy diet. I am talking about the fatigue that is not cured by sleep, rest or diet. I am sure that if a person is having such a problem he should consult a doctor to find out the cause. Of course there are hundreds of other causes that should be considered first on priority basis but as this condition is being on the rise in our country so this so-called rare condition should not be overlooked! One female patient, 43 years of age, came with a single complaint of tiredness and fatigue only. It was amazing for her as she used to be very active in all household chores. She told me that she used to wash curtains but one day she was shocked to find out that she could not wash even a handkerchief! On questioning she admitted that she had gained some weight also. On clinical examination nothing was found contributory. Her baseline tests were also normal. Then her Thyroid profile was ordered which showed low levels of T3 and T4 and high levels of TSH confirming hypothyroidism. This disease is very easy to treat but difficult to diagnose, as the symptoms are negligible initially. The patient was put on Thyroxine replacement and she became well after the adjustment of the regular dose. Once this condition is confirmed, patient has to take this medicine throughout life. Another female patient, 36 years of age, came with a single symptom of extreme sleepiness and complained that she used to feel that she was neither awake nor asleep. She could hardly get up from the bed. She used to feel as if she had taken some sedative. The overall feeling was of something not normal. This patient was also a very active otherwise. She was also found to have raised TSH and normal T3 and T4 indicating sub clinical stage of disease where increased TSH compensates the hormone. One male patient, 68 years of age, complained that he did not like to even converse with people, as he was so tired plus he suddenly lost interest in reading books and newspaper. Initial diagnosis of depression was made and an anti-depressant was started but it did not help, as the patient had no such event that could be attributed to cause depression. Due to his continuous complaining. the doctor tested thyroid profile that became positive for Hypothyroidism. On taking Thyroxine he became well and active. In all these cases, I found out that it is the patient who becomes curious about a certain symptom of fatigue provided that person is active enough to recognize that this fatigue is not normal. Complaint of tiredness and fatigue is so common among our people that unless they are not active enough in doing household chores or if they are lazy by nature, they are not going to recognize that something is wrong and they should go to a doctor and convince him to find out the cause. If treatment is delayed, Hypothyroidism will progress to complete thyroid failure and then the signs and symptoms will be ultimately attributed to almost all the systems of the body which are multiple and complex.