Understanding the cause (client) What do you think has been causing the significant increase in weight? I don’t know, but something is really wrong, I think. Even my periods are going wrong. Your practitioner impression
Suzanne is obviously obese. Your first impression of her is someone who lacks confidence and is quite unsure of herself.

TABLE 4.2 CONTEXT

Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease.
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Family health
Has anyone else in your family experienced similar problems?	My mum is pretty big, but not as big as I am. Her sister is a lot like me, she’s really big.
Supplements and side effects of medication
Are you taking any supplements or medications from the doctor?	I went to the chemist and got a multivitamin and I also bought some weight-loss tablets, but they haven’t helped my energy or my weight.
Endocrine/reproductive
Did your irregular period cycle come on suddenly or begin to slow down gradually?	I used to be more regular and then it began to slow down and chop and change. Now I get confused about when it’s going to come.
Stress and neurological
Do you feel stressed at the moment?	Yes. I feel so bad about putting on this weight and I know I don’t do enough exercise, but I feel so tired all of the time.
Eating habits and energy
Describe your diet.	Suzanne’s description of her diet indicates it is quite healthy, containing good amounts of whole foods, fresh fruit and vegetables. She insists her portion sizes are normal and on further questioning her description of her portion sizes indicates she is not eating excessive amounts at mealtimes.

TABLE 4.3 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Support systems
Do you have a good support system?	I have my parents and some friends.
Emotional health
Do you think you are depressed?	I think I am.
Stress release
How do you manage your stress?	I don’t know, I just usually read or watch TV.
Family and friends
Do you spend much time with family or friends?	I see my parents at least once a week. I haven’t seen my friends much recently since I feel really embarrassed whenever I go out with them. They’re always nice to me, but I just feel they think I should try harder.
Action needed to heal
What do you think you need to do to get better?	I really don’t know, I’ve tried dieting and exercising but it didn’t really work. I’m hoping you can help me.
Long-term goals
What are your long-term goals?	To get slimmer and fitter and to get my energy back. I want to get a job and am thinking of retraining and doing something different.

TABLE 4.4 SUZANNE’S SIGNS AND SYMPTOMS [2, 6–8]

Results of medical investigations

Suzanne has not had any medical investigations.

TABLE 4.5 UNLIKELY DIAGNOSTIC CONSIDERATIONS [2, 7–11]

CONDITIONS AND CAUSES	WHY UNLIKELY
INFECTION AND INFLAMMATION
Chronic salpingo-oophoritis: irregular cycle; can be minimal or excessive menstrual bleed	Usually congestive dysmenorrhoea is the predominant symptom; associated with purulent discharge, fever, period pain and abdominal pain
Postpartum thyroiditis: transient hypothyroid after pregnancy	No pregnancies that we know of
ENDOCRINE/REPRODUCTIVE
Diabetes: anovulatory cycles	Urinalysis NAD
Primary dysmenorrhoea: lower abdominal pain, can get worse with menstrual cycle	Period pain usually begins at menarche and is often associated with no pelvic abnormality, nausea vomiting, headache and dizziness
Secondary dysmenorrhoea: acquired due to pathology; period pain begins several years after menarche and due to a pelvic abnormality	No menstrual pain
Endometriosis: irregular periods	No significant pelvic pain or pain on menstrual bleed reported; no bleeding from the bowel; usually brown discharge with associated abdominal and pelvic pain
Premenstrual syndrome: pain in the abdomen before menses	Will experience premenstrual mood changes, feel teary, bloated and swollen 1–12 days before her period; experiences a dull pelvic ache, abdominal bloating
Ovarian cyst: irregular periods	Ovarian cysts almost never cause heavy menstrual bleeding
Ovulatory bleed: have a bleed mid-cycle as well as regular menses and ovulation has occurred	Feel emotional, premenstrual symptoms such as ovulation pain (mittelschmerz) and mood changes; usually spotting or light bleed at time of ovulation, regular cycle; check basal body temperature as it will be biphasic and fluctuate indicating ovulation has occurred

Case analysis

TABLE 4.6 POSSIBLE DIFFERENTIAL DIAGNOSIS

NOT RULED OUT BY TESTS/INVESTIGATIONS ALREADY DONE [2, 7–11, 56–58]
CONDITIONS AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
FAMILY HEALTH
Familial or idiopathic hirsutism: excess hair growth would not be typically androgenic	Excess hair appearing on hormonal influenced areas of the body where hair will grow, such as the face	Check if family history of excess hair growth for females
ALLERGIES AND IRRITANTS
Food intolerance/allergy	Fatigue, depression; skin and hair changes; constipation	Need to gain more insight into Suzanne’s diet and associated symptoms
CANCER AND HEART DISEASE
Thyroid cancer	Deep voice, thyroid swelling	Will have signs of pain in neck or throat, difficulty swallowing, nodule or lump around laryngeal prominence, trouble breathing, difficulty speaking, hoarse throat; thyroid gland will have a single firm nodule that has developed rapidly
Ovarian, uterine cancer	Heavy irregular bleeding	No vaginal discharge reported
Adult onset and congenital adrenal hyperplasia/adrenal tumour: can cause primary and secondary amenorrhoea anovulatory cycles	Usually presents with severe acne and hirsutism; can present with anovulatory irregular menstrual bleeding	Check if there was rapid development of symptoms and how severe symptoms of virilisation are; usually will be severe and can include symptoms such as frontal balding, enlarged clitoris
TRAUMA AND PRE-EXISTING ILLNESS
Congenital – dyshormonogenesis: genetic defects in synthesis of thyroid hormone – primary cause	Goitre and hypothyroid symptoms	Rare condition; may have associated deafness; need to investigate for family history of thyroid disease; will present with childhood symptoms such as dwarfism, mental retardation, pot belly, delayed bone age
OBSTRUCTION AND FOREIGN BODY
Intestinal obstruction (bowel cancer, adhesions, hernias, faecal impaction with overflow)	Abdominal constipation	No vomiting, abdominal pain and distension
FUNCTIONAL DISEASE
Thyroid benign nodules: follicular adenomas, cysts, focal thyroiditis	Deep voice, thyroid swelling, hypothyroid symptoms	Nodules develop rapidly
Fibromyalgia: pain in axial skeleton with tender points that has lasted more than 3 months	Tiredness, aches and pains more common in women; can be worse from being in cold weather; depression	Will often present with irritable bowel symptoms, difficulty sleeping; normal laboratory results; rule out organic reasons for symptoms
Obstructive sleep apnoea	Fatigue during the day; more common when overweight or obese; does not usually complain of ‘sleepiness’ but fatigue generally	Need to define if Suzanne does not feel well rested in the morning and if she snores during the night; can be made worse by alcohol consumption prior to sleeping
Obesity	BMI 35; lack of exercise; usually general distribution of weight gain	Goitre visible; usually no other abnormal health features other than being overweight; appetite is usually increased; oedema present (unusual); need to define if Suzanne has a family history of obesity; need to define if Suzanne’s weight gain has been gradual with increased caloric intake and/or with eating more sugar
Chronic fatigue syndrome: fatigue for at least 6 months that has no physical, psychoses, bipolar affective disorder, eating disorder or organic brain disease	Severe disabling fatigue affects both mental and physical functioning for at least 6 months; sleeping more, depression, feelings of guilt, social withdrawal, crying spells; muscular aches and pains	Goitre indicates a physical reason for fatigue; need to define if Suzanne’s fatigue improves as the day progresses
Functional constipation	Constipation, lack of exercise, stress	Need to check if more than 1 in 4 bowel motions is lumpy and hard, and causes strain, a feeling of incomplete evacuation or blockage; need to check if manual help is needed to facilitate a bowel motion passing; does she have fewer than 3 evacuations in a week?
DEGENERATIVE AND DEFICIENCY
Iodine deficiency: iodine required for thyroid hormone synthesis – primary cause	Goitre and hypothyroid or euthyroid	In mountainous areas of Alps, Himalayas, South America, Central Africa; thyroid gland can have multiple nodules
Pernicious anaemia: lack of B12 absorption due to immune destruction of intrinsic factor in atrophic gastritis and loss of stomach parietal cells	Fatigue, slow movements, cognitive impairment, can present with hypothyroidism	Usually low blood pressure and rapid heart rate, shortness of breath, swollen red tongue, diarrhoea, can also present with hyperthyroidism
Anaemia: iron deficiency, pernicious anaemia, due to heavy menstrual bleeding	Fatigue, depression	Usually signs of shortness of breath, palpitations, increased heart rate
INFECTION AND INFLAMMATION
Post-subacute thyroiditis: primary cause	Goitre and hypothyroid symptoms	Would be a transient condition of infective origin rather than the symptoms gradually building up over time; soft tender, sometimes painful goitre
Riedel’s thyroiditis: fibrous tissue infiltrates and replaces the thyroid gland	Goitre hypothyroid symptoms; more common in women	Very hard goitre; rare form of thyroid disease
Osteoarthritis	Pain in many joints and more common in women	Usually develops in older age groups; presents with signs of limited range of movement, bony swellings and instability of joints; not necessarily associated with severe fatigue; need to check family history as it can be congenital and begin at an early age
Postviral infection	Depression, fatigue	Need to rule out if Suzanne has had viral symptoms prior to feeling fatigued and depressed
SUPPLEMENTS AND SIDE EFFECTS OF MEDICATION
Drugs: lithium, antithyroid medication, cytokines	Cause hypothyroid symptoms	Need to check medication history
ENDOCRINE/REPRODUCTIVE
Hypothalamic-pituituary disease: tumour, hypopituitarism is secondary cause of hypothyroidism	Goitre; symptoms of hypothyroid such as irregular periods, depression, weight gain, slow pulse, constipation, low body temperature	Blood tests will rule out secondary causes of hypothyroidism
Hypothyroidism: cause of secondary amenorrhoea due to hyperprolactinaemia and endocrine disorder; anovulatory cycles	Goitre, weight gain, fatigue, depression, irregular periods, heavy menses, constipation, increased facial hair (hirsutism), puffy eyes, deep voice, dry hair, low body temperature, slow pulse, muscle aches, slow movements, change in appetite
Subclinical hypothyroidism [59, 60]	Weight gain, fatigue, depression, irregular periods, heavy menses, constipation, change in appetite	Need to check if serum TSH levels are above limit and T3 and T4 levels present as normal; could indicate clinical hypothyroidism may develop
Pregnancy	Irregular periods; missed periods; most common cause of secondary amenorrhoea; can present with vaginal discharge and pelvic/abdominal pain	Suzanne claims she is not sexually active at the moment and has no partner; pregnancy can present with fever; will have signs of breast tenderness and may have morning sickness
Uterine fibroids and polyps: fibroids form due to excess oestrogen and can cause symptoms of heavy bleeding, uterine enlargement	Usually causes menorrhagia (blood loss of 80 mL per day and lasting more than 7 days)	Often maintains normal cycle unless submucosal or nearly extruded
Polycystic ovarian syndrome (PCOS): extremely common cause of secondary amenorrhoea; anovulatory cycles	Irregular menstrual cycles, acne, increased facial hair (hirsutism), weight gain; irregular periods came on slowly	Can occur with androgenic alopecia (thinning of hair on the head such as men have); may not be associated with heavy menstrual bleeding
Cushing’s syndrome: cause amenorrhoea, irregular menstrual cycles	Irregular menstrual cycles, increased facial hair, depression, weight gain, higher scale blood pressure	There was not a rapid development of symptoms; no moon-shaped face or frontal balding; urinalysis NAD and indicating no glucose intolerance or diabetes that can be associated with Cushing’s syndrome
Dysfunctional uterine bleeding (DUB): endometrial hyperplasia, PCOS, from taking exogenous oestrogen; endocrine dysfunction; (not associated with inflammation, tumour or pregnancy) anovulatory hormone-related bleeding is most common	Usually causes bleeding with unpredictable volume and frequency; often accompanied by menorrhagia (heavy bleed with regular cycle) but interval between periods is shorter to make the cycle appear irregular	No use of exogenous oestrogen reported
Anovulatory bleeding: have irregular bleed that appears menstrual although no ovulation has occurred; can be associated with both short and long cycles	Irregular cycle; no significant premenstrual symptoms reported to show evidence of regular association with menses cycle; bleed is painless and unexpected; blood volume can be excessive but irregular; physical findings will often include hirsutism, acne	Check basal body temperature; if anovulatory it will not fluctuate (monophasic)
Oestrogen-withdrawal bleeding: causes intermenstrual bleeding; occurs when the endometrium proliferates and becomes unstable when oestrogen drops below threshold; can happen outside of the secretory phase or in the absence of progesterone	Common cause of irregular periods in reproductive years, especially if ovulation has not occurred; menstrual bleeding is prolonged and profuse when it does occur; bleed is painless
Progesterone-withdrawal bleeding: only occurs when there is an oestrogen-primed endometrium; can occur when oestrogen therapy continued and progesterone stopped; also when progesterone is administered to test endogenous oestrogen	Irregular menstrual bleed; often present in conditions such as amenorrhoea
Oestrogen-breakthrough bleeding – 1st type: when oestrogen levels are low but constant causing sections of endometrium to degenerate	Intermenstrual bleed	Need to investigate if experience any spotting of blood
Oestrogen-breakthrough bleeding – 2nd type: oestrogen levels are well above threshold causing endometrium to become hyperplastic and outgrow blood-borne hormone supply	Causes degeneration of endometrium with prolonged and irregular bleeding	More common in oestrogen-based tumours
AUTOIMMUNE DISEASE
Atrophic thyroiditis: (autoimmune) most common cause of primary hypothyroidism; will cause atrophy and fibrosis of the thyroid gland	Goitre; may be intermittent and recover; symptoms of hypothyroidism; common in women	Check for the presence of antithyroid antibodies and pernicious anaemia; thyroid gland will be enlarged, sometimes painful and soft swelling
Hashimoto’s thyroiditis: [58] important to rule out an autoimmune cause of primary hypothyroidism	Goitre; common in women	More often presents in late middle age
Rheumatoid arthritis	Muscle aches and pain; common in women, fatigue due to anaemia of chronic disease	Check if family history of rheumatoid arthritis
Systemic lupus erythematosus	Generalised aches and pains, skin changes, more common in women, increased fatigue	See if there is a butterfly rash on Suzanne’s face
STRESS AND NEUROLOGICAL DISEASE
Depression: important differential diagnosis to rule out before exploring other possibilities of mental or organic causes for fatigue symptoms
*Primary origins* Primary depression and endogenous depression are associated conditions that are regarded as primary disorders, i.e. that do not occur secondarily to other medical or psychiatric disorders; these terms refer to depression that is caused by internal chemical and biological factors rather than external stressors
Type 1 – major (clinical) depression	Has at least five symptoms of depression every day for more than 2 weeks, which causes considerable incapacity with daily activities; people often describe symptoms in physical terms; depressed daily, loss of interest in daily activities, change of appetite, weight gain, increased fatigue, slower movements, feelings of worthlessness	Need to define if Suzanne feels worse in the morning and has a sense of apprehension; visible goitre indicates the feelings of depression come from a secondary origin
Dysthymia: mild depressive illness	Could be experiencing ‘double depression’ if Suzanne has had intermittent periods of depression in the past; symptoms include tiredness, lack of interest in life and low mood	Lasts intermittently for 2 years or more; need to determine if Suzanne has had a tendency to have episodes of feeling low prior to the onset of her physical changes
*Secondary origins* Reactive depression and associated conditions that occur after or in response to a pre-existing medical or psychiatric disorder; brought on by external life experiences
Seasonal affective disorder: secondary to the winter months	Symptoms include increased sleep, tiredness, change in appetite, weight gain	Need to determine if Suzanne has experienced episodes of depression during the winter months in the past; usually appetite increases
*Psychological* Functional fatigue (depression)	Tiredness that has lasted several months	Need to determine if Suzanne’s fatigue improves as the day progresses; determine if her fatigue began after a specific life event or only when her physical symptoms began
EATING HABITS AND ENERGY
Causal factor:Diet high in brassica and cassava foods: when in excess can cause hypothyroid symptoms	Symptoms of underactive thyroid	Need to ask if Suzanne regularly eats broccoli, spinach, cabbage, cauliflower, brussels sprouts, kale, collard greens, pak choi and tapioca is in Suzanne’s diet
Causal factor:Lack of exercise	Weight gain, fatigue, depression

TABLE 4.7 DECISION TABLE FOR REFERRAL [2, 7–12]

COMPLAINT	CONTEXT	CORE
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• BMI over 30 indicating obesity • Weight gain associated with goitre

• A menstruating woman of any age can bleed from pregnancy complications

• Irregular bleeding in menstrual cycle for years

• Change in volume of menstrual bleed

• Hirsutism associated with menstrual change and other virilising symptoms such as acne

• Weight gain with decreased appetite

• Pattern of premenstrual symptoms have stopped, indicating lack of ovulation

• Social isolation

• Significant depression

• Symptoms have worsened without Suzanne seeking medical help

ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE

• Lack of exercise

• Puffy eyes, dry hair and skin

• Significant fatigue although sleeping well at night

• Worsening constipation

• Embarrassed about weight and hirsutism

• Unemployed

• Would like to have children and a husband

• Family pressure regarding marriage

REFERRAL REFERRAL REFERRAL

• Signs and symptoms warrant further investigations for a definitive diagnosis of hypothyroidism [56, 57]; we have a duty of care to Suzanne to encourage her to be informed regarding possible treatment using thyroxine medication [58, 60]

• Dietary assessment

• Medical assessment on associated menstrual, metabolic and virilising symptoms

• Mental health assessment and counselling

• Career advice

TABLE 4.8 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [2, 6–11, 13, 57, 60]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Pelvic, vaginal, abdominal examination	Check for bulging uterus, ovaries can be palpable in PCOS, abdominal rebound tenderness, overactive bowel sounds, genital deformities, signs of trauma
Musculoskeletal examination	Back strain, trauma, deformities, inflammation
Human chorionic gonadotropin (HCG) blood test/radioimmunoassay (RIA)	Pregnancy, ectopic pregnancy
Full blood count	Check for signs of infection, virus or allergic reaction; rule out anaemia
Thyroid function test Thyroid stimulating hormone (TSH) Thyroid hormones (T4, T3 synthesised in the thyroid gland)	TSH: High in primary and subclinical hypothyroidism; normal or low in secondary hypothyroidism (hypothalamic-pituitary cause) T4: Low in primary and secondary hypothyroidism; normal reading in subclinical hypothyroidism T3: Low in primary and secondary hypothyroidism; normal reading in subclinical hypothyroidism
‘Free’ T4: available for tissue action	Measures only the unbound active T4 hormone; will be low in hypothyroid
Thyroxine-binding globulin (TBG) – binds T4 and T3 in plasma	Will be increased in hypothyroidism
Thyroid antibody: blood test thyroid perioxidase antibody, antithyroglobulin antibody	Autoimmune causes of hypothyroidism
Serum cholesterol	Can be raised in hypothyroidism
ESR/CRP	Inflammation such as in systemic lupus erythematosus (SLE) and rheumatoid arthritis
Progesterone level	Test 7 days before menstruation due to see if ovulation has occurred; low serum progesterone level in anovulatory cycles
Oestradiol	Normal: PCOS, weight loss, excess exercise Raised: pregnancy, ovarian tumour, testicular tumour, adrenal tumour Low: PCOS, polycystic ovarian disease, ovarian failure, anorexia nervosa, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal hyperplasia, menopause, Turner’s syndrome, failing pregnancy, fetal death
FSH (follicle-stimulating hormone)	Normal: PCOS, pregnancy, anorexia, weight loss, excess exercise Raised: ovarian failure, menopause Low: polycystic ovarian disease, anorexia, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal tumour/hyperplasia
LH (luteinising hormone) due to pulsatile action of this hormone it may not be accurately measured on one random sample	Normal: pregnancy, anorexia, weight loss, excess exercise Raised: PCOS, polycystic ovarian disease, ovarian failure, menopause Low: anorexia, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal tumour/hyperplasia
PRL (prolactin) commonly raised in secondary amenorrhoea	Normal: ovarian failure, anorexia, weight loss, excess exercise, adrenal tumour/hyperplasia Raised: PCOS (mildly), hypothyroidism, Cushing’s syndrome, pregnancy, amenorrhoea Low: pituitary destruction from tumour
Testosterone	Normal: ovarian failure, anorexia, weight loss, excess exercise, hypothyroidism, pregnancy Raised: PCOS, Cushing’s syndrome, adrenal tumour/hyperplasia, testicular tumour, ovarian tumour Low: corticosteriod use
SHBG (sex hormone-binding globulin)	Low SHBG would indicate the presence of elevated levels of free androgens
Fasting blood glucose test	Raised levels can indicate diabetes mellitus, Cushing’s syndrome
Cervical smear	To detect cervical cancer
HOME TESTS:
Basal body temperature	Normally drops 24–36 hours after menses commences; with endometriosis there is often a delay in basal body temperature to the second or third day of menses; a decrease indicates preovulation and an increase of 5 degrees occurs after ovulation Monitors thyroid function; low temperature readings consistently over a period of days can indicate subclinical or clinical hypothyroidism
Ovulation prediction kits	Designed to detect an increase in urinary luteinising hormone (LH) excretion 24–36 hrs prior to ovulation
Diet dairy	Assess caloric intake and possible food sensitivities
IF NECESSARY:
Serum aspartate transferase	Will be increased from muscle and liver in hypothyroid
Serum creatine kinase levels	Increased with associated myopathy in hypothyroidism
Sodium levels	Low due to increase in ADH and slow free water clearance
Thyrotropin releasing hormone (TRH)	TRH is released in the hypothalamus to stimulate release of TSH from pituitary; determine hypothalamic-pituitary disease
Anti-nuclear antibody	Autoimmune disorders, SLE, rheumatoid arthritis
RH factor	Rheumatoid arthritis
Epstein-Barr virus blood test	Postviral symptoms, may show that Suzanne has had this virus in the past without realising it
Abdominal and pelvic x-ray/ultrasound	Most accurate diagnosis of PCOS, ovarian mass, ovarian cyst or tumour, retroverted uterus, tubo-ovarian abscesses, fibroids, trauma; intestinal obstruction
Brain scan CT/MRI	Pituitary tumour
Back x-ray CT scan and MRI	Degenerative disc disease, disc prolapse, Ankylosing spondylitis, Paget’s disease, osteoporosis

Confirmed diagnosis

Suzanne and hypothyroidism

Suzanne is a 32-year-old woman who has come to the clinic asking for help with weight loss – she has now reached a BMI of 35. Additionally Suzanne is experiencing significant fatigue despite sleeping long hours at night, has worsening constipation, a lack of appetite and is depressed. She has also been experiencing irregular and heavy periods, has developed facial hair growth and acne, dry skin and hair and suffers from generalised aches and pains in her body. On the whole Suzanne is feeling very low about herself and this is not made any better by her family being disappointed that she does not yet have a husband and children. Suzanne is currently unemployed and does not leave her home often. She is not exercising because she is too embarrassed to do so outside of her home and is not motivated on her own.

On physical examination it became evident that Suzanne has a visible goitre, deep voice, puffy eyes, slow movements and speech, low body temperature and pulse rate and high blood pressure. Suzanne required immediate referral for a medical and mental health assessment. A medical diagnosis of hypothyroidism was confirmed, which explains the range of symptoms she has been experiencing.

Hypothyroidism is an ailment characterised by under-activity of the thyroid gland (i.e. insufficient production of thyroid hormones). The most ‘observable’ sign of hypothyroidism is a goitre and low basal temperature in the morning. Other symptoms include fatigue, weight gain, memory and mental impairment, dry skin, cold intolerance, decreased concentration, constipation, depression, loss of hair, coarse hair, muscle and joint pain, goitre, hyperlipidaemia, irregular periods, infertility, hoarseness, yellow skin, lowered body temperature, drooping swollen eyes, reduced or excessive sweating, brittle nails, diminished sex drive and slow healing.

Hypothyroidism occurs most frequently in women over the age of 40 (however, men and teenagers may also have hypothyroidism). It is possible for a woman or man to have symptoms of subclinical hypothyroidism for many years before developing a clinical manifestation of the disease. Approximately 50 per cent of people with hypothyroidism are unaware they have the condition [56]. Although clients with this disorder can be asymptomatic, some clients have subtle findings including alteration in lipid metabolism as well as abnormalities in cardiac, gastrointestinal, neuropsychotic and reproductive functions [57].

General references used in this diagnosis: 2, 7, 8, 10, 11, 56–58

Prescribed medication

• Thyroxine

TABLE 4.9 DECISION TABLE FOR TREATMENT

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Improve thyroid function and endogenous production of thyroid hormones via recommendations to increase dietary intake of nutrients essential for thyroid hormone production • Improve thyroid function and endogenous production of thyroid hormones via physical therapy suggestions and recommendation to increase exercise • Improve thyroid function and endogenous production of thyroid hormones by identifying and addressing chemical or heavy metal exposure, which may affect thyroid function