WOMEN WITH GRAVES’ DISEASE. A NURSE PERSPECTIVE ON HOLISTIC TREATMENT

LYDIA F DANIELS GATWARD AND AILEEN JF KING | Features

Hyperthyroidism is a common endocrine condition, affecting 2% of women in the UK. The average age of onset is 30–60 years.¹ Nurse-led services can play a pivotal role in helping women to navigate the challenges of hyperthyroidism by providing a holistic approach. Building on NICE guidance, assessing and managing each individual patient’s physical, psychological, social and faith-based needs can facilitate and inform shared decision making, with the essential aim of euthyroidism.²

PHYSICAL CONSIDERATIONS

A holistic patient review allows for the exploration of physical and lifestyle considerations that aid management and encourage health promotion. For instance, assessing a patient’s menstrual status can identify menopause, which is often missed, given that symptoms are similar to those of hyperthyroidism. If menopause is suspected, patients can be advised to arrange a GP review to consider conventional hormone replacement therapy or be directed to alternative management options. Haematinic assessment should be considered in those women with menorrhagia.

In women of childbearing age, advice on avoiding pregnancy while thyrotoxic, and navigating the most appropriate treatment options in consideration of pregnancy planning, are important. For example, a 39-year-old woman planning to conceive may choose not to have radioiodine, due to the restrictions on conceiving post-treatment.

Assessment of nutritional status, in particular dietary restrictions and intolerances, is helpful if euthyroidism is achieved but symptoms of hyperthyroidism persist. Iron and vitamin B12 deficiency can present with similar symptoms to hyperthyroidism, and are more commonly found in people who follow plant-based diets (where nutrition may not be optimal) and coeliac disease. Screening for coeliac disease should also be considered in patients with autoimmune thyroid disease.¹ This is especially pertinent for female patients, due to a higher prevalence among women. Provision of dietary advice, with or without haematinics assessment and treatment, can aid optimisation of nutritional status.

Weight gain is a recognised phenomenon in the treatment of hyperthyroidism^3,4 and menopause can further exacerbate this.⁵ Promoting healthy eating habits and providing advice on managing satiety at diagnosis can potentially reduce the impact of weight gain and avoid intentional non-adherence to anti-thyroid drugs.⁶

ADDITIONAL LIFESTYLE AND HEALTH PROMOTION CONSIDERATIONS

These should include:

bone health – consider assessment of vitamin D status if at high risk (e.g. low exposure to sunlight or not using supplements during the autumn/winter months)
smoking cessation advice to reduce the risk of thyroid eye disease⁷
selenium supplements for active thyroid eye disease⁷
advice on how to safely continue exercising
avoiding alcohol and caffeine when thyrotoxic
sleep hygiene advice
identifying supplements that may lead to assay interference and misinterpretation of thyroid results (e.g. biotin)
provision of patient information and signposting to patient support groups.

PSYCHOLOGICAL CONSIDERATIONS

At initial review, the psychological impact of hyperthyroidism and support systems available should be highlighted, along with reassurance that symptoms generally improve with treatment. In the interim period, patients can be signposted to well-being apps, such as Headspace and NHS resources, to address anxiety, depression and sleep disturbances.

Mental health status should be assessed at every review, given that anxiety and depression are associated with hyperthyroidism and may not fully resolve following achievement of euthyroidism, and further intervention may be required.⁸

Physical symptoms and changes in appearance can cause embarrassment and affect self-confidence, which may lead to social withdrawal. While fatigue, sleep disturbance, diarrhoea, tremor and increased sweating generally improve, changes in weight and thyroid eye disease may not return to baseline^4,7 and can significantly impact self-esteem and confidence.

Lifestyle advice and the provision of patient information at initial review can improve outcomes and reduce psychological burden. Examples include smoking cessation, selenium supplementation, psychological support and achieving euthyroidism in patients with thyroid eye disease.⁷

Listening to and addressing patient concerns regarding the impact of hyperthyroidism and its management can improve outcomes, such as adherence to treatment and psychological well-being.⁴ The NHS has a wealth of information supporting mental health, with the option of self-referral widely available.

SOCIAL AND FAITH-BASED CONSIDERATIONS

Social factors, including work, study, family, living situation, finances and cognitive abilities, influence the management of hyperthyroidism. Patient-centred assessment, shared decision making and evaluation of social factors highlight potential issues, with management options that enable care to be tailored to the individual’s needs. For example, radioiodine may not be an acceptable treatment option for a woman seeking pregnancy and/or with young children.

Financial constraints can affect adherence to treatment and engagement in care. Examples include an inability to fund prescriptions or being unable to attend appointments due to childcare and/or the cost of travel.

While we cannot change a person’s circumstances, we can individualise support, for example, by providing virtual reviews with blood tests undertaken locally to reduce the impact on work and travel costs. We should also be conscious of our prescribing choices, e.g. recommending carbimazole 5mg tablets to allow for easier dose titration, avoidance of waste, and prescription costs. However, careful consideration is required to balance this against potential adherence issues associated with taking multiple doses.⁶

Identifying barriers to patients’ understanding, and the provision of appropriate and accessible patient information, are crucial for facilitating effective communication and improving patient’s knowledge of their condition.⁹ A mixture of learning materials, i.e. written or media-based, allows information to be tailored to the individual’s needs. For example, a webinar may be more helpful to someone with a low reading age.

Religious beliefs can also influence thyroid management, so identifying and addressing needs and providing support can improve outcomes. For instance, providing guidance on medication management during Ramadan may support adherence, and it can be helpful to provide counselling on treatment options where religious beliefs may conflict, such as the use of artificial contraception.

IN SUMMARY

NICE guidance highlights the importance of patient-centred care and shared decision making in the management of hyperthyroidism, both of which are inherent to holistic practice.¹ Barriers to the provision of holistic care include time, insufficient resources or training, and financial constraints.² Examples include limited consultation time or no trained endocrine nurse.

Patient support groups, such as the British Thyroid Foundation, provide invaluable support and resources to patients and thyroid services across the UK. When there are constraints on service provision, patients can be signposted to a wide range of resources (see panel).

A holistic approach to hyperthyroidism identifies the individual patient factors and needs, which affect management choices and outcomes. Holistic care promotes shared decision making with the aim of improving patient experience and euthyroidism through patient engagement and adherence to treatment.

LOUISE BREEN
Advanced Nurse Practitioner and Lead Nurse in Endocrinology, Guy’s and St Thomas’ NHS Foundation Trust, Chair of the Society’s Nurse Committee

LISA SHEPHERD
Advanced Nurse Practitioner at University Hospitals Birmingham NHS Foundation Trust, NIHR Clinical Doctoral Research Fellow at the University of Birmingham, Member of the Society’s Nurse Committee