Whether you know it or not, there is a small, butterfly-shaped gland located directly under your larynx that affects the function of virtually every organ in your body. It regulates your metabolism, it affects your mood, it even affects your cognitive abilities. And it affects your voice. If it is functioning properly, you might never give it a thought—but if you are one of more than 20 million Americans affected by thyroid disease, then you will, indeed, take an interest.
This article originally appeared in Classical Singer magazine. To subscribe to the print magazine, go to www.csmusic.info/subscribe.
Disclaimer: I have managed a condition known as Hashimoto’s thyroiditis (an autoimmune disease also known as autoimmune thyroiditis) for the past dozen years. Much of the information in this article was hard won, gathered as I researched the topic in hopes of finding a solution to my condition that would leave me in good health, both physically and vocally.
That disclaimer made, this article is not “The Thyroid: One Woman’s Story,” though I will share parts of my experience when I think they may offer a useful insight. And nothing in this article is intended as medical advice. It is simply an overview of the subject that will cover the basics of how the thyroid functions and what happens when it does not function properly—along with what steps you might want to consider taking to protect your current and future thyroid health.
I hope that by the time you finish reading you will have an idea of how to determine if you should suspect a thyroid problem and be armed with some helpful facts if it is an issue in the future. Even if you are in perfect health now, you may want to consider having thyroid blood tests done to get a baseline of what your thyroid numbers are when you’re feeling well. That way, if you turn out to be one of the one in eight women—or the fewer but still significant number of men—who will experience thyroid disease in your life, you’ll be able to compare your numbers.
For singers, the locale of the gland should be reason enough to care. Part of the thyroid, the isthmus, goes directly across the front of the throat. Let’s learn more about it.
The Thyroid Gland: The Body’s Gas Station
The thyroid, from the Greek thyreos for “shield,” is a two-lobed gland located at the front of the neck, directly underneath and around the larynx. It produces and stores hormones and helps to regulate many of the body’s functions, including metabolism. It affects mood, brain function, skeletal health, and much more. Because it stores both iodine and hormones, the size of the thyroid varies. If the thyroid is larger than normal, or the isthmus is enlarged, the larynx will have difficulty moving properly, which is why problems with the thyroid can affect vocal function greatly.
Iodine is a chemical element and an essential nutrient. It is an important part of thyroid function. Part of the thyroid’s job is to trap iodine. This is why, in cases of radiation exposure, people are provided with Potassium Iodide to, essentially, fill up the thyroid with that type of iodine so that it is not available to absorb radioactive iodine. People who have been exposed to a significant amount of radiation have higher incidences of thyroid cancer. (More on the controversies around iodine supplementation later.)
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The thyroid gland is particularly sensitive to changes in hormonal fluctuations and, as a result, thyroid problems are often exposed for women during times of hormonal changes, such as puberty, pregnancy, and menopause. Thyroid hormone affects fetal brain development, so pregnancy is a particularly important time to make sure the thyroid is healthy. Though more common in women than men, all sources indicate that thyroid disease can happen to men or women at any age.
All this is to say that it is important. And without the right amount of thyroid hormone, the body does not function well.
Thyroid Disease: Two Sides of the Coin
Thyroid cancer, though uncommon compared with other types of cancer, is the only type of cancer that is currently on the rise, and that is a subject worthy of concern and study. But the focus of this article is the more commonly occurring conditions of the thyroid: hypothyroidism and hyperthyroidism.
A quick side note: one of the best resources I have found on the subject of thyroid illness is the work of journalist Mary Shomon. She went through a difficult process getting properly diagnosed and treated for hypothyroidism in 1995. Her own struggles triggered a strong journalistic curiosity as well as a desire to see that other thyroid sufferers have an easier time than she did. Shomon has gone on to write several useful and best-selling books on the subject (see resources sidebar). My own problems might have become a genuine tale of woe had it not been for her groundbreaking work. Shomon has since become known as a patient advocate, and her books include suggestions for navigating the health care system that are useful well beyond the topic of thyroid disease.
Hypothyroidism
“Hypo” means less than normal, or deficient. Symptoms of hypothyroidism include weight gain, digestive problems, lethargy, depression, sensitivity to cold, change in appearance around eyes (such as drooping of the eyelids and some hair loss with the outer portion of the eyebrow), and slowed thought process. Dry skin and hair loss can also occur. Other symptoms include—pay attention singers—hoarseness and impaired memory. People also report a “thick-tongued” feeling. When I listen back to recordings of my speech when I was particularly “hypo,” I can hear that my diction is poor. And on the topic of vocal changes, the first symptom I noticed when I became ill was that it was extremely difficult to lower my larynx properly, making singing above my upper passaggio very difficult and even painful.
Hyperthyroidism
“Hyper” means excessive. Hyperthyroidism is basically the opposite of being “hypo”: the thyroid produces too much hormone, often leading to an enlargement of the gland. The most common cause of hyperthyroidism is Graves’ Disease, which is also an autoimmune disorder. Instead of too little energy, the person has too much. Other symptoms include weight loss, muscle weakness, jittery nerves, and also a change in eye appearance (different than with “hypo”) where the eyes appear very large, almost “bug-eyed.”
With both hypo- and hyperthyroidism, not all symptoms are always present.
Testing One, Two, Three
The tests and treatments outlined below are those used by conventional western medical practitioners. They are offered with the intention of navigating that system more easily, not at all to exclude other possible avenues for wellness.
If you suspect a thyroid problem and go to the doctor to ask about it, or if your doctor considers you to be at risk and decides to test you, you are likely to be given a blood test. This basic, starter kit of a thyroid test is called the “TSH” test. As a gland that makes hormones, the thyroid has a special hormone to kick off their production. This hormone is called the thyroid-stimulating hormone (TSH). If doctors order only one blood test for thyroid, it will be this. But there is cause to be concerned about the use of this test alone as an indicator.
The problem is this: What constitutes normal? I know singers who were tested for deafness when they were children, because their voices were so abnormally loud! In most instances, there is a range among people of what is considered normal, and TSH is no exception. The American Thyroid Association states that as many as 60 percent of people with thyroid conditions are unaware of their condition, which can cause difficulty in creating an accurate reference range. Awareness of this issue exists in the medical establishment to the degree that in 2003 what constitutes a “normal” range for the TSH was substantially altered.
The American Association of Clinical Endocrinologists recommended the use of a new, narrower range, stating, “AACE believes the new range will result in proper diagnosis for millions of Americans who suffer from a mild thyroid disorder, but have gone untreated until now.” The higher your TSH, the harder your gland is working to produce the hormone. Normally, if everything is A-OK, it won’t have to work that hard, so a high TSH is certainly cause for concern. But knowing how high is too high for you may not be so simple. That is why I say that if you feel fine, why not have your thyroid tested as a baseline for normal?
But there is another problem with, as Shomon calls it, “the Tyranny of the TSH.” Many thyroid problems are autoimmune in nature. Autoimmunity is when the immune system goes into overdrive and starts attacking things that it shouldn’t, like your thyroid hormone. If you are suffering from Hashimoto’s thyroiditis (named after the Japanese doctor who discovered it in 1912), then your body is actually making antibodies to fight off your thyroid hormone, as if it were something attacking your body.
Your actual thyroid hormone levels can be checked with tests for the two types of thyroid your body needs (called T4 and T3.) But no matter how much thyroid hormone you have, if you are producing antibodies to it, your body will not, let’s say, get the memo. The antibodies will cancel out the thyroid hormone, and you will be left feeling “hypo.” High levels of antibodies would be revealed with antibodies blood tests, but not by a TSH test. Ultrasounds are also used as diagnostic tool, though there is some controversy there as well as to whether the presence of nodules on the gland is the cause of illness.
Treatments
In very general terms, the treatment for hypothyroidism, whether it is autoimmune in nature or caused for other reasons, is to offer a thyroid hormone replacement to your body, whether a synthetic thyroid or a natural one derived from an animal source, usually pig thyroid.
The treatments for hyperthyroidism are more complex, because the goal is to get the thyroid to stop overproducing. Sometimes radioactive iodine is used, as are anti-thyroid medications or beta blockers—or, in extreme cases, the thyroid may be partially removed.
The thyroid is also sometimes removed in cases of hypothyroidism when the thyroid is very enlarged or a goiter—a severe enlargement of the thyroid—is present. If the thyroid is removed altogether, replacement hormone is offered. (Surgery of this kind, so near all the delicate musculature of the larynx, would almost certainly be a last resort for any singer.)
Summary and Iodine Supplements
As in any field, there are people who are more conservative than others, those who maintain the status quo and those who push the envelope. Naturally, there is a wide spectrum of opinion and practice among doctors. That is precisely why Shomon’s books, and others on the topic of patient empowerment, are valuable—so that you learn to navigate whatever health challenges (thyroid or otherwise) you may face as a true partner in your own wellness, choosing practitioners that make sense to you and that help you feel better!
Shomon’s website is a great starting point and ongoing resource, not only for Western medical approaches but also information on alternative treatments, supplements, and other topics. But beware: too much time on the Internet researching health issues can be bad for your health! Learn to gather your information from a variety of reliable sources at a pace and with a method you feel is right for you.
I am happy to say that I am in good health, vocally and otherwise, and though I can think of things that are more fun than having thyroiditis, I have learned a lot from the experience. The worst year, by far, was the first, when I experienced great difficulty reaching a proper diagnosis and treatment. Being a singer saying that there was something wrong with my voice, when my throat and vocal cords appeared completely normal, did not win me any points in the credibility department with doctors. “No, really, Doctor, my voice feels funny!” As a result, I learned to do my own research, stand up for myself with the “experts” and, ultimately, I believe, trust myself at a deeper level. So, I suppose I am grateful for the experience—which is to say I wouldn’t wish it on anyone.
Finally, there is an important point to be made regarding iodine. As mentioned, the thyroid gland is involved in the body’s absorption of iodine, and it’s tempting to read about iodine deficiency and see the shelf at the health food store full of wonderful, natural iodine supplements from fish oil to kelp and think, “Hey, I’ll grab a bottle of those and exercise more and live happily ever after.”
But it’s not that simple. “That practice can be problematic for many people, because many cases of autoimmune thyroid disease—which is by far the most common cause of thyroid conditions in the U.S.—are not due to iodine deficiency,” says Shomon. Iodine deficiency is a very serious problem globally, but predominantly in regions well outside the U.S.
One article on iodine goes so far as to say “Iodine. Crucial nutrient or harmful toxin?” In my case, taking iodine supplements dramatically worsened my symptoms, as did doing yoga inversions, which can be used to stimulate the thyroid gland but, in my case, exacerbated my symptoms.
I mention this to underscore the fact that gathering information is useful only if it is measured against your own experience. It doesn’t do any good to follow the latest “health trend” if it doesn’t actually help you feel well. And new information is always coming in. For example, there is currently research being done on the relationship between gluten and autoimmune disease. But with any health problem, you can only do the best you can with the information and resources available at the time.
The thyroid is a shield, in shape and function, protecting the body in many ways. And while there may be no absolute way to protect yourself from having a thyroid problem, if you do proper research, trust your intuitive wisdom, and find knowledgeable and compassionate health practitioners, you can care for this essential part of your—and your voice’s—health and well being.
