Hashimoto’s thyroiditis is an autoimmune disorder in which the immune system attacks the thyroid gland. This autoimmune response is often triggered by genetic and environmental factors and is more common in women. This leads to chronic inflammation and gradual destruction of thyroid tissue. 

In some areas of Sub-Saharan Africa, limited access to iodine-rich foods and iodized salt contributes to inadequate thyroid hormone synthesis. Iodine is crucial for the production of thyroxine (T4) and triiodothyronine (T3). In deficiency states, the thyroid gland becomes hyper-stimulated by thyroid-stimulating hormone (TSH), leading to goiter development. Over time, this compensatory mechanism may fail, resulting in decreased hormone levels and clinical hypothyroidism. Other nutrients like selenium are vital for the thyroid gland. Food high in thiocyanide are goitrogens which contribute to hypothyroidism by blocking the uptake of iodine. Contributing factors in the region may include poor healthcare access, lack of public health education, and underdiagnosis, especially in women and the elderly.

Symptoms of hypothyroidism may often go unrecognized or be mistaken for other conditions. It may be asymptomatic, being diagnosed during routine thyroid function testing. Common symptoms include:

• Fatigue and weakness
• Weight gain despite poor appetite
• Cold intolerance
• Dry skin and coarse hair
• Constipation
• Depression or slowed mental activity
• Menstrual irregularities in women
• Goiter (enlarged thyroid gland)

These findings may be subtle or advanced, often missed due to limited diagnostic resources and overlap with other endemic conditions like malnutrition or anemia.

• Goiter – common if due to iodine deficiency
• Bradycardia – slow heart rate
• Dry, rough skin and coarse hair
• Puffy face and periorbital swelling
• Delayed reflexes, especially ankle jerk
• Pale or cool skin
• Weight gain with poor appetite
• Signs of anemia (pale conjunctiva)

Careful clinical assessment and basic lab tests (TSH, T3/T4) are important to distinguish hypothyroidism from these conditions, though access to testing may be limited.

• Iron-deficiency anemia – shares symptoms like fatigue and pallor
• Chronic malnutrition – can cause weight changes, weakness, and dry skin
• Depression – may present with low mood, fatigue, and slowed thinking
• Heart failure – can cause edema, fatigue, and bradycardia
• Tuberculosis – chronic illness with weight loss and lethargy
• Nephrotic syndrome – causes facial puffiness and fatigue
• Menopause – in women, may present with fatigue and menstrual changes

Diagnosis of hypothyroidism relies on both clinical suspicion and laboratory testing.

Key investigations include:

• Serum TSH – elevated in primary hypothyroidism
• Free T4 (FT4) – usually low
• Free T3 (FT3) – may be low or normal
• Thyroid antibodies – (e.g., anti-TPO) if autoimmune thyroiditis is suspected (limited availability)
• Neck ultrasound – for goiter assessment or nodules (where available)
• Hemoglobin level – to check for anemia
• Serum cholesterol – may be elevated

Treatment can only be commenced when there is laboratory evidence of a high TSH (>5) and low T4 or T3 and/or clinical symptoms. ON NO ACCOUNT MUST THE TREATMENT BE STARTED BASED ON CLINICAL SYMPTOMS ALONE WITH/WITHOUT THE PRESENCE OF A GOITER.

The main treatment for hypothyroidism is levothyroxine, a synthetic thyroid hormone:

• Levothyroxine is given orally, once daily, with the dose adjusted based on TSH levels and clinical response. And must be taken 2 hours before or after a meal to avoid its absorption being affected. Safely, one may ask the patient to use it as he/she wakes up in the morning or at bedtime. In addition, it must be started at the lowest doses (12.5 to 25mcg) in the elderly to avoid the adverse side effects such as arrhythmias.
• Lifelong therapy may be required, especially in cases of permanent thyroid failure.
• In areas with iodine deficiency, iodine supplementation (iodized salt or iodine tablets) is essential for prevention and in mild cases.
• As monitoring may be limited because of poor resources, patient should endeavor to check at least the serum TSH 3 to 4 times a year because symptom improvement alone is not enough to assess good control. When the blood level of the thyroid gland is stabilized, the thyroid tests could be done annually.

Challenges include irregular drug supply, poor access to lab testing, and limited awareness, especially in rural settings.

• Iodine supplementation: Widespread use of iodized salt is the most effective preventive measure to reduce iodine deficiency, the leading cause of hypothyroidism in the region.
• Eating balanced diet containing minerals like selenium
• Avoid consuming food high in thiocyanate: Example of such food are in cultivated yams, wild yams, bananas and cassava flour.
• Public health campaigns: Education on the importance of iodine-rich foods (e.g., fish, dairy, and eggs) can improve dietary habits.
• Routine screening with serum TSH: Implementing screening programs for newborns and vulnerable populations, such as pregnant women, can help detect hypothyroidism early.
• Improved healthcare access: Expanding access to thyroid function tests and treatment options, especially in rural areas, is essential for better management and control.
• Local production of thyroid medications: Ensuring a steady supply of affordable levothyroxine for treatment can improve long-term outcomes.

These strategies, combined with public health efforts and stronger healthcare infrastructure, can significantly reduce the burden of hypothyroidism in Sub-Saharan Africa.

Hypothyroidism in Sub-Saharan Africa is not only an autoimmune disease like it is globally but it may also be driven by iodine deficiency that are still prevalent in some areas of SSA, with significant challenges in diagnosis and treatment due to limited healthcare access and resources. Early detection, iodine supplementation, balanced diet and improved access to thyroid hormone replacement therapy are crucial for reducing the burden of this condition. Public health initiatives and healthcare infrastructure improvements are key to better managing hypothyroidism in the region.