Thyroid gland is one of the most important and sensitive endocrine gland. As it easily responds to stress and stimuli the global incidence of hypothyroidism is increasing day by day. The major function of thyroid gland is to control the rate of metabolism. The principle function of thyroxine is to act as a catalyst –of the nature of a ‘’spark’’ for the maintenance of oxidative metabolism in most tissues. Cells in the body take their "cue" from thyroxine.  The amount of stimulation the cells receive from thyroxine will determine how "quickly" they perform their functions¹. These functions similar with the description of agni “angati vyapnoti iti va agnihi” and “agnyate mreeyate iti va agnihi”.

                         Hypothyroidism results from inadequate production of thyroid hormone. Any structural or functional defects of thyroid gland that significantly impairs its output of hormones will lead to the hypo metabolic state of hypothyroidism².

                          The symptoms of hypothyroidism are notorious for their nonspecific nature and for the way in which they mimic many symptoms of other diseases. So it often remains undiagnosed or misdiagnosed. Vertigo, weight gain, mood disturbances, easy fatigability, tiredness, lethargy, slowness of memory, intellect and thought, menstrual irregularities, cold intolerance, dry rough skin, thin brittle hair, hair fall, Muscle stiffness, aching, myalgias, cramps, weakness and fatigue, myxedema, constipation, hoarseness of voice, goiter etc.³

Galaganda

                            There is no direct mention of thyroid gland in ayurveda. But a disease by the name galaganda is mentioned in samhitas. The earliest description of neck swelling is found in atharva veda by the name apachi. Charaka first described about the disease under the 20 varieties of sleshma vikaras¹⁰. Susutha has described that out of seven layers of the skin, the sixth layer Rohini is galaganda rogadhistana (Su.Sa.4/4). In nidana sthana he described galaganda as two encapsulated small or big swellings in the anterior angle of the neck, which hang like scrotum¹¹ (Su.Ni.11), whereas charaka mentioned galaganda as solitary swelling (Ch.Ch.11).

           The etiological factors in galaganda include climatic conditions, water supply, dietary conditions and other surroundings etc. Susrutha stated that rivers flowing towards east might give rise to the occurrence of galaganda¹¹. Bhela described that sleepda and galaganda are more common in prachya desa (eastern part) of the country¹², and the persons consuming predominantly fish are liable to develop galgaganda. Harita samhitakara described the role of dustambu and krimi dosha in the precipitation of Galaganda. Kashyapa samhitakara¹³added that any part of the country which is cold, damp, with densely grown long trees, water stagnation and heavy rains may be prone for the development of Galaganda. 

          From the above descriptions Galaganda can be correlated with goiter or some tumour pathology, where thyroid functions may or may not be affected. But hypothyroidism is not just a localized disease. It has many symptoms related to many systems of the body. So it is better not to restrict hypothyroidism with galaganda.

Management of hypothyroidism

                     As mentioned by charaka¹⁰ “vikaranamakusalo…”exact nomenclature is not necessary for all the diseases. It insists on diagnosis of constitutional status of the disease.

                    As per the nidana Hypothyroidism can be classified as 1.Primary (thyroid failure) 2. Secondary, (due to pituitary TSH deficit). And 3. Tertiary (due to hypothalamic deficiency of TRH), the later two are rare and may not be amicable to ayurvedic treatments.

                   If hypothyroidism results due to Genetical and hereditary defects, these comes under adibala pravritta vyadhis and these are asadhya.

                  If hypothyroidism results due to Congenital defects like thyroid gland agenesis, dysgenesis, ectopic thyroid gland comes under Janmabala pravritta vyadhis. These are preventable if proper pathyapathya is followed during pregnancy.

                  The main cause of hypothyroidism is iodine deficiency, as per sarvadha sarva bahvanam-iodine containing drugs like shigru, jalakumbhi are advised here.

     Another main cause autoimmune thyroid disease is characterized by gradual lymphatic infiltration and progressive destruction of the functional thyroid tissue.  So it may be Yapya, means that the treatment should be continued Jeevanaparvantam with immuno modulatory drugs.       

Selection of drugs acting at various levels

1.      At hypothalamo pituitary level: anti stress drugs, medhya rasayana drugs, nasya karma may be beneficial.

2. At thyroid gland level: thyroid stimulatory drugs are recommended here.
3. At metabolism level: deepana, pacahana, ushna, teekshna, sukshma, lekhana drugs which pep-up body metabolism is recommended.
4. Immuno-modulatory drugs for autoimmune related hypothyroidism.

                       As the symptoms of hypothyroidsm are notorious, the symptomatic treatment is followed according to the suitabily of the individual cases, i.e., sthoulya, sodha etc.

                      The recent research work done by Dr. Tripathi and others.  Animal studies have revealed that guggul supports healthy thyroid function, mostly by increasing the conversion of less active Thyroxin (T4) to more active Triiodotyronine (T3) through increasing thyroid proteolytic activity and the uptake of iodine into thyroxin, and without increasing the production of Thyroid Stimulating Hormone.

                           Selenium is required for a number of enzymes known as selenoproteins. The chemical reaction, which converts thyroid hormone T4 into T3, is catalyzed by specific selenoproteins. Selenium deficiency can impair thyroid function. The drug pippali increases the absroption of selinium and this may be cause for the effectiveness of vardhamana pipppli in hypothyroid conditions.

                        The patient who has complications like heart diseases like bradycardia and cardiomagaly, myxedema coma, are Pratyakhyeya indicates Achikitsavastha of Vyadhi.

                       The present trial drug kanchanara guggulu (Sa. Sam), is found in usage for many years for Gandhamala, Apache, Arbuda, Grandhi, Kushta, etc, has been selected to evaluate the efficacy of this drug in hypothyroidism. Its main ingredients kanchanara, varuna, triphala, trikatu, trijataka may also useful in hypothyroidism.

                   Shigru is a well-known plant in India. It is rich in iodine, which is an essential component of thyroid hormones, T3 and T4.   It has deepana, pacahna, kapha vata hara properties. It is recommended in galaganda, kandu, sotha, apachi, vrana, medoroga, vidradhi, gulma etc.is selected as anupana along with KNG. It appears to provide it with the nutrition and substitutes the Iodine, thyroid gland require. Hence the drug is selected for the study.

The main aim of the study is

                       1. To normalize the levels of TSH in the fresh cases.

2.      To maintain the TSH levels in the patients who are already using the allopathic drug thyronorm and gradually replacing the allopathic drug with the trail drug.                  

                        For fresh cases the trial drug started immediately after the diagnosis confirmed.

                        For the patients who are already using thyronorm/ eltroxin they were advised to withdraw the 25 mcg of the drug before starting the trail drug. The patients were observed carefully for 1 month, if they are comfortable with the drug and dosage and TSH levels are maintained well they are advised to withdraw another 25mcg. This way the drug will be totally replaced with the trail drug.

The trail was conducted on 32 patients from the Govt Ayurvedic Hospital, Erragadda; the progress of the patient is observed and recorded. Analysis was made to assess the results in relation to various factors. 32 patients were included and examined thoroughly examined and the Diagnosis of hypothyroidism is based on a person's medical history, a physical examination, and blood tests. Of the blood tests for hypothyroidism, the TSH is the most sensitive test¹⁴.  

As Hypothyroidism doesn’t have any characteristic symptoms, the following most common symptoms were carefully screened¹⁵. 

Inclusion criteria:

Weight gain/unable to loss weight                                             Vertigo

Easy fatigability                                                                          Lethargy

Cold intolerance                                                                         Hair loss

Slowness of memory, intellect and thought                               Anorexia

Constipation                                                                               Gaseous distention

Hoarseness/slowness of voice                                                    Menstrual irregularities

Oligomenorrhoea /Amenorrhea                                                  Parasthesias

Muscle cramps and weakness                                                    Muscle stiffness and aching

Dry skin                                                                                      Coarse, brittle, dull hair

Puffiness of the face, hands, feet                                                slow reflexes

Goiter

Exclusion criteria:

1. Patients with Cardiomegaly and Bradycardia.

2. Patients who are above 65 yrs and using the allopathic drug thyronorm.

3. Patients who are suffering from hypothyroidism for more than 10 years.

2. DRUGS

1. KANCHANARA GUGGULU^5,7,8 ( Sa. Sam )

                           The drug Kanchanara guggulu a compound Ayurvedic preparation consists of Guggulu, Kanchanara, Varuna, Triphala, Trikatu and Trijataka (preparation of the drug mentioned in drug aspect). It is one of the safest and the very useful drug in ayurveda, is found in usage for many years for gandhamala, apachi, Arbuda, Granthi, Vrana, Gulma, Kusta, Bhagandara etc. In the present study KNG is evaluated for thyroid stimulating activity.

2. SHIGRU PATRA KWATHA^6,7:

                     Shigru is a well-known plant in India. It has deepana, pachana, kapha vata hara properties. It is recommended in galaganda, kandu, sotha, apachi, vrana, medoroga, vidradhi, gulma etc. As it is rich in iodine, which is the main cause for hypothyroidism, is selected as anupana along with KNG.

                             Shigru leaves are dried and the powder was given to the patients and advised them to make decoction.

Kwatha preparation: To the coarse powder of one part of drug, add 8 parts of water, boil and reduce them to 1/4^th and filter it.

THE METHODOLOGY:

The aim of the study of the study:

1.      Normalize the levels of TSH in the fresh cases.

2.      To maintain the TSH levels in the patients who are already using the allopathic drug thyronorm and gradually replacing the allopathic drug with the trail drug

Type of trial: Open trail

Mode of administration: Oral

Method of administration:

1.      For fresh cases started immediately after the diagnosis confirmed.

2.      For the patients who are already using thyronorm advised withdraw the 25 mcg of the drug before starting the rail drug.

3.      The patients were observed carefully for 1 month, if they are comfortable with the drug and dosage and TSH levels are maintained well they are advised to withdraw another 25mcg. This way the drug is totally replaced with the trail drug.

Dose of the drug:  i) Kanchanara guggulu 250mg b.d.

                              ii) Shigru patra kwatha 250ml b.d

Period of study: 3 months

Patients were advised not to take Kapha and Medo vardhaka Ahara and Vihara’s like diwaswapna, madhura guru dravya sevana etc.

CLINICAL ASSESSMENT:

                        The progress of the patient is observed and recorded after every 15 days. This procedure is followed for duration of 90 days.  After the completion of the duration the results are assessed basing on observations. The results are assessed in terms of complete relief, marked, moderate and mild relief and no relief.

1.      Complete relief: TSH levels normalized and 100% symptoms relieved.

2.      Marked relief: TSH levels normalized and symptomatic relief up to 75%.

3.      Moderate relief: TSH levels normalized and symptomatic relief up to 50-75%.

4.      Mild relief: TSH levels normalized and symptomatic relief up to 25-50%.

5.      No relief: no change in the TSH levels and no symptomatic relief.

                    32 patients were recruited in the study and the assessment was done for every 15days.Of the 32 patients 16 patients were fresh cases and 16 patients are already using the modern medicine eltroxin. The results of the patients who completed the treatment of 90days were analyzed.

                   In the 16 fresh cases the TSH levels came to normal range after the completion of the treatment. The 16 who are already using allopathic medicine were gradually replaced with the trial drug and the TSH levels were in normal range as summarized in table 5.11 and 5.12.

            Table 5.11 showing the levels of TSH before and after treatment:

                        For the patients who are already using thyronorm advised withdraw the 25 mcg of the drug before starting the trail drug. The patients were observed carefully for I month, if they are comfortable with the drug and dosage and TSH levels are maintained well they are advised to withdraw another 25mcg and the drug was totally replaced with

Trial drug.         

Table 5.12 showing the levels of TSH before and after the treatment in chronic cases.