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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 1  |  Page : 30-36  

A study of correlation of perceived stress and thyroid function among females in a rural population of reproductive age group


1 Department of Physiology, Rampurhat Government Medical College and Hospital, Rampurhat, West Bengal, India
2 Department of Biochemistry, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India

Date of Submission27-Oct-2018
Date of Acceptance27-Feb-2019
Date of Web Publication16-Dec-2019

Correspondence Address:
Samarjit Koner
Department of Biochemistry, College of Medicine and Sagore Dutta Hospital, Kamarhati, Kolkata - 700 054, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_219_18

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  Abstract 


Background: Thyroid dysfunction may be associated with increased perceived stress. Aims: We aimed to study the correlation of perceived stress and thyroid function among females in a rural population of reproductive age group. Materials and Methods: This pilot study was conducted in Burdwan Medical College on 200 newly diagnosed female hypothyroid patients in a period of 12 months after taking institutional ethical clearance and informed consent of the participants. Parameters studied were body mass index (BMI), Presumptive Stressful Life Event Stress Scale (PSLES) scores, Perceived Stress Scale scores (PSS scores), thyroid-stimulating hormone (TSH), and free thyroxine (fT4) levels. To avoid stress effects of the premenstrual phase, we examined our participants during the postmenstrual phase. All the participants were on nonvegetarian diet and their dietary habits were nearly similar. Participants were divided into two groups: G1 – hypothyroid patients and G2 – patients with subclinical hypothyroidism. The computer software “Statistical Package for the Social Sciences (SPSS) version 16 (SPSS Inc., Released 2007. SPSS for Windows, version 16.0. SPSS Inc., Chicago, Illinois, USA)” was used to analyze the data. Results: Two hundred newly diagnosed hypothyroid females were included in the present study. Among them, 130 were clinical hypothyroid (G1) and 70 were subclinical hypothyroid patients (G2). A significant difference was found between clinical and subclinical hypothyroid females for mean PSS scores (P = 0.002). There was no significant difference in PSLES scores between the two groups. A significant difference was found between clinical and subclinical hypothyroid females for BMI (P = 0.002), TSH (P < 0.0001), and fT4 (P < 0.0001). There was no significant difference in age between the two groups. There was a significant positive correlation between PSS scores and TSH levels with r value of 0.97 in G1 and r value of 0.26 in G2, respectively. Conclusion: Females of reproductive age group with clinical and subclinical hypothyroidism faced the same amount of stressful life events. However, their perception of stress was significantly different. High TSH was positively correlated with high score on PSS. Clinical hypothyroidism is associated with hypercortisolemia and also depression. However, a cause–effect relation is yet to be established. Moreover, depression and serum cortisol were not assessed, so no further conclusions can be drawn from the present study.

Keywords: Females in reproductive age group, hypothyroidism, perceived stress


How to cite this article:
Chaudhuri A, Koner S. A study of correlation of perceived stress and thyroid function among females in a rural population of reproductive age group. Med J DY Patil Vidyapeeth 2020;13:30-6

How to cite this URL:
Chaudhuri A, Koner S. A study of correlation of perceived stress and thyroid function among females in a rural population of reproductive age group. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Jul 7];13:30-6. Available from: http://www.mjdrdypv.org/text.asp?2020/13/1/30/272880




  Introduction Top


In today's world, most people are overburdened with stressful situations, as they have stressful jobs, stressful relationships, financial issues, and many issues that lead to chronic stress. Stress is body's way of responding to the demand which is caused by both good and bad events/experiences. The body reacts by releasing chemicals in the blood to combat this demand by a complex repertoire of behavioral and physiologic adaptive responses.

Thyroid diseases are common worldwide. It has been estimated that about 42 million people in India suffer from thyroid diseases.[1] Thyro-stress is defined as an emotional state, characterized by extreme apprehension, discomfort, or dejection, caused by the challenges and demand of living with thyroid disorders such as hypothyroidism. There is a significant evidence to show that hypothyroidism is usually associated with an impact on psychological health. The physical complaints may impair emotional health and quality of life. However, not much attention has been paid till date to the psychosocial aspects of hypothyroidism.[2]

The adrenal glands are designed to handle acute stressful conditions. Thyroid gland works in tandem with adrenals. The ways in which the stressed out adrenals can cause thyroid malfunction may be the following: when the adrenal glands are stressed out, they put the body in a state of catabolism. The thyroid gland controls the metabolism of the body and so the body slows down activities of the thyroid gland to slow down the catabolic process as a homeostatic measure and can develop a compromised immune system. This eventually can lead to autoimmune thyroid disorders, such as Graves' disease or Hashimoto's thyroiditis.[1],[2],[3]

Numerous human and animal studies have demonstrated that psychological and physiologic stressors induce various immunologic changes. Stress affects the immune system either directly or indirectly through the nervous and endocrine systems. These immune modulations may contribute to the development of autoimmunity as well as the susceptibility to autoimmune disease in genetically predisposed individuals. Stress can be one of the environmental factors for the development of thyroid autoimmunity.[3]

A potential explanation for the positive thyroid-stimulating hormone (TSH)–cortisol relationship is that hypothyroidism, subclinical or clinical, is associated with subtle metabolic stress. Metabolic stress may impose an effect on the adrenocorticotropic hormone-adrenal axis leading to an increase in stress hormone (i.e., cortisol) release and production, and this hypothesis has been confirmed through the measurement of other stress hormones including the catecholamines, norepinephrine/epinephrine, and/or prolactin.[4]

Chronic elevations in serum cortisol and hypothyroidism (including subclinical hypothyroidism) have been separately linked with increased rates of depression, anxiety, and poor cognitive functioning. The association between TSH levels and cortisol suggests the possibility of a pathway through which hypothyroidism may promote poor mental health. It is possible that the relationship described is physiologic rather than representative of pathology.[2],[3],[4]

Dayan and Panicker in 2013[5] reviewed literature on thyroid function and depression. They performed a search on the PubMed database using the terms “thyroid” and “mental health,” “depression,” and “well-being.” Large epidemiological studies generally suggested no association between thyroid function and depression in participants without thyroid disease. Participants on thyroxine were found to have poorer psychological well-being than Participants with no thyroid disease even if biochemically euthyroid.[5] Engum et al.[6] showed the rate of psychological morbidity to be lower in those with a previously undiagnosed raised TSH than in the euthyroid population. Walsh et al. in a study found no association between thyroid function and psychological well-being.[7] The size and trial length suggested that a larger study with longer treatment times may be required for confirmation of this finding.[7]

The postmodern overindustrialized and highly competitive metropolitan culture has added up to stresses in human lives at many levels. Women have major roles to play in the collective social well-being. Stress may lead to early aging and death or sometimes in reduced levels of performances in females. Eighty-seven percent of Indian women feel stressed most of the times, with 82% having insufficient time to relax.[8] As is evident from Neilson's reports, women in emerging economic and social markets are more stressed than those in developed countries.[8] In a survey conducted in 2011,[8] it was found that the highest stress is perceived by women between 25 and 55 years who have to manage multiple roles in various fields. It is seen that the average life span of Indian women is 65 years, while in developed countries, it is 80 years.[9] Hence, women of our country specifically of this age group deserve special attention. Women have a life expectancy advantage over men but a marked disadvantage with regard to morbidity. Individual differences in physical and mental health are further notably explained by the degree of stress individuals who endure, with women being more affected by stressors than men.[8]

In the above context, the present study was conducted to assess the correlation of TSH levels and Perceived Stress Scale (PSS) scores in newly diagnosed hypothyroid females and patients with subclinical hypothyroidism so that early lifestyle modification with stress management programs may improve the quality of life in these individuals. A study in these participants on these parameters in a rural population of West Bengal is lacking, and the study may have some positive impact in this population.


  Materials and Methods Top


This pilot study was conducted in Burdwan Medical College on 200 newly diagnosed female hypothyroid patients in a period of 12 months after taking institutional ethical clearance and informed consent of the patients. The formula used to calculate the size of the required sample was n = (z)2 p(1-p)/d2, where n = sample size, z = z statistic for a level of confidence (95% level of confidence used, therefore, z value is 1.96), P = expected prevalence of proportion, and d = desired precision (taken as 6%), and previous studies were taken into consideration.[10],[11]

Inclusion criteria

Newly diagnosed hypothyroid females in the reproductive age group attending in the Department of Biochemistry, Burdwan Medical College, were included in the study.

Exclusion criteria

  1. Pregnancy
  2. Lactation
  3. Liver diseases
  4. Renal diseases
  5. Any history suggestive of visual field defect/headache/seizure
  6. Postmenopausal females and participants on treatment from psychiatry problem or with a past history of treatment were excluded
  7. Adolescent girls, perimenopausal women, sportswomen, yogis, and participants on regular meditation and exercise regimen were not included.


Parameters studied

  1. Anthropometric measurements – height, weight, and body mass index (BMI)
  2. Presumptive Stressful Life Event Stress Scale (PSLES) scores and PSS scores.
  3. TSH and free thyroxine (fT4) levels.


Methods

  1. Approval from the Institutional Ethics Committee of Burdwan Medical College was obtained before conduction of the study
  2. Participants were recruited by random sampling
  3. Informed consent was obtained from the participants
  4. PSLES scores were assessed
  5. A detailed history was taken regarding any past or current illness, hospitalization, medication, smoking and alcoholism, and daily habits
  6. Participants were further screened based on the inclusion and exclusion criteria for final selection
  7. Pretest instructions were given to avoid consumption of any drugs that may alter the cardiorespiratory parameters 48 h prior to the test. The participants were advised for a good restful sleep and to fast at least for 12 h after a light dinner at the night before the test day. On the day of the test, no cigarette, nicotine, coffee, or drugs were permitted
  8. Life event stress and perceived stress of the participants were measured using Presumptive Stressful Life Event Stress Scale (PSLES) scores, Perceived Stress Scale scores (PSS Scores), respectively
  9. Anthropometric measurements were recorded
  10. Blood samples were drawn from the participants by sterile needle and syringes and sent to biochemical laboratory in sterile vials for the analysis.


Increased sympathetic activity has been observed during the premenstrual phase, and this was positively correlated with the stress levels in previous studies. To avoid stress effects of the premenstrual phase, we examined the participants during the postmenstrual phase.

All the participants were on nonvegetarian diet and their dietary habits were nearly similar.

Stress level of the participants was assessed according to the PSLES. Accordingly, they were categorized into two groups: less/moderate stress (41–200), and severe stress (>200).[12]

The PSS of Sheldon Cohen, the most widely used psychological instrument for measuring the perception of stress, was used. It is a measure of the degree to which situations in one's life are appraised to be stressful. The questions in the PSS ask about feelings and thoughts during the last month. It comprises 10 items, four of which are reverse scored, measured on a 5-point scale from 0 to 4. PSS scores are obtained by reversing responses (e.g., 0 = 4, 1 = 3, 2 = 2, 3 = 1, and 4 = 0) to the four positively stated items (items 4, 5, 7, and 8) and then summing across all scale items. Total score ranges from 0 to 40.[13]

Participants were divided into two groups: G1 – hypothyroid patients and G2 – patients with subclinical hypothyroidism.

Hypothyroidism was defined as clinical as an elevated TSH (>6.16 μIU/ml) with a decreased serum fT4 level (<0.8 ng/dl) and subclinical as an elevated TSH (>6.16 μIU/ml) together with normal fT4 levels (0.8–2.0 ng/dl).[10],[11]

Estimation of serum TSH level was done by quantitative determination of TSH concentration by microplate immunoenzymometric assay using Monobind Inc., USA, manufactured TSH AccuBind enzyme-linked immunosorbent assay (ELISA) Kit.

Estimation of serum fT4 level was done by quantitative determination of fT4 concentration by microplate enzyme immunoassay using Monobind Inc., USA, manufactured fT4 AccuBind ELISA Kit.

Statistical analysis

The computer software “Statistical Package for the Social Sciences (SPSS) version 16 (SPSS Inc., Released 2007. SPSS for Windows, version 16.0. SPSS Inc., Chicago, Illinois, USA,)” was used to analyze the data. P < 0.05* was considered as significant and P < 0.01** was considered as highly significant.


  Results Top


Two hundred newly diagnosed hypothyroid females were included in the present study. Among them, 130 were clinical hypothyroid (G1) and 70 were subclinical hypothyroid patients (G2).

A significant difference was found between clinical and subclinical hypothyroid females for mean PSS scores (P = 0.002) [Table 1] and [Figure 1]. There was no significant difference in PSLES scores between the two groups.
Table 1: Presumptive Stressful Life Event Stress Scale scores and Perceived Stress Scale scores in clinical, subclinical hypothyroid patients

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Figure 1: Presumptive Stressful Life Event Stress Scale scores and Perceived Stress Scale scores clinical, subclinical hypothyroid patients

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A significant difference was found between clinical and subclinical hypothyroid females for BMI (P = 0.002), TSH (P < 0.0001), and fT4 (P < 0.0001) [Table 2] and [Figure 2], [Figure 3], [Figure 4]. There was no significant difference in age between the two groups.
Table 2: Age, body mass index, thyroid-stimulating hormone values, and free thyroxine values of clinical, subclinical hypothyroid patients

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Figure 2: Age, body mass index, thyroid-stimulating hormone values of clinical, subclinical hypothyroid patients

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Figure 3: Thyroid-stimulating hormone values of clinical, subclinical hypothyroid patients

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Figure 4: Free thyroxine values of clinical, subclinical hypothyroid patients

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[Table 2] shows that the difference of BMI, TSH values, and fT4 values between clinical and subclinical hypothyroidism was highly significant.

There was a significant positive correlation between PSS scores and TSH levels with r value of 0.26 in G2, as shown in [Figure 5].
Figure 5: Positive correlation of Perceived Stress Scale and thyroid-stimulating hormone in subclinical hypothyroid patients

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There was a significant positive correlation between PSS scores and TSH levels with r value of 0.97 in G1, as shown in [Figure 6].
Figure 6: Positive correlation of Perceived Stress Scale and thyroid-stimulating hormone in clinical hypothyroid patients

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  Discussion Top


The relation between thyroid function and depression has long been established. Patients with thyroid disorders are more prone to develop depressive symptoms, and depression may be also accompanied by various subtle thyroid abnormalities. The hypothalamic–pituitary–thyroid axis (HPT) is a complex interplay between several factors: thyroid hormones, deiodinase enzymes, transporter proteins, and receptors.[14],[15]

The present study was conducted to observe the correlation of thyroid function with perceived stress in newly diagnosed hypothyroid females of reproductive age group. Two hundred participants were included in the study and divided into two groups G1 and G2 according to the levels of TSH and fT4. Participants in G1 had significantly higher BMI, PSS scores, TSH levels, and lower fT4 levels as compared to G2. In both the groups, PSS scores were positively correlated to TSH levels with a more significant correlation in G1 (r = 0.97).

Acute and chronic stress can affect thyroid function via the hypothalamus–pituitary–adrenal axis and the HPT axis. Acupuncture can reduce the body's stress response and therefore should improve thyroid function. A research was conducted by Tsuda [16] to determine if acupuncture is a viable treatment option for subclinical hypothyroid patients. Two cases were studied for replication. The female patients, aged 34 and 44 years, received 12 Japanese Meridian acupuncture constitutional treatments and moxibustion once per week. Serum TSH, FT4, FT3, salivary cortisol, and PSS-10 were measured at pretreatment, mid-treatment, and posttreatment. A number of hypothyroid symptoms present (Zulewski Index) were assessed prior to each treatment. All measurements were analyzed for changes over time and cross-case comparison. Both the patients had decreases in TSH and number of hypothyroid symptoms present and increases in total cortisol load and morning diurnal cortisol rhythm. Both the patients reported improvements in bowel movements and menstruation. From this study, the researcher concluded that acupuncture is a viable treatment option for subclinical hypothyroidism; however, it was suggested that more rigorous large-scale research studies need to be conducted to validate and extend these findings.[16]

These study findings are similar to the present study in respect of positive correlation of PSS and TSH in subclinical hypothyroidism.

Many studies have demonstrated a connection between stress and autoimmune disease, but most of the evidence for stress contributing to the onset and course of autoimmune disease are circumstantial, and the mechanisms by which stress affects autoimmune disease are not fully understood till date. The best circumstantial evidence for an effect of stress on autoimmune thyroid disease is the well-known relationship between the onset of Graves' hyperthyroidism and major stress. There are few studies which have reported the possible relationship between stress and Hashimoto's thyroiditis. Usually, the onset and course of Hashimoto's thyroiditis are generally insidious, so the effect of stress on Hashimoto's thyroiditis might have been overlooked. Psychological and physiologic stressors may induce various immunologic changes. Stress affects the immune system either directly or indirectly through the nervous and endocrine systems. These immune modulations may contribute to the development of autoimmunity as well as the susceptibility to autoimmune disease in genetically predisposed individuals. Stress may be considered as one of the environmental factors responsible for thyroid autoimmunity.[3]

A study was conducted by Moncayo and Moncayo in 2014 in hypothyroid patients. Clinical examination was centered on musculoskeletal features together with a simple evaluation of psychological stressors (scaled 1–3). Laboratory diagnosis was focused on serum magnesium. This study included data from 58 euthyroid controls (six males) and 108 patients with hypothyroidism (eight males).[17]

The most common complaints seen in patients included fatigue, being easily tired, concentration deficit, ankle instability, and gait insecurity, giving way of the ankle, muscle cramps in the shanks, visual disturbances, irritability, and vertigo sensation. Besides this symptomatology, a great majority of the patients (89.5%) presented musculoskeletal alterations. Stress scores in patients were higher in patients than in the control group.[17] Our study also demonstrated higher PSS scores in hypothyroid patients.

Pelúcio et al. in 2016[18] reviewed scientific articles that investigated psychiatric comorbidities and quality of life in patients with hypothyroidism. A search was conducted in three databases: ISI Web of Science, PubMed, and PsycINFO, and 1333 references were found. Twenty-seven articles were chosen for this review. Thyroid disease, be it an excess or a deficiency of thyroid hormones, may produce psychiatric symptoms. The results of 14 studies selected for this review positively proved the association of thyroid disease with psychiatric disorders affecting the quality of life. Anxiety and depression disorders were highly prevalent in the population with hypothyroidism.[18]

A study by Mezzomo and Nadal in 2016[19] was aimed to review literature demonstrating effect of food nutrients and substances that can impact thyroid function. A literature review using “hypothyroidism” associated with the descriptors iodine, selenium, zinc, soy, gluten, and flavonoids was conducted on the PubMed database. One hundred and seventy-two articles were found and 42 were selected. It was observed that iodide participates in the organification reaction and subsequently engages with tyrosyl residues to form the thyroid hormones. Excessive or deficient amounts of iodine contribute to thyroid dysfunction, including hypothyroidism. Selenium and zinc are cofactors for deiodination reactions, which convert thyroxine (T4) into triiodothyronine (T3) peripherally. Deficiency of these minerals can be developed from restrictive diets or unbalanced diet at any stage of life and lead to a decreased production of thyroid hormones. Ingested substances, such as thiocyanate and isothiocyanate, can compete with iodide for the entry in thyroid follicles and compromise hormone synthesis.[19] In the present study, participants of both the groups had similar dietary habits, so the effect of nutrients and dietary substances in thyroid function and hypothyroidism was excluded.

Chronic stress can cause a lot of different problems, and if not managed, it can ultimately lead to thyroid dysfunction. Of course, this does not mean that all thyroid conditions are caused by stress, but there is no question that stress is the culprit in many thyroid disorders. In patients with hypothyroidism on conventional medical treatments, it may still be beneficial to follow stress management strategies.

The present study demonstrates that in spite of having similar PSLES scores and dietary habits, patients having clinical hypothyroidism had higher PSS scores which may have elevated their TSH levels more as compared to subclinical hypothyroid patients through a complex pathophysiological mechanism. Increased perceived stress may be a significant contributing factor in the development of hypothyroidism in females of reproductive age group. Stress management programs need to implement in large scale for benefit of the population as a whole.

Limitations and future scope

Our study is a cross-sectional study, so it has its own limitations; A longitudinal study with a larger sample size is on the way. Clinical hypothyroidism is associated with hypercortisolemia and also depression. However, a cause–effect relation is yet to be established. Depression and serum cortisol were not assessed, so no further conclusions can be drawn from the present study.


  Conclusion Top


Females of reproductive age group with clinical and subclinical hypothyroidism faced the same amount of stressful life events. However, their perception of stress was significantly different. High TSH was positively correlated with high score on PSS. Clinical hypothyroidism is associated with hypercortisolemia and also depression. However, a cause–effect relation is yet to be established. Moreover, depression and serum cortisol were not assessed, so no further conclusions can be drawn from the present study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Hage MP, Azar ST. The link between thyroid function and depression. J Thyroid Res 2012;2012:590648.  Back to cited text no. 14
    
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Moncayo R, Moncayo H. Exploring the aspect of psychosomatics in hypothyroidism: The WOMED model of body-mind interactions based on musculoskeletal changes, psychological stressors, and low levels of magnesium. Woman Psychosom Gynaecol Obstet 2014;1:1-11.  Back to cited text no. 17
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]



 

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