Some thyroid gland disorders can have serious implications. Simon Taylor gives an underwriter's view of the various levels of risk associated with each condition
Disorders of the thyroid gland may be a common occurrence encountered by the IFA. These will in the main be when the applicant discloses either an underactive or over-active thyroid gland, each causing their own set of symptoms and requiring different methods of treatment. An underactive thyroid is more easily treated and of less concern to the underwriter, an over-active thyroid needs to be underwritten more carefully but can be adequately treated and still attract favourable terms.
The thyroid gland belongs to the endocrine system, the endocrine glands between them produce over a hundred hormones, which play a major part in regulating the activity of most of the body's vital organs and performing such activities as fighting infections, determining growth and influencing physical agility and sex drive. The thyroid gland is the largest of the endocrine glands, it has two lobes, is butterfly shaped, weighs about an ounce and sits in the front of the neck just below the voice box. It releases two main hormones into the bloodstream, triidothyronine (T3) and thyroxine (T4), and the thyroid relies on a regular supply of iodine in order to supply thyroxine. Iodine is found in fish and milk and is added to table salt.
When the levels of T3 and T4 in the blood fall the hypothalamus (in the brain) sends out thyroid-releasing hormone (TRH) into the blood, as these TRH levels rise the pituitary gland then releases a thyroid stimulating hormone (TSH) which stimulates the thyroid to produce more T3 and T4.
The thyroid gland thus controls the rate of metabolism or the rate at which energy is produced. If you are exerting yourself, and therefore require energy, the thyroid will increase production of its hormones to increase the metabolism to produce the energy that is required.
Hypothyroidism (under-active thyroid)
This is the term used to describe when there is severe under activity of the thyroid gland. There are six well-known basic symptoms, weight gain, dry skin and hair, hoarse voice, fatigue, cold intolerance and facial puffiness. It can cause mental and physical sluggishness. The whole body relies on thyroid hormones and therefore the effects of thyroid deficiency are felt everywhere. It can not only affect the ability to perform daily tasks effectively due to lack of energy but long term, if untreated, can increase the risk of high blood pressure, diabetes, emphysema and other conditions.
Childhood hypothyroidism is called cretinism and adult is referred to as myxoedema. The causes can be primary (i.e. a disorder of the thyroid gland), rarely it can also be due to pituitary gland failure. Childhood hypothyroidism must be diagnosed early and treated adequately to avoid the complications of failure of growth and development.
Hypothyroidism is nowadays quite easily recognised and diagnosed and the thyroid function blood test is one of the first tests a GP will perform when a patient complains of persistent tiredness. These blood tests will show reduced T3 and T4 levels with an elevated TSH as the body tries to stimulate more thyroid hormone. Treatment is straightforward with the method being direct replacement of the deficient thyroid hormone, thyroxine the most commonly used. Once the correct dosage has been established the treatment will rapidly restore thyroid function to normal levels, usually in just a few weeks. Life long replacement is usually required to avoid relapse and the GP will normally monitor thyroid function levels every six or 12 months to ensure the treatment dosage is maintaining the correct levels of thyroid hormones. Provided the condition is identified early and well controlled the prognosis is very good.
Hyperthyroidism (over-active thyroid)
Also known as thyrotoxicosis or Grave's disease, this is potentially more serious than underactivity and not unsurprisingly the symptoms include the direct opposite of those caused by lack of thyroid hormone. As the thyroid over produces, the metabolism does not have the ability to slow down, and there is increased heat production, rapid pulse, hyperactivity, anxiety and loss of weight.
This fast pulse can produce atrial fibrillation (irregular heart rhythm) and palpitations. Eye disease can occur with exopthalmus or bulging, staring eyes (the famous comedian Marty Feldman suffered from this condition).
Initial treatment will usually involve anti-thyroid drugs such as carbimazole which restrict the thyroid's activity, beta-blockers can also be used to reduce any cardiac rhythm problems. Surgical removal of part of the gland can be used as an alternative to long term medical treatment, radioactive iodine can be used, often deliberately using a dose which causes permanent hypothyroidism, which can then be treated with thyroxine replacement, as it is easier to treat hypothyroidism than hyperthyroidism.
Remission is usually achieved in all patients with the use of anti-thyroid medication, however relapse rates can be as high as 50% when treatment is stopped. Once adequately treated the prognosis is usually good.
Goitre
This is where the thyroid gland enlarges due to insufficient iodine supply. Simple non-toxic goitre is where the thyroid attempts to maximise iodine capture and the enlargement maintains normal thyroid function during a temporary period such as during pregnancy. When the demand returns to normal the goitre normally disappears. Toxic goitre is where the enlargement results in hyperthyroidism. The gland can become very large and cause pressure on the trachea.
Investigations are carried out such as biopsy or fine needle aspiration to exclude any risk of malignancy in the goitre, treatment will then involve the administration of iodine to replace the deficiency, stop the thyroid enlarging and cause the swelling to reduce.
Benign and uncomplicated goitre once adequately treated, if necessary, also carries a good prognosis.
Simon Taylor is a senior underwriter with Scottish Equitable Protect
Thyroid problems - the statistics
K Primary adult hypothyroidism is more common in women than men (5:1) and usually occurs between ages 30 and 50
K Overt hypothyroidism incidence is 19 per 1000 women and one per 1000 men, annual incidence is four per 1000 women and 0.6 per 1000 men
K Hyperthyroidism is ten times as common in women than men, 20 in 1000 and two in 1,000 respectively, annual incidence is one per 1,000 women, annual incidence per men is negligible
K Highest incidence of hyperthyroidism is between ages 20 and 40
K Atrial fibrillation is present in about 15% of hyperthyroid cases
Sources: www.cancerbacup.org, www.endotext.org, www.prodigy.nhs.uk, www. Freespace.virgin.net, Swiss Re
Underwriting implications
The underwriter will firstly be looking for a full and detailed disclosure from the client on the application form and this is where the IFA can help by obtaining as much information as possible. The client should detail the exact nature of the condition, whether under or over active, when diagnosed and how treated, what current treatment they are taking and whether they are under specialist care or under the care of their GP only.
If there is a comprehensive disclosure then terms may be available without the need for any further information on all benefits, particularly when the disclosure is hypothyroidism.
Hyperthyroidism if historic, adequately treated and resolved may also be accepted for all benefits at standard rates without the need for a GP's report. If the condition is still under investigation then the underwriter will wish to await the results before considering terms and if there are complications such as atrial fibrillation it is likely the application would be postponed until treatment has stabilised the condition fully.
If diagnosis was within the last six months and treatment continues then a loading of +50/75 on life cover and +100 on critical illness may be charged. If all treatment has ceased for longer than three months and normal thyroid function has been achieved then it may be possible to offer standard rates on all benefits. In these instances where the diagnosis was recent and/or treatment continues the underwriter is likely to obtain a GP's report.
The IFA may wish to discuss any applicant with a history of past or present thyroid gland disorder with the company's underwriting help line before submitting the application.
