Hematuria is diagnosed with urinalysis, which is testing of a urine sample. The urine sample is collected in a special container in a health care providers office or commercial facility and can be tested in the same location or sent to a lab for analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color when RBCs are present in urine. When blood is visible in the urine or a dipstick test of the urine indicates the presence of RBCs, a health care provider examines the urine with a microscope to make an initial diagnosis of hematuria. The next step is to diagnose the cause of the hematuria.

The health care provider will take a thorough medical history. If the history suggests a cause that does not require treatment, the urine should be tested again after 48 hours for the presence of RBCs. If two of three urine samples show too many RBCs when viewed with a microscope, more serious causes should be explored. The health care provider may order one or more of the following tests:

- Urinalysis. Further testing of the urine may be done to check for problems that can cause hematuria, such as infection, kidney disease, and cancer. The presence of white blood cells signals a UTI. RBCs that are misshapen or clumped together to form little tubes, called casts, may indicate kidney disease. Large amounts of protein in the urine, called proteinuria, may also indicate kidney disease. The urine can also be tested for the presence of cancer cells.  - Blood test. A blood test involves drawing blood at a health care providers office or commercial facility and sending the sample to a lab for analysis. A blood test can show the presence of high levels of creatinine, a waste product of normal muscle breakdown, which may indicate kidney disease.  - Biopsy. A biopsy is a procedure that involves taking a piece of kidney tissue for examination with a microscope. The biopsyis performed by a health care provider in a hospital with light sedation and local anesthetic. The health care provider uses imaging techniques such as ultrasound or a computerized tomography (CT) scan to guide the biopsy needle into the kidney. The kidney tissue is examined in a lab by a pathologista doctor who specializes in diagnosing diseases. The test helps diagnose the type of kidney disease causing hematuria.  - Cystoscopy. Cystoscopy is a procedure that uses a tubelike instrument to look inside the urethra and bladder. Cystoscopy is performed by a health care provider in the office, an outpatient facility, or a hospital with local anesthesia. However, in some cases, sedation and regional or general anesthesia are needed. Cystoscopy may be used to look for cancer cells in the bladder, particularly if cancer cells are found with urinalysis. More information is provided in the NIDDK health topic,Cystoscopy and Ureteroscopy.   - Kidney imaging tests. Intravenous pyelogram (IVP) is an x ray of the urinary tract. A special dye, called contrast medium, is injected into a vein in the persons arm, travels through the body to the kidneys, and makes urine visible on the x ray. The contrast medium also shows any blockage in the urinary tract. When a small mass is found with IVP, another imaging test, such as an ultrasound, CT scan, or magnetic resonance imaging (MRI), can be used to further study the mass. Imaging tests are performed in an outpatient center or hospital by a specially trained technician, and the images are interpreted by a radiologista doctor who specializes in medical imaging. Anesthesia is not needed, though light sedation may be used in some cases. Imaging tests may show a tumor, a kidney or bladder stone, an enlarged prostate, or other blockage of the normal flow of urine. More information is provided in the NIDDK health topic, Imaging of the Urinary Tract.


Hematuria is treated by treating its underlying cause. If no serious condition is causing hematuria, no treatment is needed. Hematuria caused by a UTI is treated with antibiotics; urinalysis should be repeated 6 weeks after antibiotic treatment ends to be sure the infection has resolved.


Eating, diet, and nutrition have not been shown to play a role in causing or preventing hematuria.


- Hematuria is blood in the urine.  - Most people with microscopic hematuria do not have symptoms. People with gross hematuria have urine that is pink, red, or cola-colored due to the presence of red blood cells (RBCs).  - Hematuria can be caused by menstruation, vigorous exercise, sexual activity, viral illness, trauma, or infection, such as a urinary tract infection (UTI). More serious causes of hematuria include      - cancer of the kidney or bladder    - inflammation of the kidney, urethra, bladder, or prostate    - polycystic kidney disease    - blood clots    - blood clotting disorders, such as hemophilia    - sickle cell disease    - When blood is visible in the urine or a dipstick test of the urine indicates the presence of RBCs, the urine is examined with a microscope to make an initial diagnosis of hematuria. The next step is to diagnose the cause of the hematuria.  - If a thorough medical history suggests a cause that does not require treatment, the urine should be tested again after 48 hours for the presence of RBCs. If two of three urine samples show too many RBCs when viewed with a microscope, more serious causes should be explored.  - One or more of the following tests may be ordered: urinalysis, blood test, biopsy, cytoscopy, and kidney imaging tests.  - Hematuria is treated by treating its underlying cause.


Erectile dysfunction* is when you cannot get or keep an erection firm enough to have sex. You may have ED if you

- can get an erection sometimes, though not every time  - can get an erection, yet it does not last long enough for sex  - are unable to get an erection at all

ED is sometimes called impotence; however, doctors use this term less often now.

*See the Pronunciation Guide for tips on how to say the words in bold type.


Erectile dysfunction often has more than one cause. Many diseases can damage nerves, arteries, and muscles. Some can lead to ED, such as

- high blood pressure  - diabetes, when your blood glucose, also called blood sugar, is too high  - clogged arteries  - heart and blood vessel disease  - chronic kidney disease  - multiple sclerosis, a disease that attacks the nerves  - treatments for prostate cancer, including radiation, surgery to remove the prostate, and hormone treatments  - injury to the penis, spinal cord, prostate, bladder, or pelvis  - surgery for bladder cancer  - Peyronies disease, in which scar tissue, called a plaque, forms in the penis

Unhealthy lifestyle choices, such as smoking, drinking too much alcohol, using illegal drugs, being overweight, and not exercising, can lead to ED.

Mental health problems such as the following can also cause or worsen ED:

- depression  - fear of sexual failure  - guilt  - low self-esteem  - stress  - worry

Even when ED has a physical cause, mental health problems can make ED worse. For example, a physical problem may slow your sexual arousal, which may make you more nervous and worsen your ED.

In addition, ED can be a side effect of many common medicines. A small number of ED cases result from low testosterone, a male hormone.


Erectile dysfunction affects men of all races and in all parts of the world. Men are more likely to have ED as they get older. For example, ED occurs in

- about 12 percent of men younger than 60  - 22 percent of men age 60 to 69  - 30 percent of men age 70 or older


Having ED can cause you to feel depressed or anxious. ED may also cause low self-esteem. When you have ED, you may not have a satisfying sex life. You may not feel as close with your sexual partner, which may strain your relationship.

See Your Doctor if You Have Erectile Dysfunction, as Erectile Dysfunction Could Mean You Have a More Serious Condition   If you have problems getting or keeping an erection, and the problems last for more than a few weeks, you should talk with your doctor. ED can be a sign of other health problems, such as diabetes or heart disease.   When you meet with your doctor, you might use phrases like, Ive been having problems in the bedroom or Ive been having erection problems. Remember that a healthy sex life is part of a healthy life. Dont be shy about seeking help. Your doctor treats medical problems every day.   If talking with your doctor doesnt put you at ease, ask for a referral to another doctor. Your doctor may send you to a urologista doctor who specializes in sexual and urinary problems.


To find the cause of your ED, your doctor may

- take your medical and sexual history  - ask you questions about your mental health  - give you a physical exam  - test your blood  - give you a nighttime erection test  - perform an injection test  - perform a Doppler penile ultrasound

Medical and Sexual History

Your doctor will ask general questions about your health, as well as specific questions about your erection problems and your relationship with your sexual partner. Your doctor might ask you questions such as

- Have you ever had surgery?  - What medicines do you take?  - How sure are you that you can get and keep an erection?  - When you have erections, how often are they hard enough for sex?  - During sex, how often are you able to keep your erection?  - When you try to have sex, how often are you happy with the sex?  - How would you rate your level of sexual desire?  - How often are you able to reach climax and ejaculate?  - Do you have an erection when you wake up in the morning?  - Do you use illegal drugs, drink alcohol, or smoke?

The answers to these questions will help your doctor understand the problem.

Bring a list of all the medicines you take, or the actual medicines, to show to your doctor.

Mental Health Questions

Your doctor may ask you questions about your mental health. For example, the doctor may ask if you feel nervous or depressed. He or she may also ask you to answer questions on paper. The doctor may also ask your sexual partner questions to get more information about the problem.

Physical Exam

A physical exam can help your doctor find the cause of your ED. As part of the exam, the doctor will examine your testes and penis, take your blood pressure, and check for problems with your blood flow.

Blood Tests

A blood test involves drawing your blood at a doctors office or a commercial facility and sending the sample to a lab for analysis. Blood tests can show possible causes of ED, such as diabetes, clogged blood vessels, or chronic kidney disease. Low levels of testosterone in your blood can explain why you may have lost interest in sex.

Nighttime Erection Test

During a nighttime erection test, you wear a plastic band around your penis to test whether you have nighttime erections. The band easily breaks if your penis expands. This test shows if you had at least one erection during the night. Another test uses an electronic device that can record the number of erections, how long they last, and how firm they are. A man normally has three to five erections during the night while he sleeps. If you do have an erection, it probably means that your ED is more likely a mental health issue. If you do not have these erections, you probably have nerve damage or poor blood flow to your penis. You may do this test in your home or in a special sleep lab.

Injection Test

During an injection test, the doctor will inject a medicine into your penis to cause an erection. If the erection is not firm or does not last, it may mean you have a problem with blood flow. This test most often takes place in the doctors office.

Doppler Penile Ultrasound

An x-ray technician most often performs a Doppler penile ultrasound in a doctors office or an outpatient center. During a Doppler penile ultrasound, the x-ray technician or doctor lightly passes a device over your penis to create images of blood vessels in your penis. An injection is used to create an erection. The images can show if you have a blood flow problem. The pictures appear on a computer screen. A radiologista doctor who specializes in medical imaginglooks at the images to find possible problems.


Your doctor can offer you a number of treatments for ED. For many men, the answer is as simple as taking a pill. Other men have to try two or three options before they find a treatment that works for them. Dont give up if the first treatment doesnt work. Finding the right treatment can take time. You may want to talk with your sexual partner about which treatment fits you best as a couple.

A doctor can treat ED by

- treating the cause of your ED:      - lifestyle changes    - changing the medicines you take to treat other health problems    - counseling    - prescribing medicines to treat your ED:      - medicine by mouth    - other forms of medicine    - prescribing a vacuum device  - performing surgery:      - implanted devices    - surgery to repair blood vessels

Treating the Cause of Your Erectile Dysfunction

The first step is to treat any health problems that may be causing your ED. Untreated diabetes or high blood pressure may be part of the cause of your ED.

Lifestyle changes. For some men, the following lifestyle changes help:

- quitting smoking  - drinking less alcohol  - increasing physical activity  - stopping illegal drug use

Changing medicines you take to treat other health problems. Talk with your doctor about all the medicines you are taking, including over-the-counter medicines. The doctor may find that a medicine you are taking is causing your ED. Your doctor may be able to give you another medicine that works in a different way, or your doctor may tell you to try a lower dose of your medicine.

Counseling. Counseling can help couples deal with the emotional effects of ED. Some couples find that counseling adds to the medical treatment by making their relationship stronger.

Prescribing Medicines to Treat Your Erectile Dysfunction

Depending on which medicine your doctor gives you, you may take it by mouth or by putting it directly into your penis.

Medicine by mouth. Your doctor may be able to prescribe a pill to treat ED. Common medicines include

- sildenafil (Viagra)  - vardenafil (Levitra, Staxyn)  - tadalafil (Cialis)  - avanafil (Stendra)

If your health is generally good, your doctor may prescribe one of these medicines. You should not take any of these pills to treat ED if you take any nitrates, a type of heart medicine. All ED pills work by increasing blood flow to the penis. They do not cause automatic erections. Talk with your doctor about when to take the pill. You may need to experiment to find out how soon the pill takes effect.

Other forms of medicine. Taking a pill doesnt work for all men. You may need to use medicine that goes directly into your penis. You may use an injection into the shaft of your penis, or you may use medicine placed in your urethra, at the tip of your penis. The urethra is the tube that carries urine and semen outside of the body. Your doctor will teach you how to use the medicines. They most often cause an erection within minutes. These medicines can be successful, even if other treatments fail.

Prescribing a Vacuum Device

Another way to create an erection is to use a device with a specially designed vacuum tube. You put your penis into the tube, which is connected to a pump. As air is pumped out of the tube, blood flows into your penis and makes it larger and firmer. You then move a specially designed elastic ring from the end of the tube to the base of your penis to keep the blood from flowing back into your body. You may find that using a vacuum device requires some practice.

Performing Surgery

If the other options fail, you may need surgery to treat ED.

Implanted devices. A urologist can place a device that fills with fluid or a device with bendable rods inside the penis to create an erection.

One kind of implant uses two cylinders that fill with fluid like a balloon. Tubing connects the cylinders to a small ball that holds the fluid. You fill the cylinders by squeezing a small pump that the urologist places under the skin of the scrotum, in front of your testes. The pump causes fluid to flow into the two cylinders in your penis, making it hard. The fluid can make the penis slightly longer and wider. An implant that uses fluids instead of bendable rods leaves the penis in a more natural state when not in use.

Implants that bend most often have two rods that the urologist places side by side in your penis during surgery. You use your hands to adjust the position of the rods to make your penis straight. Your penis does not get larger. After sex, you bend the rods down.

Implanted devices do not affect the way sex feels or the ability to have an orgasm.

Once you have an implanted device, you must use the device to have an erection every time. Talk with your doctor about the pros and cons of having an implanted device.

Surgery to repair blood vessels. Doctors treat some cases of ED with surgery to repair the blood vessels that carry blood to the penis. This type of surgery is more likely to work in men younger than 30.


You can prevent many of the causes of ED by making healthy lifestyle choices. Following a healthy diet may help prevent ED. Quitting smoking and getting physical activity are also important ways to prevent ED.

Physical activity increases blood flow throughout your body, including your penis. Talk with your doctor before starting new activities. If you have not been active, start slow, with easier activities such as walking at a normal pace or gardening. Then you can work up to harder activities such as walking briskly or swimming. Try to aim for at least 30 minutes of activity most days of the week.


To prevent ED, you should eat a healthy diet of whole-grain foods, fruits and vegetables, low-fat dairy foods, and lean meats. A diet that causes you to be overweight and have heart and blood vessel disease can also lead to ED. You should avoid foods high in fat and sodium, the main part of salt. You should also avoid smoking, drinking too much alcohol, or using illegal drugs.


- Erectile dysfunction (ED) is when you cannot get or keep an erection firm enough to have sex. You may have ED if you      - can get an erection sometimes, though not every time    - can get an erection, yet it does not last long enough for sex    - are unable to get an erection at all    - An erection occurs when blood flow into the penis increases, making the penis larger and firmer. Hormones, blood vessels, nerves, and muscles all work together to cause an erection.  - ED often has more than one cause. Many diseases can damage nerves, arteries, and muscles.  - To find the cause of your ED, your doctor may      - take your medical and sexual history    - ask you questions about your mental health    - give you a physical exam    - test your blood    - give you a nighttime erection test    - perform an injection test    - perform a Doppler penile ultrasound    - Your doctor can offer you a number of treatments for ED. For many men, the answer is as simple as taking a pill. Other men have to try two or three options before they find a treatment that works for them.  - You can prevent many of the causes of ED by making healthy lifestyle choices. Following a healthy diet may help prevent ED. Quitting smoking and getting physical activity are also important ways to prevent ED.


Celiac disease is an immune disorder in which people cannot tolerate gluten because it damages the inner lining of their small intestine and prevents it from absorbing nutrients. The small intestine is the tubeshaped organ between the stomach and large intestine. Gluten is a protein found in wheat, rye, and barley and occasionally in some products such as vitamin and nutrient supplements, lip balms, and certain medications.

The immune system is the body's natural defense system and normally protects the body from infection. However, when a person has celiac disease, gluten causes the immune system to react in a way that can cause intestinal inflammationirritation or swellingand long-lasting damage.

When people with celiac disease eat foods or use products containing gluten, their immune system responds by damaging or destroying villithe tiny, fingerlike projections on the inner lining of the small intestine. Villi normally absorb nutrients from food and pass the nutrients through the walls of the small intestine and into the bloodstream. Without healthy villi, people can become malnourished, no matter how much food they eat.


Researchers do not know the exact cause of celiac disease. Celiac disease sometimes runs in families. In 50 percent of people who have celiac disease, a family member, when screened, also has the disease.1

A person's chances of developing celiac disease increase when his or her genestraits passed from parent to childhave variants, or changes. In celiac disease, certain gene variants and other factors, such as a person's exposure to things in his or her environment, can lead to celiac disease. Read more about genes and genetic conditions at www.ghr.nlm.nih.gov.

For most people, eating something with gluten is harmless. For others, an exposure to gluten can cause, or trigger, celiac disease to become active. Sometimes surgery, pregnancy, childbirth, a viral infection, or severe emotional stress can also trigger celiac disease symptoms.


As many as one in 141 Americans has celiac disease, although most remain undiagnosed.2 Celiac disease affects children and adults in all parts of the world and is more common in Caucasians and females.

Celiac disease is also more common among people with certain genetic diseases, including Down syndrome and Turner syndromea condition that affects girls' development.


A person may experience digestive signs and symptoms, or symptoms in other parts of the body. Digestive signs and symptoms are more common in children and can include

- abdominal bloating  - chronic diarrhea  - constipation  - gas  - pale, foul-smelling, or fatty stool  - stomach pain  - nausea  - vomiting

Being unable to absorb nutrients during the years when nutrition is critical to a child's normal growth and development can lead to other health problems, such as

- failure to thrive in infants  - slowed growth and short stature  - weight loss  - irritability or change in mood  - delayed puberty  - dental enamel defects of permanent teeth

Adults are less likely to have digestive signs and symptoms and may instead have one or more of the following:

- anemia  - bone or joint pain  - canker sores inside the mouth  - depression or anxiety  - dermatitis herpetiformis, an itchy, blistering skin rash  - fatigue, or feeling tired  - infertility or recurrent miscarriage  - missed menstrual periods  - seizures  - tingling numbness in the hands and feet  - weak and brittle bones, or osteoporosis  - headaches

Intestinal inflammation can cause other symptoms, such as

- feeling tired for long periods of time  - abdominal pain and bloating  - ulcers  - blockages in the intestine

Celiac disease can produce an autoimmune reaction, or a self-directed immune reaction, in which a person's immune system attacks healthy cells in the body. This reaction can spread outside of the gastrointestinal tract to affect other areas of the body, including the

- spleen  - skin  - nervous system  - bones  - joints

Recognizing celiac disease can be difficult because some of its symptoms are similar to those of other diseases and conditions. Celiac disease can be confused with

- irritable bowel syndrome (IBS)  - iron-deficiency anemia caused by menstrual blood loss  - lactose intolerance  - inflammatory bowel disease  - diverticulitis  - intestinal infections  - chronic fatigue syndrome

As a result, celiac disease has long been underdiagnosed or misdiagnosed. As health care providers become more aware of the many varied symptoms of the disease and reliable blood tests become more available, diagnosis rates are increasing, particularly for adults.

Dermatitis Herpetiformis   Dermatitis herpetiformis is a chronic, itchy, blistering skin rashusually on the elbows, knees, buttocks, back, or scalpthat affects about 5 to 10 percent of people with celiac disease.3 Men with dermatitis herpetiformis may also have oral or genital lesions. People with dermatitis herpetiformis may have no other signs or symptoms of celiac disease. Skin deposits of antibodiesproteins that react against the body's own cells or tissuescommon in celiac disease cause dermatitis herpetiformis. Ingesting gluten triggers these antibodies.   More information is provided in the NIDDK health topic, Dermatitis Herpetiformis: Skin Manifestation of Celiac Disease.


Signs and symptoms of celiac disease vary from person to person because of numerous factors, including

- the length of time a person was breastfed as an infant; some studies have shown that the longer an infant was breastfed, the later the symptoms of celiac disease appear  - the age a person started eating gluten  - the amount of gluten a person eats  - agesymptoms can vary between young children and adults  - the degree of damage to the small intestine

Some people with celiac disease have no signs or symptoms; however, they can still develop complications of the disease over time. Long-term complications include

- malnutrition  - liver diseases  - intestinal cancer  - lymphoma


A health care provider diagnoses celiac disease with

- a medical and family history  - a physical exam  - blood tests  - an intestinal biopsy  - a skin biopsy

Medical and Family History

Taking a medical and family history may help a health care provider diagnose celiac disease. He or she will ask the patient or caregiver to provide a medical and family history, specifically if anyone in the patient's family has a history of celiac disease.

Physical Exam

A physical exam may help diagnose celiac disease. During a physical exam, a health care provider usually

- examines the patient's body for malnutrition or a rash  - uses a stethoscope to listen to sounds within the abdomen  - taps on the patient's abdomen checking for bloating and pain

Blood Tests

A blood test involves drawing blood at a health care provider's office or a commercial facility and sending the sample to a lab for analysis. A blood test can show the presence of antibodies that are common in celiac disease.

If blood test results are negative and a health care provider still suspects celiac disease, he or she may order additional blood tests, which can affect test results.

Before the blood tests, patients should continue to eat a diet that includes foods with gluten, such as breads and pastas. If a patient stops eating foods with gluten before being tested, the results may be negative for celiac disease even if the disease is present.

Intestinal Biopsy

If blood tests suggest that a patient has celiac disease, a health care provider will perform a biopsy of the patient's small intestine to confirm the diagnosis. A biopsy is a procedure that involves taking a piece of tissue for examination with a microscope. A health care provider performs the biopsy in an outpatient center or a hospital. He or she will give the patient light sedation and a local anesthetic. Some patients may receive general anesthesia.

During the biopsy, a health care provider removes tiny pieces of tissue from the patient's small intestine using an endoscopea small, flexible camera with a light. The health care provider carefully feeds the endoscope down the patient's esophagus and into the stomach and small intestine. A small camera mounted on the endoscope transmits a video image to a monitor, allowing close examination of the intestinal lining. The health care provider then takes the samples using tiny tools that he or she passes through the endoscope. A pathologista doctor who specializes in examining tissues to diagnose diseasesexamines the tissue in a lab. The test can show damage to the villi in the small intestine.

Skin Biopsy

When a health care provider suspects that a patient has dermatitis herpetiformis, he or she will perform a skin biopsy. A skin biopsy is a procedure that involves removing tiny pieces of skin tissue for examination with a microscope. A health care provider performs the biopsy in an outpatient center or a hospital. The patient receives a local anesthetic; however, in some cases, the patient will require general anesthesia.

A pathologist examines the skin tissue in a lab and checks the tissue for antibodies that are common in celiac disease. If the skin tissue tests positive for the antibodies, a health care provider will perform blood tests to confirm celiac disease. If the skin biopsy and blood tests both suggest celiac disease, the patient may not need an intestinal biopsy for diagnosis.

Genetic Tests   In some cases, a health care provider will order genetic blood tests to confirm or rule out a diagnosis of celiac disease. Most people with celiac disease have gene pairs that contain at least one of the human leukocyte antigen (HLA) gene variants.4 However, these variants are also common in people without celiac disease, so their presence alone cannot diagnose celiac disease.   If a biopsy and other blood tests do not give a clear diagnosis of celiac disease, a health care provider may test a patient for HLA gene variants. If the gene variants are not present, celiac disease is unlikely.


In some cases, a health care provider will order genetic blood tests to confirm or rule out a diagnosis of celiac disease. Most people with celiac disease have gene pairs that contain at least one of the human leukocyte antigen (HLA) gene variants.4 However, these variants are also common in people without celiac disease, so their presence alone cannot diagnose celiac disease.

If a biopsy and other blood tests do not give a clear diagnosis of celiac disease, a health care provider may test a patient for HLA gene variants. If the gene variants are not present, celiac disease is unlikely.


Most people with celiac disease have a significant improvement in symptoms when they follow a gluten-free diet. Health care providers typically refer people to a dietitian who specializes in treating people with the disease. The dietitian will teach the person to avoid gluten while following a healthy and nutritious diet. The dietitian will give the person instructions for how to

- read food and product labels and identify ingredients that contain gluten  - make healthy choices about the types of foods to eat  - design everyday meal plans

For most people, following a gluten-free diet will stop symptoms, heal existing intestinal damage, and prevent further damage. Symptoms may improve within days to weeks of starting the diet. The small intestine usually heals in 3 to 6 months in children. Complete healing can take several years in adults. Once the intestine heals, the villi will absorb nutrients from food into the bloodstream normally.

Some people with celiac disease show no improvement after starting a gluten-free diet. The most common reason for poor response to dietary changes is that people are still consuming small amounts of gluten, which can damage the small intestineeven in people without symptoms. Most people start responding to the gluten-free diet once they find and eliminate hidden sources of gluten from their diet. Hidden sources of gluten include additives made with wheat, such as

- modified food starch  - preservatives  - stabilizers

Did you know that medications and nonfood products may contain gluten?   Medications, supplements, and other products may also contain lecithin, a hidden source of gluten. People with celiac disease should ask a pharmacist about the ingredients in   - prescription and over-the-counter medications   - vitamins and mineral supplements   - herbal and nutritional supplements    Other products can be ingested or transferred from a person's hands to his or her mouth. Reading product labels can help people avoid gluten exposure. If a product's label does not list its ingredients, the manufacturer should provide a list upon request.   Products that can contain gluten include   - lipstick, lip gloss, and lip balm   - cosmetics   - skin and hair products   - toothpaste and mouthwash   - glue on stamps and envelopes   - children's modeling dough, such as Play-Doh

Some people who continue to have symptoms even after changing their diet may have other conditions or disorders that are more common in people with celiac disease. These conditions may include

- small intestinal bacterial overgrowth, which happens when too many bacteria grow in the small intestine  - pancreatic exocrine insufficiency, in which the pancreas does not produce enough digestive juice  - microscopic colitis, an inflammation of the colon that a health care provider can see only with a microscope  - IBS  - lactose intolerance, a condition in which people have symptoms after consuming milk or milk products  - other food intolerances, which may occur because of continued damage to the intestine

In some cases, people continue to have difficulty absorbing nutrients despite following a strict gluten-free diet. People with this condition, known as refractory celiac disease, have severely damaged intestines that cannot heal. Their intestines are not absorbing enough nutrients, so they may need to receive nutrients intravenously. Researchers continue to evaluate medications to treat refractory celiac disease.

Depending on a person's age at diagnosis, some complications of celiac disease will not improve, such as short stature and dental enamel defects.

For people with dermatitis herpetiformis, skin symptoms generally respond to a gluten-free diet and may recur if a person adds gluten back into his or her diet. Medications such as dapsone can control the rash's symptoms. Dapsone does not treat intestinal symptoms or damage, so people with dermatitis herpetiformis should maintain a gluten-free diet, even if they don't have digestive symptoms. Even when a person follows a gluten-free diet, the skin lesions from dermatitis herpetiformis may take months or even years to fully heal and often recur over the years.


Eating, diet, and nutrition play a significant role in treating celiac disease. People with the disease should maintain a gluten-free diet by avoiding products that contain gluten. In other words, a person with celiac disease should not eat most grains, pasta, and cereal, and many processed foods.

People with celiac disease can eat a wellbalanced diet with a variety of foods. They can use potato, rice, soy, amaranth, quinoa, buckwheat, or bean flour instead of wheat flour. They can buy gluten-free bread, pasta, and other products from stores, or order products from special food companies. Meanwhile, "plain"meaning no additives or seasoningsmeat, fish, rice, fruits, and vegetables do not contain gluten, so people with celiac disease can eat these foods.

In the past, health care providers and dietitians advised people with celiac disease to avoid eating oats. Evidence suggests that most people with the disease can safely eat small amounts of oats, as long as the oats are not contaminated with wheat gluten during processing. People with celiac disease should talk with their health care team when deciding whether to include oats in their diet.

Eating out and shopping can be a challenge. Newly diagnosed people and their families may find support groups helpful as they adjust to a new approach to eating. People with celiac disease should

- read food labelsespecially canned, frozen, and processed foodsfor ingredients that contain gluten  - avoid ingredients such as hydrolyzed vegetable protein, also called lecithin or soy lecithin  - ask restaurant servers and chefs about ingredients and food preparation inquire whether a gluten-free menu is available  - ask a dinner or party host about glutenfree options before attending a social gathering

Foods that are packaged as gluten-free tend to cost more than the same foods containing gluten. People following a gluten-free diet may find that naturally gluten-free foods are less expensive. With practice, looking for gluten can become second nature.

The Gluten-free Diet: Some Examples

The Academy of Nutrition and Dietetics has published recommendations for a glutenfree diet. The following chart illustrates these recommendations. This list is not complete, so people with celiac disease should discuss gluten-free food choices with a dietitian or health care professional who specializes in celiac disease. People with celiac disease should always read food ingredient lists carefully to make sure the food does not contain gluten.

Table 1. Gluten-free foods and foods that contain gluten

Foods and Ingredients That Contain Gluten         barley rye triticale (a cross between wheat and rye) wheat, including          - including einkorn, emmer, spelt, kamut      - wheat starch, wheat bran, wheat germ, cracked wheat, hydrolyzed wheat protein        brewer's yeast dextrin malt (unless a gluten-free source is named, such as corn malt) modified food starch oats (not labeled gluten-free) starch         Other Wheat Products That Contain Gluten         bromated flour durum flour enriched flour farina    graham flour phosphated flour plain flour    self-rising flour semolina white flour        Processed Foods That May Contain Wheat, Barley, or Rye*         bouillon cubes brown rice syrup candy chewing gum chips/potato chips cold cuts, hot dogs, salami, sausage    communion wafers french fries gravies imitation fish matzo and matzo meal rice mixes    sauces seasoned tortilla chips self-basting turkey soups soy sauce vegetables in sauce        *Most of these foods can be found gluten-free. When in doubt, check with the food manufacturer.         Food Products and Ingredients Made from Barley*         ale beer malt malt beverages    malted milk malt extract malt syrup malt vinegar    other fermented beverages porter stout        *People should only consume these foods if they are labeled gluten-freesuch as sorghum-based beeror they list a grain source other than barley, wheat, or ryesuch as corn malt.         Foods That Do Not Contain Gluten         amaranth arrowroot buckwheat cassava corn flax    legumes lentils millet nuts oats (labeled gluten-free) potatoes    quinoa rice sago seeds sorghum soy    tapioca tef (or teff) wild rice yucca

Food Labeling Requirements   On August 2, 2013, the U.S. Food and Drug Administration (FDA) published a new regulation defining the term "glutenfree" for voluntary food labeling. This new federal definition standardizes the meaning of "gluten-free" foods regulated by the FDA. Foods regulated by the U.S. Department of Agriculture, including meat and egg products, are not subject to this regulation. The regulation requires that any food with the term "gluten-free" on the label must meet all of the requirements of the definition, including that the food should contain fewer than 20 parts per million of gluten. The FDA rule also requires foods with the claims "no gluten," "free of gluten," and "without gluten" to meet the definition for "gluten-free."   If a food that is labeled "gluten-free" includes "wheat" on the ingredients list or "contains wheat" after the list, the following statement must be included on the label: "The wheat has been processed to allow this food to meet the Food and Drug Administration requirements for gluten-free food." If this statement is included, people with celiac disease may consume foods labeled "gluten-free."


- Celiac disease is an immune disorder in which people cannot tolerate gluten because it damages the lining of their small intestine and prevents absorption of nutrients.  - When people with celiac disease eat foods or use products containing gluten, their immune system responds by damaging or destroying villithe tiny, fingerlike projections on the inner lining of the small intestine.  - A person may experience digestive signs and symptoms, or symptoms in other parts of the body.  - Recognizing celiac disease can be difficult because some of its symptoms are similar to those of other diseases and conditions.  - Dermatitis herpetiformis is a chronic, itchy, blistering skin rashusually on the elbows, knees, buttocks, back, or scalpthat affects about 5 to 10 percent of people with celiac disease.  - Signs and symptoms of celiac disease vary from person to person because of numerous factors.  - Some people with celiac disease have no signs or symptoms; however, they can still develop complications of the disease over time. Long-term complications include malnutrition, liver diseases, intestinal cancer, and lymphoma.  - A health care provider diagnoses celiac disease with a medical and family history, a physical exam, blood tests, an intestinal biopsy, and a skin biopsy.  - Since celiac disease sometimes runs in families, blood relatives of people with celiac disease should talk with their health care provider about their chances of getting the disease.  - Most people with celiac disease have a significant improvement in symptoms when they follow a gluten-free diet.  - Health care providers typically refer people to a dietitian who specializes in treating people with the disease.  - The dietitian will give the person instructions for how to read food and product labels and identify ingredients that contain gluten.  - Medications, supplements, and other products may also contain a hidden source of gluten.  - People with celiac disease can eat a wellbalanced diet with a variety of foods.


Your nervous system carries signals between your brain and other parts of your body through your spinal cord. Nerves are bundles of special tissues that transmit these signals.

The signals share information between your brain and body about how things feel. The signals also send information between your brain and body to control automatic body functions, such as breathing and digestion, and to move your body parts.

The nerves in your spinal cord branch out to all of your organs and body parts. All your nerves together make up your nervous system.

Your nervous system is composed of the

- central nervous systemyour brain and spinal cord  - cranial* nervesnerves that connect your brain to your head, neck, and face  - peripheral nervous systemnerves that connect your spinal cord to your entire body, including your organs and your arms, hands, legs, and feet

*See the Pronunciation Guide for tips on how to say the the words in bold type.


Nerve damage symptoms depend on which nerves have damage. Some people have no symptoms or mild symptoms. Other people have painful and long-lasting symptoms. As most nerve damage develops over many years, a person may not notice mild cases for a long time. In some people, the onset of pain may be sudden and severe.


Peripheral Neuropathy

Peripheral neuropathy is the most common type of diabetic neuropathy, and it affects the sensory nerves of your feet, legs, hands, and arms. These areas of your body may feel

- numb  - weak  - cold  - burning or tingling, like pins and needles

You may feel extreme pain in these areas of your body, even when they are touched lightly. You also may feel pain in your legs and feet when walking.

These feelings are often worse at night and can make it hard to sleep. Most of the time, you will have these feelings on both sides of your body, such as in both feet; however, they can occur just on one side.

You might have other problems, such as

- swollen feet  - loss of balance  - loss of muscle tone in your hands and feet  - a deformity or shape change in your toes and feet  - calluses or open sores on your feet

Autonomic Neuropathy

Autonomic neuropathy can affect your

- digestive system  - sex organs  - bladder  - sweat glands  - eyes  - heart rate and blood pressure  - ability to sense low blood glucose

Digestive system. Damage to nerves in your stomach, intestines, and other parts of your digestive system may

- make it hard to swallow both solid food and liquids  - cause stomach pain, nausea, vomiting, constipation, or diarrhea  - make it hard to keep your blood glucose under control

Your doctor or dietitian may advise you to eat smaller, more frequent meals; avoid fatty foods; and eat less fiber.

Sex organs. Damage to nerves in the sex organs may

- prevent a mans penis from getting firm when he wants to have sex, called erectile dysfunction or impotence. Many men who have had diabetes for several years have impotence.  - prevent a womans vagina from getting wet when she wants to have sex. A woman might also have less feeling around her vagina.

Bladder. Damage to nerves in your bladder may make it hard to know when you need to urinate and when your bladder is empty. This damage can cause you to hold urine for too long, which can lead to bladder infections. You also might leak drops of urine.

Sweat glands. Damage to nerves in your sweat glands may prevent them from working properly. Nerve damage can cause you to sweat a lot at night or while eating.

Eyes. Damage to nerves in your pupils, the parts of your eyes that react to changes in light and darkness, may make them slow to respond to these changes. You may have trouble seeing the lights of other cars when driving at night. Your eyes may take longer to adjust when you enter a dark room.

Heart rate and blood pressure. Damage to nerves that control your heart rate and blood pressure may make these nerves respond more slowly to changes in position, stress, physical activity, sleep, and breathing patterns. You might feel dizzy or pass out when you go from lying down to standing up or when you do physical activity. You also might have shortness of breath or swelling in your feet.

Ability to sense low blood glucose. Autonomic nerves also let you know when your blood glucose is low. Damage to these nerves can prevent you from feeling the symptoms of low blood glucose, also called hypoglycemia. This kind of nerve damage is more likely to happen if you have had diabetes for a long time or if your blood glucose has often been too low. Low blood glucose can make you

- hungry  - dizzy or shaky  - confused  - pale  - sweat more  - weak  - anxious or cranky  - have headaches  - have a fast heartbeat

Severe hypoglycemia can cause you to pass out. If that happens, youll need help bringing your blood glucose level back to normal. Your health care team can teach your family members and friends how to give you an injection of glucagon, a hormone that raises blood glucose levels quickly. If glucagon is not available, someone should call 911 to get you to the nearest emergency room for treatment.

Consider wearing a diabetes medical alert identification bracelet or necklace. If you have hypoglycemia and are not able to communicate, the emergency team will know you have diabetes and get you the proper treatment. You can find these bracelets or necklaces at your pharmacy or on the Internet. You can also ask your doctor for information on available products.

Other Neuropathies

Other types of neuropathies from diabetes can cause

- damage to the joint and bones of your foot, called Charcots foot, in which you cannot sense pain or the position of your foot  - carpal tunnel syndrome, in which a nerve in your forearm is compressed at your wrist, causing numbness, swelling, and pain in your fingers  - paralysis on one side of your face, called Bells palsy  - double vision or not being able to focus your eyes  - aching behind one eye


The treatment for nerve damage from diabetes is based on your symptoms. No treatment can reverse nerve damage; however, it can help you feel better. Your doctor might suggest taking low doses of medicines that both treat other health problems and help the pain of neuropathy. Some of these medicines include

- antidepressants  - anticonvulsants, or anti-seizure medicines

Other treatment options include

- creams or patches on your skin for burning pain  - over-the-counter pain medicines  - acupuncture, a form of pain treatment that uses needles inserted into your body at certain pressure points  - physical therapy, which helps with muscle weakness and loss of balance  - relaxation exercises, such as yoga  - special shoes to fit softly around sore feet or feet that have changed shape

Your doctor also can prescribe medicines to help with problems caused by nerve damage in other areas of your body, such as poor digestion, dizziness, sexual problems, and lack of bladder control.

Stopping smoking and drinking alcoholic beverages also may help with symptoms.


You can keep your nervous system healthy by taking these steps:

- Eat healthy meals and follow the meal plan that you and your doctor or dietitian have worked out.  - If you drink alcoholic beverages, limit your intake to no more than one drink per day for women and two drinks per day for men. Drinking too many alcoholic beverages can make nerve damage worse.

More information is provided in the NIDDK health topic, What I need to know about Eating and Diabetes.


Hemochromatosis is the most common form of iron overload disease. Too much iron in the body causes hemochromatosis. Iron is important because it is part of hemoglobin, a molecule in the blood that transports oxygen from the lungs to all body tissues. However, too much iron in the body leads to iron overloada buildup of extra iron that, without treatment, can damage organs such as the liver, heart, and pancreas; endocrine glands; and joints.

The three types of hemochromatosis are primary hemochromatosis, also called hereditary hemochromatosis; secondary hemochromatosis; and neonatal hemochromatosis.


Primary Hemochromatosis

Inherited genetic defects cause primary hemochromatosis, and mutations in the HFE gene are associated with up to 90 percent of cases.1 The HFE gene helps regulate the amount of iron absorbed from food. The two known mutations of HFE are C282Y and H63D. C282Y defects are the most common cause of primary hemochromatosis.

People inherit two copies of the HFE geneone copy from each parent. Most people who inherit two copies of the HFE gene with the C282Y defect will have higher-than-average iron absorption. However, not all of these people will develop health problems associated with hemochromatosis. One recent study found that 31 percent of people with two copies of the C282Y defect developed health problems by their early fifties.2 Men who develop health problems from HFE defects typically develop them after age 40.1 Women who develop health problems from HFE defects typically develop them after menopause.1

People who inherit two H63D defects or one C282Y and one H63D defect may have higher-than-average iron absorption.3 However, they are unlikely to develop iron overload and organ damage.

Rare defects in other genes may also cause primary hemochromatosis. Mutations in the hemojuvelin or hepcidin genes cause juvenile hemochromatosis, a type of primary hemochromatosis. People with juvenile hemochromatosis typically develop severe iron overload and liver and heart damage between ages 15 and 30.

Secondary Hemochromatosis

Hemochromatosis that is not inherited is called secondary hemochromatosis. The most common cause of secondary hemochromatosis is frequent blood transfusions in people with severe anemia. Anemia is a condition in which red blood cells are fewer or smaller than normal, which means they carry less oxygen to the bodys cells. Types of anemia that may require frequent blood transfusions include

- congenital, or inherited, anemias such as sickle cell disease, thalassemia, and Fanconis syndrome  - severe acquired anemias, which are not inherited, such as aplastic anemia and autoimmune hemolytic anemia

Liver diseasessuch as alcoholic liver disease, nonalcoholic steatohepatitis, and chronic hepatitis C infectionmay cause mild iron overload. However, this iron overload causes much less liver damage than the underlying liver disease causes.

Neonatal Hemochromatosis

Neonatal hemochromatosis is a rare disease characterized by liver failure and death in fetuses and newborns. Researchers are studying the causes of neonatal hemochromatosis and believe more than one factor may lead to the disease.

Experts previously considered neonatal hemochromatosis a type of primary hemochromatosis. However, recent studies suggest genetic defects that increase iron absorption do not cause this disease. Instead, the mothers immune system may produce antibodiesproteins made by the immune system to protect the body from foreign substances such as bacteria or virusesthat damage the liver of the fetus. Women who have had one child with neonatal hemochromatosis are at risk for having more children with the disease.4 Treating these women during pregnancy with intravenous (IV) immunoglobulina solution of antibodies from healthy peoplecan prevent fetal liver damage.4

Researchers supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) recently found that a combination of exchange transfusionremoving blood and replacing it with donor bloodand IV immunoglobulin is an effective treatment for babies born with neonatal hemochromatosis.5


A person with hemochromatosis may notice one or more of the following symptoms:

- joint pain  - fatigue, or feeling tired  - unexplained weight loss  - abnormal bronze or gray skin color  - abdominal pain  - loss of sex drive

Not everyone with hemochromatosis will develop these symptoms.


Without treatment, iron may build up in the organs and cause complications, including

- cirrhosis, or scarring of liver tissue  - diabetes  - irregular heart rhythms or weakening of the heart muscle  - arthritis  - erectile dysfunction

The complication most often associated with hemochromatosis is liver damage. Iron buildup in the liver causes cirrhosis, which increases the chance of developing liver cancer.

For some people, complications may be the first sign of hemochromatosis. However, not everyone with hemochromatosis will develop complications.


Health care providers use medical and family history, a physical exam, and routine blood tests to diagnose hemochromatosis or other conditions that could cause the same symptoms or complications.

- Medical and family history. Taking a medical and family history is one of the first things a health care provider may do to help diagnose hemochromatosis. The health care provider will look for clues that may indicate hemochromatosis, such as a family history of arthritis or unexplained liver disease.    - Physical exam. After taking a medical history, a health care provider will perform a physical exam, which may help diagnose hemochromatosis. During a physical exam, a health care provider usually      - examines a patients body    - uses a stethoscope to listen to bodily sounds    - taps on specific areas of the patients body      - Blood tests. A blood test involves drawing blood at a health care providers office or a commercial facility and sending the sample to a lab for analysis. Blood tests can determine whether the amount of iron stored in the body is higher than normal:1      - The transferrin saturation test shows how much iron is bound to the protein that carries iron in the blood. Transferrin saturation values above or equal to 45 percent are considered abnormal.    - The serum ferritin test detects the amount of ferritina protein that stores ironin the blood. Levels above 300 g/L in men and 200 g/L in women are considered abnormal. Levels above 1,000 g/L in men or women indicate a high chance of iron overload and organ damage.    If either test shows higher-than-average levels of iron in the body, health care providers can order a special blood test that can detect two copies of the C282Y mutation to confirm the diagnosis. If the mutation is not present, health care providers will look for other causes.    - Liver biopsy. Health care providers may perform a liver biopsy, a procedure that involves taking a piece of liver tissue for examination with a microscope for signs of damage or disease. The health care provider may ask the patient to temporarily stop taking certain medications before the liver biopsy. The health care provider may ask the patient to fast for 8 hours before the procedure.  During the procedure, the patient lies on a table, right hand resting above the head. The health care provider applies a local anesthetic to the area where he or she will insert the biopsy needle. If needed, a health care provider will also give sedatives and pain medication. The health care provider uses a needle to take a small piece of liver tissue. He or she may use ultrasound, computerized tomography scans, or other imaging techniques to guide the needle. After the biopsy, the patient must lie on the right side for up to 2 hours and is monitored an additional 2 to 4 hours before being sent home.  A health care provider performs a liver biopsy at a hospital or an outpatient center. The health care provider sends the liver sample to a pathology lab where the pathologista doctor who specializes in diagnosing diseaselooks at the tissue with a microscope and sends a report to the patients health care provider. The biopsy shows how much iron has accumulated in the liver and whether the patient has liver damage.

Hemochromatosis is rare, and health care providers may not think to test for this disease. Thus, the disease is often not diagnosed or treated. The initial symptoms can be diverse, vague, and similar to the symptoms of many other diseases. Health care providers may focus on the symptoms and complications caused by hemochromatosis rather than on the underlying iron overload. However, if a health care provider diagnoses and treats the iron overload caused by hemochromatosis before organ damage has occurred, a person can live a normal, healthy life.

Who should be tested for hemochromatosis?   Experts recommend testing for hemochromatosis in people who have symptoms, complications, or a family history of the disease.   Some researchers have suggested widespread screening for the C282Y mutation in the general population. However, screening is not cost-effective. Although the C282Y mutation occurs quite frequently, the disease caused by the mutation is rare, and many people with two copies of the mutation never develop iron overload or organ damage.   Researchers and public health officials suggest the following:   - Siblings of people who have hemochromatosis should have their blood tested to see if they have the C282Y mutation.   - Parents, children, and other close relatives of people who have hemochromatosis should consider being tested.   - Health care providers should consider testing people who have severe and continuing fatigue, unexplained cirrhosis, joint pain or arthritis, heart problems, erectile dysfunction, or diabetes because these health issues may result from hemochromatosis.


Health care providers treat hemochromatosis by drawing blood. This process is called phlebotomy. Phlebotomy rids the body of extra iron. This treatment is simple, inexpensive, and safe.

Based on the severity of the iron overload, a patient will have phlebotomy to remove a pint of blood once or twice a week for several months to a year, and occasionally longer. Health care providers will test serum ferritin levels periodically to monitor iron levels. The goal is to bring serum ferritin levels to the low end of the average range and keep them there. Depending on the lab, the level is 25 to 50 g/L.

After phlebotomy reduces serum ferritin levels to the desired level, patients may need maintenance phlebotomy treatment every few months. Some patients may need phlebotomies more often. Serum ferritin tests every 6 months or once a year will help determine how often a patient should have blood drawn. Many blood donation centers provide free phlebotomy treatment for people with hemochromatosis.

Treating hemochromatosis before organs are damaged can prevent complications such as cirrhosis, heart problems, arthritis, and diabetes. Treatment cannot cure these conditions in patients who already have them at diagnosis. However, treatment will help most of these conditions improve. The treatments effectiveness depends on the degree of organ damage. For example, treating hemochromatosis can stop the progression of liver damage in its early stages and lead to a normal life expectancy. However, if a patient develops cirrhosis, his or her chance of developing liver cancer increases, even with phlebotomy treatment. Arthritis usually does not improve even after phlebotomy removes extra iron.


Iron is an essential nutrient found in many foods. Healthy people usually absorb less than 10 percent of iron in the food they eat.6 People with hemochromatosis absorb up to 30 percent of that iron.6 People with hemochromatosis can help prevent iron overload by

- eating only moderate amounts of iron-rich foods, such as red meat and organ meat  - avoiding supplements that contain iron  - avoiding supplements that contain vitamin C, which increases iron absorption

People with hemochromatosis can take steps to help prevent liver damage, including

- limiting the amount of alcoholic beverages they drink because alcohol increases their chance of cirrhosis and liver cancer  - avoiding alcoholic beverages entirely if they already have cirrhosis


- Hemochromatosis is the most common form of iron overload disease. Too much iron in the body causes hemochromatosis.  - Inherited genetic defects cause primary hemochromatosis.  - Primary hemochromatosis mainly affects Caucasians of Northern European descent.  - A person with hemochromatosis may notice one or more of the following symptoms: joint pain; fatigue, or feeling tired; unexplained weight loss; abnormal bronze or gray skin color; abdominal pain; and loss of sex drive. Not everyone with hemochromatosis will develop these symptoms.  - Without treatment, iron may build up in the organs and cause complications, including cirrhosis, diabetes, irregular heart rhythms or weakening of the heart muscle, arthritis, and erectile dysfunction.  - If a health care provider diagnoses and treats the iron overload caused by hemochromatosis before organ damage has occurred, a person can live a normal, healthy life.  - Experts recommend testing for hemochromatosis in people who have symptoms, complications, or a family history of the disease.  - Health care providers treat hemochromatosis by drawing blood. This process is called phlebotomy.


Adrenal insufficiency is an endocrine, or hormonal, disorder that occurs when the adrenal glands do not produce enough of certain hormones. The adrenal glands are located just above the kidneys.

Adrenal insufficiency can be primary or secondary. Addisons disease, the common term for primary adrenal insufficiency, occurs when the adrenal glands are damaged and cannot produce enough of the adrenal hormone cortisol. The adrenal hormone aldosterone may also be lacking. Addisons disease affects 110 to 144 of every 1 million people in developed countries.1

Secondary adrenal insufficiency occurs when the pituitary glanda pea-sized gland at the base of the brainfails to produce enough adrenocorticotropin (ACTH), a hormone that stimulates the adrenal glands to produce the hormone cortisol. If ACTH output is too low, cortisol production drops. Eventually, the adrenal glands can shrink due to lack of ACTH stimulation. Secondary adrenal insufficiency is much more common than Addisons disease.

1


Adrenal Insufficiency

The most common symptoms of adrenal insufficiency are

- chronic, or long lasting, fatigue   - muscle weakness   - loss of appetite   - weight loss   - abdominal pain

Other symptoms of adrenal insufficiency can include

- nausea   - vomiting   - diarrhea   - low blood pressure that drops further when a person stands up, causing dizziness or fainting   - irritability and depression   - craving salty foods   - hypoglycemia, or low blood sugar   - headache   - sweating   - irregular or absent menstrual periods   - in women, loss of interest in sex

Hyperpigmentation, or darkening of the skin, can occur in Addisons disease, although not in secondary adrenal insufficiency. This darkening is most visible on scars; skin folds; pressure points such as the elbows, knees, knuckles, and toes; lips; and mucous membranes such as the lining of the cheek.

The slowly progressing symptoms of adrenal insufficiency are often ignored until a stressful event, such as surgery, a severe injury, an illness, or pregnancy, causes them to worsen.

Adrenal Crisis

Sudden, severe worsening of adrenal insufficiency symptoms is called adrenal crisis. If the person has Addisons disease, this worsening can also be called an Addisonian crisis. In most cases, symptoms of adrenal insufficiency become serious enough that people seek medical treatment before an adrenal crisis occurs. However, sometimes symptoms appear for the first time during an adrenal crisis.

Symptoms of adrenal crisis include

- sudden, severe pain in the lower back, abdomen, or legs   - severe vomiting and diarrhea   - dehydration   - low blood pressure   - loss of consciousness

If not treated, an adrenal crisis can cause death.

Get Treatment for Adrenal Crisis Right Away   People with adrenal insufficiency who have weakness, nausea, or vomiting need immediate emergency treatment to prevent an adrenal crisis and possible death. An injection with a synthetic glucocorticoid hormone called a corticosteroid can save a persons life. People should make sure to have a corticosteroid injection with them at all times, and make sure their friends and family know how and when to give the injection.   Read more under How is adrenal insufficiency treated?


People with adrenal insufficiency who have weakness, nausea, or vomiting need immediate emergency treatment to prevent an adrenal crisis and possible death. An injection with a synthetic glucocorticoid hormone called a corticosteroid can save a persons life. People should make sure to have a corticosteroid injection with them at all times, and make sure their friends and family know how and when to give the injection.

Read more under How is adrenal insufficiency treated?


Autoimmune disorders cause most cases of Addisons disease. Infections and medications may also cause the disease.

Autoimmune Disorders

Up to 80 percent of Addisons disease cases are caused by an autoimmune disorder, which is when the bodys immune system attacks the bodys own cells and organs.2 In autoimmune Addisons, which mainly occurs in middle-aged females, the immune system gradually destroys the adrenal cortexthe outer layer of the adrenal glands.2

Primary adrenal insufficiency occurs when at least 90 percent of the adrenal cortex has been destroyed.1 As a result, both cortisol and aldosterone are often lacking. Sometimes only the adrenal glands are affected. Sometimes other endocrine glands are affected as well, as in polyendocrine deficiency syndrome.

Polyendocrine deficiency syndrome is classified into type 1 and type 2. Type 1 is inherited and occurs in children. In addition to adrenal insufficiency, these children may have

- underactive parathyroid glands, which are four pea-sized glands located on or near the thyroid gland in the neck; they produce a hormone that helps maintain the correct balance of calcium in the body.   - slow sexual development.   - pernicious anemia, a severe type of anemia; anemia is a condition in which red blood cells are fewer than normal, which means less oxygen is carried to the bodys cells. With most types of anemia, red blood cells are smaller than normal; however, in pernicious anemia, the cells are bigger than normal.   - chronic fungal infections.   - chronic hepatitis, a liver disease.

Researchers think type 2, which is sometimes called Schmidts syndrome, is also inherited. Type 2 usually affects young adults and may include

- an underactive thyroid gland, which produces hormones that regulate metabolism   - slow sexual development   - diabetes, in which a person has high blood glucose, also called high blood sugar or hyperglycemia   - vitiligo, a loss of pigment on areas of the skin

Infections

Tuberculosis (TB), an infection that can destroy the adrenal glands, accounts for 10 to 15 percent of Addisons disease cases in developed countries.1 When primary adrenal insufficiency was first identified by Dr. Thomas Addison in 1849, TB was the most common cause of the disease. As TB treatment improved, the incidence of Addisons disease due to TB of the adrenal glands greatly decreased. However, recent reports show an increase in Addisons disease from infections such as TB and cytomegalovirus. Cytomegalovirus is a common virus that does not cause symptoms in healthy people; however, it does affect babies in the womb and people who have a weakened immune systemmostly due to HIV/AIDS.2 Other bacterial infections, such as Neisseria meningitidis, which is a cause of meningitis, and fungal infections can also lead to Addisons disease.

Other Causes

Less common causes of Addisons disease are

- cancer cells in the adrenal glands   - amyloidosis, a serious, though rare, group of diseases that occurs when abnormal proteins, called amyloids, build up in the blood and are deposited in tissues and organs   - surgical removal of the adrenal glands   - bleeding into the adrenal glands   - genetic defects including abnormal adrenal gland development, an inability of the adrenal glands to respond to ACTH, or a defect in adrenal hormone production   - medication-related causes, such as from anti-fungal medications and the anesthetic etomidate, which may be used when a person undergoes an emergency intubationthe placement of a flexible, plastic tube through the mouth and into the trachea, or windpipe, to assist with breathing

2


A lack of CRH or ACTH causes secondary adrenal insufficiency. The lack of these hormones in the body can be traced to several possible sources.

Stoppage of Corticosteroid Medication

A temporary form of secondary adrenal insufficiency may occur when a person who has been taking a synthetic glucocorticoid hormone, called a corticosteroid, for a long time stops taking the medication. Corticosteroids are often prescribed to treat inflammatory illnesses such as rheumatoid arthritis, asthma, and ulcerative colitis. In this case, the prescription doses often cause higher levels than those normally achieved by the glucocorticoid hormones created by the body. When a person takes corticosteroids for prolonged periods, the adrenal glands produce less of their natural hormones. Once the prescription doses of corticosteroid are stopped, the adrenal glands may be slow to restart their production of the bodys glucocorticoids. To give the adrenal glands time to regain function and prevent adrenal insufficiency, prescription corticosteroid doses should be reduced gradually over a period of weeks or even months. Even with gradual reduction, the adrenal glands might not begin to function normally for some time, so a person who has recently stopped taking prescription corticosteroids should be watched carefully for symptoms of secondary adrenal insufficiency.

Surgical Removal of Pituitary Tumors

Another cause of secondary adrenal insufficiency is surgical removal of the usually noncancerous, ACTH-producing tumors of the pituitary gland that cause Cushings syndrome. Cushings syndrome is a hormonal disorder caused by prolonged exposure of the bodys tissues to high levels of the hormone cortisol. When the tumors are removed, the source of extra ACTH is suddenly gone and a replacement hormone must be taken until the bodys adrenal glands are able to resume their normal production of cortisol. The adrenal glands might not begin to function normally for some time, so a person who has had an ACTH-producing tumor removed and is going off of his or her prescription corticosteroid replacement hormone should be watched carefully for symptoms of adrenal insufficiency.

More information is provided in the NIDDK health topic, Cushings Syndrome.

Changes in the Pituitary Gland

Less commonly, secondary adrenal insufficiency occurs when the pituitary gland either decreases in size or stops producing ACTH. These events can result from

- tumors or an infection in the pituitary   - loss of blood flow to the pituitary   - radiation for the treatment of pituitary or nearby tumors   - surgical removal of parts of the hypothalamus   - surgical removal of the pituitary


In its early stages, adrenal insufficiency can be difficult to diagnose. A health care provider may suspect it after reviewing a persons medical history and symptoms.

A diagnosis of adrenal insufficiency is confirmed through hormonal blood and urine tests. A health care provider uses these tests first to determine whether cortisol levels are too low and then to establish the cause. Imaging studies of the adrenal and pituitary glands can be useful in helping to establish the cause.

A lab technician performs the following tests in a health care providers office, a commercial facility, or a hospital.

Hormonal Blood and Urine Tests

- ACTH stimulation test. The ACTH stimulation test is the most commonly used test for diagnosing adrenal insufficiency. In this test, the patient is given an intravenous (IV) injection of synthetic ACTH, and samples of blood, urine, or both are taken before and after the injection. The cortisol levels in the blood and urine samples are measured in a lab. The normal response after an ACTH injection is a rise in blood and urine cortisol levels. People with Addisons disease or longstanding secondary adrenal insufficiency have little or no increase in cortisol levels.  Both low- and high-dose ACTH stimulation tests may be used depending on the suspected cause of adrenal insufficiency. For example, if secondary adrenal insufficiency is mild or has only recently occurred, the adrenal glands may still respond to ACTH because they have not yet shut down their own production of hormone. Some studies have suggested a low dose1 microgram (mcg)may be more effective in detecting secondary adrenal insufficiency because the low dose is still enough to raise cortisol levels in healthy people, yet not in people with mild or recent secondary adrenal insufficiency. However, recent research has shown that a significant proportion of healthy children and adults can fail the low-dose test, which may lead to unnecessary treatment. Therefore, some health care providers favor using a 250 mcg ACTH test for more accurate results.   - CRH stimulation test. When the response to the ACTH test is abnormal, a CRH stimulation test can help determine the cause of adrenal insufficiency. In this test, the patient is given an IV injection of synthetic CRH, and blood is taken before and 30, 60, 90, and 120 minutes after the injection. The cortisol levels in the blood samples are measured in a lab. People with Addisons disease respond by producing high levels of ACTH, yet no cortisol. People with secondary adrenal insufficiency do not produce ACTH or have a delayed response. CRH will not stimulate ACTH secretion if the pituitary is damaged, so no ACTH response points to the pituitary as the cause. A delayed ACTH response points to the hypothalamus as the cause.

Diagnosis during Adrenal Crisis

Although a reliable diagnosis is not possible during adrenal crisis, measurement of blood ACTH and cortisol during the crisisbefore treatment with corticosteroids is givenis often enough to make a preliminary diagnosis. Low blood sodium, low blood glucose, and high blood potassium are also sometimes present at the time of adrenal crisis. Once the crisis is controlled, an ACTH stimulation test can be performed to help make a specific diagnosis. More complex lab tests are sometimes used if the diagnosis remains unclear.


After Addisons disease is diagnosed, health care providers may use the following tests to look at the adrenal glands, find out whether the disease is related to TB, or identify antibodies associated with autoimmune Addisons disease.

- Ultrasound of the abdomen. Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. A specially trained technician performs the procedure in a health care providers office, an outpatient center, or a hospital, and a radiologista doctor who specializes in medical imaginginterprets the images; a patient does not need anesthesia. The images can show abnormalities in the adrenal glands, such as enlargement or small size, nodules, or signs of calcium deposits, which may indicate bleeding.   - Tuberculin skin test. A tuberculin skin test measures how a patients immune system reacts to the bacteria that cause TB. A small needle is used to put some testing material, called tuberculin, under the skin. A nurse or lab technician performs the test in a health care providers office; a patient does not need anesthesia. In 2 to 3 days, the patient returns to the health care provider, who will check to see if the patient had a reaction to the test. The test can show if adrenal insufficiency could be related to TB.  To test whether a person has TB infection, which is when TB bacteria live in the body without making the person sick, a special TB blood test is used. To test whether a person has TB disease, which is when TB bacteria are actively attacking a persons lungs and making the person sick, other tests such as a chest x ray and a sample of sputumphlegm that is coughed up from deep in the lungsmay be needed.   - Antibody blood tests. A blood test involves drawing blood at a health care providers office or a commercial facility and sending the sample to a lab for analysis. The blood test can detect antibodiesproteins made by the immune system to protect the body from foreign substancesassociated with autoimmune Addisons disease.

After secondary adrenal insufficiency is diagnosed, health care providers may use the following tests to obtain a detailed view of the pituitary gland and assess how it is functioning:

- Computerized tomography (CT) scan. CT scans use a combination of x rays and computer technology to create images. For a CT scan, the patient may be given a solution to drink and an injection of a special dye, called contrast medium. CT scans require the patient to lie on a table that slides into a tunnel-shaped device where the x rays are taken. An x-ray technician performs the procedure in an outpatient center or a hospital, and a radiologist interprets the images. The patient does not need anesthesia. A CT scan can show size and shape of the pituitary gland to find out if an abnormality is present.   - Magnetic resonance imaging (MRI). MRI machines use radio waves and magnets to produce detailed pictures of the bodys internal organs and soft tissues without using x rays. An MRI may include the injection of contrast medium. With most MRI machines, the patient lies on a table that slides into a tunnel-shaped device that may be open ended or closed at one end; some machines are designed to allow the patient to lie in a more open space. A specially trained technician performs the procedure in an outpatient center or a hospital, and a radiologist interprets the images. The patient does not need anesthesia, though people with a fear of confined spaces may receive light sedation, taken by mouth. MRIs can be used to produce a three-dimensional (3-D) image of the hypothalamus and the pituitary gland to find out if an abnormality is present.   - Hormonal blood tests. Hormonal blood tests can assess how the pituitary gland is functioning and its ability to produce other hormones.


Adrenal insufficiency is treated by replacing, or substituting, the hormones that the adrenal glands are not making. The dose of each medication is adjusted to meet the needs of the patient.

Cortisol is replaced with a corticosteroid, such as hydrocortisone, prednisone, or dexamethasone, taken orally one to three times each day, depending on which medication is chosen.

If aldosterone is also deficient, it is replaced with oral doses of a mineralocorticoid hormone, called fludrocortisone acetate (Florinef), taken once or twice daily. People with secondary adrenal insufficiency normally maintain aldosterone production, so they do not require aldosterone replacement therapy.

During adrenal crisis, low blood pressure, low blood glucose, low blood sodium, and high blood levels of potassium can be life threatening. Standard therapy involves immediate IV injections of corticosteroids and large volumes of IV saline solution with dextrose, a type of sugar. This treatment usually brings rapid improvement. When the patient can take liquids and medications by mouth, the amount of corticosteroids is decreased until a dose that maintains normal hormone levels is reached. If aldosterone is deficient, the person will need to regularly take oral doses of fludrocortisone acetate.

Researchers have found that using replacement therapy for DHEA in adolescent girls who have secondary adrenal insufficiency and low levels of DHEA can improve pubic hair development and psychological stress. Further studies are needed before routine supplementation recommendations can be made.


Adrenal crisis is treated with adrenal hormones. People with adrenal crisis need immediate treatment. Any delay can cause death. When people with adrenal crisis are vomiting or unconscious and cannot take their medication, the hormones can be given as an injection.

A person with adrenal insufficiency should carry a corticosteroid injection at all times and make sure that others know how and when to administer the injection, in case the person becomes unconscious.

The dose of corticosteroid needed may vary with a persons age or size. For example, a child younger than 2 years of age can receive 25 milligrams (mg), a child between 2 and 8 years of age can receive 50 mg, and a child older than 8 years should receive the adult dose of 100 mg.


The following steps can help a person prevent adrenal crisis:

- Ask a health care provider about possibly having a shortage of adrenal hormones, if always feeling tired, weak, or losing weight.   - Learn how to increase the dose of corticosteroid for adrenal insufficiency when ill. Ask a health care provider for written instructions for sick days. First discuss the decision to increase the dose with the health care provider when ill.   - When very ill, especially if vomiting and not able to take pills, seek emergency medical care immediately.


Some people with Addisons disease who are aldosterone deficient can benefit from following a diet rich in sodium. A health care provider or a dietitian can give specific recommendations on appropriate sodium sources and daily sodium guidelines if necessary.

Corticosteroid treatment is linked to an increased risk of osteoporosisa condition in which the bones become less dense and more likely to fracture. People who take corticosteroids should protect their bone health by consuming enough dietary calcium and vitamin D. A health care provider or a dietitian can give specific recommendations on appropriate daily calcium intake based upon age and suggest the best types of calcium supplements, if necessary.


- Adrenal insufficiency is an endocrine, or hormonal, disorder that occurs when the adrenal glands do not produce enough of certain hormones.   - Addisons disease, the common term for primary adrenal insufficiency, occurs when the adrenal glands are damaged and cannot produce enough of the adrenal hormone cortisol. The adrenal hormone aldosterone may also be lacking.   - Secondary adrenal insufficiency occurs when the pituitary gland fails to produce enough adrenocorticotropin (ACTH), a hormone that stimulates the adrenal glands to produce cortisol. If ACTH output is too low, cortisol production drops.   - The most common symptoms of adrenal insufficiency are chronic fatigue, muscle weakness, loss of appetite, weight loss, and abdominal pain. The slowly progressing symptoms are often ignored until a stressful event, such as surgery, a severe injury, an illness, or pregnancy, causes them to worsen.   - If not treated, an adrenal crisis can cause death.   - A diagnosis of adrenal insufficiency is confirmed through hormonal blood and urine tests. Imaging studies of the adrenal and pituitary glands can be useful in helping to establish the cause.   - Adrenal insufficiency is treated by replacing, or substituting, the hormones that the adrenal glands are not making.   - Problems can occur in people with adrenal insufficiency who are undergoing surgery, suffer a severe injury, have an illness, or are pregnant. These conditions place additional stress on the body, and people with adrenal insufficiency may need additional treatment to respond and recover.   - People with adrenal insufficiency should always carry identification stating their condition, adrenal insufficiency, in case of an emergency, as well as the supplies necessary to administer an emergency corticosteroid injection.


Hypothyroidism is a disorder that occurs when the thyroid gland does not make enough thyroid hormone to meet the bodys needs. Thyroid hormone regulates metabolismthe way the body uses energyand affects nearly every organ in the body. Without enough thyroid hormone, many of the bodys functions slow down. About 4.6 percent of the U.S. population age 12 and older has hypothyroidism.1


The thyroid is a 2-inch-long, butterfly-shaped gland weighing less than 1 ounce. Located in the front of the neck below the larynx, or voice box, it has two lobes, one on each side of the windpipe. The thyroid is one of the glands that make up the endocrine system. The glands of the endocrine system produce and store hormones and release them into the bloodstream. The hormones then travel through the body and direct the activity of the bodys cells.

The thyroid gland makes two thyroid hormones, triiodothyronine (T3) and thyroxine (T4). T3 is made from T4 and is the more active hormone, directly affecting the tissues. Thyroid hormones affect metabolism, brain development, breathing, heart and nervous system functions, body temperature, muscle strength, skin dryness, menstrual cycles, weight, and cholesterol levels.


Hypothyroidism has several causes, including

- Hashimotos disease  - thyroiditis, or inflammation of the thyroid  - congenital hypothyroidism, or hypothyroidism that is present at birth  - surgical removal of part or all of the thyroid  - radiation treatment of the thyroid  - some medications

Less commonly, hypothyroidism is caused by too much or too little iodine in the diet or by abnormalities of the pituitary gland.

Hashimotos Disease

Hashimotos disease, also called chronic lymphocytic thyroiditis, is the most common cause of hypothyroidism in the United States.1 Hashimotos disease is a form of chronic inflammation of the thyroid gland. Hashimotos disease is also an autoimmune disorder.

Normally, the immune system protects the body against foreign invaderssuch as viruses and bacteriathat can cause illness. But in autoimmune diseases, the immune system attacks the bodys own cells and organs. With Hashimotos disease, the immune system attacks the thyroid, causing inflammation and interfering with its ability to produce thyroid hormones.

More information is provided in the NIDDK health topic, Hashimotos Disease.

Thyroiditis

Thyroiditis causes stored thyroid hormone to leak out of the thyroid gland. At first, the leakage raises hormone levels in the blood, leading to hyperthyroidismwhen thyroid hormone levels are too highthat lasts for 1 or 2 months. Most people then develop hypothyroidism before the thyroid is completely healed.

Several types of thyroiditis can cause hyperthyroidism followed by hypothyroidism:

- Subacute thyroiditis. This condition involves painful inflammation and enlargement of the thyroid. Experts are not sure what causes subacute thyroiditis, but it may be related to a viral or bacterial infection. The condition usually goes away on its own in a few months.  - Postpartum thyroiditis. This type of thyroiditis develops after a woman gives birth. For more information, see the section titled What happens with pregnancy and thyroid conditions?  - Silent thyroiditis. This type of thyroiditis is called silent because it is painless, as is postpartum thyroiditis, even though the thyroid may be enlarged. Like postpartum thyroiditis, silent thyroiditis is probably an autoimmune condition and sometimes develops into permanent hypothyroidism.

Congenital Hypothyroidism

Some babies are born with a thyroid that is not fully developed or does not function properly. If untreated, congenital hypothyroidism can lead to mental retardation and growth failure. Early treatment can prevent these complications, so most newborns in the United States are screened for hypothyroidism.

Surgical Removal of the Thyroid

When part of the thyroid is removed, the remaining part may produce normal amounts of thyroid hormone, but some people who have this surgery develop hypothyroidism. Removal of the entire thyroid always results in hypothyroidism.

Part or all of the thyroid may be surgically removed as a treatment for

- hyperthyroidism  - a large goiter, which is an enlarged thyroid that may cause the neck to appear swollen and can interfere with normal breathing and swallowing  - thyroid nodules, which are noncancerous tumors, called adenomas, or lumps in the thyroid that can produce excess thyroid hormone  - thyroid cancer

Radiation Treatment of the Thyroid

Radioactive iodine, a common treatment for hyperthyroidism, gradually destroys the cells of the thyroid. Most people who receive radioactive iodine treatment eventually develop hypothyroidism. People with Hodgkins disease, other lymphomas, and head or neck cancers are treated with radiation, which can also damage the thyroid.

Medications

Some drugs can interfere with thyroid hormone production and lead to hypothyroidism, including

- amiodarone, a heart medication  - interferon alpha, a cancer medication  - lithium, a bipolar disorder medication  - interleukin-2, a kidney cancer medication


Hypothyroidism has many symptoms that can vary from person to person. Some common symptoms of hypothyroidism are

- fatigue  - weight gain  - a puffy face  - cold intolerance  - joint and muscle pain  - constipation  - dry skin  - dry, thinning hair  - decreased sweating  - heavy or irregular menstrual periods and impaired fertility  - depression  - slowed heart rate

However, hypothyroidism develops slowly, so many people dont notice symptoms of the disease.

Symptoms more specific to Hashimotos disease are a goiter and a feeling of fullness in the throat.

Hypothyroidism can contribute to high cholesterol, so people with high cholesterol should be tested for hypothyroidism. Rarely, severe, untreated hypothyroidism may lead to myxedema coma, an extreme form of hypothyroidism in which the bodys functions slow to the point that it becomes life threatening. Myxedema requires immediate medical treatment.


Many symptoms of hypothyroidism are the same as those of other diseases, so hypothyroidism usually cannot be diagnosed based on symptoms alone. With suspected hypothyroidism, health care providers take a medical history and perform a thorough physical examination. Health care providers may then use several blood tests to confirm a diagnosis of hypothyroidism and find its cause:

TSH test. The ultrasensitive TSH test is usually the first test a health care provider performs. This test detects even tiny amounts of TSH in the blood and is the most accurate measure of thyroid activity available. Generally, a TSH reading above normal means a person has hypothyroidism and a reading below normal means a person has hyperthyroidism.

Mildly elevated TSH without symptoms indicates subclinical hypothyroidism. Some health care providers treat subclinical hypothyroidism immediately. Others prefer to leave it untreated but monitor their patients for signs that the condition is worsening.

Health care providers may conduct additional tests to help confirm the diagnosis or determine the cause of hypothyroidism.

T4 test. This test measures the actual amount of circulating thyroid hormone in the blood. In hypothyroidism, the level of T4 in the blood is lower than normal.

Thyroid autoantibody test. This test looks for the presence of thyroid autoantibodies. Most people with Hashimotos disease have these antibodies, but people whose hypothyroidism is caused by other conditions do not.

More information about testing for thyroid problems is provided in the NIDDK health topic, Thyroid Tests.


Health care providers treat hypothyroidism with synthetic thyroxine, a medication that is identical to the hormone T4. The exact dose will depend on the patients age and weight, the severity of the hypothyroidism, the presence of other health problems, and whether the person is taking other drugs that might interfere with how well the body uses thyroid hormone.

Health care providers test TSH levels about 6 to 8 weeks after a patient begins taking thyroid hormone and make any necessary adjustments to the dose. Each time the dose is adjusted, the blood is tested again. Once a stable dose is reached, blood tests are normally repeated in 6 months and then once a year.

Hypothyroidism can almost always be completely controlled with synthetic thyroxine, as long as the recommended dose is taken every day as instructed.


Experts recommend that people eat a balanced diet to obtain most nutrients. More information about diet and nutrition can be found on the National Agricultural Library website at www.nutrition.gov.

Dietary Supplements

Iodine is an essential mineral for the thyroid. However, people with autoimmune thyroid disease may be sensitive to harmful side effects from iodine. Taking iodine drops or eating foods containing large amounts of iodinesuch as seaweed, dulse, or kelpmay cause or worsen hypothyroidism or hyperthyroidism. More information about iodine can be found in the National Library of Medicine fact sheet Iodine in diet, available at www.nlm.nih.gov/medlineplus/ency/article/002421.htm.

Women need more iodine when they are pregnantabout 250 micrograms a day because the baby gets iodine from the mothers diet. In the United States, about 7 percent of pregnant women may not get enough iodine in their diet or through prenatal vitamins.3 Choosing iodized salt salt supplemented with iodineover plain salt and prenatal vitamins containing iodine will ensure this need is met.

To help ensure coordinated and safe care, people should discuss their use of dietary supplements, such as iodine, with their health care provider. Tips for talking with health care providers are available through the National Center for Complementary and Integrative Health.


- Hypothyroidism is a disorder that occurs when the thyroid gland does not make enough thyroid hormone to meet the bodys needs. Thyroid hormone regulates metabolism. Without enough thyroid hormone, many of the bodys functions slow down.  - Hypothyroidism has several causes, including      - Hashimotos disease    - thyroiditis    - congenital hypothyroidism    - surgical removal of part or all of the thyroid    - radiation treatment of the thyroid    - some medications    - Hypothyroidism has many symptoms that can vary from person to person. Some common symptoms of hypothyroidism are fatigue, weight gain, cold intolerance, constipation, impaired fertility, and depression.  - Women are much more likely than men to develop hypothyroidism.  - Women with hypothyroidism should discuss their condition with their health care provider before becoming pregnant.  - Hypothyroidism can almost always be completely controlled with synthetic thyroxine, as long as the recommended dose is taken every day as instructed.


A UTI is an infection in the urinary tract. Infections are caused by microbesorganisms too small to be seen without a microscopeincluding fungi, viruses, and bacteria. Bacteria are the most common cause of UTIs. Normally, bacteria that enter the urinary tract are rapidly removed by the body before they cause symptoms. However, sometimes bacteria overcome the bodys natural defenses and cause infection. An infection in the urethra is called urethritis. A bladder infection is called cystitis. Bacteria may travel up the ureters to multiply and infect the kidneys. A kidney infection is called pyelonephritis.


The urinary tract is the body's drainage system for removing wastes and extra water. The urinary tract includes two kidneys, two ureters, a bladder, and a urethra. The kidneys are a pair of bean-shaped organs, each about the size of a fist and located below the ribs, one on each side of the spine, toward the middle of the back. Every minute, a persons kidneys filter about 3 ounces of blood, removing wastes and extra water. The wastes and extra water make up the 1 to 2 quarts of urine a person produces each day. The urine travels from the kidneys down two narrow tubes called the ureters. The urine is then stored in a balloonlike organ called the bladder and emptied through the urethra, a tube at the bottom of the bladder.

When the bladder empties, a muscle called the sphincter relaxes and urine flows out of the body through the urethra. The opening of the urethra is at the end of the penis in males and in front of the vagina in females.


Most UTIs are caused by bacteria that live in the bowel. The bacterium Escherichia coli (E. coli) causes the vast majority of UTIs. Microbes called Chlamydia and Mycoplasma can infect the urethra and reproductive system but not the bladder. Chlamydia and Mycoplasma infections may be sexually transmitted and require treatment of sexual partners.

The urinary tract has several systems to prevent infection. The points where the ureters attach to the bladder act like one-way valves to prevent urine from backing up toward the kidneys, and urination washes microbes out of the body. In men, the prostate gland produces secretions that slow bacterial growth. In both sexes, immune defenses also prevent infection. But despite these safeguards, infections still occur. Certain bacteria have a strong ability to attach themselves to the lining of the urinary tract.


Urinary tract infections are the second most common type of infection in the body, accounting for about 8.1 million visits to health care providers each year.1 Women are especially prone to UTIs for anatomical reasons. One factor is that a womans urethra is shorter, allowing bacteria quicker access to the bladder. Also, a womans urethral opening is near sources of bacteria from the anus and vagina. For women, the lifetime risk of having a UTI is greater than 50 percent.2 UTIs in men are not as common as in women but can be serious when they occur.