Lower leg edema hypothyroidism signs am wondering if Hypothyrodism have some combination of both estrogen dominance and hypothyroidism. I was seeing flashes of lights, floaters, I was having episodes of extreme coldness, pain in my tail bone, dizziness, tieredness, blues, and hair loss. Tanya November 12, at am - Reply. Alone, it may not be enough to normalize body temperatures. Happy to day that the Insomnia is better now, everything else too, my guess was Adrenal Fatigue, but i cannot tolerate cortisol, at any rate, most Docs dont buy in AF, let me tell you, it REAL!.
I do yoga daily and work out a few times a week.
Show more related content. Post-thrombotic syndrome after deep venous thrombosis: risk factors, prevention, and therapeutic options.
Your vital functions and level of consciousness are also continually monitored during this process.
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Home » Hypothyroidism and Water Retention. Cochrane Database Syst Rev. Without a rapid diagnosis, myxedema crisis is often fatal.
Thus by checking your thyroid function regularly and taking the hypothyrkidism thyroid medications you can manage the edema effectively. Subscribe to our mailing list and get interesting stuff and updates to your email inbox. Weight loss does not affect this condition. Local skin and wound care of venous ulcers is essential in preventing secondary cellulitis and dermatitis. The signs and symptoms of hypothyroidism vary, depending on the severity of the hormone deficiency.
Elston, Timothy G. When the nerve compression is more in the forearm or wrist region, it causes carpal tunnel syndrome, which exhibits symptoms such as tingling, numbness, aches and burning sensation. Along with the signs and symptoms of severe hypothyroidism, symptoms of myxedema crisis can include:. Celecoxib Celebrexibuprofen.
Assessment of Edema
Weight loss does not affect this condition. What Is Subclinical Hypothyroidism? Clin Med. Comparison of obstructive sleep apnea patients with and without leg edema. Symptomatic lower extremity deep venous thrombosis: accuracy, limitations, and role of color duplex flow imaging in diagnosis [published correction appears in Radiology.
I was seeing flashes of lights, floaters, I was having episodes of extreme coldness, pain in my tail bone, dizziness, tieredness, blues, and hair loss. I could just cry right now.
Armour Thyroid Side Effects. Physical therapies for reducing and controlling lymphoedema of the limbs.
Still swelling — lies down and fluid receeds, up for about 1 hour — sitting and the fluid returns.
I also acquired blood clots and was being treated with coumadin for a year. I must say, having tried all mes pain etc that nothing worked, thats why i dont anymore.
Andrews' Diseases of the skin : clinical dermatology 11th ed. Wilson's syndrome: An accepted medical diagnosis? Differential sigbs, investigation, and current treatment of lower limb lymphedema. The mortality rates may be as high as 25 to 60 percent even with treatment. Mixed evidence exists for the use of pneumatic compression devices in patients with chronic venous insufficiency. Vasc Med. Pittler MH, Ernst E.
Iliac vein obstruction. Venous ultrasonography is the imaging modality of choice in the evaluation of suspected DVT. Weight gain, for example, often causes significant distress…. Babies born to ley with untreated thyroid disease may have a higher risk of birth defects compared to babies born to healthy mothers. The chronic accumulation of more generalized edema is due to the onset or exacerbation of chronic systemic conditions, such as congestive heart failure CHFrenal disease, or hepatic disease. Categories : Endocrine-related cutaneous conditions Skin conditions resulting from errors in metabolism.
1. Your hair is thinning.
Katie Slou April 6, at pm - Reply. Over the last 5 years my hypothyroidism has gotten worse and the more medication armour the worse I get. Weight gain, for example, often causes significant distress…. My body temp ranges between 90 to 94 yet t3 is
I thought the foot, ankle and leg swelling was going away. Hi Lower leg edema hypothyroidism signs, low body temperatures are certainly one possible explanation of fluid retention. I was told it was because I am heavy and it is a drainage issue. I have seen this type of result with other thyroid problems.
I get chest palpations have become pre diabetic 6. I was free edema hypothyroidism signs swelling after about three weeks, for about a week and then it came back with a vengance. The fluid retention, swelling of the legs and ankles used to occur mostly in the heat of the summer and would disappear for long periods of time. I was told that it was probably due to the T3 in the Armour medication and was switched to Synthroid 1. Surinder Sharma November 6, at pm - Reply.
This causes retention of fluids which is manifested as swollen fingers, wrist, feet, face, ankles and hands. Vasc Med. This version of the article contains supplemental content.
My body temperature has been running How is myxedema treated? Coconut Oil or not? You may want to check your temperature with another thermometer. Is it ok to use the scarf or am I creating a false reading? I swell everywhere though.
I have seen this type of result with other thyroid problems.
Soft, pitting edema.
If you have signs or symptoms of myxedema, you need immediate emergency medical treatment. I would expect your thyroid symptoms to resolve until your body temperature is normal.
Is edema hypothyroidism a known medical condition or do you need to see a special dr? My temp avg is about My symptoms were getting out of hand. Babies born to women with untreated thyroid disease may have a higher risk of birth defects compared to babies born to healthy mothers. You can check your temperature. Ferri FF.
This causes retention of fluids which is manifested as swollen fingers, wrist, feet, face, ankles and hands. In patients with suspected medication-induced edema, the offending medication should be discontinued if possible. The symptoms that indicate water retention in hypothyroidism include swollen ankles, feet, face, abdomen, fingers, wrist and hands. Read this next. ISSN
On June 16th, I noticed a weird feeling in my ankle. Thyroid disease is much more common in women, BTW. She is not diabetic. I was told that it was because I was so sick with an infection and sometimes people have a low temp instead of high.
In the late stages of hypothyroidism signs regional pain syndrome, the skin may appear shiny with atrophic changes. J Fam Pract. The history should include the timing of the lowwr, whether it changes with position, and if it is unilateral or bilateral, as well as a medication history and an assessment for systemic diseases Table 2. Its signs and symptoms include intense cold intolerance and drowsiness followed by profound lethargy and unconsciousness. Also called as edema, water retention indicates accumulation of fluids at above normal levels inside the tissues present in the body. Enlarge Print eFigure D.
I had thyroid cancer and had edema hypothyroidism complete thyroid removed. Severely advanced hypothyroidism can lead to htpothyroidism is called a myxedema crisis, a medical emergency. I am wondering if I have some combination of both estrogen dominance and hypothyroidism. What are the symptoms of myxedema crisis? I suffer from horrific complex migraines and take many pain meds along with Botox treatments every 10 weeks. I went to the dr because I have never had a problem with swelling even during periods.
Edema in hypothyroidism
Like what you read? Lipodermatosclerosis from chronic venous insufficiency associated with marked sclerotic and hyperpigmented tissue. Int J Dermatol. Complex regional pain syndrome type 1 reflex sympathetic dystrophy. ABC of arterial and venous disease.
Those undergoing a myxedema crisis need to be treated in an ICU. Myxedema crisis is considered a medical emergency and requires immediate attention. Denis Wilson January 17, at pm - Reply. The most common cause of hypothyroidism is an autoimmune disorder known as Hashimoto's thyroiditis.
I am more fatigued than normal.
Myxedema can also occur in Hashimoto thyroiditis and other long-standing forms of hypothyroidism.
So happy that I stumbled upon this website!! Or are we being victims of theoretical experiments??
Table 2. See the CME Quiz.
This fluid is going to cause a major cardiac event I can feel it in my soul.
Mechanical therapies, including leg elevation and compression stockings with 20 to 30 mm Hg for mild edema and 30 to 40 mm Hg for severe edema complicated by ulceration, are recommended.
Myxedema describes a specific hypothyroidism signs of cutaneous and dermal edema secondary to increased deposition of connective tissue components. Autoimmune disease. Comparison of obstructive sleep apnea patients with and without leg edema. Other than the visible puffiness, the retention also triggers several health conditions. There is no treatment for lipedema. In patients who present with acute onset of unilateral upper or lower extremity swelling, a d -dimer enzyme-linked immunosorbent assay can rule out DVT in low-risk patients.
Denis Wilson May lower leg edema hypothyroidism signs, at pm - Reply. If your temperature on thyroid medicine is still averaging less than She has edema in her legs sighs face. Also I drive 3 hours and 15 minutes one way for treatment and it is well worth it. According to the American Academy of Dermatology AADyour dermatologist might be the first doctor to notice signs of thyroid disease since many signs and symptoms show up on your skin, hair, and nails.
2. Your eyes feel dry and look puffy.
I am not seeing the doctor until the end of April. All water. Elderly people are at a higher risk of having a poor outcome. Denis Wilson. If your temperature on thyroid medicine is still averaging less than
Pitting describes htpothyroidism indentation that remains in the edematous area after pressure is applied Figure 3. Primary Hypothyroidism. Daily hydration with emollients and short courses of topical steroid creams for severely inflamed skin should be used to treat eczematous stasis dermatitis associated with chronic venous insufficiency. The fluid between the interstitial and intravascular spaces is regulated by the capillary hydrostatic pressure gradient and the oncotic pressure gradient across the capillary. Primary: congenital lymphedema, lymphedema praecox, lymphedema tarda. New England Journal of Medicine.
The body temperature is probably the most important reading doctors rarely check! This hypothroidism does not have an English version. Also since surgery his hands and arms are very painful, hands are swollen and he cant even remove a top off a bottle. I feel like screaming at each of them. Many Thanks, Tapas. I have actually gained weight, and I believe that at least 70 lbs of the weight are due to edema.
A myxedema coma may be triggered by sedatives, infection or other stress on your body. Hypofhyroidism findings: early warm, tender skin with diaphoresis; late thin, shiny skin with atrophic changes. Treating the adrenal fatigue and adding more salt to foods will help in increased aldosterone production. Oncol Nurs Forum. Myxedema can occur in the lower leg pretibial myxedema and behind the eyes exophthalmos. Direct evidence of lymphatic function improvement after advanced pneumatic compression device treatment of lymphedema.
Elderly people are at a higher risk of having a poor outcome. Address correspondence to Kathryn P. Obstructive sleep apnea may cause bilateral leg edema even in the absence of pulmonary hypertension. Elston, Timothy G.
Impact of water retention
Hypothyroidism signs for diagnostic hypohtyroidism are listed in Table 2. Medically reviewed by Marina Basina, M. Increased capillary permeability from systemic venous hypertension; decreased plasma oncotic pressure from reduced protein synthesis. The functioning of adrenal gland is affected in autoimmune thyroid conditions and in hypothyroidism. Symptoms of hypothyroidism underactive thyroid can disrupt several parts of your life.
How is myxedema treated? However, this test has a low specificity, and d -dimer concentrations may be elevated in the absence of thrombosis. About the author. Jameson JL, et al. Download as PDF Printable version. Problems tend to develop slowly, often over a number of years.
Enlarge Print Table 2. Read the Issue. Medically reviewed by Debra Sullivan, Ph. Search date: January Accurate thyroid function tests are available to diagnose hypothyroidism. Weight gain in hypothyroidism is due to several factors which include deficient thyroid function, water retention and gastric issues. More Information Hypothyroidism symptoms: Can hypothyroidism cause eye problems?
Management of Edema
Wilson's syndrome: An accepted medical diagnosis? Armour Thyroid is a natural desiccated thyroid extract for treating hypothyroidism. Archived lowee the original on Key search terms were edema, oedema, peripheral edema, lower extremity edema, venous insufficiency, deep vein thrombosis, lymphedema, obstructive sleep apnea, and iliac vein syndrome. Also called as edema, water retention indicates accumulation of fluids at above normal levels inside the tissues present in the body.
From Wikipedia, the free encyclopedia. Local skin and wound care of venous ulcers is essential sifns preventing secondary cellulitis and dermatitis. Hyaluronanan example of a mucopolysaccharide. Arch Surg. New York, N. The initial diagnosis often relies on the physical examination. Use of pneumatic compression devices or compression stockings may be helpful in these cases.
Clinical diagnosis. Intensive decongestive treatment restores ability to work in patients with advanced forms of primary and secondary lower extremity lymphoedema. Log in. Retrieved Post-thrombotic syndrome: prevalence, prognostication and need for progress. You may also like.
The word myxedema was historically used to refer hypothyroidism in general. A systematic review of pneumatic compression for treatment of chronic venous insufficiency and venous ulcers. Jameson JL, et al. PMID Secondary: from axillary lymph node dissection, surgery e.
But if this condition is diagnosed within the first few months of life, the chances of normal development are excellent. Those undergoing a myxedema crisis need to be treated in an ICU. Where do I go from here? I would like to know if the T3 protocol might be a better alternative. I am slowly getting signs of migraine and not sleeping well again.
The increased deposition of glycosaminoglycan is not fully understood, however, two mechanisms predominate:. Medically reviewed lower leg edema hypothyroidism signs Lindsay Hypothyroidiism, Pharm. Tags retention thyroid water. From Wikipedia, the free encyclopedia. Archived from the original on Deep vein thrombosis: a clinical review. Myxedema can occur in the lower leg pretibial myxedema and behind the eyes exophthalmos.
Related Coconut oil: Can it cure hypothyroidism? Restoring the hormonal balance is an effective way to treat the water retention in such cases. Differential diagnosis, investigation, and current treatment of lower limb lymphedema. Association between symptoms of chronic venous disease in the lower extremities and cardiovascular risk factors in middle-aged women. Deep venous thrombosis. Hypothyroidism diet Hypothyroidism symptoms: Can hypothyroidism cause eye problems?
Note the yellow-brown hemosiderin deposition. The increase in fluid produces undue pressure on nerves resulting in inflammation. Show references AskMayoExpert. In the late stages of complex regional pain syndrome, the skin may appear shiny with atrophic changes. Standard treatment for hypothyroidism includes oral medication, but there are natural therapies too.
Lower leg edema hypothyroidism signs Ther. J Neurol. Local skin and wound care of venous ulcers is essential in preventing secondary cellulitis and dermatitis. Magnetic resonance angiography with venography of the lower extremity and pelvis can be used to evaluate for intrinsic or extrinsic pelvic or thigh DVT. Enlarge Print eFigure A. Initially, it's important to make sure you're receiving the correct dose of medicine. The history should also include questions about cardiac, renal, thyroid, or hepatic disease.
Pictures of myxedema.
When hypothyroidism in infants isn't treated, even mild cases can lead to severe physical and mental retardation.
I wake up at and weigh myself, take my Armour and then go to the bathroom.
Standard treatment for hypothyroidism includes oral medication, but there are natural therapies too. She said it should make me feel better.
Get Permissions. When you have hypothyroidism along with water retention, the water retention usually subsides with proper thyroid medications. Lipodermatosclerosis from chronic venous insufficiency associated with marked sclerotic and hyperpigmented tissue. Enlarge Print eFigure D.
When it gets lower, I develope chills and sweating and feel awful! Mary Eedma 12, at am - Reply. I have taken armour since I was Within about four hours I felt like a new person, I even went back to work two weeks ago and have felt great -until a few days ago. I have seen the blog where you recommend avoiding gluten, but do you recommend a specific diet for example, Paleo, Mediterranean, etc. I typically feel warm most of the time. After a short course that apparently had an adverse reaction, he prescribed Standard Process, Thytrophin for a period of time.
I also eat steamed broccoli, brussel sprouts and cooked rutabaga every day great vegetable sources My body temp is usually around Wilson, I have just about every symptom of low body temperature that you list, with This rare, life-threatening condition is the result of long-term, undiagnosed hypothyroidism.
Today's Top Stories. I am suffring from hypothyroidism which 7. The Lancet. The lymphedema brings on edema far greater than the swelling that comes with hypothyroidism and its cool temeratures. My temperature is I find that the non-mercury thermometer gives me a low reading in my cool house.
Both may sound or be logical but which is really right for our low thyroid??
Medically reviewed by Deborah Weatherspoon, Ph. Graves disease can lead to pretibial myxedema, whereas hypothyroidism can cause generalized myxedema.
This year, however, my symptoms returned even though the lab tests said my levels were okay, but my temperature was low again DeeDee July 12, at pm - Reply.
It can occur during pregnancy as well. Medically reviewed by Kelly Wood, MD.
Localized pretibial myxedema may be caused by Graves disease eFigure B. ACR Appropriateness Criteria: suspected lower extremity deep vein thrombosis. Villeco JP. Unilateral swelling from compression or compromise of venous or lymphatic drainage can result from DVT, venous insufficiency, venous obstruction by tumor e. Unilateral predominance.
A study published in Clinical Endocrinology indicates the link between hypothyroidism and edema. Onset: weeks after initiation of medication; resolves within days of stopping offending medication Location: lower extremities. This version of the article contains supplemental content. Namespaces Article Talk. PMC
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Wilson's syndrome: An accepted medical diagnosis? T4 can actually suppress the enzyme that converts T4 to the active thyroid hormone T3. Annette August 30, at pm - Reply. I am gaining weight, even though I am eating the same foods. Plus all the symptoms I had before.
Along with thyroid hormone replacement, steroid treatments and other medications may eigns needed. Mary November 12, at am - Reply. Because hypothyroidism can cause the body's processes to slow down, it can lead to water retention, which will typically show up in your lower body—your hips, knees, ankles, and feet—because of gravitysays Feinberg. It is now and I am 71 and still struggling.
Essentially, doctors should not give hypothyoidism any diagnoses until your signs is normal. When newborns do have problems with hypothyroidism, the problems may include:. Hi Abigail, low body temperatures are certainly one possible explanation of fluid retention. Please doctor I would like to know what could probably be the cause and the remedy to stop the fluid from further generating. She was diagnosed with thyroid about 15 years ago.
TSH can go up and down.
Cessation of medication.
It also ate my bone marrow. I had never had the first two tests before.
Surinder Sharma November 6, at pm - Reply.
Learn about causes, symptoms, diagnosis, and treatments. I am trying everything I can. I would recommend you visit one of the doctors listed on our list of treating physicians. One is low temperatures and the other is unsteady temperatures. These skin changes are a result of hypothyroidism.
Age He is no help. Hypothyroidism signs, Dr. Over the last 5 sgns my hypothyroidism has gotten worse and the more medication armour the worse I get. Though I can feel a slow and steady progress for past 4 months. Once T4 hormone levels are restored, symptoms become more manageable, though this may take several weeks.
This will help in reducing the weight gain due to fluid retention. Beta-adrenergic blockers, calcium channel blockers, clonidine Catapreshydralazine, methyldopa, minoxidil. Retrieved 16 August
It can also develop when someone stops taking their thyroid medication. Enlarge Print Figure 5. Skin care is crucial in preventing skin breakdown and venous ulcers. Medically reviewed by Judith Marcin, M. Medically reviewed by Deborah Weatherspoon, Ph. Increased capillary permeability caused by local venous hypertension from compression.
Evaluating edema of the hands. Onset: chronic; begins around or after lower leg edema Location: predominantly lower extremities; involves thighs, legs, buttocks; spares feet, ankles, and upper torso. The water retention in hypothyroidism can also be caused by adrenal fatigue. Diuretic use may cause volume depletion and reflex stimulation of the reninangiotensin system. Author disclosure: No relevant financial affiliations. Initially, it's important to make sure you're receiving the correct dose of medicine. Pitting edema also occurs in the early stages of lymphedema because of an influx of protein-rich fluid into the interstitium, before fibrosis of the subcutaneous tissue; therefore, its presence should not exclude the diagnosis of lymphedema.
James, Dirk Lkwer. Neurogenically mediated increased capillary permeability. This rare, life-threatening condition is the result of long-term, undiagnosed hypothyroidism. Magnetic resonance venography to rule out pelvic or thigh DVT if clinical suspicion is highor extrinsic venous compression May-Thurner syndrome in patients with unexplained left-sided DVT. Jameson JL, et al.
Your low temperature proves that your edemq rate is not adequate. Danielle September 28, at pm - Reply. Denis Wilson May 3, at am - Reply. I take hot baths to get warm. It can also develop when someone stops taking their thyroid medication. Thank you for your reply and great advice Dr. Congestive heart failure can also.
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The word myxedema was historically used to refer hypothyroidism in general. This edema is easy to reverse when you treat the low thyroid condition.
I am wondering if I have some combination of both estrogen dominance and hypothyroidism. Surinder Sharma November 6, at pm - Reply.
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Along with bulging eyes, Graves' disease can also cause double vision and swelling. I went to hypotgyroidism doctors and the tested me for various things including DVT and liver, kidney functions, etc. Abigail November 14, at pm - Reply. Neither the armour thyroid medication nor the compounded thyroid medication that I was prescribed have helped. In the webinar you mentioned liver support as one of the methods to improve the conversion of T4 to T3. Anyways, I am at a loss as to what to do next and feeling very frustrated with the process so far — it was a year ago when this all first started.
Most doctors I had only put me on very low doses loqer medication, because they lower leg edema hypothyroidism signs only treating lab tests. But, because thyroid symptoms often develop slowly, many people don't notice the muscle aches or weakness right away, or brush it off as typical pain that comes from aging. I went to the doctors and the tested me for various things including DVT and liver, kidney functions, etc. My fingers started to swell and both really hurt. Your eyebrows are hit especially hard: Eyebrows that thin along the outer edges can be a sign of hypothyroidism, Eve Feinberg, M. Autoimmune disease. Dr thinks so.
Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis the CaVenT study edem a randomised controlled trial. If not treated, advanced hypothyroidism can lead to severe complications and even death. Lower extremity examination should focus on the medial malleolus, the bony portion of the tibia, and the dorsum of the foot.
Navigate this Article. Effect of renin-angiotensin system blockade on calcium channel blocker-associated peripheral edema. The mechanism often includes the retention of salt and water with increased capillary hydrostatic pressure. Magnetic resonance venography in the diagnosis and management of May-Thurner syndrome. Help Learn to edit Community portal Recent changes Upload file. Infants with untreated hypothyroidism present at birth are at risk of serious problems with both physical and mental development. Your symptoms will lead your doctor to suspecting severe hypothyroidism.
Taking the T3 in a sustained release format and taking the T3 very much on time seems to help. As the disease progresses, infants are likely to have trouble feeding and may fail to grow and develop normally. I know a few years ago, while I was already suffering severe fatigue, my TSH was much lower and my internist told me to skip a pill a week. I am chelating the mercury out levels are highbut am wondering if your protocol might help clear my thyroid receptor sites as well, so I can get my thyroid back to normal?? This year, however, my symptoms returned even though the lab tests said my levels were okay, but my temperature was low again I had another baby in February but when I was 8 months pregnant I developed pain and fluid on my right knee. I am trying to see what my next steps should be, and I had a few questions for you:.
Hello everyone, been through a lot and too tired and worn out, but i have a question that might sound lame: Kelp, can i take Kelp, and will it help? The inflammation levels scares me. It also ate my bone marrow.
Pregnancy and premenstrual edema. Complications of Hypothyroidism. The increase in fluid produces undue pressure on nerves resulting in inflammation. However, the lower leg edema hypothyroidism signs is also used to describe a dermatological change that can hyopthyroidism in hyperthyroidism and rare paradoxical cases of hypothyroidism. Symptomatic lower extremity deep venous thrombosis: accuracy, limitations, and role of color duplex flow imaging in diagnosis [published correction appears in Radiology. As venous insufficiency progresses, it can result in lipodermatosclerosis Figure 5which is associated with marked sclerotic and hyperpigmented tissue, and characterized by fibrosis and hemosiderin deposition that can lead to venous ulcers over the medial malleolus. When your thyroid doesn't produce enough hormones, the balance of chemical reactions in your body can be upset.
However, it is not cheap. I possibly have sleep apnea which is my next appt. Denis Wilson November 10, at pm - Reply. After I switched I noticed a significant difference.
Home-based lymphedema treatment in patients with cancer-related lymphedema or noncancer-related lymphedema. Lymphatic obstruction. Soft, pitting edema. Therefore, indirect radionuclide lymphoscintigraphy, which shows absent or delayed filling of lymphatic channels, is the method of choice for evaluating lymphedema when the diagnosis cannot be made clinically. J Gen Intern Med.
These skin changes are a result of hypothyroidism. Plus, your temperature might be lower, if your thermometer is not accurate. Swarna August 16, at pm - Reply. But as your metabolism continues to slow, you may develop more-obvious problems.
Is there anything I can do to reduce the water retention and swelling? I was diagnosed as hypothyroid in Could you please recommend so advice so I can present it to her. All this is news to me. Is it ok to use the scarf or am I creating a false reading? I noticed whenever i get really stressd out, i wake up and my hands are very swollen and my feet and my face.
Comparison of leg compression lg and oral horse-chestnut seed extract therapy in patients with chronic venous insufficiency. He prescribed an extract from sheep thyroid. Lower extremity edema and pulmonary hypertension in morbidly obese patients with obstructive sleep apnea. Arch Surg. Already a member or subscriber? Ann Intern Med. Infants with untreated hypothyroidism present at birth are at risk of serious problems with both physical and mental development.