Highlights & Basics
- Primary hypothyroidism usually presents with nonspecific symptoms of fatigue, depression, constipation, and mild weight gain; physical exam may show dry skin, eyelid edema, and bradycardia.
- Elevated thyroid-stimulating hormone and low free thyroxine confirms diagnosis of overt primary hypothyroidism.
- Commonly, disease is subclinical with minimal elevation of thyroid-stimulating hormone and normal thyroxine.
- Treatment is with levothyroxine; starting dose depends on age and presence of coexisting cardiac disease.
- Over-treatment is uncommon but can lead to iatrogenic hyperthyroidism.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Citations
Taylor PN, Medici MM, Hubalewska-Dydejczyk A, et al. Hypothyroidism. Lancet. 2024 Oct 5;404(10460):1347-64.[Abstract]
Alexander EK, Pearce EN, Brent GA, et al. 2017 guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum. Thyroid. 2017 Mar;27(3):315-89.[Abstract][Full Text]
American Association of Clinical Endocrinologists; American Thyroid Association. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012 Nov-Dec;18(6):988-1028.[Abstract][Full Text]
Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Thyroid. 2014 Dec;24(12):1670-751.[Abstract][Full Text]
1. Chaker L, Razvi S, Bensenor IM, et al. Hypothyroidism. Nat Rev Dis Primers. 2022 May 19;8(1):30.[Abstract]
2. Taylor PN, Medici MM, Hubalewska-Dydejczyk A, et al. Hypothyroidism. Lancet. 2024 Oct 5;404(10460):1347-64.[Abstract]
3. Cooper DS, Biondi B, Cappola AR. Subclinical hypothyroidism: a review. JAMA. 2019 Jul 9;322(2):153-60. [Abstract]
4. Elkattawy S, Dhanoa P, Kotys J, et al. Myxedema coma: case report and literature review. Cureus. 2021 May 27;13(5):e15277. [Abstract][Full Text]
5. Hollowell JG, Staehling NW, Flanders WD, et al. Serum TSH, T(4) and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab. 2002 Feb;87(2):489-99.[Abstract][Full Text]
6. Wyne KL, Nair L, Schneiderman CP, et al. Hypothyroidism prevalence in the United States: a retrospective study combining National Health and Nutrition Examination Survey and Claims Data, 2009-2019. J Endocr Soc. 2022 Nov 17;7(1):bvac172.[Abstract][Full Text]
7. Taylor PN, Albrecht D, Scholz A, et al. Global epidemiology of hyperthyroidism and hypothyroidism. Nat Rev Endocrinol. 2018 May;14(5):301-16.[Abstract]
8. Canaris GJ, Manowitz NR, Mayor G, et al. The Colorado thyroid disease prevalence study. Arch Intern Med. 2000 Feb 28;160(4):526-34.[Abstract]
9. Vanderpump MP, Tunbridge WM, French JM, et al. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham survey. Clin Endocrinol. 1995 Jul;43(1):55-68.[Abstract]
10. Han X, Ding S, Lu J, et al. Global, regional, and national burdens of common micronutrient deficiencies from 1990 to 2019: a secondary trend analysis based on the Global Burden of Disease 2019 study. EClinicalMedicine. 2022 Feb;44:101299.[Abstract][Full Text]
11. Dold S, Zimmermann MB, Jukic T, et al. Universal salt iodization provides sufficient dietary iodine to achieve adequate iodine nutrition during the first 1000 days: a cross-sectional multicenter study. J Nutr. 2018 Apr 1;148(4):587-98.[Abstract][Full Text]
12. Zimmermann MB, Andersson M. Global endocrinology: global perspectives in endocrinology: coverage of iodized salt programs and iodine status in 2020. Eur J Endocrinol. 2021 Jun 10;185(1):R13-21.[Abstract][Full Text]
13. Lazarus JH. The importance of iodine in public health. Environ Geochem Health. 2015 Aug;37(4):605-18.[Abstract]
14. Caldwell KL, Pan Y, Mortensen ME, et al. Iodine status in pregnant women in the National Children's Study and in US women (15-44 years), National Health and Nutrition Examination Survey 2005-2010. Thyroid. 2013 Aug;23(8):927-37.[Abstract][Full Text]
15. Pearce EN, Farwell AP, Braverman LE. Thyroiditis. N Engl J Med. 2003 Jun 26;348(26):2646-55.[Abstract]
16. Hu X, Chen Y, Shen Y, et al. Global prevalence and epidemiological trends of Hashimoto's thyroiditis in adults: a systematic review and meta-analysis. Front Public Health. 2022 Oct 13;10:1020709.[Abstract][Full Text]
17. Ragusa F, Fallahi P, Elia G, et al. Hashimotos' thyroiditis: epidemiology, pathogenesis, clinic and therapy. Best Pract Res Clin Endocrinol Metab. 2019 Dec;33(6):101367.[Abstract]
18. Solmunde E, Falstie-Jensen AM, Lorenzen EL, et al. Breast cancer, breast cancer-directed radiation therapy and risk of hypothyroidism: a systematic review and meta-analysis. Breast. 2023 Apr;68:216-24.[Abstract][Full Text]
19. Rizzo LFL, Mana DL, Serra HA. Drug-induced hypothyroidism. Medicina (B Aires). 2017;77(5):394-404.[Abstract][Full Text]
20. Gabora K, Piciu A, Bădulescu IC, et al. Current evidence on thyroid related adverse events in patients treated with protein tyrosine kinase inhibitors. Drug Metab Rev. 2019 Nov;51(4):562-9.[Abstract]
21. Micali C, Russotto Y, Celesia BM, et al. Thyroid diseases and thyroid asymptomatic dysfunction in people living with HIV. Infect Dis Rep. 2022 Sep 1;14(5):655-67.[Abstract][Full Text]
22. Bianco AC, Dumitrescu A, Gereben B, et al. Paradigms of dynamic control of thyroid hormone signaling. Endocr Rev. 2019 Aug 1;40(4):1000-47.[Abstract][Full Text]
23. Oetting A, Yen PM. New insights into thyroid hormone action. Best Pract Res Clin Endocrinol Metab. 2007 Jun;21(2):193-208.[Abstract]
24. Sorrenti S, Baldini E, Pironi D, et al. Iodine: its role in thyroid hormone biosynthesis and beyond. Nutrients. 2021 Dec 14;13(12):4469.[Abstract][Full Text]
25. Zimmermann MB, Boelaert K. Iodine deficiency and thyroid disorders. Lancet Diabetes Endocrinol. 2015 Apr;3(4):286-95.[Abstract]
26. Lisco G, De Tullio A, Triggiani D, et al. Iodine Deficiency and Iodine Prophylaxis: An Overview and Update. Nutrients. 2023 Feb 16;15(4):.[Abstract][Full Text]
27. Rayman MP. Multiple nutritional factors and thyroid disease, with particular reference to autoimmune thyroid disease. Proc Nutr Soc. 2019 Feb;78(1):34-44.[Abstract][Full Text]
28. Leung AM, Braverman LE. Consequences of excess iodine. Nat Rev Endocrinol. 2014 Mar;10(3):136-42.[Abstract][Full Text]
29. Kahaly GJ, Frommer L. Polyglandular autoimmune syndromes. J Endocrinol Invest. 2018 Jan;41(1):91-8.[Abstract]
30. Trohman RG, Sharma PS, McAninch EA, et al. Amiodarone and thyroid physiology, pathophysiology, diagnosis and management. Trends Cardiovasc Med. 2019 Jul;29(5):285-95.[Abstract][Full Text]
31. Apostolou K, Paunovic I, Frountzas M, et al. Posthemithyroidectomy hypothyroidism: updated meta-analysis of risk factors and rates of remission. J Surg Res. 2024 Jan;293:102-20.[Abstract]
32. Shearn-Nance G, Politano S, Cabrera CI, et al. Development of hypothyroidism following hemithyroidectomy: a population-based study. Am J Otolaryngol. 2024 May-Jun;45(3):104239.[Abstract]
33. Cooper D, Kaur R, Ayeni FE, et al. Hypothyroidism after hemithyroidectomy: a systematic review and meta-analysis. Thyroid Res. 2024 Jul 8;17(1):18.[Abstract][Full Text]
34. Keely EJ. Postpartum thyroiditis: an autoimmune thyroid disorder which predicts future thyroid health. Obstet Med. 2011 Mar;4(1):7-11.[Abstract][Full Text]
35. Kyritsi EM, Kanaka-Gantenbein C. Autoimmune thyroid disease in specific genetic syndromes in childhood and adolescence. Front Endocrinol (Lausanne). 2020 Aug 19;11:543.[Abstract][Full Text]
36. Huber A, Menconi F, Corathers S, et al. Joint genetic susceptibility to type 1 diabetes and autoimmune thyroiditis: from epidemiology to mechanisms. Endocr Rev. 2008 Oct;29(6):697-725.[Abstract][Full Text]
37. Alexander L, Cheng-Ting T, Åke L, et al. Type 1 diabetes, celiac disease, and autoimmune thyroiditis autoantibodies in population-based type 2 diabetes patients. J Clin Transl Endocrinol. 2024 Sep;37:100367.[Abstract][Full Text]
38. Hwang GB, Yoon JS, Park KJ, et al. Prevalence of autoimmune thyroiditis in patients with type 1 diabetes: a long-term follow-up study. Ann Pediatr Endocrinol Metab. 2018 Mar;23(1):33-7.[Abstract][Full Text]
39. Piątkowska E, Szalecki M. Autoimmune thyroiditis in children and adolescents with type 1 diabetes. Pediatr Endocrinol Diabetes Metab. 2011;17(4):173-7.[Abstract]
40. Rooney MK, Andring LM, Corrigan KL, et al. Hypothyroidism following radiotherapy for head and neck cancer: a systematic review of the literature and opportunities to improve the therapeutic ratio. Cancers (Basel). 2023 Aug 29;15(17):4321.[Abstract][Full Text]
41. Sirikul W, Sapbamrer R. Exposure to pesticides and the risk of hypothyroidism: a systematic review and meta-analysis. BMC Public Health. 2023 Sep 26;23(1):1867.[Abstract][Full Text]
42. Zhong B, Wang Y, Zhang G, et al. Environmental iodine content, female sex and age are associated with new-onset amiodarone-induced hypothyroidism: a systematic review and meta-analysis of adverse reactions of amiodarone on the thyroid. Cardiology. 2016;134(3):366-71.[Abstract]
43. Mohammadi K, Shafie D, Vakhshoori M, et al. Prevalence of amiodarone-induced hypothyroidism; a systematic review and meta-analysis. Trends Cardiovasc Med. 2023 May;33(4):252-62.[Abstract]
44. Rahimi-Bashar F, Vahedian-Azimi A, Dalvand S, et al. Prevalence of amiodarone induced hypothyroidism and hyperthyroidism in patients with heart diseases: a systematic review and meta-analysis. Curr Med Chem. 2023;30(23):2690-9.[Abstract]
45. Banyi N, Kwon JJY, Turkdogan S, et al. Incidence and complications of hypothyroidism postlaryngectomy: a systematic review and meta-analysis. Head Neck. 2024 Feb;46(2):249-61.[Abstract]
46. Tola HH, Holakouie-Naieni K, Lejisa T, et al. Is hypothyroidism rare in multidrug resistance tuberculosis patients on treatment? a systematic review and meta-analysis. PLoS One. 2019;14(6):e0218487.[Abstract][Full Text]
47. Quiroz-Aldave JE, Durand-Vásquez MDC, Gamarra-Osorio ER, et al. Drug-induced hypothyroidism in tuberculosis. Expert Rev Endocrinol Metab. 2024 May;19(3):199-206.[Abstract]
48. Harding KB, Peña-Rosas JP, Webster AC, et al. Iodine supplementation for women during the preconception, pregnancy and postpartum period. Cochrane Database Syst Rev. 2017 Mar 5;3(3):CD011761.[Abstract][Full Text]
49. World Health Organization. e-Library of evidence for nutrition actions (eLENA): iodine supplementation in pregnant and lactating women. Aug 2023 [internet publication].[Full Text]
50. Siskind SM, Lee SY, Pearce EN. Investigating hypothyroidism. BMJ. 2021 Apr 27;373:n993.[Abstract][Full Text]
51. British Columbia Ministry of Health. Thyroid function testing in the diagnosis and monitoring of thyroid function disorder. Dec 2022 [internet publication].[Full Text]
52. Carlé A, Pedersen IB, Knudsen N, et al. Hypothyroid symptoms and the likelihood of overt thyroid failure: a population-based case-control study. Eur J Endocrinol. 2014 Nov;171(5):593-602.[Abstract]
53. Canaris GJ, Steiner JF, Ridgway EC. Do traditional symptoms of hypothyroidism correlate with biochemical disease? J Gen Intern Med. 1997 Sep;12(9):544-50.[Abstract][Full Text]
54. Ferreira-Hermosillo A, Toledo JO, Cordoba K. Evaluation of the risk of hypothyroidism and its clinical manifestations using the Zulewski scale. Front Endocrinol (Lausanne). 2024 Aug 16;15:1416663.[Abstract][Full Text]
55. American Society for Clinical Pathology. Thirty five things physicians and patients should question. Choosing Wisely, an initiative of the ABIM Foundation. Jul 2021 [internet publication].[Full Text]
56. National Institute for Health and Care Excellence. Thyroid disease: assessment and management. Oct 2023 [internet publication].[Full Text]
57. Alexander EK, Pearce EN, Brent GA, et al. 2017 guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum. Thyroid. 2017 Mar;27(3):315-89.[Abstract][Full Text]
58. Wopereis DM, Du Puy RS, van Heemst D, et al. The relation between thyroid function and anemia: a pooled analysis of individual participant data. J Clin Endocrinol Metab. 2018 Oct 1;103(10):3658-67.[Abstract][Full Text]
59. Endocrine Society. Five things physicians and patients should question. Choosing Wisely, an initiative of the ABIM Foundation. Jun 2022 [internet publication].[Full Text]
60. American College of Radiology. ACR appropriateness criteria: thyroid disease. 2018 [internet publication].[Abstract][Full Text]
61. Hage MP, Azar ST. The link between thyroid function and depression. J Thyroid Res. 2012;2012:590648.[Abstract][Full Text]
62. Urmi SJ, Begum SR, Fariduddin M, et al. Hypothyroidism and its effect on menstrual pattern and fertility. Mymensingh Med J. 2015 Oct;24(4):765-9.[Abstract]
63. Berta E, Lengyel I, Halmi S, et al. Hypertension in thyroid disorders. Front Endocrinol (Lausanne). 2019 Jul 17;10:482.[Abstract][Full Text]
64. Cappola AR, Desai AS, Medici M, et al. Thyroid and cardiovascular disease: research agenda for enhancing knowledge, prevention, and treatment. Circulation. 2019 Jun 18;139(25):2892-909.[Abstract][Full Text]
65. American Association of Clinical Endocrinologists; American Thyroid Association. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012 Nov-Dec;18(6):988-1028.[Abstract][Full Text]
66. Persani L, Cangiano B, Bonomi M. The diagnosis and management of central hypothyroidism in 2018. Endocr Connect. 2019 Feb;8(2):R44-54.[Abstract][Full Text]
67. Samuels MH. Psychiatric and cognitive manifestations of hypothyroidism. Curr Opin Endocrinol Diabetes Obes. 2014 Oct;21(5):377-83.[Abstract][Full Text]
68. Mintziori G, Veneti S, Poppe K, et al. EMAS position statement: thyroid disease and menopause. Maturitas. 2024 Jul;185:107991.[Abstract][Full Text]
69. LeFevre ML, U.S. Preventive Services Task Force. Screening for thyroid dysfunction: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2015 May 5;162(9):641-50.[Abstract][Full Text]
70. Rastogi MV, LaFranchi SH. Congenital hypothyroidism. Orphanet J Rare Dis. 2010 Jun 10;5:17.[Abstract][Full Text]
71. Kopel J. A global perspective on newborn congenital hypothyroidism screening. Proc (Bayl Univ Med Cent). 2020 Jan;33(1):137-9.[Abstract][Full Text]
72. Rose SR, Wassner AJ, Wintergerst KA, et al. Congenital hypothyroidism: screening and management. Pediatrics. 2023 Jan 1;151(1):e2022060419. [Abstract][Full Text]
73. Rugge JB, Bougatsos C, Chou R. Screening and treatment of thyroid dysfunction: an evidence review for the US Preventive Services Task Force. Ann Intern Med. 2015 Jan 6;162(1):35-45.[Abstract][Full Text]
74. Vissenberg R, van den Boogaard E, van Wely M, et al. Treatment of thyroid disorders before conception and in early pregnancy: a systematic review. Hum Reprod Update. 2012 Jul;18(4):360-7.[Abstract]
75. Spencer L, Bubner T, Bain E, et al. Screening and subsequent management for thyroid dysfunction pre-pregnancy and during pregnancy for improving maternal and infant health. Cochrane Database Syst Rev. 2015 Sep 21;2015(9):CD011263.[Abstract][Full Text]
76. Reid SM, Middleton P, Cossich MC, et al. Interventions for clinical and subclinical hypothyroidism pre-pregnancy and during pregnancy. Cochrane Database Syst Rev. 2013 May 31;(5):CD007752.[Abstract][Full Text]
77. Negro R, Schwartz A, Gismondi R, et al. Universal screening versus case finding for detection and treatment of thyroid hormonal dysfunction during pregnancy. J Clin Endocrinol Metab. 2010 Apr;95(4):1699-707.[Abstract]
78. American College of Obstetricians and Gynecologists. Thyroid disease in pregnancy: ACOG practice bulletin, number 223. Obstet Gynecol. 2020 Jun;135(6):e261-74.[Abstract]
79. Birtwhistle R, Morissette K, Dickinson JA, et al. Recommendation on screening adults for asymptomatic thyroid dysfunction in primary care. CMAJ. 2019 Nov 18;191(46):E1274-80.[Abstract][Full Text]
80. Toward Optimized Practice Clinical Practice Guideline Working Group Canada. Clinical practice guideline: investigation and management of primary thyroid dysfunction. April 2014 [internet publication].[Full Text]
81. Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Thyroid. 2014 Dec;24(12):1670-751.[Abstract][Full Text]
82. Villar HC, Saconato H, Valente O, et al. Thyroid hormone replacement for subclinical hypothyroidism. Cochrane Database Syst Rev. 2007 Jul 18;2007(3):CD003419.[Abstract][Full Text]
83. Pearce SH, Brabant G, Duntas LH, et al. 2013 ETA guideline: management of subclinical hypothyroidism. Eur Thyroid J. 2013 Dec;2(4):215-28.[Abstract][Full Text]
84. Ku EJ, Yoo WS, Chung HK. Management of subclinical hypothyroidism: a focus on proven health effects in the 2023 Korean Thyroid Association guidelines. Endocrinol Metab (Seoul). 2023 Aug;38(4):381-91.[Abstract][Full Text]
85. Feller M, Snel M, Moutzouri E, et al. Association of thyroid hormone therapy with quality of life and thyroid-related symptoms in patients with subclinical hypothyroidism: a systematic review and meta-analysis. JAMA. 2018 Oct 2;320(13):1349-59.[Abstract][Full Text]
86. Bekkering GE, Agoritsas T, Lytvyn L, et al. Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline. BMJ. 2019 May 14;365:l2006.[Abstract]
87. Rodondi N, den Elzen WP, Bauer DC, et al. Subclinical hypothyroidism and the risk of coronary heart disease and mortality. JAMA. 2010 Sep 22;304(12):1365-74.[Abstract]
88. Stott DJ, Rodondi N, Kearney PM, et al. Thyroid hormone therapy for older adults with subclinical hypothyroidism. N Engl J Med. 2017 Jun 29;376(26):2534-44.[Abstract][Full Text]
89. Dhillon-Smith RK, Boelaert K, Jeve YB, et al. Subclinical hypothyroidism and antithyroid autoantibodies in women with subfertility or recurrent pregnancy loss: scientific impact paper no. 70 June 2022: scientific impact paper no. 70 June 2022. BJOG. 2022 Nov;129(12):e75-88.[Abstract][Full Text]
90. Triggiani V, Cittadini A, Lisco G. Effect of levothyroxine replacement therapy in patients with subclinical hypothyroidism and chronic heart failure: a systematic review. Front Endocrinol (Lausanne). 2022 Nov 15;13:1013641.[Abstract][Full Text]
91. Jiao XF, Zhang M, Chen J, et al. The impact of levothyroxine therapy on the pregnancy, neonatal and childhood outcomes of subclinical hypothyroidism during pregnancy: an updated systematic review, meta-analysis and trial sequential analysis. Front Endocrinol (Lausanne). 2022 Aug 5;13:964084.[Abstract][Full Text]
92. Akhtar MA, Agrawal R, Brown J, et al. Thyroxine replacement for subfertile women with euthyroid autoimmune thyroid disease or subclinical hypothyroidism. Cochrane Database Syst Rev. 2019 Jun 25;6(6):CD011009.[Abstract][Full Text]
93. Biondi B, Cappola AR. Subclinical hypothyroidism in older individuals. Lancet Diabetes Endocrinol. 2022 Feb;10(2):129-41.[Abstract]
94. Roos A, Linn-Rasker SP, van Domburg RT, et al. The starting dose of levothyroxine in primary hypothyroidism treatment: a prospective, randomized, double-blind trial. Arch Intern Med. 2005 Aug 8-22;165(15):1714-20.[Abstract][Full Text]
95. Lee SY, Pearce EN. Assessment and treatment of thyroid disorders in pregnancy and the postpartum period. Nat Rev Endocrinol. 2022 Mar;18(3):158-71.[Abstract][Full Text]
96. Okosieme O, Gilbert J, Abraham P, et al. Management of primary hypothyroidism: statement by the British Thyroid Association Executive Committee. Clin Endocrinol (Oxf). 2016 Jun;84(6):799-808.[Abstract][Full Text]
97. Thayakaran R, Adderley NJ, Sainsbury C, et al. Thyroid replacement therapy, thyroid stimulating hormone concentrations, and long term health outcomes in patients with hypothyroidism: longitudinal study. BMJ. 2019 Sep 3;366:l4892.[Abstract][Full Text]
98. Maraka S, Mwangi R, McCoy RG, et al. Thyroid hormone treatment among pregnant women with subclinical hypothyroidism: US national assessment. BMJ. 2017;356:i6865.[Abstract][Full Text]
99. Wilson SA, Stem LA, Bruehlman RD. Hypothyroidism: diagnosis and treatment. Am Fam Physician. 2021 May 15;103(10):605-13.[Abstract][Full Text]
100. Efthymiadis A, Henry M, Spinos D, et al. Adequacy of thyroid hormone replacement for people with hypothyroidism in real-world settings: a systematic review and meta-analysis of observational studies. Clin Endocrinol (Oxf). 2024 May;100(5):488-501.[Abstract][Full Text]
