4/11/24, 1:11 PM Hypothyroidism: Practice Essentials, Background, Pathophysiology
Hypothyroidism
Updated: May 25, 2022
Author: Philip R Orlander, MD, FACP; Chief Editor: George T Griffing, MD more...
OVERVIEW
Practice Essentials
Hypothyroidism is a common endocrine disorder resulting from deficiency of thyroid hormone. In the
United States and other areas of adequate iodine intake, autoimmune thyroid disease (Hashimoto
disease) is the most common cause of hypothyroidism; worldwide, iodine deficiency remains the
foremost cause.
The image below depicts the hypothalamic-pituitary-thyroid axis.
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4/11/24, 1:11 PM Hypothyroidism: Practice Essentials, Background, Pathophysiology
The hypothalamic-pituitary-thyroid axis. Levels of circulating thyroid hormones are regulated by a complex feedback system
involving the hypothalamus and pituitary gland.
See 21 Hidden Clues to Diagnosing Nutritional Deficiencies, a Critical Images slideshow, to help
identify clues to conditions associated with malnutrition.
ICD-10 codes
These include the following:
The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
code for Log
“otherinhypothyroidism” is E03 [1]
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The ICD-10-CM code for "hypothyroidism, unspecified," is E03.9 [2]
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Signs and symptoms of hypothyroidism
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Hypothyroidism commonly manifests as a slowing in physical and mental activity but may be
asymptomatic. Symptoms and signs are often subtle and neither sensitive nor specific.
The following are symptoms of hypothyroidism:
· Fatigue, loss of energy, lethargy
· Weight gain
· Decreased appetite
· Cold intolerance
· Dry skin
· Hair loss
· Sleepiness
· Muscle pain, joint pain, weakness in the extremities
· Depression
· Emotional lability, mental impairment
· Forgetfulness, impaired memory, inability to concentrate
· Constipation
· Menstrual disturbances, impaired fertility
· Decreased perspiration
· Paresthesias and nerve entrapment syndromes
· Blurred vision
· Decreased hearing
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4/11/24, 1:11 PM Hypothyroidism: Practice Essentials, Background, Pathophysiology
· Fullness in the throat, hoarseness
The following are symptoms more specific to Hashimoto thyroiditis:
· Feeling of fullness in the throat
· Painless thyroid enlargement
· Exhaustion
· Transient neck pain, sore throat, or both
Physical signs of hypothyroidism include the following:
· Weight gain
· Slowed speech and movements
· Dry skin (or, rarely, yellow-hued skin from carotene)
· Jaundice
· Pallor
· Coarse, brittle, straw-like hair
· Loss of scalp hair, axillary hair, pubic hair, or a combination
· Dull facial expression
· Coarse facial features
· Periorbital puffiness
· Macroglossia
· Goiter (simple or nodular)
· Hoarseness
· Decreased systolic blood pressure and increased diastolic blood pressure
· Bradycardia
· Pericardial effusion
· Abdominal distention, ascites (uncommon)
· Hypothermia (only in severe hypothyroid states)
· Nonpitting edema (myxedema)
· Pitting edema of lower extremities
· Hyporeflexia with delayed relaxation (pseudomyotonia), ataxia, or both
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4/11/24, 1:11 PM Hypothyroidism: Practice Essentials, Background, Pathophysiology
Myxedema coma is a severe form of hypothyroidism that most commonly occurs in individuals with
undiagnosed or untreated hypothyroidism who are subjected to an external stress. Features are as
follows:
· Altered mental status
· Hypothermia
· Bradycardia
· Hypercapnia
· Hyponatremia
· Cardiomegaly, pericardial effusion, cardiogenic shock, and ascites may be present
See Clinical Presentation for more detail.
Diagnosis of hypothyroidism
Third-generation thyroid-stimulating hormone (TSH) assays are generally the most sensitive screening
tool for primary hypothyroidism. [3] If TSH levels are above the reference range, the next step is to
measure free thyroxine (T4) or the free thyroxine index (FTI), which serves as a surrogate of the free
hormone level. Routine measurement of triiodothyronine (T3) is not recommended.
Biotin, a popular health supplement, may interfere with immunoassays of many hormones, resulting
in values that are falsely elevated or suppressed, including for thyroid levels. To avoid misleading test
results, the American Thyroid Association recommends cessation of biotin consumption at least 2
days prior to thyroid testing. [4]
Results in patients with hypothyroidism are as follows:
· Elevated TSH with decreased T4 or FTI
· Elevated TSH (usually 4.5-10.0 mIU/L) with normal free T4 or FTI is considered mild or
subclinical hypothyroidism
Abnormalities in the complete blood count and metabolic profile that may be found in patients with
hypothyroidism include the following [5] :
· Anemia [6]
· Dilutional hyponatremia (with increased antidiuretic hormone [ADH])
· Hyperlipidemia
· Reversible increases in creatinine [5]
· Elevations in transaminases and creatinine kinase
No universal screening recommendations exist for thyroid disease for adults. The American Thyroid
Association recommends screening at age 35 years and every 5 years thereafter, with closer attention
to patients who are at high risk, such as the following [7] :
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4/11/24, 1:11 PM Hypothyroidism: Practice Essentials, Background, Pathophysiology
· Pregnant women
· Women older than 60 years
· Patients with type 1 diabetes or other autoimmune disease
· Patients with a history of neck irradiation
However, the American College of Obstetricians and Gynecologists (ACOG) does not recommend
universal screening for thyroid disease in pregnant women. However, those who are at increased risk
warrant screening. This includes pregnant women with a personal or family history of thyroid disease,
type 1 diabetes, or symptoms suggestive of thyroid disease. There is no proven benefit in screening
pregnant women with a mildly enlarged thyroid gland, whereas those with a significant goiter or
distinct thyroid nodules require screening. [8]
See Workup for more detail.
Management of hypothyroidism
The treatment goals for hypothyroidism are to reverse clinical progression and correct metabolic
derangements, as evidenced by normal blood levels of thyroid-stimulating hormone (TSH) and free
thyroxine (T4). Thyroid hormone is administered to supplement or replace endogenous production. In
general, hypothyroidism can be adequately treated with a constant daily dose of levothyroxine (LT4).
Significant controversy persists regarding the treatment of patients with mild hypothyroidism. [9]
Reviews by the US Preventive Services Task Force [10] and an independent expert panel [11] found
inconclusive evidence to recommend aggressive treatment of patients with TSH levels of 4.5-10
mIU/L.
In patients with myxedema coma, an effective approach consists of the following:
Give 4 µg of LT4 per kilogram of lean body weight (approximately 200-250 µg) as an IV bolus in
a single or divided dose, depending on the patient’s risk of cardiac disease and age
24 hours later, give 100 µg IV
Subsequently, give 50 µg/day IV, along with stress doses of IV glucocorticoids
Adjust the dosage on the basis of clinical and laboratory findings
Provide antibiotic coverage for sepsis
Avoid volume contraction
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