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Clinical manifestations of hypothyroidism

Martin I Surks, MD
Section Editor
Douglas S Ross, MD
Deputy Editor
Jean E Mulder, MD


Whether hypothyroidism results from hypothalamic-pituitary disease or primary thyroid disease, symptoms and signs of the disease vary in relation to the magnitude of the thyroid hormone deficiency, and the acuteness with which the deficiency develops. Hypothyroidism is less prominent clinically and better tolerated when there is a gradual loss of thyroid function (as in most cases of primary hypothyroidism) than when it develops acutely after thyroidectomy or abrupt withdrawal of exogenous thyroid hormone.

The typical clinical manifestations of hypothyroidism may be modified by factors such as coexisting nonthyroidal illness. Furthermore, when hypothyroidism is caused by hypothalamic-pituitary disease, the manifestations of associated endocrine deficiencies such as hypogonadism and adrenal insufficiency may mask the manifestations of hypothyroidism. Finally, when hypothyroidism follows treatment of Graves' hyperthyroidism, some manifestations of Graves' disease, such as ophthalmopathy and vitiligo, may persist throughout the patient's life.

This topic will review the major clinical manifestations of hypothyroidism. The diagnosis and treatment of hypothyroidism, subclinical hypothyroidism, and goiter are discussed separately. (See "Diagnosis of and screening for hypothyroidism in nonpregnant adults" and "Treatment of hypothyroidism" and "Subclinical hypothyroidism in nonpregnant adults" and "Clinical presentation and evaluation of goiter in adults".)


Many of the manifestations of hypothyroidism reflect one of two changes induced by lack of thyroid hormone (table 1):

A generalized slowing of metabolic processes. This can lead to abnormalities such as fatigue, slow movement and slow speech, cold intolerance, constipation, weight gain (but not morbid obesity), delayed relaxation of deep tendon reflexes, and bradycardia.


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Literature review current through: Sep 2016. | This topic last updated: Mar 8, 2016.
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  1. Smith TJ, Bahn RS, Gorman CA. Connective tissue, glycosaminoglycans, and diseases of the thyroid. Endocr Rev 1989; 10:366.
  2. Heymann WR. Cutaneous manifestations of thyroid disease. J Am Acad Dermatol 1992; 26:885.
  3. Squizzato A, Romualdi E, Büller HR, Gerdes VE. Clinical review: Thyroid dysfunction and effects on coagulation and fibrinolysis: a systematic review. J Clin Endocrinol Metab 2007; 92:2415.
  4. Manfredi E, van Zaane B, Gerdes VE, et al. Hypothyroidism and acquired von Willebrand's syndrome: a systematic review. Haemophilia 2008; 14:423.
  5. Green ST, Ng JP. Hypothyroidism and anaemia. Biomed Pharmacother 1986; 40:326.
  6. Colon-Otero G, Menke D, Hook CC. A practical approach to the differential diagnosis and evaluation of the adult patient with macrocytic anemia. Med Clin North Am 1992; 76:581.
  7. Cinemre H, Bilir C, Gokosmanoglu F, Bahcebasi T. Hematologic effects of levothyroxine in iron-deficient subclinical hypothyroid patients: a randomized, double-blind, controlled study. J Clin Endocrinol Metab 2009; 94:151.
  8. Woeber KA. Thyrotoxicosis and the heart. N Engl J Med 1992; 327:94.
  9. Klein I, Ojamaa K. Thyroid hormone and the cardiovascular system: from theory to practice. J Clin Endocrinol Metab 1994; 78:1026.
  10. Dillmann WH. Biochemical basis of thyroid hormone action in the heart. Am J Med 1990; 88:626.
  11. O'Brien T, Dinneen SF, O'Brien PC, Palumbo PJ. Hyperlipidemia in patients with primary and secondary hypothyroidism. Mayo Clin Proc 1993; 68:860.
  12. Diekman T, Lansberg PJ, Kastelein JJ, Wiersinga WM. Prevalence and correction of hypothyroidism in a large cohort of patients referred for dyslipidemia. Arch Intern Med 1995; 155:1490.
  13. Hussein WI, Green R, Jacobsen DW, Faiman C. Normalization of hyperhomocysteinemia with L-thyroxine in hypothyroidism. Ann Intern Med 1999; 131:348.
  14. Becker C. Hypothyroidism and atherosclerotic heart disease: pathogenesis, medical management, and the role of coronary artery bypass surgery. Endocr Rev 1985; 6:432.
  15. Laroche CM, Cairns T, Moxham J, Green M. Hypothyroidism presenting with respiratory muscle weakness. Am Rev Respir Dis 1988; 138:472.
  16. Siafakas NM, Salesiotou V, Filaditaki V, et al. Respiratory muscle strength in hypothyroidism. Chest 1992; 102:189.
  17. Ladenson PW, Goldenheim PD, Ridgway EC. Prediction and reversal of blunted ventilatory responsiveness in patients with hypothyroidism. Am J Med 1988; 84:877.
  18. Rosenow F, McCarthy V, Caruso AC. Sleep apnoea in endocrine diseases. J Sleep Res 1998; 7:3.
  19. Curnock AL, Dweik RA, Higgins BH, et al. High prevalence of hypothyroidism in patients with primary pulmonary hypertension. Am J Med Sci 1999; 318:289.
  20. Peacock AJ. Primary pulmonary hypertension. Thorax 1999; 54:1107.
  21. Shafer RB, Prentiss RA, Bond JH. Gastrointestinal transit in thyroid disease. Gastroenterology 1984; 86:852.
  22. Lauritano EC, Bilotta AL, Gabrielli M, et al. Association between hypothyroidism and small intestinal bacterial overgrowth. J Clin Endocrinol Metab 2007; 92:4180.
  23. Elfström P, Montgomery SM, Kämpe O, et al. Risk of thyroid disease in individuals with celiac disease. J Clin Endocrinol Metab 2008; 93:3915.
  24. Krassas GE, Pontikides N, Kaltsas T, et al. Disturbances of menstruation in hypothyroidism. Clin Endocrinol (Oxf) 1999; 50:655.
  25. Burrow G. Thyroid diseases. In: Medical complications during pregnancy, 2nd, Burrow GN, Ferris TF (Eds), WB Saunders, Philadelphia 1982. p.187.
  26. Honbo KS, van Herle AJ, Kellett KA. Serum prolactin levels in untreated primary hypothyroidism. Am J Med 1978; 64:782.
  27. Donnelly P, White C. Testicular dysfunction in men with primary hypothyroidism; reversal of hypogonadotrophic hypogonadism with replacement thyroxine. Clin Endocrinol (Oxf) 2000; 52:197.
  28. Carani C, Isidori AM, Granata A, et al. Multicenter study on the prevalence of sexual symptoms in male hypo- and hyperthyroid patients. J Clin Endocrinol Metab 2005; 90:6472.
  29. Krassas GE, Papadopoulou F, Tziomalos K, et al. Hypothyroidism has an adverse effect on human spermatogenesis: a prospective, controlled study. Thyroid 2008; 18:1255.
  30. Giordano N, Santacroce C, Mattii G, et al. Hyperuricemia and gout in thyroid endocrine disorders. Clin Exp Rheumatol 2001; 19:661.
  31. Kreisman SH, Hennessey JV. Consistent reversible elevations of serum creatinine levels in severe hypothyroidism. Arch Intern Med 1999; 159:79.