Patient information: Hypothyroidism (underactive thyroid) (Beyond the Basics)
- Douglas S Ross, MD
Douglas S Ross, MD
- Section Editor — Thyroid Disease
- Professor of Medicine
- Harvard Medical School
Hypothyroidism is a condition in which the thyroid gland does not produce enough thyroid hormone. It is the most common thyroid disorder.
This topic discusses hypothyroidism. hyperthyroidism is discussed separately. (See "Patient information: Hyperthyroidism (overactive thyroid) (Beyond the Basics)".)
WHAT IS THE THYROID?
The thyroid is a butterfly-shaped gland in the middle of the neck, located below the larynx (voice box) and above the clavicles (collarbones) (figure 1). The thyroid produce two hormones, triiodothyronine (T3) and thyroxine (T4), which regulate how the body uses and stores energy (also known as the body's metabolism).
Thyroid function is controlled by a gland in the brain, known as the pituitary (figure 2). The pituitary produces thyroid-stimulating hormone (TSH), which stimulates the thyroid to produce T3 and T4.
In about 95 percent of cases, hypothyroidism is due to a problem in the thyroid gland itself and is called primary hypothyroidism. However, certain medications and diseases can also decrease thyroid function. As an example, hypothyroidism can also develop after medical treatments for hyperthyroidism, such as thyroidectomy (surgical removal of the thyroid) or radioactive iodine treatment (to destroy thyroid tissue). In some cases, hypothyroidism is a result of decreased production of thyroid-stimulating hormone (TSH) by the pituitary gland (called secondary hypothyroidism). (See "Patient information: Hyperthyroidism (overactive thyroid) (Beyond the Basics)".)
Thyroid problems are more common in women, increase with age, and are more common in whites and Mexican Americans than in blacks.
The symptoms of hypothyroidism vary widely; some people have no symptoms while others have dramatic symptoms or, rarely, life-threatening symptoms. The symptoms of hypothyroidism are notorious for being nonspecific and for mimicking many of the normal changes of aging. Usually, symptoms are milder when hypothyroidism develops gradually. Symptoms, when caused by hypothyroidism, generally are related to the degree of hypothyroidism. Many patients with mild hypothyroidism are identified on screening tests for potential hypothyroid symptoms, but have few or no symptoms that ultimately are attributed to hypothyroidism or respond to treatment of hypothyroidism. In contrast, patients with moderate to severe hypothyroidism are usually symptomatic and improve significantly with thyroid hormone replacement.
The following list of symptoms are those that may be present prior to treatment; hypothyroid patients on appropriate treatment should no longer be symptomatic. If symptoms persist, they likely have causes other than hypothyroidism.
General symptoms — Thyroid hormone normally stimulates the metabolism, and most of the symptoms of hypothyroidism reflect slowing of metabolic processes. General symptoms may include fatigue, sluggishness, weight gain, and intolerance of cold temperatures.
Skin — Hypothyroidism can decrease sweating. The skin may become dry and thick. The hair may become coarse or thin, eyebrows may disappear, and nails may become brittle.
Eyes — Hypothyroidism can lead to mild swelling around the eyes. People who develop hypothyroidism after treatment for Graves' disease may retain some of the eye symptoms of Graves' disease, including protrusion of the eyes, the appearance of staring, and impaired movement of the eyes. (See "Patient information: Hyperthyroidism (overactive thyroid) (Beyond the Basics)".)
Cardiovascular system — Hypothyroidism slows the heart rate and weakens the heart's contractions, decreasing its overall function. Related symptoms may include fatigue and shortness of breath with exercise. These symptoms may be more severe in people who also have heart disease. In addition, hypothyroidism can cause mild high blood pressure and raise blood levels of cholesterol.
Respiratory system — Hypothyroidism weakens the respiratory muscles and decreases lung function. Symptoms can include fatigue, shortness of breath with exercise, and decreased ability to exercise. Hypothyroidism can also lead to swelling of the tongue, hoarse voice, and sleep apnea. Sleep apnea is a condition in which there is intermittent blockage of the airway while sleeping, causing fitful sleep and daytime sleepiness. (See "Patient information: Sleep apnea in adults (Beyond the Basics)".)
Gastrointestinal system — Hypothyroidism slows the actions of the digestive tract, causing constipation. Rarely, the digestive tract may stop moving entirely. (See "Patient information: Constipation in adults (Beyond the Basics)".)
Reproductive system — Women with hypothyroidism often have menstrual cycle irregularities, ranging from absent or infrequent periods to very frequent and heavy periods. The menstrual irregularities can make it difficult to become pregnant, and pregnant women with hypothyroidism have an increased risk for miscarriage during early pregnancy. Treatment of hypothyroidism can decrease these risks. (See "Patient information: Absent or irregular periods (Beyond the Basics)" and "Patient information: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics)".)
Myxedema coma — In people with severe hypothyroidism, trauma, infection, exposure to the cold, and certain medications can rarely trigger a life-threatening condition called myxedema coma, which causes a loss of consciousness and hypothermia (low body temperature).
In the past, hypothyroidism was not diagnosed until symptoms had been present for a long time. However, simple blood tests can now detect hypothyroidism at an early stage. A person may be tested for hypothyroidism if there are signs and symptoms, such as those discussed above, or as a screening test.
Blood tests — Blood tests can confirm the diagnosis and pinpoint the underlying cause of the thyroid hormone deficiency. The most common blood test for hypothyroidism is thyroid-stimulating hormone (TSH). TSH is the most sensitive test because it can be elevated even with small decreases in thyroid function. Thyroxine (T4), the main product of the thyroid gland, may also be measured to confirm and assess the degree of hypothyroidism.
Routine screening — All newborn babies in the United States are routinely screened for thyroid hormone deficiency. It is not clear if all adults should be tested for thyroid disease .
The goal of treatment for hypothyroidism is to return blood levels of thyroid-stimulating hormone (TSH) and thyroxine (T4) to the normal range and to alleviate symptoms.
Medication — The treatment for hypothyroidism is thyroid hormone replacement therapy. This is usually given as an oral form of T4 (levothyroxine). T4 should be taken once per day on an empty stomach (ideally one hour before eating or two hours after; most patients take their hormone as soon as they wake in the morning, and delay eating breakfast as long as practical before leaving for work or school). Generic (levothyroxine) and brand-name (Synthroid, Levoxyl, Levothroid, Unithyroid, Tirosint) formulations are equally effective. However, it is preferable to stay on the same manufacturer of T4 rather than switching between brand name and/or generic formulations.
If a switch is necessary and the patient feels that their levels may be off, a blood test can be done six weeks later to determine if the dose needs to be adjusted. Color-coded tablets can help with dose adjustments.
Some clinicians prescribe another form of thyroid hormone, T3 (liothyronine), in combination with T4. However, since T4 is converted into triiodothyronine (T3) in other organs, the majority of studies have not shown an advantage of combination T3 and T4 therapy over T4 alone.
In most cases, symptoms of hypothyroidism begin to improve within two weeks of starting thyroid replacement therapy. However, people with more severe symptoms may require several months of treatment before they fully recover.
Duration and dose — A healthcare provider will prescribe an initial dose of T4 and then retest the blood level of TSH after six weeks. The T4 dose can be adjusted at that time, depending upon these results. This process may be repeated several times before hormone levels become normal. After the optimal dose is identified, a provider may recommend monitoring blood tests once yearly, or more often as needed. Most people with hypothyroidism require lifelong treatment, although the dose of T4 may need to be adjusted over time.
Never increase or decrease the T4 dose without first consulting a healthcare provider. Overreplacement of T4 can cause mild hyperthyroidism, with the associated dangers of atrial fibrillation (irregular heart beat) and, possibly, accelerated bone loss (osteoporosis).
Dose changes — Changes in the T4 dose are based upon the person's TSH and T4 level. The dose may need to be increased if thyroid disease worsens, during pregnancy, if gastrointestinal conditions impair T4 absorption, or if the person gains weight. A high fiber diet, calcium- or aluminum-containing antacids, and iron tablets can interfere with the absorption of T4 and should be taken at a different time of day.
The dose may need to be decreased as the person gets older, after childbirth, or if the person loses weight.
Monitoring — Individual T4 doses can vary widely and depend upon a variety of factors, including the underlying cause of hypothyroidism. People with certain conditions require more frequent monitoring.
Advanced age and heart disease — Thyroid hormone makes the heart work a bit harder. Therefore, a clinician may opt for more conservative T4 treatment in older adults and in people with coronary artery disease.
Pregnancy — Women often need higher doses of T4 during pregnancy. Testing is usually recommended every four weeks, beginning after conception, until levels are stable, then once each trimester. After delivery, the woman's dose of T4 will need to be adjusted again, usually returning to the pre-pregnancy dose.
Surgery — Hypothyroidism can increase the risk of certain surgery-related complications; bowel function may be slow to recover and infection may be overlooked if there is no fever. If pre-operative blood tests reveal low thyroid hormone levels, non-emergency surgery is usually postponed until treatment has returned T4 levels to normal.
Hypothyroidism without symptoms — In some cases, hypothyroidism is extremely mild or causes no obvious symptoms (called subclinical hypothyroidism). The decision to treat subclinical hypothyroidism with T4 is controversial. Many experts treat patients with subclinical hypothyroidism if their TSH is >7 to 10 mU/L to prevent the development of hypothyroidism and associated symptoms. Treatment is also recommended for people who have a goiter or nonspecific symptoms of hypothyroidism, such as fatigue, constipation, or depression.
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient information: Hypothyroidism (underactive thyroid) (The Basics)
Patient information: Hemochromatosis (The Basics)
Patient information: Thyroid nodules (The Basics)
Patient information: Congenital hypothyroidism (The Basics)
Patient information: Hypoparathyroidism (The Basics)
Patient information: Panhypopituitarism (The Basics)
Patient information: Thyroiditis after pregnancy (The Basics)
Patient information: Thyroiditis (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient information: Hyperthyroidism (overactive thyroid) (Beyond the Basics)
Patient information: Sleep apnea in adults (Beyond the Basics)
Patient information: Constipation in adults (Beyond the Basics)
Patient information: Absent or irregular periods (Beyond the Basics)
Patient information: Heavy or prolonged menstrual bleeding (menorrhagia) (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Acquired hypothyroidism in childhood and adolescence
Cardiovascular effects of hypothyroidism
Clinical features and detection of congenital hypothyroidism
Clinical manifestations of hypothyroidism
Diagnosis of and screening for hypothyroidism in nonpregnant adults
Disorders that cause hypothyroidism
Laboratory assessment of thyroid function
Neurologic manifestations of hypothyroidism
Overview of thyroid disease in pregnancy
Subclinical hypothyroidism in nonpregnant adults
Treatment and prognosis of congenital hypothyroidism
Treatment of hypothyroidism
Endocrinopathies in the childhood cancer survivor
The following organizations also provide reliable health information.
●National Library of Medicine
●The American Thyroid Association
●Hormone Health Network
Patient support — There are a number of online forums where patients can find information and support from other people with similar conditions.
●About.com Thyroid Conditions Forum
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.