Patient education: Hypothyroidism (underactive thyroid) (Beyond the Basics)

HYPOTHYROIDISM OVERVIEW — 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 education: 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 just below the brain, known as the pituitary. The pituitary produces thyroid-stimulating hormone (TSH), which stimulates the thyroid to produce T3 and T4.

HYPOTHYROIDISM CAUSES — In approximately 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 radioiodine 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 education: Hyperthyroidism (overactive thyroid) (Beyond the Basics)".)

Thyroid problems are more common in females, increase with age, and (in the United States) are more common in white people and Mexican Americans than in African Americans.

HYPOTHYROIDISM SYMPTOMS — 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 generally are related to the degree of hypothyroidism. Many people 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, people 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; people 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, slight weight gain, and intolerance of cold temperatures.

Skin — Hypothyroidism can decrease sweating. The skin may become dry and thick. The hair may become coarse, eyebrows may become more sparse, and nails may become brittle.

Eyes — Hypothyroidism can lead to mild facial swelling. People who develop hypothyroidism after treatment for Graves' disease may retain some of the eye symptoms of Graves' disease, including protrusion of the eyes, swelling around the eyes, the appearance of staring, and impaired movement of the eyes. (See "Patient education: 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 (the diastolic or second number) 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 education: 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 education: Constipation in adults (Beyond the Basics)".)

Reproductive system — Women with hypothyroidism often have menstrual cycle irregularities; this commonly involves heavy periods, but some people have absent or infrequent periods.

Irregular periods can make it difficult to get pregnant, and pregnant people with hypothyroidism have an increased risk for early pregnancy loss (miscarriage). For these reasons, it is particularly important to get treatment if you have hypothyroidism and want to get pregnant. (See "Patient education: Absent or irregular periods (Beyond the Basics)" and "Patient education: 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. Symptoms can include hypothermia (low body temperature), sleepiness, and, in severe cases, loss of consciousness.

HYPOTHYROIDISM DIAGNOSIS — Simple blood tests can tell if a person has hypothyroidism. Doctors can order these tests if they suspect a person has hypothyroidism based on their signs and symptoms (see 'Hypothyroidism symptoms' above), or they can use them for screening, ie, to check for thyroid problems in a person with no symptoms.

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.

"Overt" hypothyroidism is diagnosed when the TSH is elevated and the T4 is low. "Subclinical" (very mild) hypothyroidism is diagnosed when the TSH is elevated but the T4 is still within the normal reference range for the population.

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.

HYPOTHYROIDISM TREATMENT — The goal of treatment is to return blood levels of thyroid-stimulating hormone (TSH) and thyroxine (T4) to the normal range and to relieve symptoms.

Hypothyroidism is treated with thyroid hormone replacement therapy. This is usually given as an oral (pill) form of T4, called "levothyroxine." Most people with hypothyroidism need to keep taking levothyroxine for the rest of their life. This gives your body the right level of the hormone that it cannot make on its own.

In most cases, symptoms of hypothyroidism begin to improve within two weeks of starting thyroid replacement therapy. However, people with more severe symptoms, especially muscle pain and weakness, may require several months of treatment before they fully recover.

Tips for taking your medication — Levothyroxine should be taken once per day on an empty stomach (ideally one hour before eating or two to four hours after). Most people take their medication as soon as they wake in the morning and delay eating breakfast as long as practical before leaving for work or school.

Foods with a lot of fiber, calcium- or aluminum-containing antacids, and iron tablets can interfere with the absorption of levothyroxine and should be taken at a different time of day.

Generic (levothyroxine) and brand-name (for example, Synthroid, Levoxyl, Unithroid, Euthyrox) are available as tablets, and gel-caps and liquid preparations are also available (Tirosint, Thyquidity). These formulations are equally effective.

It is preferable to stay on the same manufacturer of levothyroxine if possible, rather than switching between brand name and/or generic formulations. However, if you do need to switch to a different formulation of levothyroxine, the dose usually doesn't need to change. If you don't feel as well with the new formulation, your health care provider can do a blood test to check your thyroid hormone levels about six weeks after making the switch. This can help them determine whether your dose needs to be adjusted. (See 'Dose changes' below.)

Duration and dose — Your health care provider will prescribe an initial dose of levothyroxine and then retest your blood level of TSH after six weeks. Your dose can be adjusted at that time if needed. This process may need to be repeated several times before your hormone levels become normal. Color-coded tablets can help with dose adjustments.

Thyroid hormone makes the heart work a bit harder. For this reason, most health care providers prescribe a lower initial dose of levothyroxine in older adults and in people with coronary artery disease.

Once the optimal dose has been identified, your provider may recommend monitoring blood tests once yearly, or more often as needed. Most people with hypothyroidism require lifelong treatment, although the dose of levothyroxine may need to be adjusted over time.

Dose changes — Changes in the levothyroxine dose usually are based upon your TSH level. Your dose may need to be increased if thyroid disease worsens, you get pregnant, gastrointestinal conditions impair levothyroxine absorption, or you gain weight.

The dose may need to be decreased as you get older, after childbirth, or if you lose weight.

Never increase or decrease the levothyroxine dose without talking with your health care provider. Over-replacement of T4 can cause mild hyperthyroidism, with the associated risks of atrial fibrillation (irregular heartbeat) and, possibly, accelerated bone loss (osteoporosis). (See "Patient education: Hyperthyroidism (overactive thyroid) (Beyond the Basics)".)

Monitoring — Individual levothyroxine 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.

Pregnancy — People often need higher doses of levothyroxine during pregnancy. Testing is usually recommended every four weeks, beginning after conception, until levels are stable, then once each trimester. After giving birth, the woman's dose of levothyroxine 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 you are scheduled for a non-emergency surgical procedure and your preoperative blood tests reveal low thyroid hormone levels, your procedure will likely be postponed until treatment has returned T4 levels to normal.

Subclinical hypothyroidism — Subclinical hypothyroidism is when the TSH is elevated but the T4 is normal.

The decision to treat subclinical hypothyroidism with levothyroxine is controversial. We treat all patients with a TSH >10 mU/L. The decision to treat patients with a TSH that is above the upper limit of normal (this cutoff can vary but is usually around 4.2 to 5 mU/L) but below 10 mU/L is based upon age and the presence of goiter (enlargement of the thyroid) or new or worsening symptoms of hypothyroidism.

Younger people (under age 65 to 70 years) are frequently treated before the TSH exceeds 7 mU/L. In contrast, older adults with a similar slight elevation in TSH are often not treated. This is because the normal range for TSH is higher in older people, with an upper limit of approximately 7.5 mU/L in 80-year-olds.

WHERE TO GET MORE INFORMATION — Your health care 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 website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care 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 education: Hypothyroidism (underactive thyroid) (The Basics)
Patient education: Hemochromatosis (The Basics)
Patient education: Thyroid nodules (The Basics)
Patient education: Congenital hypothyroidism (The Basics)
Patient education: Hypoparathyroidism (The Basics)
Patient education: Panhypopituitarism (The Basics)
Patient education: Thyroiditis after pregnancy (The Basics)
Patient education: 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 education: Hyperthyroidism (overactive thyroid) (Beyond the Basics)
Patient education: Sleep apnea in adults (Beyond the Basics)
Patient education: Constipation in adults (Beyond the Basics)
Patient education: Absent or irregular periods (Beyond the Basics)
Patient education: 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
Central 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
Myxedema coma
Neurologic manifestations of hypothyroidism
Overview of thyroid disease and pregnancy
Subclinical hypothyroidism in nonpregnant adults
Treatment and prognosis of congenital hypothyroidism
Treatment of primary hypothyroidism in adults
Endocrinopathies in cancer survivors and others exposed to cytotoxic therapies during childhood

The following organizations also provide reliable health information.

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)

●The American Thyroid Association

(www.thyroid.org)

●Hormone Health Network

(www.hormone.org/diseases-and-conditions/thyroid/hypothyroidism)

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