Department of Medicine
HYPOTHYROIDISM
DEFINITION
Hypothyroidism is a condition where the thyroid gland
does not make enough thyroid hormone( thyroxine).
EPIDEMIOLOGY
It is very common, increasing in incidence with
increasing age.
Incidence:
Overt form - 2% women, 0.2% men.
Subclinical - 6-8% women, 3% men.
2.5% of pregnant women develop hypothyroidism.
The most common cause worldwide for hypothyroidism
is iodine deficiency
In areas where iodine deficiency is not a problem,
autoimmune & iatrogenic hypothyroidism are the most
frequent causes
RISK FACTORS
Increasing age
Female sex
Autoimmune disease eg. Coeliac, Addisons disease
Drugs eg. Lithium, amiodarone, carbimazole
Occurs more commonly in patients with Turners
syndrome & Trisomy 21
Genetic predisposition
Pregnancy or post partum
Cystic fibrosis
Thyroid surgery or radiation/ radio- iodine.
SYMPTOMS OF HYPOTHYROIDISM
Tiredness, lethargy, intolerance to cold.
Dry skin and hair loss
Slowing of intellectual activity, eg poor memory and
difficulty concentrating
Constipation
Decreased appetite with weight gain
Deep hoarse voice
Menorrhagia and later oligomenorrhoea or amenorrhoea.
Impaired hearing due to fluid in middle ear.
Reduced libido
Low mood
myalgia
CLINICAL FEATURES OF
HYPOTHYROIDISM
Tiredness Puffy Eyes
Forgetfulness/Slower Thinking Enlarged Thyroid (Goiter)
Moodiness/ Irritability Hoarseness/
Deepening of Voice
Depression
Persistent Dry or Sore Throat
Inability to Concentrate
Thinning Hair/Hair Loss Difficulty Swallowing
Loss of Body Hair Slower Heartbeat
Dry, Patchy Skin Menstrual Irregularities/
Heavy Period
Weight Gain Infertility
Cold Intolerance
Elevated Cholesterol Constipation
Muscle Weakness/
Family History of Thyroid Cramps
Disease or Diabetes
SIGNS
Dry coarse skin/ dry brittle Carpal tunnel syndrome
hair/ hair loss Serous cavity effusions, eg
Cold peripheries pericarditis or pleural
Goitre effusions.
Loss of outer third of the Periorbital oedema
eyebrow Cerebellar signs
Puffy face, hands and feet
(myxoedema)
Bradycardia
Delayed tendon reflex
relaxation
Raised BMI
Proximal muscle weakness
HYPOTHYROIDISM
Department of Medicine,
INVESTIGATIONS
Thyroid function tests
Low T4
Raised TSH
Anti- thyroid peroxidase antibodies
Anti- thyroglobulin antibodies
If patient has asymmetric goitre, needs ultrasound to
look for neoplastic lesion
Diagnosis
Diagnosis Hypothyroidism
TSH
FT4 and T3
Department of Medicine,
RCSI
SCREENING FOR COMPLICATIONS
Fasting lipoprotein profile
Cholestrol & triglycerides often raised
Full blood count
Macrocytosis, macrocytic anaemia, normocytic anaemia
CAUSES OF HYPOTHYROIDISM
Causes of primary hypothyroidism
Hashimotos thyroiditis( autoimmune)
Primary atrophic hypothyroidism
Other causes
Post thyroidectomy or radioiodine
Drug induced eg. Carbimazole, lithium, amiodarone
Subacute thyroiditis
Iodine deficiency
Congential hypothyroidism
Post partum thyroiditis
Infiltrative causes eg. haemochromatosis
Secondary hypothyroidism
Due to TSH deficiency eg. Hypopituitarism ( rare)
Department of Medicine,
RCSI
HASHIMOTOS THYROIDITIS
Commonest cause of hypothyroidism in iodine
sufficient areas
Characterized by
High antibody titers (TPO positive in 90% of patients)
Painless diffuse goiter
More common in women
Prevalence increases with age
Department of Medicine,
RCSI
TREATMENT OF HYPOTHYROIDISM
All causes of hypothyroidism
L-Thyroxine
Usual dose is approximately 1.6ug/kg/day
Start at 50-100 micrograms per day
Adjust 4-6 weekly in increments of 25- 50 micrograms
Aim to normalize TSH
Once TFTs stable, monitor every 6-12 months
Caution:
Elderly or ischaemic heart disease: Start at 25micrograms daily
& adjust slowly in 4 weekly increments of 25 micrograms ( risk of
precipitating angina or myocardial infarction)
SIDE-EFFECTS
None, except with under or over replacement
Conditions that alter L-thyroxine requirements
1. Pregnancy ( increased requirement)
2. Drug that interfere with absorption
Antacids (aluminum containing)
Iron tables
Calcium tablets
3. Drugs that increase metabolism
Anti-epileptic
Rifampicin
Department of Medicine,
RCSI
COMPLICATIONS OF HYPOTHRYOIDISM
Myxoedema coma
Ischaemic heart disease
Weight gain/ obesity
Rare neurologic problems include reversible cerebellar
ataxia, dementia, psychosis, and myxedema coma.
Hashimoto's encephalopathy
SUBCLINICAL HYPOTHYROIDISM
Normal FT4 and T3 with elevated TSH ( > 4mU/L)
Usually asymptomatic
Prevalence rate vary 1-10% (depends on age, sex, ethnic)
Highest rate is in women >60yo
~prevalence 20%
Reasons to treat
1. Increase risk of future clinical hypothyroidism
2. Hyperlipidaemia and atherosclerosis
3. Pregnancy
4. Reduce quality of life if symptomatic
SUBCLINICAL HYPOTHYROIDISM
Management
Treat if TSH > 10mU/L
Treat if TSH between 4-10 mU/L
If symptomatic
If positive thyroid autoantibodies
Goitre
If pregnant or trying to conceive
If previous Graves disease or other autoimmune diseases, consider
treatment as more likely to progress to overt hypothyroidism
If TSH between 4-10mU/L & asymptomatic: controversy remains
over whether should be treated or not
PROGNOSIS OF HYPOTHYROIDISM
If treated, prognosis is excellent
However, if not diagnosed can have profound
consequences e.g. dementia, ischaemic heart disease,
myxoedema coma
MCQ 1
A 78 year old lady is seen in Geriatrics outpatients for
review of cognitive decline. On investigations, her TFTs
show a TSH > 50mU/L ( 0.5-5.5mU/L) & T 4 of 8 (9-
22pmol/L). Which of the following is the most suitable
treatment regime for this lady?
A. L-thyroxine 100micrograms po od
B. Donepezil 10mgs po od
C. Donepezil 5mgs po od
D. L-thyroxine 25micrograms po od
E. Carbimazole 10mgs po od
D. L-thyroxine 25micrograms po od ( start low & titrate
slowly if elderly or history of ischaemic heart disease, as
may precipitate angina)
MCQ 2
A 56 year old woman with a history of coeliac disease
presents to her GP with lethargy, cold intolerance & low
mood. On examination, she is overweight with dry skin &
brittle hair. Which of the following is most likely to represent
her thyroid function test ( TFTs) results?
A. High T4, low TSH
B. Low T4, elevated TSH
C. Normal T4, normal TSH
D. Low T4, low TSH
E. Low T4, normal TSH
B. Low T4, elevated TSH
M. E.Q.
A 21 year old woman with a background history of type 1 diabetes presents with
cold intolerance, weight gain & lethargy. A diagnosis of hypothroidism is
considered.
Q1. List 5 signs on clinical examination that would support this diagnosis (5 marks)
Answer= see slide 6
Q2. What is the most common cause of hypothyroidism? ( 3 marks)
Hashimotos thyroiditis
Q3. What precaution would you take in starting thyroxine replacement if this
patient was 72 years old & had a history of ischaemic heart disease? Give details (
8 marks)
Answer= administer 25micrograms( 2 marks) of l-thyroxine ( 2 marks) as a
starting dose & titrate slowly ( 2 marks) e.g.. increase every 4 wks in 25 mcg
increments according to TFTs. ( 2 marks)
Q4. Describe the thyroid function tests results you would expect to find in this
patient `(4 marks)
Answer = T4 low, TSH raised
REFERENCES
Uptodate.com
Kumar & Clark- Clinical Medicine 2012
Harrisons clinical medicine 2012
Oxford handbook of clinical medicine 8th edition
