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Author:
Martin I Surks, MD
Section Editor:
Douglas S Ross, MD
Deputy Editor:
Jean E Mulder, MD
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All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Dec 2016. | This topic last updated: Mar 08, 2016.
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".)
Skin — The skin is cool and pale in patients with hypothyroidism because of decreased
blood flow. The epidermis has an atrophied cellular layer and hyperkeratosis that results in
the characteristic dry roughness of the skin [2].
The following skin changes may also occur:
Anemia — Patients with hypothyroidism have a decrease in red blood cell mass and a
normochromic, normocytic hypoproliferative anemia [5]. Pernicious anemia occurs in 10
percent of patients with hypothyroidism caused by chronic autoimmune thyroiditis. Such
patients present with a macrocytic anemia with marrow megaloblastosis. However,
occasional patients without anemia may display macrocytosis without marrow
megaloblastosis [6]. (See "Physiology of vitamin B12 and folate
deficiency" and "Macrocytosis/Macrocytic anemia".)
Women in the childbearing years may develop iron deficiency anemia, secondary to
menorrhagia. In patients with iron deficiency anemia and hypothyroidism, combined therapy
with levothyroxine and oral iron supplements results in correction of the anemia, which may
be refractory to treatment with iron alone [7].
Reduced cardiac output probably contributes to decreased exercise capacity and shortness
of breath during exercise, two common complaints in patients with hypothyroidism. However,
symptoms and signs of congestive heart failure are usually absent in patients who have no
other cardiac disease. By contrast, heart failure or angina may worsen when hypothyroidism
develops in patients with heart disease. In such patients, T4 (levothyroxine) replacement
should be administered cautiously, beginning with a low initial dose (eg, 25 mcg) and then
increasing in small increments every one or two months. (See "Treatment of
hypothyroidism".)
The prevalence of hypothyroidism is high among patients with idiopathic pulmonary arterial
hypertension, although hypothyroidism is not currently believed to be a risk factor for the
condition [19,20]. The basis of the observed association of the two disorders is unclear.
(See "Overview of pulmonary hypertension in adults".)
These menstrual changes result in decreased fertility. If pregnancy does occur, there is an
increased likelihood for early abortion [25]. Hyperprolactinemia may occur, and is
occasionally sufficiently severe to cause amenorrhea or galactorrhea [26].
The serum sex hormone-binding globulin concentration may be low in hypothyroidism. This
will lower serum total but not free sex hormone concentrations, a change that can be
misleading in the evaluation of gonadal function. However, some men with hypothyroidism
have low serum free testosterone concentrations but normal serum luteinizing hormone
concentrations, suggesting a direct effect of hypothyroidism on the hypothalamus or pituitary
[27]; their serum free testosterone concentrations rise with T4 treatment.
Decreased libido, erectile dysfunction, and delayed ejaculation are found in 64 percent of
hypothyroid men [28]. In one report, sperm morphology was abnormal in 64 percent of
hypothyroid men before treatment and 24 percent after T4 therapy [29].
Joint pains, aches, and stiffness may also occur in patients with hypothyroidism, although
they are not a common presentation. (See "Evaluation of the adult with polyarticular pain".)
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
SUMMARY
●The symptoms and signs of hypothyroidism vary in relation to the magnitude of the
thyroid hormone deficiency and the acuteness with which the deficiency develops.
(See 'Introduction' above.)
●Many of the manifestations of hypothyroidism reflect one of two changes induced by
lack of thyroid hormone: a generalized slowing of metabolic processes and
accumulation of matrix glycosaminoglycans in the interstitial spaces of many tissues
(table 1). Other symptoms and signs include depression, decreased hearing, diastolic
hypertension, and pleural and pericardial effusions. (See 'Clinical
manifestations' above.)
●The clinical manifestations of central hypothyroidism are similar to those of primary
hypothyroidism. 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. (See "Central
hypothyroidism" and "Diagnostic testing for hypopituitarism".)
●A variety of metabolic abnormalities can occur in hypothyroidism, including
hyponatremia, hyperlipidemia, anemia, and high serum muscle enzyme concentrations.
(See 'Metabolic abnormalities' above and "Hypothyroid myopathy", section on
'Elevation in serum creatine kinase'.)
●The clearance of many drugs, including antiepileptic, anticoagulant, hypnotic and
opioid drugs, is decreased in hypothyroidism. (See 'Drug clearance' above.)
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