Hypothyroidism


Article Author:
Nikita Patil
Anis Rehman


Article Editor:
Ishwarlal Jialal


Editors In Chief:
David Wood
Andrew Wilt
Mary Cataletto


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
9/2/2019 10:00:22 PM

Introduction

Hypothyroidism results from low levels of thyroid hormone with varied etiology and manifestations. The drug of choice for the treatment of hypothyroidism is levothyroxine. Untreated hypothyroidism increases morbidity and mortality. This article reviews etiology, clinical presentation, diagnosis, and management of hypothyroidism.

Etiology

The most common etiology is iodine deficiency in iodine-deficient geographic areas worldwide. Autoimmune thyroid diseases are the leading cause of hypothyroidism in the United States and the iodine-sufficient regions. Etiology can be influenced locally by iodine fortification and emergence of new iodine-deficient areas.[1]

Other common causes of hypothyroidism are drugs such as amiodarone and lithium,[1] thyroid radioactive iodine therapy or thyroid surgery, radiotherapy to head or neck area, and central hypothyroidism from neoplastic, infiltrative, inflammatory, or iatrogenic disorders of the pituitary or hypothalamus.[2]

Epidemiology

The NHANESIII (National Health and Nutrition Examination Survey) study found the prevalence of overt hypothyroidism among US adults (12 years of age and older) to be 0.3% and subclinical hypothyroidism 4.3%. Female gender and increasing age were associated with higher thyroid-stimulating hormone (TSH) and prevalence of antithyroid antibodies.[3]

Pathophysiology

The hypothalamus secretes thyrotropin-releasing hormone (TRH) that stimulates the pituitary gland to produce thyroid-stimulating hormone (TSH). Thyroid-stimulating hormone stimulates the thyroid gland to produce and secrete mainly T4 while T3 is produced mainly by conversion of T4 to T3. Levels of T3 and T4, in turn, exert a negative feedback on the production of TRH and TSH. Alteration in structure and function of any of these organs or pathways can result in hypothyroidism.

Histopathology

Predominant T-cell lymphocytic infiltration is seen in autoimmune thyroid disease.[2] Co-existing or associated malignancy such as papillary thyroid cancer can also be seen.[4]

History and Physical

It is important to maintain a high index of suspicion for hypothyroidism since the signs and symptoms can be mild and nonspecific and different symptoms may be present in different patients.

Inquire about dry skin, voice changes, hair loss, constipation, fatigue, muscle cramps, cold intolerance, sleep disturbances, menstrual cycle abnormalities, weight gain, galactorrhea.[2] Also obtain a complete medical, surgical, medication and family history.

History of adverse pregnancy and neonatal outcomes should also be sought.[5]

Symptoms of depression, anxiety, psychosis, cognitive impairments such as memory loss can be present.[6] Rarely patients can present with ascites,[7] rhabdomyolysis, and pericardial effusion.[8]

Patients can also present with carpal tunnel syndrome, sleep apnea, hyponatremia, Hypercholesterolemia, congestive heart failure, and prolonged QT interval.[2]

A physical examination may reveal an enlarged thyroid gland, the presence of nodules, prolonged ankle reflex relaxation time, hoarse voice, and skin and hair changes.[2]

Evaluation

Serum TSH level is used to screen for primary hypothyroidism in most patients. In overt hypothyroidism, TSH levels are elevated, and free T4 levels are low. In subclinical hypothyroidism, TSH levels are elevated, and free T4 levels are normal.[2]

Central hypothyroidism is of pituitary or hypothalamic origin. TSH produced can be biologically inactive and can affect the levels of bioactive TSH, hence diagnosis of central hypothyroidism should be based on free T4 rather than TSH.[2]

Labs should include evaluation for autoimmune thyroid diseases with levels of anti-thyroid antibodies: the thyroid peroxidase antibodies and anti-thyroglobulin antibodies. Particularly in patients with thyroid nodules, fine-needle aspiration biopsy should be considered.[2]

Patients with subclinical hypothyroidism and thyroid peroxidase antibody positivity have a greater risk of developing overt hypothyroidism[2] and should be followed up periodically with clinical evaluation and lab tests for the same.

T3 levels are not a reliable or recommended test. Hospitalized patients should undergo TSH testing only when thyroid dysfunction is suspected.[2]

On labs, hyperlipidemia, elevated serum CK, elevated hepatic enzymes, anemia can be present.[2]

BUN, creatinine, and uric acid levels can also be elevated.[9]

Treatment / Management

Hypothyroidism is mainly treated with levothyroxine monotherapy.[10]

Thyroid replacement treatment can exacerbate co-existing adrenal insufficiency. Patients with known or suspected adrenal insufficiency should be tested and treated for the adrenal insufficiency while awaiting results.[2] Adrenal insufficiency can also be associated with subclinical hypothyroidism that is reversible with treatment of adrenal insufficiency.[11] In patients who have confirmed adrenal insufficiency consider a reassessment of thyroid tests following adequate treatment of adrenal insufficiency.

Replacement levothyroxine dose is 1.6 mcg/kg per day, should be taken 60 minutes before a meal and at least 3 hours post-meal which makes before breakfast or at bedtime the practical times for most patients. Maintaining a consistent formulation or brand of levothyroxine is important.[10]

When switching to the intravenous (IV) form, reduce the dose to 70% of the oral dose. Malabsorption syndromes, medications such as sucralfate, calcium preparations, and bile acid sequestrants can interfere with the absorption of levothyroxine.[2]

Based on the 2012 Clinical Practice Guidelines for Hypothyroidism in Adults by American Association of Clinical Endocrinologists and the American Thyroid Association, therapy should be monitored and titrated based on TSH measurements. Serum free T4 can also be used. Labs should be drawn every 4 to 8 weeks until target levels are achieved after starting the treatment, after any dose changes, changes in formulation or brand of levothyroxine,[2] after starting or stopping of any medications that may affect levels. If stable, then monitoring interval can be extended to 6 months, and if stable then, further monitoring can be extended to 12 months or can be done at shorter intervals on a case-to-case basis along with clinical evaluation.[2] Central hypothyroidism should be monitored based on free T4 rather than TSH.[2]

For elderly patients and patients with cardiac diseases, starting at a lower dose and titrating slowly is recommended.[10] Patients with cardiac disease should be monitored for the development of any symptoms of angina.[2] Monitor for side effects of treatment such as atrial fibrillation and osteoporosis.[10]

Effective treatment should achieve a clinical improvement of signs and symptoms, along with an improved sense of patient well-being and normal TSH (or free T4 levels as applicable).[12]

A comprehensive differential diagnosis workup is recommended for unresolved symptoms in the presence of biochemical euthyroidism. There is a lack of strong evidence supporting the routine inclusion of triiodothyronine (T3) preparations with levothyroxine in the treatment of hypothyroidism.[13]

If symptoms persist despite normalization of TSH/free T4 levels, then consultation with an endocrinologist should also be considered.

Differential Diagnosis

Differential diagnosis is based on signs and symptoms; for example, fatigue can point to iron deficiency anemia, sleep apnea, depression, and rheumatological diseases.[13]

Complications

Myxedema coma is a presentation of severe hypothyroidism and is an endocrine emergency. Early recognition and prompt treatment in the intensive care unit (ICU) is essential, and even then, mortality reaches 25% to 60%.[14]

Myxedema crisis should be suspected in patients that have encephalopathy, hypothermia, seizures, severe hyponatremia, hypoglycemia, cardiogenic shock and arrhythmias, respiratory failure, and manifestations of fluid retention.[14] A combination of a few or all of these manifestations and other symptoms of mild to severe hypothyroidism as stated above can be present.

Factors leading to an increased risk of myxedema crisis include inadequate doses of thyroid hormone, interruption in treatment, undiagnosed hypothyroidism, or presence of acute illness such as sepsis [14] perhaps due to increased metabolic demands.

Supportive treatment should be provided in the intensive care unit with fluid and electrolyte management, ventilator support, vasopressors, treatment of coexisting acute illness, and hypothermia.[14]

Thyroid replacement treatment is with intravenous hydrocortisone at stress doses followed by intravenous levothyroxine then switched to oral levothyroxine after clinical improvement. If effective, this should result in cardiopulmonary and cognitive improvement.[10] There should also be an associated improvement in laboratory derangements including a down trending of TSH which should be measured every 1 to 2 days during the initial treatment period. Intravenous liothyronine (T3) can be considered until initial improvement.[10]

Endocrinology consultation should be considered.

Enhancing Healthcare Team Outcomes

Hypothyroidism affects multiple organ systems across all age groups and affects patient well-being and ability to function on a daily basis. Treatment is with levothyroxine monotherapy (Grade A, Best Evidence Level 1).[2]

Effective treatment calls for a team-based and patient-centered approach. When patient symptoms are not adequately controlled an endocrinology consult should be obtained.

Endocrinology consultation is also recommended in complex scenarios such as preconception, pregnancy, congenital and pediatric hypothyroidism, failure of treatment, co-existing cardiac or other endocrine disorders, difficulty in interpretation of thyroid test results, drug-induced hypothyroidism.[2] Other specialists that may be needed are a psychiatrist, obstetrician-gynecologist, pediatrician, cardiologist, and intensivist.

It is helpful to work closely with a pharmacist to determine medication and food interactions, the effect of changes in levothyroxine formulations, to investigate the causes for the requirement of unusually high doses of levothyroxine or fluctuating TSH levels. Prompt notification of unusually high levels of TSH by laboratory personnel, close monitoring of vital signs and mental status by nurses can facilitate early treatment and better outcomes, especially in the inpatient setting such as in myxedema coma. Rapid response teams can be effectively utilized when hypothyroidism causes hemodynamic instability.


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Hypothyroidism - Questions

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A 65-year-old female presents to her clinician for evaluation of chronic headaches. She says her headaches feel like they are "always there." She adds that she has chronic fatigue which is accompanied by difficulty concentrating, depression, cold intolerance, and weight gain. She does not understand why she is depressed as she recently got a job promotion, and her relationships at home are stable. She denies any other psychiatric or medical history. Further evaluation with bloodwork reveals a thyroid-stimulating hormone (TSH) of 100 mU/L (0.3-5.5 mU/L) with low free T4 of 0.2 ng/dl ( 0.5-1.5 ng/dL), confirming that patient has severe hypothyroidism. The provider orders a brain MRI. Which of the following finding is most likely expected?



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Cystic fibrosis, and what other common endocrine disorder, correlate with elevated levels of sweat chloride?



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Dysphonia may associate with which endocrine disorder?



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A 19-year old female presents for a regular visit to primary care. She states that she does not have any other medical conditions, nor does she take any medications. However, she complains of feeling sad and significant weight gain despite a decreased appetite for the last six months. When evaluated further, she states that her skin has become dry, and she is losing more hair than usual which she thought was associated with stress due to her freshman year in college. She adds that she has to wear a sweater to college because she feels the classrooms are too cold. Which of the following physical exam finding would be expected in this patient?



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A 35-year-old female is diagnosed with hypothyroidism when her thyroid-stimulating hormone (TSH) was 12 mU/L (0.27-4.2 mU/L). She was then started on levothyroxine 25 mcg/day. Six weeks later, her symptoms have slightly improved. The thyroid-stimulating hormone is still in the same range at 10.1 mU/L (0.27 to 4.2). Which of the following is the most appropriate management for this patient?



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A 40-year-old female patient on levothyroxine for hypothyroidism has had normal thyroid-stimulating hormone (TSH) levels for years. She read on the internet that a combination product with thyroxine (T4) and triiodothyronine (T3) might help with her obesity and fatigue. Which of the following would be the most appropriate in the management of this patient?



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A 40-year-old female presents to the physician's office for her general physical examination. On physical examination, the physician observes the thinning of the outer third of the eyebrow. This is most likely seen in a patient with which condition?



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In hypothyroidism, which of the following deep tendon reflexes will most likely appear very sluggish on examination?



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A 36-year-old female is started on Levothyroxine treatment, Which of the following instructions should be included when discharging a patient with a prescription for levothyroxine 100 mcg/day daily?



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A 65-year-old female with a past medical history of hypothyroidism is admitted to the hospital for pyelonephritis. Her home dose of levothyroxine was continued by the clinical provider. On evaluating the patient before her scheduled dose of levothyroxine, her heart rate is noted to be 146 beats per minute. Her blood pressure is 110/70 mmHg. What is the appropriate management for this patient at this time?



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A patient is receiving the thyroid hormone replacement levothyroxine and has been scheduled for an I-131 uptake study. When must the patient discontinue the levothyroxine?



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Which of the following should be included in instructions to a pregnant female who is on thyroid replacement?



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Which is not a risk factor for hypothyroidism?



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Xerosis is often seen in patients with which of the following conditions?



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Which of the following hormones is important to evaluate in a 70-year-old female with hair loss?



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Which of the following is NOT a neurologic manifestation of hypothyroidism?



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A 33-year-old female with abnormal monthly periods presents to the office with abnormal thyroid laboratory evaluation. What is the most likely diagnosis in a patient with low (thyroxine) T4 and high thyroid-stimulating hormone (TSH)?



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What is the most common cause of hypothyroidism in geriatric patients?



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A 37-year-old female presents complaining of fatigue and constipation. Her menses have become irregular. Which additional symptom is she least likely to have?



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A 45-year-old female presents to the clinic with a new onset of fatigue with dry skin. Upon detailed questions, it was revealed the patient has a history of a pituitary macroadenoma, which was treated surgically and cured. Based on the presentation, the physician suspects a thyroid abnormality. Which laboratory result is suggestive of secondary hypothyroidism?



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Which of the following is used to treat hypothyroidism?



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A 68-year-old male complains of poor concentration, lethargy, and inattentiveness. He feels like the central intelligence agency is watching him. The physical examination reveals ataxia, proximal muscle weakness, edema, pale and coarse skin, macroglossia, and delayed relaxation of deep tendon reflexes. Which of the following is the most likely diagnosis?



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Which of the following can be secondary to hypothyroidism?



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A patient is diagnosed with carpal tunnel syndrome. She also has complaints of fatigue, muscle soreness, and weight gain. What is the most likely cause of her symptoms?



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Select the true statement about hypothyroidism.



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A 70-year-old female presents to the clinician with complaints of new onset fatigue and cold intolerance. Upon detailed discussion, the patient states that she is very healthy and has no current issues. She lost her husband two years ago. Her weight has been stable; diet and appetite have not changed in the last six months. Her vitals are stable, and there were no significant findings on physical examination. What is the first diagnostic test that the provider should order keeping in mind the most likely diagnosis?



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A 30-year-old female with hypothyroidism who has been treated with levothyroxine during the pregnancy presents to her primary care provider. Her thyroid-stimulating hormone (TSH) levels were normal <2.5 mU/L as per American Thyroid Association 2017 guidelines for the pregnancy. Following the birth, the newborn was found to have decreased thyroxine (T4) and a markedly elevated TSH. What is the etiology of these abnormal thyroid lab findings?



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A 40-year-old female presents to the emergency department with an increased pulse. She says that this has been happening for a couple of hours. She adds that she feels anxiety and palpitations. Her vitals include a blood pressure of 130/87 mmHg, a pulse of 115 beats per minute, respiration of 15 breaths per minute and a temperature of 98.7 degrees Fahrenheit. Further evaluation of blood shows that thyroid-stimulating hormone (TSH) is suppressed at 0.3 mU/L (0.5-4.5 mU/L). Free T4 is slightly over the normal limit at 1.6 ng/dL (.5 - 1.5 ng/dL). Upon reviewing medical records, the provider finds images of a recent radio-iodine uptake scan. What is the probable diagnosis of a patient that exhibits a low radioiodine uptake on the exam?



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Which of the following are symptoms associated with central hypothyroidism?



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What is the most common cause of hypothyroidism in the world?



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Which statement is most accurate regarding thyroid hormone replacement therapy for hypothyroidism?



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A female patient with hypothyroidism will most likely present with?



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What is the most likely diagnosis for a 35-year-old female with weight gain, fatigue, cold intolerance, and slow reflexes?



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A 43-year-old woman presents to the clinician with complaints of low energy, cold intolerance, and constipation. She further adds that she has gained 10 lb in a short period. The provider suspects that she has hypothyroidism. Further laboratory workup revealed a T4 of 0.3 ng/dL (normal range 0.4 to 1.7 nanograms per deciliter) and a TSH (thyroid-stimulating hormone) of 12 mU/L (normal range 0.4 to 4.0 milli-international units per liter). The patient starts receiving hormone replacement therapy in the form of Levothyroxine 100 mcg/day. Which of the following hormones is measured to adjust the dosage of Levothyroxine?



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A client has recently had a thyroidectomy and has been placed on thyroid hormone replacement therapy. Which of the following are signs of too little thyroid hormone? Select all that apply.



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In a patient with hypothyroidism, what symptoms commonly are present? Select all that apply.



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A patient comes to the clinic complaining of fatigue and weight gain for the past 6 months. The physical exam is remarkable for delayed deep tendon reflex. CBC and CMP are within normal ranges. A thyroid panel reveals TSH is 7.6 mIU/L (normal range = 0.5 mIU/L to 5.5 mIU/L). Free T4 is 1.2 ng/dL (normal range = 0.8 ng/dL to 1.6 ng/dL), and thyroid peroxidase antibody positive. What is the next best step in the management of this patient?



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A provider is reviewing a patient's laboratory findings who has been diagnosed with untreated primary hypothyroidism. Which of the following is most likely to be elevated in this patient?



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Hypothyroidism - References

References

Current evidence for the treatment of hypothyroidism with levothyroxine/levotriiodothyronine combination therapy versus levothyroxine monotherapy., Hennessey JV,Espaillat R,, International journal of clinical practice, 2018 Feb     [PubMed]
Global epidemiology of hyperthyroidism and hypothyroidism., Taylor PN,Albrecht D,Scholz A,Gutierrez-Buey G,Lazarus JH,Dayan CM,Okosieme OE,, Nature reviews. Endocrinology, 2018 May     [PubMed]
Hollowell JG,Staehling NW,Flanders WD,Hannon WH,Gunter EW,Spencer CA,Braverman LE, Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). The Journal of clinical endocrinology and metabolism. 2002 Feb     [PubMed]
Mathew V,Misgar RA,Ghosh S,Mukhopadhyay P,Roychowdhury P,Pandit K,Mukhopadhyay S,Chowdhury S, Myxedema coma: a new look into an old crisis. Journal of thyroid research. 2011     [PubMed]
Saini V,Yadav A,Arora MK,Arora S,Singh R,Bhattacharjee J, Correlation of creatinine with TSH levels in overt hypothyroidism - a requirement for monitoring of renal function in hypothyroid patients? Clinical biochemistry. 2012 Feb     [PubMed]
Jonklaas J,Bianco AC,Bauer AJ,Burman KD,Cappola AR,Celi FS,Cooper DS,Kim BW,Peeters RP,Rosenthal MS,Sawka AM, Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid : official journal of the American Thyroid Association. 2014 Dec     [PubMed]
Garber JR,Cobin RH,Gharib H,Hennessey JV,Klein I,Mechanick JI,Pessah-Pollack R,Singer PA,Woeber KA, Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid : official journal of the American Thyroid Association. 2012 Dec     [PubMed]
Anand A,Singh KR,Kushwaha JK,Hussain N,Sonkar AA, Papillary Thyroid Cancer and Hashimoto's Thyroiditis: An Association Less Understood. Indian journal of surgical oncology. 2014 Sep     [PubMed]
Abdullatif HD,Ashraf AP, Reversible subclinical hypothyroidism in the presence of adrenal insufficiency. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2006 Sep-Oct     [PubMed]
Hou J,Yu P,Zhu H,Pan H,Li N,Yang H,Jiang Y,Wang L,Wang B,Wang Y,You L,Chen S, The impact of maternal hypothyroidism during pregnancy on neonatal outcomes: a systematic review and meta-analysis. Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology. 2016     [PubMed]
Samuels MH, Psychiatric and cognitive manifestations of hypothyroidism. Current opinion in endocrinology, diabetes, and obesity. 2014 Oct     [PubMed]
Khalid S,Asad-Ur-Rahman F,Abbass A,Gordon D,Abusaada K, Myxedema Ascites: A Rare Presentation of Uncontrolled Hypothyroidism. Cureus. 2016 Dec 5     [PubMed]
Zare-Khormizi MR,Rahmanian M,Pourrajab F,Akbarnia S, Massive pericardial effusion and rhabdomyolysis secondary to untreated severe hypothyroidism: the first report. Acta clinica Belgica. 2014 Oct     [PubMed]
Guglielmi R,Frasoldati A,Zini M,Grimaldi F,Gharib H,Garber JR,Papini E, ITALIAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS STATEMENT-REPLACEMENT THERAPY FOR PRIMARY HYPOTHYROIDISM: A BRIEF GUIDE FOR CLINICAL PRACTICE. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists. 2016 Nov     [PubMed]

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