If you have an underactive thyroid gland, the condition is called hypothyroidism. In hypothyroidism, there is a reduced level of thyroid hormone in the body. This can cause various symptoms, the most common being tiredness, weight gain, constipation, aches, dry skin, lifeless hair and feeling cold.
Treatment usually involves taking a daily tablet of thyroid hormone to replace the missing thyroxine. Treatment works very well for most people with hypothyroidism but is required for life.
What is hypothyroidism?
The thyroid gland is located in the neck and produces thyroid hormones. These are called thyroxine (T4) and tri-iodothyronine (T3) and are carried round the body in the bloodstream. They help to keep the body's functions (the metabolism) working at the correct pace. Many cells and tissues in the body need thyroxine to keep them going correctly. Thyroid hormones are released when the thyroid gland is stimulated by thyroid stimulating hormone (TSH). This is a hormone released by another gland, in the brain. See the separate leaflet called Thyroid Problems (also including Parathyroid Glands) for further information about the thyroid gland.
Underactive thyroid gland (hypothyroidism) results from the thyroid gland being unable to make enough thyroid hormones, so that many of the body's functions slow down. Thyroid hormone levels are lower than normal. So some people call it having a 'low thyroid'. Hypothyroidism may also occur if there is not enough thyroid gland left to make thyroxine - for example, after surgical removal or injury.
Hypo- means not enough and hyper- means too much. If you have hyperthyroidism, you make too much thyroxine. This causes many of the body's functions to speed up. See the separate leaflet called Overactive Thyroid Gland (Hyperthyroidism) for more information.
Many symptoms of having an underactive thyroid gland (hypothyroidism) can be caused by a low level of thyroxine. Basically, many body functions slow down. Not all symptoms develop in all cases.
- Symptoms and signs that commonly occur include:
- Weight gain
- Feeling cold
- Dry skin
- Lifeless hair
- Fluid retention
- Mental slowing
- Less common symptoms include:
- A hoarse voice.
- Irregular or heavy menstrual periods in women.
- Loss of sex drive.
- Carpal tunnel syndrome (which causes pains and numbness in the hand).
- Memory loss or confusion in the elderly.
However, all these symptoms can be caused by other conditions and sometimes the diagnosis is not obvious. Symptoms usually develop slowly and gradually become worse over months or years as the level of thyroxine in the body gradually falls.
What are the possible complications of hypothyroidism?
If you have an untreated underactive thyroid gland (hypothyroidism):
- You may feel generally unwell due to the symptoms above.
- You have an increased risk of developing heart disease. This is because a low thyroxine level causes the blood fats (lipids) - cholesterol, etc - to rise. You may have a higher risk of coronary heart disease and of heart failure.
- If you are pregnant, you have an increased risk of developing some pregnancy complications - for example:
- Premature labour.
- Low birth weight.
- Abnormalities in the baby.
- Serious bleeding after the birth.
- Hypothyroid coma (myxoedema coma) is a very rare complication.
However, with treatment, the outlook (prognosis) is excellent. With treatment, symptoms usually go and you are very unlikely to develop any complications.
Who develops hypothyroidism?
Having an underactive thyroid gland (hypothyroidism) is ten times more common in women than it is in men. In the UK, around 1-2 in 100 people have hypothyroidism. It most commonly develops in adult women and becomes more common with increasing age. However, it can occur at any age and can affect anyone.
What causes hypothyroidism?
Autoimmune thyroiditis - the common cause in the UK
The most common cause of having an underactive thyroid gland (hypothyroidism) is an autoimmune disease called autoimmune thyroiditis. The immune system normally makes antibodies to attack bacteria, viruses and other germs. If you have an autoimmune disease, the immune system makes antibodies against certain tissues of your body.
If you have autoimmune thyroiditis, you make antibodies that attach to your own thyroid gland, which affect the gland's function. The thyroid gland is then not able to make enough thyroxine and hypothyroidism gradually develops. It is thought that something triggers the immune system to make antibodies against the thyroid. The trigger is not known.
Autoimmune thyroiditis is more common than usual in people with:
- A family history of hypothyroidism caused by autoimmune thyroiditis.
- Down's syndrome. Hypothyroidism develops in 1 in 3 people with Down's syndrome before the age of 25 years. Symptoms of hypothyroidism may be missed more easily in people with Down's syndrome. Therefore, some doctors recommend that all people with Down's syndrome should have an annual blood test to screen for hypothyroidism.
- Turner syndrome. Again, an annual blood test to screen for hypothyroidism is usually advised for people with this condition.
- An enlarged thyroid gland (diffuse goitre).
- A past history of Graves' disease or thyroiditis following childbirth.
- A personal or family history of other autoimmune disorders - for example:
Some people with autoimmune thyroiditis also develop a swollen thyroid gland (goitre). Autoimmune thyroiditis with a goitre is called Hashimoto's disease. Also, people with autoimmune thyroiditis have a small increased risk of developing other autoimmune conditions such as vitiligo, pernicious anaemia, etc.
Surgery or radioactive treatment to the thyroid gland
If the thyroid gland has been damaged or destroyed by treatment (for another thyroid disorder, or for other problems in the neck), it may not produce enough thyroid hormone.
Other causes of hypothyroidism include:
- Worldwide, iodine deficiency is the most common cause of hypothyroidism. (Your body needs iodine to make thyroxine.) This affects some countries more commonly than others, depending on the level of iodine in the diet.
- A side-effect to some medicines - for example, amiodarone and lithium. Also some people who have been treated for high thyroid levels with medicines such as propylthiouracil or carbimazole go on to develop hypothyroidism in later years.
- Other types of thyroid inflammation (thyroiditis) caused by various rare conditions.
- A pituitary gland problem is a rare cause. The pituitary gland that lies just under the brain makes a hormone called thyroid-stimulating hormone (TSH). This stimulates the thyroid gland to make thyroxine. If the pituitary does not make TSH then the thyroid cannot make enough thyroxine. This is called secondary hypothyroidism.
- Some children are born with an underactive thyroid gland (congenital hypothyroidism). Babies in the UK are screened for this with a blood test at birth.
How is hypothyroidism diagnosed?
A blood test can diagnose an underactive thyroid gland (hypothyroidism). A normal blood test will also rule it out if symptoms suggest that it may be a possible diagnosis. One or both of the following may be measured:
- TSH. This hormone is made in the pituitary gland. It is released into the bloodstream. It stimulates the thyroid gland to make thyroxine. If the level of thyroxine in the blood is low, then the pituitary releases more TSH to try to stimulate the thyroid gland to make more thyroxine. Therefore, a raised level of TSH means the thyroid gland is underactive and is not making enough thyroxine.
- Thyroxine (T4). A low level of thyroxine confirms hypothyroidism. Test results might be described as having 'low thyroid levels' or a 'low thyroid'.
A test for thyroid antibodies may be done to confirm the diagnosis if the cause is thought to be autoimmune. Other tests are not usually necessary unless a rare cause of hypothyroidism is suspected. For example, tests of the pituitary gland may be done if both the TSH and thyroxine levels are low. If you have a swollen thyroid gland when the doctor examines you (a goitre), you would usually have an ultrasound scan.
Some people have a raised TSH level but have a normal T4 level. This means that you are making enough thyroxine but the thyroid gland is needing extra stimulation from TSH to make the required amount of thyroxine. In this situation you have an increased risk of developing hypothyroidism in the future. Your doctor may advise a repeat blood test every so often to see if you do eventually develop hypothyroidism. In many people, the blood test returns to normal on its own without treatment. So usually the test is repeated in a few months rather than starting treatment straightaway. See the next section on hypothyroidism treatment for recommendations on treatment.
New recommendations on treatment of subclinical hypothyroidism
Dr Sarah Jarvis, 28th May 2019.
Most current guidelines tend to recommend giving levothyroxine replacement therapy even if your T4 level is normal, as long as your TSH level is raised over 10 mIU/litre. This blood result picture - normal T4 but raised TSH - is called 'subclinical hypothyroidism'. In people who have symptoms suggestive of underactive thyroid gland, and in younger people, levothyroxine has sometimes been given at lower levels of TSH.
A new guideline has looked at 21 studies of people given treatment for subclinical hypothyroidism. It found that levothyroxine treatment does not improve quality of life, weight, tiredness, low mood or other symptoms of underactive thyroid gland. There was no evidence that levothyroxine reduced the risk of heart attack, stroke or death - although there was not enough evidence from these studies to provide a firm conclusion.
The guideline therefore recommends that people with subclinical hypothyroidism should not be treated with levothyroxine.
This recommendation does not apply if your TSH is over 20 mIU/litre or if you are a woman trying to get pregnant.
The treatment of underactive thyroid gland (hypothyroidism) is usually to take levothyroxine (thyroxine) tablets each day. This replaces the thyroxine which your thyroid gland is not making. Most people feel much better soon after starting treatment.
Ideally, take the tablet on an empty stomach (at least half an hour before breakfast). This is because some foods rich in calcium or iron may interfere with the absorption of levothyroxine from the gut. (For the same reason, don't take levothyroxine tablets at the same time of day as calcium or iron tablets.) Caffeine can also interfere with absorption of levothyroxine so avoid tea and coffee for half an hour after taking the tablet also. Some other medicines can also affect thyroxine levels so ideally do not take levothyroxine with any other tablets. Check with your pharmacist if you do need to take another tablet at the same time.
What is the dose of levothyroxine?
Most adults need between 100 and 200 micrograms daily. A low dose is prescribed at first, especially in those aged over 60 or with heart problems. The dose is then gradually increased over a period of time. Blood tests are usually taken regularly and the dose may be adjusted accordingly. It may take a few months for you to start to feel better.
The blood test measures TSH (see above). Once the blood TSH level is normal it usually means you are taking the correct amount of levothyroxine. It is then common practice to check the TSH blood level once a year. The dose may need adjustment in the early stages of pregnancy. Also, as you get into late middle age and older, you may need a reduced dose of levothyroxine.
Missed a tablet?
Everyone forgets to take their tablets from time to time. Don't worry as it is not dangerous to miss the odd forgotten levothyroxine tablet. If you forget to take a dose, take it as soon as you remember if this is within two or three hours of your usual time. If you do not remember until after this time, skip the forgotten dose and take the next dose at the usual time. Do not take two doses together to make up for a missed dose. However, you should try to take levothyroxine regularly each morning for maximum benefit.
Other dosing routines have been studied. However these have only been explored in small studies and are not routinely recommended. It may be that levels will not be as steady if the medicine is not taken in a daily dose. The best advice based on currently available evidence is to take the tablet once a day regularly. If you are having problems with this, discuss it with your doctor or pharmacist.
How long is the treatment for?
For most people, treatment is for life. Occasionally, the disease process reverses. This is uncommon, apart from the following:
- Children. Sometimes hypothyroidism is a temporary condition in older children. (This is not so for children who are born with an underactive thyroid gland.)
- Pregnancy. Some women develop thyroid imbalance after having a baby. If it occurs, it typically happens about three to six months after the birth. Often this lasts just a few months and corrects itself. Treatment is needed only in a small number of cases. However, afterwards it is wise to have a yearly blood test, as there is an increased risk of developing autoimmune thyroiditis and long-term hypothyroidism in the future.
What if it doesn't work?
Most people feel better once their blood tests have returned to normal with levothyroxine. In a small percentage of people, however, the blood tests go back to normal but they don't feel any better. If this is the case, you would normally be referred to a specialist (an endocrinologist). The specialist doctor may do some more tests to check your symptoms are definitely due to hypothyroidism rather than something else. They will also check there is nothing interfering with your levothyroxine (such as other medication).
Occasionally a combination of T3 and T4 therapy may be discussed as an option. Guidelines internationally do not recommend T3 or combination treatment for hypothyroidism as there is no good evidence that it is effective, and it may be harmful. In some patients, however, it may be tried as an 'experimental treatment' under specialist supervision only. Similarly there is no evidence for the use of thyroid extracts, dietary supplements or other alternative treatments. These are not recommended by guidelines.
Dr Sarah Jarvis, April 2019
Advice on prescribing of liothyronine (including Armour Thyroid and liothyronine combination products)
Liothyronine is a manufactured form of triiodothyronine (T3). Armour Thyroid contains both T4 and T3 and is extracted from the thyroid gland of pigs. It contains about four times as much T4 as T3. In humans, the usual ratio of T4 to T3 is 14 to 1, so Armour Thyroid extract has a much higher proportion of T3 than humans usually have.
UK guidelines recommend that T3 and combinations of T4 and T3 should not routinely be prescribed. The Royal College of Physicians does not recommend that T3 should ever be prescribed. It says there is not enough evidence that it helps patients and not enough evidence to be sure it is not harmful. Clinical practice guidelines worldwide do not recommend or support the routine use of combination (LT4 and LT3) therapy.
The NHS recommends that:
- Treatment with liothyronine should never be started in primary care (by a GP).
- Patients who are currently currently taking liothyronine should be reviewed by a consultant NHS endocrinologist with a view to switching to levothyroxine if appropriate.
- The British Thyroid Association states that a small number of patients have symptoms which do not improve on levothyroxine. For these, a consultant NHS endocrinologist may recommend a carefully monitored trial of liothyronine.
You can find out more from the further reading links to CKS hypothyroidism, Armour Thyroid and NHS England guidance.
Treatment for hypothyroidism in pregnancy
Pregnant women taking levothyroxine should be monitored by a specialist (endocrinologist). Pregnancy can affect the amount of medication needed, and it is very important that levels do not get either too high or too low.
Are there any side-effects or problems from treatment?
Levothyroxine tablets replace the body's natural hormone, so side-effects are uncommon. However, if you have angina, you may find that your angina pains become worse when you first start levothyroxine. Tell a doctor if this happens.
If you take too much levothyroxine it can lead to symptoms and problems of an overactive thyroid gland (hyperthyroidism) - for example:
- The sensation of a 'thumping heart' (palpitations).
- An increased risk of developing 'thinning' of the bones (osteoporosis).
This is why you need blood tests to check that you are taking the correct dose.
Other medicines may interfere with the action of levothyroxine - for example, carbamazepine, iron tablets, phenytoin, and rifampicin. If you start any of these medicines, or change the dose, you may need to alter the dose of the levothyroxine. Your doctor will advise. Also, if you take warfarin, the dose may need to be altered if you have a change in your dose of levothyroxine.
In the UK, if you have hypothyroidism, you are entitled to free prescriptions. This is for all your medicines, whether related to the hypothyroidism or not. Ask at your GP surgery for a form to fill in (form FP92A) to claim this benefit.
What is the outcome (prognosis)?
Most people get better on levothyroxine treatment, although they usually have to stay on it forever. If you are treated for hypothyroidism, a blood test each year is needed to make sure you are still on the right dose. As above, about 5 or 10 in 100 people will not feel any better on levothyroxine, even though their blood tests go back to normal. This may be more difficult to treat (as discussed above).
People who have subclinical hypothyroidism may or may not need treatment. In nearly 4 out of 10 people with subclinical hypothyroidism, the blood tests go back to normal on their own, without treatment ever being needed.
Very rarely, people who have not had their hypothyroidism treated develop a serious complication called myxoedema coma. This is rare but is very serious and can cause death.
- Having an underactive thyroid gland (hypothyroidism) is common.
- Symptoms develop gradually. They may be confused with other conditions.
- Treatment with levothyroxine tablets is usually easy and effective.
- Treatment is usually for life.
- Have a blood test once a year if you take levothyroxine tablets, once your dose has become stabilised. Blood tests are needed more often when you first start treatment.
Further reading and references
UK Guidelines for the Use of Thyroid Function Tests; British Thyroid Association (2006)
Okosieme O, Gilbert J, Abraham P, et al; Management of primary hypothyroidism: statement by the British Thyroid Association Executive Committee. Clin Endocrinol (Oxf). 2016 Jun84(6):799-808. doi: 10.1111/cen.12824. Epub 2015 Jun 25.
Pearce SH, Brabant G, Duntas LH, et al; 2013 ETA Guideline: Management of Subclinical Hypothyroidism. Eur Thyroid J. 2013 Dec2(4):215-28. doi: 10.1159/000356507. Epub 2013 Nov 27.
Hypothyroidism; NICE CKS, June 2018 (UK access only)
Dayan CM, Panicker V; Hypothyroidism and depression. Eur Thyroid J. 2013 Sep2(3):168-79. doi: 10.1159/000353777. Epub 2013 Aug 27.
Kraut E, Farahani P; A Systematic Review of Clinical Practice Guidelines' Recommendations on Levothyroxine Therapy Alone versus Combination Therapy (LT4 plus LT3) for Hypothyroidism. Clin Invest Med. 2015 Dec 438(6):E305-13.
Rajput R, Pathak V; The Effect of Daily versus Weekly Levothyroxine Replacement on Thyroid Function Test in Hypothyroid Patients at a Tertiary Care Centre in Haryana. Eur Thyroid J. 2017 Sep6(5):250-254. doi: 10.1159/000477348. Epub 2017 Aug 3.
Bekkering GE, Agoritsas T, Lytvyn L, et al; Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline. BMJ. 2019 May 14365:l2006. doi: 10.1136/bmj.l2006.