Hypothyroidism

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Vol. 1 No. 2 (2024)

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Submitted
September 1, 2024
Published
April 29, 2025

Understanding Hypothyroidism: Causes, Symptoms, Diagnosis, and Treatment

https://doi.org/10.69512/ajphi.v1i2.68
Prabha Bhandari, MD
Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
Lumanti Manandhar
Rajiv Gandhi University of Health Sciences, Bangalore, India
https://orcid.org/0009-0005-9167-3693
Dipendra Kandel, MD
Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal

Corresponding Author(s) : Prabha Bhandari, MD

bhandariprabha991@gmail.com

The American Journal of Patient Health Info, Vol. 1 No. 2 (2024)

Abstract


  1. Hypothyroidism is a condition in which the thyroid gland doesn’t produce enough thyroid hormone, leading to symptoms like fatigue, weight gain, and a feeling of cold.

  2. While the diet's lack of iodine is the leading cause of hypothyroidism, Hashimoto thyroiditis occurs in places with sufficient iodine.

  3. Women are more likely to develop hypothyroidism, with family history, autoimmune disease, and previous thyroid issues adding to the increased risk.

  4. Blood tests measuring serum-free thyroxine levels and thyroid-stimulating hormones can diagnose the condition. High TSH and low FT4 levels usually indicate Hypothyroidism.

  5. Levothyroxine is the mainstay of treatment. Treatment usually lasts for a time, with regular follow-ups to adjust the medication, especially during stress, illness, and pregnancy.

Keywords

Fatigue Hashimoto’s thyroiditis Levothyroxine Thyroid Function Test Thyroid-stimulating hormone (TSH)
Bhandari, MD, P., Manandhar, L., & Kandel, MD, D. (2025). Understanding Hypothyroidism: Causes, Symptoms, Diagnosis, and Treatment . The American Journal of Patient Health Info, 1(2). https://doi.org/10.69512/ajphi.v1i2.68
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References
  1. American Thyroid Association (ATA). Hypothyroidism [Internet]. American Thyroid Association. American Thyroid Association; 2019. Available from: https://www.thyroid.org/wp-content/uploads/patients/brochures/Hypothyroidism_web_booklet.pdf
  2. Wyne KL, Nair L, Schneiderman CP, Pinsky B, Flores OA, Guo D, et al. Hypothyroidism prevalence in the United States: A retrospective study combining national health and Nutrition examination survey and claims data, 2009–2019. Journal of the Endocrine Society [Internet]. 2022 Nov 10;7(1). Available from: https://doi.org/10.1210/jendso/bvac172
  3. Osinga JAJ, Liu Y, Männistö T, Vafeiadi M, Tao FB, Vaidya B, et al. Risk Factors for thyroid Dysfunction in Pregnancy: An Individual Participant Data Meta-Analysis. Thyroid [Internet]. 2024 May 1;34(5):646–58. Available from: https://doi.org/10.1089/thy.2023.0646
  4. Chaker L, Razvi S, Bensenor IM, Azizi F, Pearce EN, Peeters RP. Hypothyroidism. Nature Reviews Disease Primers [Internet]. 2022 May 19;8(1). Available from: https://doi.org/10.1038/s41572-022-00357-7
  5. Taylor PN, Albrecht D, Scholz A, Gutierrez-Buey G, Lazarus JH, Dayan CM, et al. Global epidemiology of hyperthyroidism and hypothyroidism. Nature Reviews Endocrinology [Internet]. 2018 Mar 23;14(5):301–16. Available from: https://doi.org/10.1038/nrendo.2018.18
  6. Chaker L, Bianco AC, Jonklaas J, Peeters RP. Hypothyroidism. The Lancet 2017;390:1550–62. https://doi.org/10.1016/S0140-6736(17)30703-1.
  7. Jordan B, Uer O, Buchholz T, Spens A, Zierz S. Physical fatigability and muscle pain in patients with Hashimoto thyroiditis. J Neurol 2021;268:2441–9. https://doi.org/10.1007/s00415-020-10394-5.
  8. Jansen HI, Boelen A, Heijboer AC, Bruinstroop E, Fliers E. Hypothyroidism: The difficulty in attributing symptoms to their underlying cause. Front Endocrinol (Lausanne) 2023;14. https://doi.org/10.3389/fendo.2023.1130661
  9. P HH, G S, K P, Penumalla S, Kandimalla R. Hypothyroidism and Its Impact on Menstrual Irregularities in Reproductive-Age Women: A Comprehensive Analysis at a Tertiary Care Center. Cureus 2024. https://doi.org/10.7759/cureus.63158.
  10. McDermott MT. Hypothyroidism. Ann Intern Med 2020;173:ITC1–16. https://doi.org/10.7326/AITC202007070.
  11. Gharib H, Papini E, Garber JR, Duick DS, Harrell RM, Hegedus L, et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules - 2016 Update Appendix. Endocrine Practice 2016;22:1–60. https://doi.org/10.4158/EP161208.GL.
  12. Wilson SA, Stem LA, Bruehlman RD. Hypothyroidism: diagnosis and treatment [Internet]. AAFP. 2021. Available from: https://www.aafp.org/pubs/afp/issues/2021/0515/p605.html
  13. Livett T, LaFranchi S. Imaging in congenital hypothyroidism. Curr Opin Pediatr 2019;31:555–61. https://doi.org/10.1097/MOP.0000000000000782.
  14. Davis MG, Phillippi JC. Hypothyroidism: Diagnosis and Evidence‐Based Treatment. Journal of Midwifery & Women S Health [Internet]. 2022 Apr 5;67(3):394–7. Available from: https://doi.org/10.1111/jmwh.13358
  15. Jonklaas J. Optimal thyroid hormone replacement. Endocrine Reviews [Internet]. 2021 Sep 20;43(2):366–404. Available from: https://doi.org/10.1210/endrev/bnab031
  16. Ahluwalia R, Baldeweg SE, Boelaert K, Chatterjee K, Dayan C, Okosieme O, et al. Use of liothyronine (T3) in hypothyroidism: Joint British Thyroid Association/Society for endocrinology consensus statement. Clinical Endocrinology [Internet]. 2023 Jun 5;99(2):206–16. Available from: https://doi.org/10.1111/cen.14935
  17. Feller M, Snel M, Moutzouri E, Bauer DC, De Montmollin M, Aujesky D, et al. Association of thyroid hormone therapy with quality of life and Thyroid-Related Symptoms in patients with subclinical hypothyroidism. JAMA [Internet]. 2018 Oct 2;320(13):1349. Available from: https://doi.org/10.1001/jama.2018.13770
  18. Pearce EN. Management of hypothyroidism and hypothyroxinemia during pregnancy. Endocrine Practice [Internet]. 2022 Jul 1;28(7):711–8. Available from: https://doi.org/10.1016/j.eprac.2022.05.004
  19. Biondi B, Cappola AR, Cooper DS. Subclinical Hypothyroidism. JAMA 2019;322:153. https://doi.org/10.1001/jama.2019.9052.
  20. Larsen D, Singh S, Brito M. Thyroid, diet, and alternative approaches. The Journal of Clinical Endocrinology & Metabolism [Internet]. 2022 Aug 11;107(11):2973–81. Available from: https://doi.org/10.1210/clinem/dgac473
  21. Galanty A, Grudzińska M, Paździora W, Służały P, Paśko P. Do brassica vegetables affect thyroid Function?A comprehensive systematic review. International Journal of Molecular Sciences [Internet]. 2024 Apr 3;25(7):3988. Available from: https://doi.org/10.3390/ijms25073988
  22. Alkhatib D, Shi Z, Ganji V. Dietary patterns and hypothyroidism in U.S. adult population. Nutrients [Internet]. 2024 Jan 28;16(3):382. Available from: https://doi.org/10.3390/nu16030382
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Prabha Bhandaria, Lumanti Manandharb, Dipendra Kandelc

a Kathmandu University School of Medical Sciences, Dhulikhel, Nepal

b Rajiv Gandhi University of Health Sciences, Bangalore, India

c Gandaki Medical College Teaching Hospital and Research Center, Pokhara, Nepal

Background

The thyroid gland is a small butterfly-shaped organ in the lower front of the neck, and it produces thyroid hormones. Thyroid hormones play an important role in regulating your body’s metabolism. When the thyroid does not produce enough hormones, it can slow down many of your body’s processes, like heart rate, energy levels, and how quickly your body uses calories. This can lead to a variety of symptoms, often developing slowly over time.

According to the American Thyroid Association, the prevalence of Hypothyroidism has increased from 9.5% in 2012 to 11.7% in 2019. Hypothyroidism is common and can affect people of all ages, but it’s more likely to occur in older adults and women. [2]

Causes and Risk Factors of Hypothyroidism

There are several factors that can increase your risk of developing hypothyroidism. These include:

Figure 1.

  1. Age: Hypothyroidism is more common in older adults, particularly those over 60. As we age, the risk of thyroid issues tends to increase due to the natural decline in thyroid function. [2]
  2. Gender: Women are much more likely to develop hypothyroidism than men, especially after menopause. Hormonal changes throughout life, such as during pregnancy or menopause, may influence thyroid function. [3]
  3. Family History: If you have a close family member, such as a parent or sibling, with thyroid disease, your chances of developing hypothyroidism are higher. A genetic predisposition to autoimmune conditions can be passed down in families. [1]
  4. Autoimmune Disease: People with autoimmune conditions like Hashimoto's thyroiditis, where the immune system mistakenly attacks the thyroid, are at higher risk. Other autoimmune diseases like type 1 diabetes or rheumatoid arthritis can also increase the risk. [4]
  5. Previous Thyroid Treatment: Individuals who have undergone thyroid surgery, radiation therapy for cancer, or treatment with certain medications (like lithium) that affect thyroid function are at higher risk of hypothyroidism. These treatments can interfere with thyroid hormone production. [4]
  6. Iodine Deficiency/Excess: Iodine is essential for thyroid hormone production. Too little iodine (common in areas where diets are deficient) or too much iodine (from supplements or medication) can cause thyroid dysfunction. Balance is key to maintaining proper thyroid health. [4,5]
  7. Congenital Hypothyroidism: Sometimes, babies are born without a thyroid or with a partially formed one. In other cases, babies are born with defective thyroid cells or enzymes that do not work correctly. [4]
  8. Damage to the Pituitary Gland: The pituitary gland, also called the master gland, ensures the thyroid is working properly and monitors the amount of hormones produced by the thyroid. If the pituitary gland is damaged by a tumor, radiation, or surgery, it may not be able to provide instructions for the thyroid gland to function properly, resulting in low thyroid hormone levels. [4]

Symptoms of Hypothyroidism

The symptoms of hypothyroidism can develop slowly over time, and many are often mistaken for other health issues. Here are the common signs:

Figure 2.

  1. Fatigue: Feeling constantly tired or lacking energy is one of the most common symptoms. This occurs because your body’s metabolism slows down when thyroid hormone levels are low, affecting energy production. [6]
  2. Weight Gain: Unexpected weight gain or difficulty losing weight is typical. The slower metabolism caused by hypothyroidism leads to less calorie burning, even if your eating and activity habits haven’t changed. [6]
  3. Cold Sensitivity: People with hypothyroidism often feel unusually cold, even in normal temperatures. The thyroid helps regulate body heat, so a sluggish thyroid reduces your body's ability to stay warm. [7]
  4. Dry Skin and Hair: Your skin may become dry, and your hair can become thin and brittle. The reduced thyroid hormone levels slow down skin cell regeneration and oil production, leading to these changes. [7]
  5. Constipation: A slower metabolism also affects the digestive system, causing constipation. Many people with hypothyroidism experience persistent constipation that doesn’t improve with dietary changes. [6]
  6. Depression or Low Mood: Hypothyroidism can lead to changes in mood, causing depression, irritability, or feelings of sadness. This is because thyroid hormones play a role in brain chemistry and mood regulation. [7]
  7. Muscle Weakness and Joint Pain: Muscle aches, stiffness, or weakness can occur because thyroid hormones help maintain muscle and joint function. When levels are low, you may feel more physically fatigued or experience pain. [8]
  8. Heavy or Irregular Menstrual Periods: Women with hypothyroidism often have heavier or more prolonged menstrual cycles. The thyroid helps regulate reproductive hormones, so an underactive thyroid can cause irregularities in the menstrual cycle. [9]

Diagnosis of Hypothyroidism

The diagnosis of hypothyroidism involves the following tests:

Figure 3.

1. Blood Tests

  • Thyroid-Stimulating Hormone (TSH) Test: The TSH test is a primary diagnostic tool for hypothyroidism, measuring the level of thyroid-stimulating hormone in the blood. TSH is produced by the pituitary gland and plays a crucial role in regulating the thyroid gland's function. When the thyroid is underactive and fails to produce enough hormones, the pituitary gland compensates by releasing more TSH. Therefore, elevated TSH levels typically indicate hypothyroidism. [10]
  • Free Thyroxine (Free T4) Test: The Free T4 test measures the amount of free thyroxine circulating in the bloodstream. Thyroxine, or T4, is the primary hormone produced by the thyroid gland. In cases of hypothyroidism, the Free T4 levels are typically low, indicating that the thyroid is not producing sufficient hormones. This test helps confirm the diagnosis, as low Free T4 levels in conjunction with elevated TSH levels strongly suggest hypothyroidism. [10]
  • Total Triiodothyronine (T3) Test: Although not routinely performed in all cases, the total T3 test measures the total amount of T3 in the blood, another hormone produced by the thyroid gland. Low levels of T3 may support the finding of hypothyroidism when TSH is elevated and Free T4 is low. [11]
  • Thyroid Peroxidase Antibodies (TPOAb): The TPOAb test is essential for diagnosing autoimmune conditions that can lead to hypothyroidism. It measures the level of antibodies against thyroid peroxidase, an enzyme critical for thyroid hormone production. High levels of TPO antibodies are commonly seen in Hashimoto's thyroiditis. [11,12]
  • Thyroglobulin Antibodies (TgAb): This test assesses the presence of antibodies against thyroglobulin, a protein produced by the thyroid gland. Elevated levels of TgAb can suggest an autoimmune response against the thyroid, further confirming a diagnosis of hypothyroidism. [11]

2. Imaging

Imaging studies are not typically needed to diagnose hypothyroidism. However, in certain cases, imaging can help provide additional information. A thyroid ultrasound may be used if your doctor suspects a structural issue, like nodules or swelling called goiter in the thyroid gland, or if hypothyroidism is due to congenital causes. It helps to visualize the gland’s size and texture and detect any abnormalities like cysts or tumors. [13]

Treatment of Hypothyroidism

The primary treatment for hypothyroidism involves hormone replacement therapy, which aims to restore normal levels of thyroid hormones in the body.

Figure 4.

  1. Levothyroxine: This medication helps replace the insufficient thyroid hormone, thereby decreasing the symptoms and restoring metabolic balance. Levothyroxine is typically taken orally, and the dosage is individualized based on your age, weight, severity of hypothyroidism, pregnancy status, and TSH levels. It is important to take the medication consistently, usually on an empty stomach, and at the same time each day to maintain stable hormone levels. Some patients do not feel better after taking Levothyroxine, and in that case, your doctor may add T3 (Cytomel) along with Levothyroxine. [16]
  2. Monitoring and Adjustments: After starting treatment, you typically have to follow up every 6 to 8 weeks until TSH levels stabilize.[10] Once the appropriate dosage is determined, annual check-ups may suffice. If symptoms persist or TSH levels remain abnormal, your doctor may adjust the dosage accordingly. TSH should be checked if you start taking any medicine that interferes with your body's ability to use thyroxine. [12]
  3. Lifestyle and Dietary Changes: While medication is the cornerstone of treatment, making certain lifestyle changes can also help manage hypothyroidism effectively. A well-balanced diet that includes adequate iodine, selenium, and zinc is essential, as these nutrients support thyroid function. You should, however, be aware that some dietary supplements or over-the-counter medications can interfere with thyroid hormone absorption. [12]
  4. Addressing Underlying Conditions: If an autoimmune condition, such as Hashimoto's thyroiditis, is the cause of hypothyroidism, additional management of related symptoms may be necessary. This may involve addressing other hormonal imbalances, treating vitamin deficiencies, or managing associated conditions like depression or high cholesterol, which can occur alongside hypothyroidism.

How Long Do You Need to Take Your Thyroid Medication?

Most thyroid problems are lifelong, so supplementary hormones are essential to managing your thyroid health. You will feel well when your thyroid hormone is at the right level. However, this does not mean you stop taking the medications since your gland cannot make enough on its own. You may be able to stop after the completion of your pregnancy or thyroid inflammation due to viral infection. However, you will need to consult your doctor to ensure the underlying condition has been resolved. [18]

Hypothyroidism and Pregnancy

Pregnancy poses unique challenges for women with hypothyroidism, requiring careful management to ensure the health of both mother and baby. [3] Medication adjustments are often required to meet the increased hormonal demands during pregnancy, making regular monitoring of thyroid levels even more important. [18]

Untreated hypothyroidism can lead to complications such as low birth weight and developmental delays in the growing fetus. Pregnant women should also be vigilant for potential complications like gestational hypertension and anemia, maintaining close communication with their doctor. [18] Postpartum thyroid hormone requirements may change again, requiring continued monitoring. With proper management, women with hypothyroidism can achieve healthy pregnancies and positive outcomes for their infants. [14]

Subclinical Hypothyroidism: What You Need to Know?

Subclinical hypothyroidism is a mild form of thyroid dysfunction and has elevated levels of TSH) levels while T4 levels remain within the normal range. It affects about 3.7% of people in the U.S. [12] It often presents with no obvious symptoms, making it challenging to diagnose without routine blood tests. This condition may be more common in older adults and is often times associated with autoimmune thyroid disease, particularly Hashimoto's thyroiditis. [19]

While many people with subclinical hypothyroidism may not require immediate treatment, regular monitoring is essential to track any changes in thyroid function. Some studies suggest that treatment with levothyroxine may be beneficial for individuals with high TSH levels, particularly if they exhibit symptoms, have other risk factors, or are planning to become pregnant. [14] Overall, the management of subclinical hypothyroidism is tailored to the individual, focusing on monitoring thyroid hormone levels and addressing any potential health implications. [10]

Diet and Thyroid Gland

Goitrogens are substances that interfere with thyroid hormone production. Goitrogens are present in everyday food items we eat. They are found in broccoli, cabbage, cauliflower, spinach, kale, and Brussels sprouts. Other fruits and vegetables like sweet potatoes, cassava, peaches, and strawberries also have goitrogens. There are limited proven benefits of avoiding these cruciferous vegetables and soy in patients with thyroid disorders. [20] Their impact is generally significant only under conditions of high intake or in conjunction with other thyroid-impairing factors. Instead of avoiding them, we recommend incorporating high-fiber foods, fruits and vegetables, coconut oil, and probiotics into your dietary plan. Moderation is key in eating food items with goitrogens to maintain your diet and thyroid health. [21,22]

When To See Your Doctor?

If you have been diagnosed with hypothyroidism, it’s important to maintain regular communication with your doctor. You need to see your doctor if:

  • You experience new or worsening symptoms like fatigue, weight gain, or mood changes.
  • Your symptoms persist despite medication or treatment seems ineffective, consult your doctor for a dosage adjustment.
  • You are pregnant or planning to conceive, as medication adjustments may be necessary.
  • You are having upcoming surgeries or got the new disease as they may affect your thyroid management. [11]
  • You have any side effects from your thyroid medication, like palpitations or weight changes
  • You notice swelling or lumps in your neck, seek further evaluation.
  • You have started or stopped taking a drug that can interfere with absorbing thyroxine, such as certain antacids, calcium supplements, medications containing estrogen, and iron tablets. [12]

Questions for your Doctor

  1. What if I forget to take my medicine and remember later?
  2. What side effects could I have from the medicine, and how do I manage them?
  3. What will happen if I don't take my thyroid hormone supplements?
  4. Can I switch my thyroid hormone supplement from one brand to another?
  5. How will my treatment plan change as I age?

Conflict of Interest Statement

Prabha Bhandari serves as a non-paid research assistant at eHealthyInfo. Lumanti Manandhar worked as a paid freelance medical journalist with eHealthyInfo from 2022 to 2023. Dipendra Kandel is also a non-paid research assistant at eHealthyInfo. There are no other conflicts of interest to declare.

References

  1. American Thyroid Association (ATA). Hypothyroidism [Internet]. American Thyroid Association. American Thyroid Association; 2019. Available from: https://www.thyroid.org/wp-content/uploads/patients/brochures/Hypothyroidism_web_booklet.pdf
  2. Wyne KL, Nair L, Schneiderman CP, Pinsky B, Flores OA, Guo D, et al. Hypothyroidism prevalence in the United States: A retrospective study combining national health and Nutrition examination survey and claims data, 2009–2019. Journal of the Endocrine Society [Internet]. 2022 Nov 10;7(1). Available from: https://doi.org/10.1210/jendso/bvac172
  3. Osinga JAJ, Liu Y, Männistö T, Vafeiadi M, Tao FB, Vaidya B, et al. Risk Factors for thyroid Dysfunction in Pregnancy: An Individual Participant Data Meta-Analysis. Thyroid [Internet]. 2024 May 1;34(5):646–58. Available from: https://doi.org/10.1089/thy.2023.0646
  4. Chaker L, Razvi S, Bensenor IM, Azizi F, Pearce EN, Peeters RP. Hypothyroidism. Nature Reviews Disease Primers [Internet]. 2022 May 19;8(1). Available from: https://doi.org/10.1038/s41572-022-00357-7
  5. Taylor PN, Albrecht D, Scholz A, Gutierrez-Buey G, Lazarus JH, Dayan CM, et al. Global epidemiology of hyperthyroidism and hypothyroidism. Nature Reviews Endocrinology [Internet]. 2018 Mar 23;14(5):301–16. Available from: https://doi.org/10.1038/nrendo.2018.18
  6. Chaker L, Bianco AC, Jonklaas J, Peeters RP. Hypothyroidism. The Lancet 2017;390:1550–62. https://doi.org/10.1016/S0140-6736(17)30703-1.
  7. Jordan B, Uer O, Buchholz T, Spens A, Zierz S. Physical fatigability and muscle pain in patients with Hashimoto thyroiditis. J Neurol 2021;268:2441–9. https://doi.org/10.1007/s00415-020-10394-5. Available from: https://pubmed.ncbi.nlm.nih.gov/33507372/
  8. Jansen HI, Boelen A, Heijboer AC, Bruinstroop E, Fliers E. Hypothyroidism: The difficulty in attributing symptoms to their underlying cause. Front Endocrinol (Lausanne) 2023;14. https://doi.org/10.3389/fendo.2023.1130661
  9. P HH, G S, K P, Penumalla S, Kandimalla R. Hypothyroidism and Its Impact on Menstrual Irregularities in Reproductive-Age Women: A Comprehensive Analysis at a Tertiary Care Center. Cureus 2024. https://doi.org/10.7759/cureus.63158.
  10. McDermott MT. Hypothyroidism. Ann Intern Med 2020;173:ITC1–16. https://doi.org/10.7326/AITC202007070.
  11. Gharib H, Papini E, Garber JR, Duick DS, Harrell RM, Hegedus L, et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules - 2016 Update Appendix. Endocrine Practice 2016;22:1–60. https://doi.org/10.4158/EP161208.GL.
  12. Wilson SA, Stem LA, Bruehlman RD. Hypothyroidism: diagnosis and treatment [Internet]. AAFP. 2021. Available from: https://www.aafp.org/pubs/afp/issues/2021/0515/p605.html
  13. Livett T, LaFranchi S. Imaging in congenital hypothyroidism. Curr Opin Pediatr 2019;31:555–61. https://doi.org/10.1097/MOP.0000000000000782.
  14. Davis MG, Phillippi JC. Hypothyroidism: Diagnosis and Evidence‐Based Treatment. Journal of Midwifery & Women S Health [Internet]. 2022 Apr 5;67(3):394–7. Available from: https://doi.org/10.1111/jmwh.13358
  15. Jonklaas J. Optimal thyroid hormone replacement. Endocrine Reviews [Internet]. 2021 Sep 20;43(2):366–404. Available from: https://doi.org/10.1210/endrev/bnab031
  16. Ahluwalia R, Baldeweg SE, Boelaert K, Chatterjee K, Dayan C, Okosieme O, et al. Use of liothyronine (T3) in hypothyroidism: Joint British Thyroid Association/Society for endocrinology consensus statement. Clinical Endocrinology [Internet]. 2023 Jun 5;99(2):206–16. Available from: https://doi.org/10.1111/cen.14935
  17. Feller M, Snel M, Moutzouri E, Bauer DC, De Montmollin M, Aujesky D, et al. Association of thyroid hormone therapy with quality of life and Thyroid-Related Symptoms in patients with subclinical hypothyroidism. JAMA [Internet]. 2018 Oct 2;320(13):1349. Available from: https://doi.org/10.1001/jama.2018.13770
  18. Pearce EN. Management of hypothyroidism and hypothyroxinemia during pregnancy. Endocrine Practice [Internet]. 2022 Jul 1;28(7):711–8. Available from: https://doi.org/10.1016/j.eprac.2022.05.004
  19. Biondi B, Cappola AR, Cooper DS. Subclinical Hypothyroidism. JAMA 2019;322:153. https://doi.org/10.1001/jama.2019.9052.
  20. Larsen D, Singh S, Brito M. Thyroid, diet, and alternative approaches. The Journal of Clinical Endocrinology & Metabolism [Internet]. 2022 Aug 11;107(11):2973–81. Available from: https://doi.org/10.1210/clinem/dgac473
  21. Galanty A, Grudzińska M, Paździora W, Służały P, Paśko P. Do brassica vegetables affect thyroid Function?A comprehensive systematic review. International Journal of Molecular Sciences [Internet]. 2024 Apr 3;25(7):3988. Available from: https://doi.org/10.3390/ijms25073988
  22. Alkhatib D, Shi Z, Ganji V. Dietary patterns and hypothyroidism in U.S. adult population. Nutrients [Internet]. 2024 Jan 28;16(3):382. Available from: https://doi.org/10.3390/nu16030382

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