Hypothyroidism Clinical Presentation

Updated: May 25, 2022
  • Author: Philip R Orlander, MD, FACP; Chief Editor: George T Griffing, MD  more...
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Hypothyroidism commonly manifests as a slowing in physical and mental activity but may be asymptomatic. Symptoms and signs of this disease are often subtle and neither sensitive nor specific. Classic signs and symptoms (eg, cold intolerance, puffiness, decreased sweating, and coarse skin) may not be present as commonly as was once believed.

Many of the more common symptoms are nonspecific and difficult to attribute to a particular cause. Individuals can also present with obstructive sleep apnea (secondary to macroglossia) or carpal tunnel syndrome. Women can present with galactorrhea and menstrual disturbances. Consequently, the diagnosis of hypothyroidism is based on clinical suspicion and confirmed by laboratory testing.

It has not yet been established whether hypothyroidism has a direct biochemical link to insomnia, although research has suggested that untreated subclinical hypothyroidism may be associated with poor sleep quality. It is also possible that the symptoms of an underactive thyroid, including muscle and joint pain, cold intolerance, and increased anxiety, may adversely affect sleep. [65]

In addition to impaired fertility, hypothyroidism in women can lead to heavy or irregular menstrual periods. [66]

Myxedema coma is a severe form of hypothyroidism that results in an altered mental status, hypothermia, bradycardia, hypercapnia, and hyponatremia. Cardiomegaly, pericardial effusion, cardiogenic shock, and ascites may be present. Myxedema coma most commonly occurs in individuals with undiagnosed or untreated hypothyroidism who are subjected to an external stress, such as low temperature, infection, myocardial infarction, stroke, or medical intervention (eg, surgery or hypnotic drugs).

The following are symptoms of hypothyroidism:

  • Fatigue, loss of energy, lethargy
  • Weight gain
  • Decreased appetite
  • Cold intolerance
  • Dry skin
  • Hair loss - With successful thyroid treatment, hypothyroidism-related hair loss is normally temporary, although regrowth takes several months, and the hair may not fully return [67]
  • Sleepiness
  • Muscle pain, joint pain, weakness in the extremities
  • Depression
  • Emotional lability, mental impairment
  • Forgetfulness, impaired memory, inability to concentrate
  • Constipation
  • Menstrual disturbances, impaired fertility
  • Decreased perspiration
  • Paresthesias, nerve entrapment syndromes
  • Blurred vision
  • Decreased hearing
  • Fullness in the throat, hoarseness

Approximately one third of individuals with hypothyroidism suffer from headache. However, the actual association between hypothyroidism and headache is uncertain, with there being evidence of a possible bidirectional relationship between the two, particularly in the case of migraine. [68]

“Brain fog,” characterized by lack of energy, forgetfulness, and fatigue, is another symptom of hypothyroidism. In one survey, 905 out of 5282 people (17.1%) reported suffering from symptoms of brain fog not long after being diagnosed with hypothyroidism. [69]

A study by Tricarico et al suggested that patients with hypothyroidism undergoing hormone replacement therapy (HRT) have a greater likelihood for recurrence of benign paroxysmal positional vertigo, particularly individuals who have Hashimoto thyroiditis and positive thyroid antibodies. The investigators indicated that this may signal a connection between autoimmunity and recurrent vertigo. [70]

Research indicates that hypothyroidism is linked to sexual dysfunction in males, including erectile dysfunction, delayed ejaculation, and hypoactive sexual desire (HSD). It is also suggested that sexual dysfunction in males results from the hypothyroid state itself rather than from the antibodies that lead to hypothyroidism. [71, 72]

Hashimoto thyroiditis is difficult to distinguish clinically, but the following symptoms are more specific to this condition:

  • Feeling of fullness in the throat
  • Painless thyroid enlargement
  • Exhaustion
  • Transient neck pain, sore throat, or both

Physical Examination

In hypothyroidism, facial changes include dulled expression, drooping eyelids, and puffiness of the eyes and face. [73]

Signs found in hypothyroidism are usually subtle, and their detection requires a careful physical examination. Moreover, such signs are often dismissed as part of aging; however, clinicians should consider a diagnosis of hypothyroidism when they are present.

Physical signs of hypothyroidism include the following:

·       Weight gain

·       Slowed speech and movements

·       Dry skin (rarely, yellow hued from carotene)

·       Jaundice

·       Pallor

·       Coarse, brittle, straw-like hair

·       Loss of scalp hair, axillary hair, pubic hair, or a combination

·       Dull facial expression

·       Coarse facial features

·       Periorbital puffiness

·       Macroglossia

·       Goiter (simple or nodular)

·       Hoarseness

·       Decreased systolic blood pressure and increased diastolic blood pressure

·       Bradycardia

·       Pericardial effusion

·       Abdominal distention, ascites (uncommon)

·       Hypothermia (only in severe hypothyroid states)

·       Nonpitting edema (myxedema)

·       Pitting edema of lower extremities

·       Hyporeflexia with delayed relaxation, ataxia, or both

Additional signs specific to different causes of hypothyroidism, such as diffuse or nodular goiter and pituitary enlargement or tumor, can occur.

A study by Piantanida et al indicated that an increased risk of masked hypertension exists with subclinical and overt hypothyroidism. The study included 64 newly diagnosed hypothyroid patients, with masked hypertension found in 26.3% of those with the subclinical condition and 15.4% of those with overt hypothyroidism, compared with 10% of controls. [74]