Hypothyroid Signs/Symptoms and Differential Diagnosis

Overview

Symptoms are an important part of diagnosing hypothyroidism. One study has shown that patient medical history (signs and symptoms) was more reliable (76%) than either physical examination (12%) or lab tests (11%) in diagnosing hypothyroidism [Peterson1992], [Starr2005, pg 72].

There are many symptoms that are associated with hypothyroidism. However, note that association does not necessarily prove cause and effect! For example, does diabetes cause hypothyroidism, or does hypothyroidism cause diabetes, or are both disorders caused by some other unidentified factor?

Pay particular attention to symptoms that are marked pathognomonic - these are symptoms that indicate an almost certain diagnosis of hypothyroidism! (I.e., they are not associated with any other diagnosis), as well as hallmark and cardinal signs that are very strongly associated with hypothyroidism but are not pathognomonic.

The following symptoms are often associated with hypothyroidism [Barnes_Research_Foundation], [Barnes1999], [Braverman2000], [Brucker_Davis1995], [DeGroot1996], [Hertogue1914], [Hertoghe1915], [Kharrazian2010], [Lisser1957], [Peterson1992], [Ramsey1974], [Starr2005], [Zondek1944].

Frequencies listed below are estimates from particular populations and are included as a general indicator.

Metabolic and Endocrine Signs/Symptoms

• Low basal body temperature (almost all).
• Dyslipidemia (High Cholesterol/Triglycerides). (hallmark sign).
• Chronic Fatigue Syndrome (84%).
• Cold intolerance (59%).
• Hyporeflexia (diminished reflexes) and delayed relaxation of deep tendon reflexes, especially Achilles tendon (53%).
• Weight gain (40%).
• Elevated TSH (before treatment with T4) (21%) [Note how small a percentage of hypothyroidism cases is associated with elevated TSH!].
• Diabetes Mellitus Type I (Insulin Dependent) or Diabetes Mellitus Type II (Insulin Resistance) (21%).
• Hypoglycemia, hyperinsuinemia (7%).
• Premature aging.
• Internal myxedema.
• Hormone imbalances.
• Infertility.
• Goiter.

Musculo-Skeletal Signs/Symptoms

• Crepitus felt in joints ("resembling the crackling of crushed snow"), especially at the knee (almost pathognomonic).
• Chronic pain (50%).
• Ligamentous laxity, e.g. flat feet, hyper-flexibility, scoliosis (3%, more common females), stooped posture, knock-kneed, tendency to sprain or strain, dislocated kneecaps.
• Joint pain, Arthritis, Rheumatoid pains (common).
• Skeletal changes such as scoliosis and general contraction of the pelvis (narrow hips), (common).
• Chronic deforming changes in the joints (common).
• Muscle Weakness.
• Gout.
• Muscle cramps [Domino2017].

Skin and Connective Tissue Signs/Symptoms

• Dry skin (85%).
• Brittle, soft, yellow, ridged, or striated nails (81%).
• Myxedema (non-pitting edema), especially around eyes (periorbital) and jaw-line (55%, pathognomonic), hands and feet.
• Cold, clammy extremities, pale nail beds, peripheral cyanosis and mottling (44%).
• Hair loss, (alopecia) especially lateral eyebrows, arms, legs (38%).
• Tendency to fat deposits, especially around the hips, above the pubic bone, and above clavicles (common).
• Slow wound healing.
• Excess cerumen in the ears.
• Osteoporosis.
• Decreased perspiration.
• Malar flush.
• Sallow complexion (carotinemia, yellow due to failure of liver to convert beta-carotene to vitamin A).
• Acne.
• Eczema.
• Psoriasis.

Urogenital and Sexual Signs/Symptoms

• Menstrual disturbances and PMS (68% of females).
• Hysterectomy (32% females).
• Endometriosis.
• Cystic breast/ ovaries.
• Loss of libido (male, female).
• Infertility.
• Premature or delayed menopause.
• Retroflexion of uterus.

Cardiovascular and Blood Signs/Symptoms

• Low systolic blood pressure with high diastolic blood pressure.
• Bradycardia (slow heart rate).
• Heart disease (16%).
• Oppressive feelings and convulsive pains in the cardiac region (common).
• Poor circulation and numbness in hands and feet.
• Congestive Heart Failure.
• Myocardial Infarction (heart attack).
• Stroke
• Heart palpitations, irregular heart beat.

Neurological and Psychological Signs/Symptoms

• Depression & mental disorders (58%).
• Slow movements, slow speech, lethargy, general indolence and inertia, lassitude, apathy, listlessness (32%).
• Paresthesias (abnormal sensations such as tingling, burning, etc.) (25%).
• Headaches (23%), especially morning headaches that wear off as the day progresses.
• Decreased appetite, Anorexia (common).
• Carpal tunnel syndrome [Domino2017].
• Excessive amount of sleep required to function properly.
• Sleepiness.
• Mental/memory impairment.
• Slow thinking.
• Hearing impairment [Domino2017].
• Deaf-mutism.
• Alcoholism.
• Various derangements and psychoses, including depression, mania, obsesions, delusion, hallucinations, and frank insanity.
• Diminished amplitude of EEG theta and delta waves.
• Prolonged evoked potentials.
• Alzheimer's Disease.
• Fibromyalgia.

Gastrointestinal Tract Signs/Symptoms

• Constipation (26%).
• Prolonged transit time in the bowels may increase development of food allergies or intolerances.
• Swelling and pallor of the mucus membranes (common).
• Chronic digestive problems, such as hypochlorhydria.
• Protuberant abdomen (common in infants).
• Nutritional imbalances.
• Scant intestinal secretions.
• Enlarged or irritated gums, gingivitis, hyperplasia.
• Enlarged tongue (macroglossia) and scalloping.
• Thickened lips.
• Downturned corners of the mouth.
• Difficulty swallowing.
• Gallbladder disease.
• Liver congestion.
• Dysbiosis (gut infections).

Respiratory Signs/Symptoms

• Emphysema (7%).
• Hoarsening or deepening of voice.
• Mouth breathing and noisy respiration due to swollen nasal passages, respiratory distress.
• Sleep Apnea.

Developmental Signs/Symptoms

• Disturbances in pregnancy: premature or long gestations, babies over 9 pounds at birth.
• Birth defects.
• Hypotonia (decreased muscle tone) (33%, infants).
• Umbilical hernia (29%, infants).
• Prolonged neonatal jaundice (29%).
• Poor suckling, failure to thrive (23%, infants).
• Delayed closing or enlarged fontanels (22%, infants).
• Enlarged tongue (macroglossia) and scalloping (19%, infants).
• Delayed dentition, tooth decay, and mis-spacing of teeth (common).
• Abnormalities in the shape of the pinna of the ear (common).
• Cretinism.
• Delayed puberty or hypoplasia of breasts and genitals.
• Deep depression of the root of the nose (where the nose meets the ridge between the eyebrows) and deep-set eyes due to faulty growth of the sphenoid bone.
• Short stature (DDX growth hormone deficiency, treat hypothyroid first).
• Disproportionate development (early or premature closure of growth plates).
• Malformation of the ends of the long bones.
• Cataracts (infants).

Immune System Signs/Signs/Symptoms

• Low immune function: (functional immune deficiency) Candida and other frequent infections, cancer (cardinal sign).
• Allergies (44%).
• Cancer (11%).
• Autoimmune disease (7%), such as Systemic Lupus Erythematosus (SLE), Adrenal insufficiency (Schmidt's syndrome), Inflammatory bowel disease, Gluten sensitivity or Celiac Disease, Pernicious anemia, Multiple Sclerosis.

Paradoxical Signs and Signs/Symptoms

Possible paradoxical signs and symptoms exhibited by some patients with low body temperature who respond well to treatment of hypothyroid condition include:

• Attention Deficit (Hyperactivity) Disorder (ADD/ADHD) (72% of males, 43% of females).
• Insomnia (52%).
• Anxiety, nervousness, irritability (35%).
• Hypertension (High Blood Pressure) (30%).
• TMJ (due to muscle dysfunction), teeth clenching (23%).
• Heat intolerance (20%).
• Tremor (20%).
• Elevated basal metabolic rate.
• Elevated heart rate.
• Underweight.
• Tall stature, prolonged growth period.
• Precocious (premature) puberty or hyperplasia of breasts and genitals.
• Abnormal muscle enlargement.
• Excessive perspiration.

Differential Diagnosis (DDX)

• Hashimoto's thyroiditis
• Iodine deficiency
• Chronic fatigue syndrome
• Anemia
• Euthyroid sick syndrome
• Depression
• Congestive heart failure
• Adrenal Deficiency (leads to intolerance of thyroid supplements)[Starr2005, pg 184].
• Adrenal Excess (shuts down thyroid) [Hill1950], [Starr2005, pg 184].
• Primary Amyloidosis [Domino2017]
• Dementia not due to hypothyroidism [Domino2017]
• Thyrotropin-secreting pituitary adenoma [Domino2017]
• Selenium deficiency [Peter1999].
• Magnesium deficiency [Starr2005, pg 183].
• Zinc deficiency [Spectracell seminar 5/2010].
• Iron deficiency [Barnes_Research_Foundation], [Starr2005, pg 182], [Spectracell seminar 5/2010].
• Estrogen causing overproduction of thyroid binding globulin, which reduces free-T3 [Kharrazian2010, pg 5].
• Myxedema (hydrated mucin) must be distinguished by palpable texture from subcutaneous fat in skinfold measurements, e.g. on the lateral arm.
• Copper toxicity can cause hypothyroidism; This may especially be a problem in "red-rock" areas of Arizona, where the soil/water may be high in copper.

References

• [Barnes_Research_Foundation] Broda O Barnes MD Research Foundation. Text: http://www.brodabarnes.org.
  Of particular note are the audio tapes Thyroid Therapy I, II, III available from this source.
• [Barnes1999] Broda O Barnes & Charlotte W Barnes Hope for Hypoglycemia, Revised Edition. America Book Company (1999). Amazon.
  Cited by [Starr2005].
• [Braverman2000] Lewis E Braverman, Robert D Utiger. Warner's & Ingbar's The Thyroid: A Fundamental and Clinical Text, 8th Edition. Philadelphia: Lippincott Williams & Wilkins (2000). Amazon.
• [Brucker_Davis1995] Francoise Brucker-Davis, Monica C Skarulis, Marcy B Grace, Jacques Benichou, Peter Hauser, Edythe Wiggs, Bruce D Weintraub. Genetic and clinical features of 42 kindreds with resistance to thyroid hormone. The National Institutes of Health Prospective Study. Ann Intern Med. 1995 Oct 15;123(8):572-83. PMID: 7677297.
• [DeGroot1996] Leslie J De Groot, P Reed Larson, Georg Hennemann. The Thyroid and Its Diseases, Sixth Edition. New York: Churchill Livingston (1996). Amazon.
• [Domino2017] Frank J Domino, et al. The 5-minute Clinical Consult. Wolters Kluwer (2017). Amazon.
• [Hertoghe1914] E. Hertoghe. Thyroid Deficiency. Lecture presented to the International Surgical Congress at the New York Polyclinic School and Hospital (April 1914). A Weekly Journal of Medicine and Surgery, Sept 19, 1914. Text: https://www.facebook.com/functionalps/photos/?tab=album&album_id=277760258936724.
• [Hertoghe1915] E Hertoghe. The Practitioner Vol XCIV, No. 1 (January), 26-69 (1915).
• [Hill1950] S Richardson Hill Jr, J Robert S Reiss, Peter H Forsham, George W Thorn. The effect of adrenocorticotropin and cortisone on thyroid function; thyroid-adrenocortical interrelationships. Journal Clinical Endocrinology 10:1375 (1950). PMID: 14794758.
• [Kharrazian2010] Datis Kharrazian. Why Do I Still Have Thyroid Symptoms When My Lab Tests Are Normal? Elephant Press (February 2, 2010). Amazon.
• [Lisser1957] H Lisser & RF Escamilla . Atlas of Clinical Endocrinology Including Text of Diagnosis and Treatment. St. Louis: C.V. Mosby (1957).
• [Peterson1992] MC Peterson, JH Holbrook, D Von Hales, NL Smith, LV Staker. Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. West J Med. 1992 Feb;156(2):163-5. PMID: 1536065. Text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1003190/.
• [Ramsey1974] Ian Ramsey. Thyroid disease and muscle dysfunction. William Heinemann Medical Books (1974). Amazon.
• [Starr2005] Mark Starr. Hypothyroidism Type 2: The Epidemic Columbia, MO: Mark Starr Trust (2005). Amazon.

  Updated 2011 added: Hashimoto's & Grave's diseases.

• [Zondek1944] Hermann Zondek. Diseases of the Endocrine Glands, Fourth Edition. Baltimore: Williams & Wilkins (1944). Amazon.