Classification and Etiopathogenesis of Hypothyroidism

  • Luca ChiovatoEmail author
  • Stefano Mariotti
  • Flavia Magri
Reference work entry
Part of the Endocrinology book series (ENDOCR)


Hypothyroidism is a graded phenomenon characterized by a deficient thyroidal production of thyroid hormone. This condition comprises multiple functional or structural disorders, both congenital and acquired. The clinical expression of hypothyroidism varies between individuals, depending on the cause, duration, and severity of the hypothyroid state, but almost all organs and systems may be affected by a deficiency of thyroid hormone production. This chapter describes the epidemiology, multiple etiologies, and clinical manifestations of hypothyroidism.


Hypothyroidism Subclinical hypothyroidism Classification Epidemiology Etiopathogenesis Clinical features 


  1. Abrahamsen B, Jørgensen HL, Laulund AS, Nybo M, Bauer DC, Brix TH, Hegedüs L. The excess risk of major osteoporotic fractures in hypothyroidism is driven by cumulative hyperthyroid as opposed to hypothyroid time: an observational register-based time-resolved cohort analysis. J Bone Miner Res. 2015;30:898.CrossRefPubMedGoogle Scholar
  2. Aghini-Lombardi F, Antonangeli L, Martino E, Vitti P, Maccherini D, Leoli F, Rago T, Grasso L, Valeriano R, Balestrieri A, Pinchera A. The spectrum of thyroid disorders in an iodine-deficient community: the Pescopagano survey. J Clin Endocrinol Metab. 1999;84:561.PubMedGoogle Scholar
  3. Ajjan RA, Weetman AP. The Pathogenesis of Hashimoto’s Thyroiditis: Further Developments in our Understanding. Horm Metab Res. 2015;47:702.CrossRefPubMedGoogle Scholar
  4. Amino N, Tada H, Hidaka Y. Postpartum autoimmune thyroid syndrome: a model of aggravation of autoimmune disease. Thyroid. 1999;9:705.CrossRefPubMedGoogle Scholar
  5. Anasti JN, Flack MR, Froehlich J, Nelson LM, Nisula BC. A potential novel mechanism for precocious puberty in juvenile hypothyroidism. J Clin Endocrinol Metab. 1995;80:276.PubMedGoogle Scholar
  6. Anwar S, Gibofsky A. Musculoskeletal manifestations of thyroid disease. Rheum Dis Clin N Am. 2010;36:637.CrossRefGoogle Scholar
  7. Bassett JH, Boyde A, Howell PG, Bassett RH, Galliford TM, Archanco M, Evans H, Lawson MA, Croucher P, St Germain DL, Galton VA, Williams GR. Optimal bone strength and mineralization requires the type 2 iodothyronine deiodinase in osteoblasts. Proc Natl Acad Sci USA. 2010;107:7604.CrossRefPubMedGoogle Scholar
  8. Biondi B, Cooper DS. The clinical significance of subclinical thyroid dysfunction. Endocr Rev. 2008;29:76.CrossRefPubMedGoogle Scholar
  9. Boelen A, Kwakkel J, Fliers E. Beyond low plasma T3: local thyroid hormone metabolism during inflammation and infection. Endocr Rev. 2011;32:670.CrossRefPubMedGoogle Scholar
  10. Bonnema SJ, Hegedüs L. Endocr Rev. 2012;33:920.CrossRefPubMedGoogle Scholar
  11. Brix TH, Kyvik KO, Hegedüs L. A population-based study of chronic autoimmune hypothyroidism in Danish twins. J Clin Endocrinol Metab. 2000;85:536.PubMedGoogle Scholar
  12. Calvino C, Imperio GE, Wilieman M, Costa ESRH, Souza LL, Trevenzoli IH, Pazos-Moura CC. Hypothyroidism Induces Hypophagia Associated with Alterations in Protein Expression of Neuropeptide Y and Proopiomelanocortin in the Arcuate Nucleus, Independently of Hypothalamic Nuclei-Specific Changes in Leptin Signaling. Thyroid. 2016;26:134.CrossRefPubMedGoogle Scholar
  13. Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med. 2000;160:526.CrossRefPubMedGoogle Scholar
  14. Coles AJ, Wing M, Smith S, Coraddu F, Greer S, Taylor C, Weetman A, Hale G, Chatterjee VK, Waldmann H, Compston A. Pulsed monoclonal antibody treatment and autoimmune thyroid disease in multiple sclerosis. Lancet. 1999;354:1691.CrossRefPubMedGoogle Scholar
  15. Constant EL, de Volder AG, Ivanoiu A, Bol A, Labar D, Seghers A, Cosnard G, Melin J, Daumerie C, Clin J. Cerebral blood flow and glucose metabolism in hypothyroidism: a positron emission tomography study. Endocrinol Metab. 2001;86:3864.CrossRefGoogle Scholar
  16. Correia N, Mullally S, Cooke G, Tun TK, Phelan N, Feeney J, Fitzgibbon M, Boran G, O’Mara S, Gibney J, Clin J. Evidence for a specific defect in hippocampal memory in overt and subclinical hypothyroidism. Endocrinol Metab. 2009;94:3789.CrossRefGoogle Scholar
  17. Curran PG, DeGroot LJ. The effect of hepatic enzyme-inducing drugs on thyroid hormones and the thyroid gland. Endocr Rev. 1991;12:135.CrossRefPubMedGoogle Scholar
  18. Daniels GH, Vladic A, Brinar V, Zavalishin I, Valente W, Oyuela P, Palmer J, Margolin DH, Hollenstein J. Alemtuzumab-related thyroid dysfunction in a phase 2 trial of patients with relapsing-remitting multiple sclerosis. J Clin Endocrinol Metab. 2014;99:80.CrossRefPubMedGoogle Scholar
  19. Danzi S, Klein I. Thyroid disease and the cardiovascular system. Endocrinol Metab Clin N Am. 2014;43:517.CrossRefGoogle Scholar
  20. Devdhar M, Ousman YH YH, Burman KD. Hypothyroidism. Endocrinol Metab Clin N Am. 2007;36:595.CrossRefGoogle Scholar
  21. Duntas LH, Brenta G. The effect of thyroid disorders on lipid levels and metabolism. Med Clin North Am. 2012;96:269.CrossRefPubMedGoogle Scholar
  22. Ebert EC. The thyroid and the gut. J Clin Gastroenterol. 2010;44:402.PubMedGoogle Scholar
  23. Effraimidis G, Wiersinga WM. Mechanisms in endocrinology: autoimmune thyroid disease: old and new players. Eur J Endocrinol. 2014;170:R241.CrossRefPubMedGoogle Scholar
  24. Fliers E, Bianco AC, Langouche L, Boelen A. Thyroid function in critically ill patients. Lancet Diabetes Endocrinol. 2015;3:816.CrossRefPubMedPubMedCentralGoogle Scholar
  25. Garber JR, Cobin HR, Gharib H, Hennessey JV, Klein I, Mechanick J, 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. 2012;22:1220.CrossRefGoogle Scholar
  26. Gereben B, Zavacki AM, Ribich S, Kim BW, Huang SA, Simonides WS, Zeöld A, Bianco AC. Cellular and molecular basis of deiodinase-regulated thyroid hormone signaling. J Endocr Rev. 2008;29:898.CrossRefGoogle Scholar
  27. Guastamacchia E, Triggiani V, Aglialoro A, Aiello A, Ianni L, Maccario M, Zini M, Giorda C, Guglielmi R, Betterle C, Attanasio R, Borretta G, Garofalo P, Papini E, Castello R, Ceriello A. Italian Association of Clinical Endocrinologists (AME) & Italian Association of Clinical Diabetologists (AMD) Position Statement : Diabetes mellitus and thyroid disorders: recommendations for clinical practice. Endocrine. 2015;49:339.CrossRefPubMedGoogle Scholar
  28. Haddow JE, Palomaki GE, Allan WC, Williams JR, Knight GJ, Gagnon J, O’Heir CE, Mitchell ML, Hermos RJ, Waisbren SE, Faix JD, Klein RZ, Engl N. Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child. J Med. 1999;341:549.Google Scholar
  29. Hancock SL, McDougall IR, Constine L-S. Thyroid abnormalities after therapeutic external radiation. Int J Radiat Oncol Biol Phys. 1995;31:1165.CrossRefPubMedGoogle Scholar
  30. Hannon MJ, O’Halloran DJ. Isolated acquired ACTH deficiency and primary hypothyroidism: a short series and review. Pituitary. 2011;14:358.CrossRefPubMedGoogle Scholar
  31. Hassan MM, Kaseb A, Li D, Patt YZ, Vauthey JN, Thomas MB, Curley SA, Spitz MR, Sherman SI, Abdalla EK, Davila M, Lozano RD, Hassan DM, Chan W, Brown TD, Abbruzzese JL. Association between hypothyroidism and hepatocellular carcinoma: a case-control study in the United States. Hepatology. 2009;49:1563.CrossRefPubMedPubMedCentralGoogle Scholar
  32. Hennessey JV. Clinical review: Riedel’s thyroiditis: a clinical review. J Clin Endocrinol Metab. 2011;96:3031.CrossRefPubMedGoogle Scholar
  33. Herwig A, Campbell G, Mayer CD, Boelen A, Anderson RA, Ross AW, Mercer JG, Barrett P. A thyroid hormone challenge in hypothyroid rats identifies T3 regulated genes in the hypothalamus and in models with altered energy balance and glucose homeostasis. Thyroid. 2014;24:1575.CrossRefPubMedPubMedCentralGoogle Scholar
  34. Heuer H. The importance of thyroid hormone transporters for brain development and function. Best Pract Res Clin Endocrinol Metab. 2007;21:265.CrossRefPubMedGoogle Scholar
  35. Hollowell NW, Staehling WD, Flanders WH, Hannon EW, Gunter CA, Spencer LE. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab. 2002;87:489.CrossRefPubMedGoogle Scholar
  36. Iglesias P, Diez JJ. Thyroid dysfunction and kidney disease. Eur J Endocrinol. 2009;160:503.CrossRefPubMedGoogle Scholar
  37. Iwama S, De Remigis A, Callahan MK, Slovin SF, Wolchok JD, Caturegli P. Pituitary expression of CTLA-4 mediates hypophysitis secondary to administration of CTLA-4 blocking antibody. Sci Transl Med. 2014;6:230ra45.CrossRefPubMedGoogle Scholar
  38. Jereczek-Fossa BA, Alterio D, Jassem J, Gibelli B, Tradati N, Orecchia R. Radiotherapy-induced thyroid disorders. Cancer Treat Rev. 2004;30:369.CrossRefPubMedGoogle Scholar
  39. Jha A, Sharma SK, Tandon N, Lakshmy R, Kadhiravan T, Handa KK, Gupta R, Pandey RM, Chaturvedi PK. Thyroxine replacement therapy reverses sleep-disordered breathing in patients with primary hypothyroidism. Sleep Med. 2006;7:55.CrossRefPubMedGoogle Scholar
  40. 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. 2014;24:1670.CrossRefPubMedPubMedCentralGoogle Scholar
  41. Kanaya AM, Harris F, Volpato S, Pérez-Stable EJ, Harris T, Bauer DC. Association between thyroid dysfunction and total cholesterol level in an older biracial population: the health, aging and body composition study. Arch Intern Med. 2002;162:773.CrossRefPubMedGoogle Scholar
  42. Kappers MHW, van Esch JHM, Smedts FMM, de Krijger RR, Eechoute K, Mathijssen RHJ, Sleijfer S, Leijten F, Danser AHJ, van den Meiracker AH, Visser TJ. Sunitinib-induced hypothyroidism is due to induction of type 3 deiodinase activity and thyroidal capillary regression. J Clin Endocrinol Metab. 2011;96:3087.CrossRefPubMedGoogle Scholar
  43. Knudsen N, Jùrgensen T, Rasmussen S, Christiansen E, Perrild H. The prevalence of thyroid dysfunction in a population with borderline iodine deficiency. Clin Endocrinol. 1999;51:361.CrossRefGoogle Scholar
  44. Krassas GE, Pontikides N. Male reproductive function in relation with thyroid alterations. Best Pract Res Clin Endocrinol Metab. 2004;18:183.CrossRefPubMedGoogle Scholar
  45. Krassas GE, Poppe K, Glinoer D. Thyroid function and human reproductive health. Endocr Rev. 2010;31:702.CrossRefPubMedGoogle Scholar
  46. Kyriakakis N, Lynch J, Ajjan R, Murray RD. The effects of pituitary and thyroid disorders on haemostasis: potential clinical implications. Clin Endocrinol. 2016;84:473.CrossRefGoogle Scholar
  47. Laurberg P, Cerqueira C, Ovesen L, Rasmussen LB, Perrild H, Andersen S, Pedersen IB, Carlé A. Iodine intake as a determinant of thyroid disorders in populations. Best Pract Res Clin Endocrinol Metab. 2010;24:13.CrossRefPubMedGoogle Scholar
  48. Lazarus JH. Lithium and thyroid. Best Pract Res Clin Endocrinol Metab. 2009;23:723.CrossRefPubMedGoogle Scholar
  49. Leung AM, Braverman LE. Consequences of excess iodine. Nat Rev Endocrinol. 2014;10:136.CrossRefPubMedGoogle Scholar
  50. Lio S. In: Monaco F, editor. Thyroid diseases. Boca Raton: CRC Press; 2012. p. 49.CrossRefGoogle Scholar
  51. Luongo C, Trivisano L, Alfano F, Salvatore D. Type 3 deiodinase and consumptive hypothyroidism: a common mechanism for a rare disease. Front Endocrinol (Lausanne). 2013;4:115.Google Scholar
  52. Magri F, Buonocore M, Oliviero A, Rotondi M, Gatti A, Accornero S, Camera A, Chiovato L. Intraepidermal nerve fiber density reduction as a marker of preclinical asymptomatic small-fiber sensory neuropathy in hypothyroid patients. Eur J Endocrinol. 2010;163:279.CrossRefPubMedGoogle Scholar
  53. Mariotti S. In: Monaco F, editor. Thyroid diseases. Boca Raton: CRC Press; 2012a. p. 77.CrossRefGoogle Scholar
  54. Mariotti S. In: Monaco F, editor. Thyroid diseases. Boca Raton: CRC Press; 2012b. p. 97.CrossRefGoogle Scholar
  55. Mariotti S, Martino E, Francesconi M, Ceccarelli C, Grasso L, Lippi F, Baschieri L, Pinchera A. Serum thyroid autoantibodies as a risk factor for development of hypothyroidism after radioactive iodine therapy for single thyroid ‘hot’ nodule. Acta Endocrinol. 1986;113:500.PubMedCrossRefGoogle Scholar
  56. Martino E, Bartalena L, Bogazzi F, Braverman LE. The effects of amiodarone on the thyroid. Endocr Rev. 2001;22:240.PubMedGoogle Scholar
  57. Menconi F, Hasham A, Tomer Y. Environmental triggers of thyroiditis: hepatitis C and interferon-α. J Endocrinol Investig. 2011;34:78.CrossRefGoogle Scholar
  58. Metso S, Jaatinen P, Huhtala H, Luukkaala T, Oksala H, Salmi J. Long-term follow-up study of radioiodine treatment of hyperthyroidism. Clin Endocrinol. 2004;61:641.CrossRefGoogle Scholar
  59. M’Rabet-Bensalah K, Aubert CE, Coslovsky M, Collet TH, Baumgartner C, den Elzen WP, Luben R, Angelillo-Scherrer A, Aujesky D, Khaw KT, Rodondi N. Thyroid dysfunction and anaemia in a large population-based study. Clin Endocrinol. 2016;84:627.CrossRefGoogle Scholar
  60. Nagamachi S, Jinnouchi S, Nishii R, Ishida Y, Fujita S, Futami S, Kodama T, Tamura S, Kawai K. Cerebral blood flow abnormalities induced by transient hypothyroidism after thyroidectomy--analysis by tc-99m-HMPAO and SPM96. Ann Nucl Med. 2004;18:469.CrossRefPubMedGoogle Scholar
  61. Nakamura H, Yamashita S, Ashizawa K, Kitahara A, Natsume H, Andoh S, Nagasawa S, Nishiyama K, Chida K, Sato A, Yoshimi T. High incidence of positive autoantibodies against thyroid peroxidase and thyroglobulin in patients with sarcoidosis. Clin Endocrinol. 1997;46:467.CrossRefGoogle Scholar
  62. Ortiga-Carvalho TM, Sidhaye AR, Wondisford FE. Thyroid hormone receptors and resistance to thyroid hormone disorders. Nat Rev Endocrinol. 2014;10:582.CrossRefPubMedPubMedCentralGoogle Scholar
  63. Pani F, Atzori F, Baghino G, Boi F, Tanca L, Ionta MT, Mariotti S. Thyroid dysfunction in patients with metastatic carcinoma treated with sunitinib: Is thyroid autoimmunity involved?. Thyroid. 2015;25:1255.CrossRefPubMedGoogle Scholar
  64. Parle JV, Franklyn JA JA, Cross KW, Jones SC, Sheppard MC. Prevalence and follow-up of abnormal thyrotrophin (TSH) concentrations in the elderly in the United Kingdom. Clin Endocrinol. 1991;34:77.CrossRefGoogle Scholar
  65. Pearce EN, Braverman LE. Environmental pollutants and the thyroid. Best Pract Res Clin Endocrinol Metab. 2009;23(6):801–13.CrossRefPubMedGoogle Scholar
  66. Poppe K, Glinoer D, Tournaye H, Maniewski U, Haentjens P, Velkeniers B. Is systematic screening for thyroid disorders indicated in subfertile men?. Eur J Endocrinol. 2006;154:363.CrossRefPubMedGoogle Scholar
  67. Refetoff S, Dumitrescu AM. Syndromes of reduced sensitivity to thyroid hormone: genetic defects in hormone receptors, cell transporters and deiodination. Best Pract Res Clin Endocrinol Metab. 2007;21:277.CrossRefPubMedGoogle Scholar
  68. Refetoff S, Weiss RE, Usala SJ. The syndromes of resistance to thyroid hormone. Endocr Rev. 1993;14:348.PubMedGoogle Scholar
  69. Rodriguez-Gutierrez R, Gonzalez-Velazquez C, Gonzalez-Saldivar G, Villarreal-Perez JZ, Gonzalez-Gonzalez JG. Glucocorticoid functional reserve in full-spectrum intensity of primary hypothyroidism. Int J Endocrinol. 2014;2014:313519.PubMedPubMedCentralGoogle Scholar
  70. Rønjom MF, Brink C, Bentzen SM, Hegedüs L, Overgaard J, Johansen J. Hypothyroidism after primary radiotherapy for head and neck squamous cell carcinoma: normal tissue complication probability modeling with latent time correction. Radiother Oncol. 2013;109:317.CrossRefPubMedGoogle Scholar
  71. Rønjom MF, Brink C, Lorenzen FL, Hegedüs L, Johansen J. Variation of normal tissue complication probability (NTCP) estimates of radiation-induced hypothyroidism in relation to changes in delineation of the thyroid gland. Acta Oncol. 2015;54:1188.CrossRefPubMedGoogle Scholar
  72. Rose NR, Bona C. Defining criteria for autoimmune diseases (Witebsky’s postulates revisited). Immunol Today. 1993;14:426.CrossRefPubMedGoogle Scholar
  73. Ross DS. Radioiodine therapy for hyperthyroidism. N Engl J Med. 2011;364:542.CrossRefPubMedGoogle Scholar
  74. Safer JD. Thyroid hormone action on skin. Curr Opin Endocrinol Diabetes Obes. 2012;19:388.CrossRefPubMedGoogle Scholar
  75. Salvatore D, Simonides WS, Dentice M, Zavacki AM, Larsen PR. Thyroid hormones and skeletal muscle–new insights and potential implications. Nat Rev Endocrinol. 2014;10:206.CrossRefPubMedGoogle Scholar
  76. Santini F, Marzullo P, Rotondi M, Ceccarini G, Pagano L, Ippolito S, Chiovato L, Biondi B. Eur J Endocrinol. 2014;171:R137.CrossRefPubMedGoogle Scholar
  77. Santos-Palacios S, Brugos-Larumbe A, Guillen-Grima F, Galofre JC. Clin Endocrinol. 2013;79:874.CrossRefGoogle Scholar
  78. Singer PA. Werner & Ingbar’s thyroid. A fundamental and clinical text. 10th ed. Philadelphia: Wolters Kluver/Lippincot Williams & Wikins; 2013. p. 552.Google Scholar
  79. Singh S, Rana P, Kumar P, Shankar LR, Khushu S. J Neuroendocrinol. 2016;28:1.Google Scholar
  80. Sorensen JR, Winther KH, Bonnema SJ, Godballe C, Hegedus L. Respiratory Manifestations of Hypothyroidism: A Systematic Review. Thyroid. 2016;26:1519.CrossRefPubMedGoogle Scholar
  81. Stagnaro-Green A, Schwartz A, Gismondi R, Tinelli A, Mangieri T, Negro R. High rate of persistent hypothyroidism in a large-scale prospective study of postpartum thyroiditis in southern Italy. J Clin Endocrinol Metab. 2011;96:652.CrossRefPubMedGoogle Scholar
  82. Surks MI, Hollowell JG. Age-specific distribution of serum thyrotropin and antithyroid antibodies in the US population: implications for the prevalence of subclinical hypothyroidism. J Clin Endocrinol Metab. 2007;92:4575.CrossRefPubMedGoogle Scholar
  83. Taylor JC, Gough SC, Hunt PJ, Brix TH, Chatterjee K, Connell JM, Franklyn JA, Hegedüs L, Robinson BG, Wiersinga WM, Wass JA, Zabaneh D, Mackay I, Weetman AP. A genome-wide screen in 1119 relative pairs with autoimmune thyroid disease. J Clin Endocrinol Metab. 2006;91:646.CrossRefPubMedGoogle Scholar
  84. Thvilum M, Brandt F, Almind D, Christensen K, Brix TH, Hegedüs L. Type and extent of somatic morbidity before and after the diagnosis of hypothyroidism. a nationwide register study. PLoS One. 2013;16:e75789.CrossRefGoogle Scholar
  85. Thvilum M, Brandt F, Almind D, Christensen K, Brix TH, Hegedüs L. Increased psychiatric morbidity before and after the diagnosis of hypothyroidism: a nationwide register study. Thyroid. 2014;24:802.CrossRefPubMedGoogle Scholar
  86. Tomer Y, Menconi F. Interferon induced thyroiditis. Best Pract Res Clin Endocrinol Metab. 2009;23:703.CrossRefPubMedPubMedCentralGoogle Scholar
  87. Torino F, Barnabei A, Paragliola R, Baldelli R, Appetecchia M, Corsello SM. Thyroid dysfunction as an unintended side effect of anticancer drugs. Thyroid. 2013;23:1345.CrossRefGoogle Scholar
  88. Tunbridge WM, Evered DC, Hall R, Appleton D, Brewis M, Clark F, Evans JG, Young E, Bird T, Smith PA. The spectrum of thyroid disease in a community: the Whickham survey. Clin Endocrinol. 1977;7:481.CrossRefGoogle Scholar
  89. Vanderpump MPJ. The epidemiology of thyroid disease. Br Med Bull. 2011;99:39.CrossRefPubMedGoogle Scholar
  90. Vanderpump MPJ, Tunbridge WMG, French JM, Appleton D, Bates D, Clark F, Grlmley Evans J, Hasan DM, Rodgers H, Tunbridge F, Young ET. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin Endocrinol. 1995;43:55.CrossRefGoogle Scholar
  91. Verloop H, Louwerens M, Schoones JW, Kievit J, Smit JWA, Dekkers OM. Risk of hypothyroidism following hemithyroidectomy: systematic review and meta-analysis of prognostic studies. J Clin Endocrinol Metab. 2012;97:2243.CrossRefPubMedGoogle Scholar
  92. Vogelius IR, Bentzen SM, Maraldo MV, Petersen PM, Specht L. Risk factors for radiation-induced hypothyroidism: a literature-based meta-analysis. Cancer. 2011;117:5250.CrossRefPubMedGoogle Scholar
  93. Yaylali O, Kirac S, Yilmaz M, Akin F, Yuksel D, Demirkan N, Akdag B. Does hypothyroidism affect gastrointestinal motility?. Gastroenterol Res Pract. 2009;2009:529802.CrossRefPubMedGoogle Scholar
  94. Zhou JY, Xu B, Lopes J, Blamoun J, Li L. Hashimoto encephalopathy: literature review. Acta Neurol Scand. 2017;135:285.CrossRefPubMedGoogle Scholar
  95. Zimmermann MB. Iodine deficiency. Endocr Rev. 2009;30:376.CrossRefPubMedGoogle Scholar
  96. Zimmermann MB, Boelaert K. Iodine deficiency and thyroid disorders. Lancet Diabetes Endocrinol. 2015;3:286.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Internal Medicine and Medical Therapy, University of Pavia - Unit of Internal Medicine and EndocrinologyIRCCS ICS MaugeriPaviaItaly
  2. 2.Departmet of Medical Sciences and Public HealthUniversity of CagliariMonserratoItaly

Personalised recommendations