Central hypothyroidism

Last reviewed: 23 Aug 2023
Last updated: 17 Jan 2023



History and exam

Key diagnostic factors

  • weakness
  • fatigue
  • cold intolerance
More key diagnostic factors

Other diagnostic factors

  • decreased memory
  • constipation
  • muscle cramps
  • weight gain
  • depression
  • dry, coarse skin
  • oligomenorrhea/amenorrhea
  • bradycardia
  • reduced body and scalp hair
  • delayed relaxation of deep tendon reflexes
  • hearing impairment
  • impassive facial expression
  • diabetes insipidus (DI)
  • headache
  • diplopia
  • decreased peripheral vision
  • atrophic breasts
  • galactorrhea
  • moon facies
  • buffalo hump
Other diagnostic factors

Risk factors

  • presence of pituitary mass lesions
  • multiple endocrine neoplasia (MEN) type I
  • head and neck irradiation
  • traumatic brain injury (TBI)
  • age between 5-15 years and 45-60 years (craniopharyngiomas)
  • age 20-50 years (prolactinomas)
  • age 40-80 years (nonfunctioning pituitary adenomas)
  • sarcoidosis
  • histiocytosis
  • hemochromatosis
  • Sheehan syndrome (postpartum pituitary necrosis)
  • lymphocytic hypophysitis
  • family history of central hypothyroidism
  • anticonvulsant drugs
More risk factors

Diagnostic investigations

1st investigations to order

  • serum free thyroxine (FT4)
  • serum thyroid-stimulating hormone (TSH)
More 1st investigations to order

Investigations to consider

  • pituitary MRI
  • head CT
  • serum prolactin (PRL)
  • fasting morning serum cortisol
  • serum testosterone
  • serum gonadotropins
  • genetic analyses
More investigations to consider

Treatment algorithm


all patients



Angela M. Leung, MD, MSc

Associate Professor of Medicine

UCLA David Geffen School of Medicine

VA Greater Los Angeles Healthcare System

Los Angeles



AML serves on the board of directors of the American Thyroid Association (ATA); speaks for China Merck; consulted for Vertice Pharma; and received article process charges paid on behalf of IBSA Institut Biochimique for an invited review article.


Dr Angela M. Leung would like to gratefully acknowledge Dr Jacqueline Gilbert and Dr Rasa Zarnegar, previous contributors to this topic.


JG and RZ declare that they have no competing interests.

Peer reviewers

James Lee, MD

Assistant Professor

Department of Endocrine Surgery

Columbia University

New York



JL declares that he has no competing interests.

James V. Hennessey, MD

Director of Clinical Endocrinology

Beth Israel Deaconess Medical Center




JVH declares that he has no competing interests.

Anthony Weetman, MD, DSc, FRCP, FMedSci

Sir Arthur Hall Professor of Medicine/Pro Vice Chancellor

University of Sheffield




AW declares that he has no competing interests.

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