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CC BY 4.0 · Avicenna J Med 2024; 14(03): 137-145
DOI: 10.1055/s-0044-1788040
Review Article

Clearing the Skepticism about Subclinical Hypothyroidism: Is It Beneficial to Treat Patients with Thyroid-Stimulating Hormone >4.5 and <10 mIU/L?

Hafsa Bushra 
1   Department of Internal Medicine, Royal Commission Hospital Jubail, Jubail, Saudi Arabia
,
Murtaza Rashid 
2   Department of Emergency Medicine, Royal Commission Hospital Jubail, Jubail, Saudi Arabia
› Institutsangaben Funding None.
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Abstract

Subclinical hypothyroidism (SCH) is a heterogeneous clinical condition ranging from asymptomatic to wide variety of clinical manifestations, which are often nonspecific. Being a common laboratory finding, clinicians often face the dilemma of whether to treat or not. Threshold of 10 mIU/L of thyroid-stimulating hormone (TSH) is often used as a cutoff limit to offer treatment. However, still, debate remains on whether to treat less than 10 mIU/L considering special clinical conditions like pregnancy. Whether SCH exists, is screening needed in asymptomatic individuals, is treating asymptomatic cases beneficial or harmful and what threshold level of TSH to be considered for treatment are all potential questions that need to be answered.

Keywords

hypothyroidism - subclinical hypothyroidism - thyroid - thyroxine


Publikationsverlauf

Artikel online veröffentlicht:
03. Juli 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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  • References

  • 1 Peeters RP. Subclinical hypothyroidism. N Engl J Med 2017; 376 (26) 2556-2565
    CrossrefPubMedSuche in Google Scholar
  • 2 Fatourechi V. Subclinical hypothyroidism: an update for primary care physicians. Mayo Clin Proc 2009; 84 (01) 65-71
    CrossrefPubMedSuche in Google Scholar
  • 3 Tunbridge WM, Evered DC, Hall R. et al. The spectrum of thyroid disease in a community: the Whickham survey. Clin Endocrinol (Oxf) 1977; 7 (06) 481-493
    CrossrefPubMedSuche in Google Scholar
  • 4 Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med 2000; 160 (04) 526-534
    CrossrefPubMedSuche in Google Scholar
  • 5 Biondi B, Cappola AR, Cooper DS. Subclinical hypothyroidism: a review. JAMA 2019; 322 (02) 153-160
    CrossrefPubMedSuche in Google Scholar
  • 6 Laurberg P, Pedersen KM, Hreidarsson A, Sigfusson N, Iversen E, Knudsen PR. Iodine intake and the pattern of thyroid disorders: a comparative epidemiological study of thyroid abnormalities in the elderly in Iceland and in Jutland, Denmark. J Clin Endocrinol Metab 1998; 83 (03) 765-769
    CrossrefPubMedSuche in Google Scholar
  • 7 Roelfsema F, Pereira AM, Adriaanse R. et al. Thyrotropin secretion in mild and severe primary hypothyroidism is distinguished by amplified burst mass and basal secretion with increased spikiness and approximate entropy. J Clin Endocrinol Metab 2010; 95 (02) 928-934
    CrossrefPubMedSuche in Google Scholar
  • 8 Hollowell JG, Staehling NW, Flanders WD. et al. 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 (02) 489-499
    CrossrefPubMedSuche in Google Scholar
  • 9 Surks MI, Boucai L. Age- and race-based serum thyrotropin reference limits. J Clin Endocrinol Metab 2010; 95 (02) 496-502
    CrossrefPubMedSuche in Google Scholar
  • 10 Porcu E, Medici M, Pistis G. et al. A meta-analysis of thyroid-related traits reveals novel loci and gender-specific differences in the regulation of thyroid function. PLoS Genet 2013; 9 (02) e1003266
    CrossrefPubMedSuche in Google Scholar
  • 11 Andersen S, Pedersen KM, Bruun NH, Laurberg P. Narrow individual variations in serum T(4) and T(3) in normal subjects: a clue to the understanding of subclinical thyroid disease. J Clin Endocrinol Metab 2002; 87 (03) 1068-1072
    CrossrefPubMedSuche in Google Scholar
  • 12 Wartofsky L, Dickey RA. The evidence for a narrower thyrotropin reference range is compelling. J Clin Endocrinol Metab 2005; 90 (09) 5483-5488
    CrossrefPubMedSuche in Google Scholar
  • 13 Fatourechi V, Klee GG, Grebe SK. et al. Effects of reducing the upper limit of normal TSH values. JAMA 2003; 290 (24) 3195-3196
    CrossrefPubMedSuche in Google Scholar
  • 14 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 (12) 4575-4582
    CrossrefPubMedSuche in Google Scholar
  • 15 Stagnaro-Green A, Abalovich M, Alexander E. et al; American Thyroid Association Taskforce on Thyroid Disease During Pregnancy and Postpartum. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid 2011; 21 (10) 1081-1125
    CrossrefPubMedSuche in Google Scholar
  • 16 Bekkering GE, Agoritsas T, Lytvyn L. et al. Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline. BMJ 2019; 365: l2006
    CrossrefPubMedSuche in Google Scholar
  • 17 Ladenson PW, Singer PA, Ain KB. et al. American Thyroid Association guidelines for detection of thyroid dysfunction. Arch Intern Med 2000; 160 (11) 1573-1575
    CrossrefPubMedSuche in Google Scholar
  • 18 Garber JR, Cobin RH, Gharib H. et al; American Association of Clinical Endocrinologists and American Thyroid Association Taskforce on Hypothyroidism in Adults. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract 2012; 18 (06) 988-1028
    CrossrefPubMedSuche in Google Scholar
  • 19 Helfand M, Redfern CC. American College of Physicians. Clinical guideline, part 2. Screening for thyroid disease: an update. Ann Intern Med 1998; 129 (02) 144-158
    CrossrefPubMedSuche in Google Scholar
  • 20 Surks MI, Ortiz E, Daniels GH. et al. Subclinical thyroid disease: scientific review and guidelines for diagnosis and management. JAMA 2004; 291 (02) 228-238
    CrossrefPubMedSuche in Google Scholar
  • 21 Gencer B, Collet TH, Virgini V. et al; Thyroid Studies Collaboration. Subclinical thyroid dysfunction and the risk of heart failure events: an individual participant data analysis from 6 prospective cohorts. Circulation 2012; 126 (09) 1040-1049
    CrossrefPubMedSuche in Google Scholar
  • 22 Rodondi N, den Elzen WP, Bauer DC. et al; Thyroid Studies Collaboration. Subclinical hypothyroidism and the risk of coronary heart disease and mortality. JAMA 2010; 304 (12) 1365-1374
    CrossrefPubMedSuche in Google Scholar
  • 23 Monzani F, Caraccio N, Kozàkowà M. et al. Effect of levothyroxine replacement on lipid profile and intima-media thickness in subclinical hypothyroidism: a double-blind, placebo- controlled study. J Clin Endocrinol Metab 2004; 89 (05) 2099-2106
    CrossrefPubMedSuche in Google Scholar
  • 24 Redford C, Vaidya B. Subclinical hypothyroidism: should we treat?. Post Reprod Health 2017; 23 (02) 55-62
    CrossrefPubMedSuche in Google Scholar
  • 25 Pasqualetti G, Pagano G, Rengo G, Ferrara N, Monzani F. Subclinical hypothyroidism and cognitive impairment: systematic review and meta-analysis. J Clin Endocrinol Metab 2015; 100 (11) 4240-4248
    CrossrefPubMedSuche in Google Scholar
  • 26 Gulseren S, Gulseren L, Hekimsoy Z, Cetinay P, Ozen C, Tokatlioglu B. Depression, anxiety, health-related quality of life, and disability in patients with overt and subclinical thyroid dysfunction. Arch Med Res 2006; 37 (01) 133-139
    CrossrefPubMedSuche in Google Scholar
  • 27 Bell RJ, Rivera-Woll L, Davison SL, Topliss DJ, Donath S, Davis SR. Well-being, health-related quality of life and cardiovascular disease risk profile in women with subclinical thyroid disease - a community-based study. Clin Endocrinol (Oxf) 2007; 66 (04) 548-556
    CrossrefPubMedSuche in Google Scholar
  • 28 van den Boogaard E, Vissenberg R, Land JA. et al. Significance of (sub)clinical thyroid dysfunction and thyroid autoimmunity before conception and in early pregnancy: a systematic review. Hum Reprod Update 2011; 17 (05) 605-619
    CrossrefPubMedSuche in Google Scholar
  • 29 Flynn RW, Bonellie SR, Jung RT, MacDonald TM, Morris AD, Leese GP. Serum thyroid-stimulating hormone concentration and morbidity from cardiovascular disease and fractures in patients on long-term thyroxine therapy. J Clin Endocrinol Metab 2010; 95 (01) 186-193
    CrossrefPubMedSuche in Google Scholar
  • 30 Chen X, Zhang N, Cai Y, Shi J. Evaluation of left ventricular diastolic function using tissue Doppler echocardiography and conventional doppler echocardiography in patients with subclinical hypothyroidism aged <60 years: a meta-analysis. J Cardiol 2013; 61 (01) 8-15
    CrossrefPubMedSuche in Google Scholar
  • 31 Biondi B, Cooper DS. The clinical significance of subclinical thyroid dysfunction. Endocr Rev 2008; 29 (01) 76-131
    CrossrefPubMedSuche in Google Scholar
  • 32 Di Bello V, Monzani F, Giorgi D. et al. Ultrasonic myocardial textural analysis in subclinical hypothyroidism. J Am Soc Echocardiogr 2000; 13 (09) 832-840
    CrossrefPubMedSuche in Google Scholar
  • 33 Aghini-Lombardi F, Di Bello V, Talini E. et al. Early textural and functional alterations of left ventricular myocardium in mild hypothyroidism. Eur J Endocrinol 2006; 155 (01) 3-9
    CrossrefPubMedSuche in Google Scholar
  • 34 Moon S, Kim MJ, Yu JM, Yoo HJ, Park YJ. Subclinical hypothyroidism and the risk of cardiovascular disease and all-cause mortality: a meta-analysis of prospective cohort studies. Thyroid 2018; 28 (09) 1101-1110
    CrossrefPubMedSuche in Google Scholar
  • 35 Kannan L, Shaw PA, Morley MP. et al. Thyroid dysfunction in cardiac failure and cardiovascular outcome. Circ Heart Fail 2018; 11 (12) e005266
    CrossrefPubMedSuche in Google Scholar
  • 36 Nagasaki T, Inaba M, Kumeda Y. et al. Increased pulse wave velocity in subclinical hypothyroidism. J Clin Endocrinol Metab 2006; 91 (01) 154-158
    CrossrefPubMedSuche in Google Scholar
  • 37 Owen PJ, Sabit R, Lazarus JH. Thyroid disease and vascular function. Thyroid 2007; 17 (06) 519-524
    CrossrefPubMedSuche in Google Scholar
  • 38 Gluvic ZM, Zafirovic SS, Obradovic MM, Sudar-Milovanovic EM, Rizzo M, Isenovic ER. Hypothyroidism and risk of cardiovascular disease. Curr Pharm Des 2022; 28 (25) 2065-2072
    CrossrefPubMedSuche in Google Scholar
  • 39 Muzurović E, Borozan S, Vujošević S, Gurnell M. Thyroid status and vascular risk: an update. Curr Vasc Pharmacol 2022; 20 (06) 460-462
    CrossrefPubMedSuche in Google Scholar
  • 40 Nagasaki T, Inaba M, Henmi Y. et al. Decrease in carotid intima-media thickness in hypothyroid patients after normalization of thyroid function. Clin Endocrinol (Oxf) 2003; 59 (05) 607-612
    CrossrefPubMedSuche in Google Scholar
  • 41 Asoğlu E, Akbulut T, Doğan Z, Asoğlu R. Evaluation of the aortic velocity propagation, epicardial fat thickness, and carotid intima-media thickness in patients with subclinical hypothyroidism. Rev Cardiovasc Med 2021; 22 (03) 959-966
    CrossrefPubMedSuche in Google Scholar
  • 42 Paschou SA, Siasos G, Bletsa E. et al. The effect of DPP-4i on endothelial function and arterial stiffness in patient with type 2 diabetes: a systematic review of randomized placebo–controlled trials. Curr Pharm Des 2020; 26 (46) 5980-5987
    CrossrefPubMedSuche in Google Scholar
  • 43 Hueston WJ, Pearson WS. Subclinical hypothyroidism and the risk of hypercholesterolemia. Ann Fam Med 2004; 2 (04) 351-355
    CrossrefPubMedSuche in Google Scholar
  • 44 Hyland KA, Arnold AM, Lee JS, Cappola AR. Persistent subclinical hypothyroidism and cardiovascular risk in the elderly: the cardiovascular health study. J Clin Endocrinol Metab 2013; 98 (02) 533-540
    CrossrefPubMedSuche in Google Scholar
  • 45 Biondi B. The management of thyroid abnormalities in chronic heart failure. Heart Fail Clin 2019; 15 (03) 393-398
    CrossrefPubMedSuche in Google Scholar
  • 46 Nakanishi K, Daimon M, Yoshida Y. et al. Subclinical hypothyroidism as an independent determinant of left atrial dysfunction in the general population. J Clin Endocrinol Metab 2021; 106 (04) e1859-e1867
    CrossrefPubMedSuche in Google Scholar
  • 47 Niknam N, Khalili N, Khosravi E, Nourbakhsh M. Endothelial dysfunction in patients with subclinical hypothyroidism and the effects of treatment with levothyroxine. Adv Biomed Res 2016; 5: 38
    CrossrefPubMedSuche in Google Scholar
  • 48 Aziz M, Kandimalla Y, Machavarapu A. et al. Effect of thyroxin treatment on carotid intima-media thickness (CIMT) reduction in patients with subclinical hypothyroidism: a meta-analysis of clinical trials. J Atheroscler Thromb 2017; 24 (07) 643-659
    CrossrefPubMedSuche in Google Scholar
  • 49 Wang X, Wang H, Li Q. et al. Effect of levothyroxine supplementation on the cardiac morphology and function in patients with subclinical hypothyroidism: a systematic review and meta-analysis. J Clin Endocrinol Metab 2022; 107 (09) 2674-2683
    CrossrefPubMedSuche in Google Scholar
  • 50 Andersen MN, Olsen AM, Madsen JC. et al. Levothyroxine substitution in patients with subclinical hypothyroidism and risk of myocardial infarction and mortality. PLoS One 2015; 10 (06) e0129793
    CrossrefPubMedSuche in Google Scholar
  • 51 Jabbar A, Ingoe L, Junejo S. et al. Effects of levothyroxine on left ventricular ejection fraction in patients with subclinical hypothyroidism and acute myocardial infarction: a randomized clinical trial. JAMA 2020; 324 (03) 249-258
    CrossrefPubMedSuche in Google Scholar
  • 52 Stott DJ, Rodondi N, Kearney PM. et al; TRUST Study Group. Thyroid hormone therapy for older adults with subclinical hypothyroidism. N Engl J Med 2017; 376 (26) 2534-2544
    CrossrefPubMedSuche in Google Scholar
  • 53 Feller M, Snel M, Moutzouri E. et al. Association of thyroid hormone therapy with quality of life and thyroid-related symptoms in patients with subclinical hypothyroidism: a systematic review and meta-analysis. JAMA 2018; 320 (13) 1349-1359
    CrossrefPubMedSuche in Google Scholar
  • 54 Magri F, Chiovato L, Croce L, Rotondi M. Thyroid hormone therapy for subclinical hypothyroidism. Endocrine 2019; 66 (01) 27-34
    CrossrefPubMedSuche in Google Scholar
  • 55 Chaker L, Baumgartner C, den Elzen WP. et al; Thyroid Studies Collaboration. Subclinical hypothyroidism and risk of stroke events and fatal stroke: an individual participant data analysis. J Clin Endocrinol Metab 2015; 100 (06) 2181-2191
    CrossrefPubMedSuche in Google Scholar
  • 56 Chaker L, Sedaghat S, Hoorn EJ. et al. The association of thyroid function and the risk of kidney function decline: a population-based cohort study. Eur J Endocrinol 2016; 175 (06) 653-660
    CrossrefPubMedSuche in Google Scholar
  • 57 Lu Y, Guo H, Liu D, Zhao Z. Preservation of renal function by thyroid hormone replacement in elderly persons with subclinical hypothyroidism. Arch Med Sci 2016; 12 (04) 772-777
    CrossrefPubMedSuche in Google Scholar
  • 58 Adrees M, Gibney J, El-Saeity N, Boran G. Effects of 18 months of L-T4 replacement in women with subclinical hypothyroidism. Clin Endocrinol (Oxf) 2009; 71 (02) 298-303
    CrossrefPubMedSuche in Google Scholar
  • 59 Rosario PWS, Calsolari MR. Impact of subclinical hypothyroidism with TSH ≤10 mIU/L on glomerular filtration rate in adult women without known kidney disease. Endocrine 2018; 59 (03) 694-697
    CrossrefPubMedSuche in Google Scholar
  • 60 Rieben C, Segna D, da Costa BR. et al. Subclinical thyroid dysfunction and risk of cognitive decline: a meta-analysis of prospective cohort studies. J Clin Endocrinol Metab 2016; 101 (12) 4945-4954
    CrossrefPubMedSuche in Google Scholar
  • 61 Jorde R, Waterloo K, Storhaug H, Nyrnes A, Sundsfjord J, Jenssen TG. Neuropsychological function and symptoms in subjects with subclinical hypothyroidism and the effect of thyroxine treatment. J Clin Endocrinol Metab 2006; 91 (01) 145-153
    CrossrefPubMedSuche in Google Scholar
  • 62 Parle J, Roberts L, Wilson S. et al. A randomized controlled trial of the effect of thyroxine replacement on cognitive function in community-living elderly subjects with subclinical hypothyroidism: the Birmingham Elderly Thyroid study. J Clin Endocrinol Metab 2010; 95 (08) 3623-3632
    CrossrefPubMedSuche in Google Scholar
  • 63 Gussekloo J, van Exel E, de Craen AJ, Meinders AE, Frölich M, Westendorp RG. Thyroid status, disability and cognitive function, and survival in old age. JAMA 2004; 292 (21) 2591-2599
    CrossrefPubMedSuche in Google Scholar
  • 64 Simonsick EM, Newman AB, Ferrucci L. et al; Health ABC Study. Subclinical hypothyroidism and functional mobility in older adults. Arch Intern Med 2009; 169 (21) 2011-2017
    CrossrefPubMedSuche in Google Scholar
  • 65 Roberts LM, Pattison H, Roalfe A. et al. Is subclinical thyroid dysfunction in the elderly associated with depression or cognitive dysfunction?. Ann Intern Med 2006; 145 (08) 573-581
    CrossrefPubMedSuche in Google Scholar
  • 66 Rodriguez-Gutierrez R, Maraka S, Ospina NS, Montori VM, Brito JP. Levothyroxine overuse: time for an about face?. Lancet Diabetes Endocrinol 2017; 5 (04) 246-248
    CrossrefPubMedSuche in Google Scholar
  • 67 Taylor PN, Iqbal A, Minassian C. et al. Falling threshold for treatment of borderline elevated thyrotropin levels-balancing benefits and risks: evidence from a large community-based study. JAMA Intern Med 2014; 174 (01) 32-39
    CrossrefPubMedSuche in Google Scholar
  • 68 Turner MR, Camacho X, Fischer HD. et al. Levothyroxine dose and risk of fractures in older adults: nested case-control study. BMJ 2011; 342: d2238
    CrossrefPubMedSuche in Google Scholar
  • 69 De Groot L, Abalovich M, Alexander EK. et al. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2012; 97 (08) 2543-2565
    CrossrefPubMedSuche in Google Scholar
  • 70 Alexander EK, Pearce EN, Brent GA. et al. 2017 Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid 2017; 27 (03) 315-389
    CrossrefPubMedSuche in Google Scholar
  • 71 Reid SM, Middleton P, Cossich MC, Crowther CA, Bain E. Interventions for clinical and subclinical hypothyroidism pre-pregnancy and during pregnancy. Cochrane Database Syst Rev 2013; (05) CD007752
    PubMedSuche in Google Scholar
  • 72 Thangaratinam S, Tan A, Knox E, Kilby MD, Franklyn J, Coomarasamy A. Association between thyroid autoantibodies and miscarriage and preterm birth: meta-analysis of evidence. BMJ 2011; 342: d2616
    CrossrefPubMedSuche in Google Scholar
  • 73 Maraka S, Ospina NM, O'Keeffe DT. et al. Subclinical hypothyroidism in pregnancy: a systematic review and meta-analysis. Thyroid 2016; 26 (04) 580-590
    CrossrefPubMedSuche in Google Scholar
  • 74 Wiles KS, Jarvis S, Nelson-Piercy C. Are we overtreating subclinical hypothyroidism in pregnancy?. BMJ 2015; 351: h4726
    CrossrefPubMedSuche in Google Scholar
  • 75 Maraka S, Mwangi R, McCoy RG. et al. Thyroid hormone treatment among pregnant women with subclinical hypothyroidism: US national assessment. BMJ 2017; 356: i6865
    CrossrefPubMedSuche in Google Scholar
  • 76 Bath SC, Rayman MP. Antenatal thyroid screening and childhood cognitive function. N Engl J Med 2012; 366 (17) 1640-1641 , author reply 1641
    CrossrefPubMedSuche in Google Scholar
  • 77 Yamamoto JM, Benham JL, Nerenberg KA, Donovan LE. Impact of levothyroxine therapy on obstetric, neonatal and childhood outcomes in women with subclinical hypothyroidism diagnosed in pregnancy: a systematic review and meta-analysis of randomised controlled trials. BMJ Open 2018; 8 (09) e022837
    CrossrefPubMedSuche in Google Scholar
  • 78 Rotondi M, Chiovato L, Pacini F, Bartalena L, Vitti P. Management of subclinical hypothyroidism in pregnancy: a comment from the Italian Society of Endocrinology and the Italian Thyroid Association to the 2017 American Thyroid Association Guidelines-“The Italian Way”. Thyroid 2018; 28 (05) 551-555
    CrossrefPubMedSuche in Google Scholar
  • 79 Wiles K. Management for women with subclinical hypothyroidism in pregnancy. Drug Ther Bull 2019; 57 (02) 22-26
    CrossrefPubMedSuche in Google Scholar
  • 80 Imaizumi M, Sera N, Ueki I. et al. Risk for progression to overt hypothyroidism in an elderly Japanese population with subclinical hypothyroidism. Thyroid 2011; 21 (11) 1177-1182
    CrossrefPubMedSuche in Google Scholar
  • 81 Cooper DS. Thyroid disease in the oldest old: the exception to the rule. JAMA 2004; 292 (21) 2651-2654
    CrossrefPubMedSuche in Google Scholar
  • 82 Biondi B, Kahaly GJ, Robertson RP. Thyroid dysfunction and diabetes mellitus: two closely associated disorders. Endocr Rev 2019; 40 (03) 789-824
    CrossrefPubMedSuche in Google Scholar
  • 83 National Institute of Health and Care Excellence. Clinical knowledge summaries. Subclinical hypothyroidism (non-pregnant). 2018 . Accessed June 16, 2024 at: http://www.nice.org.uk/guidance/ng145
    Suche in Google Scholar
  • 84 Pearce SH, Brabant G, Duntas LH. et al. 2013 ETA guideline: management of subclinical hypothyroidism. Eur Thyroid J 2013; 2 (04) 215-228
    CrossrefPubMedSuche in Google Scholar
  • 85 Ross DS. Subclinical hypothyroidism in nonpregnant adults. UpToDate. 2022 . Accessed June 16, 2024 at: http://www.uptodate.com/contents/subclinical-hypothyrodism-in-nonpregnant-adults
    Suche in Google Scholar