Hashimoto thyroiditis

Last updated: July 27, 2023

Summarytoggle arrow icon

Hashimoto thyroiditis is the most common type of autoimmune thyroiditis and the leading cause of hypothyroidism in the United States. Although it is thought to be due to chronic autoimmune-mediated lymphocytic inflammation and destruction of the thyroid tissue, the exact pathophysiology remains unclear. Patients may initially be asymptomatic or show signs of thyrotoxicosis, progressing to hypothyroidism as the organ parenchyma is destroyed. Diagnosis is based on a combination of clinical features, thyroid antibodies, and thyroid function tests. Additional studies (e.g., ultrasound, fine-needle aspiration) may be obtained to rule out alternative conditions and may support the diagnosis. Management consists of lifelong monitoring and, in most cases, hormone replacement therapy with levothyroxine.

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Pathophysiologytoggle arrow icon

Clinical featurestoggle arrow icon

Subtypes and variantstoggle arrow icon

Diagnosticstoggle arrow icon

Consider Hashimoto thyroiditis in patients with signs of hypothyroidism, thyrotoxicosis (less common), and/or painless goiter.

Approach [6][7][8]

Diagnosis of Hashimoto thyroiditis is based on clinical features, thyroid function tests, and positive TPOAbs and/or TgAbs.

Laboratory studies [6][9]

TPOAbs are positive in 70–80% of patients with Graves disease and in ∼15% of individuals without thyroid disease. [10]

Additional studies

The following studies are not required for diagnosis but may be performed during workups for thyroid disorders or goiter to rule out differential diagnoses (e.g., multinodular goiter or malignancy).

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Managementtoggle arrow icon

Treatment [6][12][16]

Lifelong oral levothyroxine replacement is required in most patients with Hashimoto thyroiditis.


  • For all phases (including euthyroidism) [6]
    • Lifelong annual TSH measurements
    • Clinical assessment for lymphoma and associated autoimmune diseases
  • After levothyroxine initiation or dosage change

Patients with Hashimoto thyroiditis are at increased risk of having or developing other autoimmune diseases (e.g., type 1 diabetes, SLE, Graves disease, Addison disease) and non-Hodgkin lymphoma. [6]

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. Staii A, Mirocha S, Todorova-Koteva K, Glinberg S, Jaume JC. Hashimoto thyroiditis is more frequent than expected when diagnosed by cytology which uncovers a pre-clinical state.. Thyroid research. 2010; 3 (1): p.11.doi: 10.1186/1756-6614-3-11 . | Open in Read by QxMD
  2. Sweeney LB, Stewart C, Gaitonde DY. Thyroiditis: An Integrated Approach. American Family Physician. 2014; 90 (6): p.389-396.
  3. Menconi F, Monti MC, Greenberg DA, et al. Molecular amino acid signatures in the MHC class II peptide-binding pocket predispose to autoimmune thyroiditis in humans and in mice. Proc Natl Acad Sci USA. 2008; 105 (37): p.14034-14039.doi: 10.1073/pnas.0806584105 . | Open in Read by QxMD
  4. Nicoline Schiess, Carlos A. Pardo. Hashimoto's Encephalopathy. Ann N Y Acad Sci. 2008; 1142 (1): p.254-265.doi: 10.1196/annals.1444.018 . | Open in Read by QxMD
  5. Mattozzi S, Sabater L, Escudero D, et al. Hashimoto encephalopathy in the 21st century. Neurology. 2019; 94 (2): p.e217-e224.doi: 10.1212/wnl.0000000000008785 . | Open in Read by QxMD
  6. Martinez Quintero B, Yazbeck C, Sweeney LB. Thyroiditis: Evaluation and Treatment.. Am Fam Physician. 2021; 104 (6): p.609-617.
  7. Dayan CM, Daniels GH. Chronic Autoimmune Thyroiditis. N Engl J Med. 1996; 335 (2): p.99-107.doi: 10.1056/nejm199607113350206 . | Open in Read by QxMD
  8. Caturegli P et al.. Hashimoto thyroiditis: Clinical and diagnostic criteria. Autoimmun Rev. 2014; 13 (4-5): p.391-397.doi: 10.1016/j.autrev.2014.01.007 . | Open in Read by QxMD
  9. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012; 18 (6): p.988-1028.doi: 10.4158/EP12280.GL . | Open in Read by QxMD
  10. Froehlich E, Wahl R. Thyroid Autoimmunity: Role of Anti-thyroid Antibodies in Thyroid and Extra-Thyroidal Diseases. Front Immunol. 2017; 8.doi: 10.3389/fimmu.2017.00521 . | Open in Read by QxMD
  11. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical ; 2018
  12. Garber JR, Cobin RH, Gharib H, et al. Clinical Practice Guidelines for Hypothyroidism in Adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid. 2012; 22 (12): p.1200-1235.doi: 10.1089/thy.2012.0205 . | Open in Read by QxMD
  13. Li Y, Zhou G, Ozaki T, et al. Distinct histopathological features of Hashimoto's thyroiditis with respect to IgG4-related disease. Mod Pathol. 2012; 25 (8): p.1086-1097.doi: 10.1038/modpathol.2012.68 . | Open in Read by QxMD
  14. James V. Hennessey. Riedel's Thyroiditis: A Clinical Review. The Journal of Clinical Endocrinology & Metabolism. 2011; 96 (10): p.3031-3041.doi: 10.1210/jc.2011-0617 . | Open in Read by QxMD
  15. Heufelder AE, Hay ID. Evidence for autoimmune mechanisms in the evolution of invasive fibrous thyroiditis (Riedel's struma). Clin Investig.. 1994; 72 (10): p.788-793.
  16. Travaglino A, Pace M, Varricchio S, et al. Hashimoto Thyroiditis in Primary Thyroid Non-Hodgkin Lymphoma. Am J Clin Pathol. 2019; 153 (2): p.156-164.doi: 10.1093/ajcp/aqz145 . | Open in Read by QxMD
  17. Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Thyroid. 2014; 24 (12): p.1670-1751.doi: 10.1089/thy.2014.0028 . | Open in Read by QxMD

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