Raiyyan Tahsan

Raiyyan Tahsan
Hello I'm Raiyyan Tahsan
Brand Model and Executive

TC(886).(20).Sexology Case No 39. Thyroid Disease

Thyroid Disease — সংজ্ঞা

Thyroid disease বলতে thyroid gland-এর hormone production কমে যাওয়া, বেড়ে যাওয়া, gland বড় হওয়া, nodule হওয়া, inflammation বা malignancy-suspected condition বোঝায়। মূল clinical ভাগগুলো হলো:

  1. Hypothyroidism — thyroid hormone কম
  2. Hyperthyroidism / Thyrotoxicosis — thyroid hormone বেশি
  3. Goitre / Thyroid nodule — গলা ফুলে যাওয়া বা গুটি
  4. Thyroiditis — thyroid gland-এর inflammation

NICE guideline অনুযায়ী suspected thyroid dysfunction-এ adult patient-এর initial test সাধারণত TSH, এরপর TSH high হলে FT4, TSH low হলে FT4 + FT3 করা উচিত; biotin supplement test result ভুল করতে পারে।

1. Cause / Etiology — কারণসমূহ

A. Hypothyroidism-এর কারণ

  1. Hashimoto thyroiditis / autoimmune thyroid disease
    শরীরের immune system thyroid gland ধীরে ধীরে damage করে। TPO antibody positive থাকতে পারে।
  2. Iodine deficiency বা iodine excess
    Iodine thyroid hormone তৈরির জন্য দরকার। deficiency হলে goitre ও hypothyroidism হতে পারে। WHO salt iodization-কে iodine deficiency control-এর preferred strategy বলেছে।
  3. Thyroid surgery / radioactive iodine-এর পরে
    Thyroid gland removal বা RAI therapy-এর পরে lifelong hypothyroidism হতে পারে।
  4. Drug-induced
    Amiodarone, lithium, interferon-alpha, tyrosine kinase inhibitor, immune-checkpoint inhibitor, excess iodine contrast ইত্যাদি।
  5. Congenital hypothyroidism
    জন্মগত thyroid gland absent/underdeveloped বা hormone synthesis defect।
  6. Central hypothyroidism
    Pituitary বা hypothalamus disease—TSH ঠিকমতো stimulate করতে পারে না।

B. Hyperthyroidism / Thyrotoxicosis-এর কারণ

  1. Graves disease
    Autoimmune TRAb/TSI antibody thyroid gland stimulate করে hormone বাড়ায়; diffuse goitre, bruit, eye sign থাকতে পারে।
  2. Toxic multinodular goitre / toxic adenoma
    Thyroid nodule নিজে নিজে hormone তৈরি করে।
  3. Thyroiditis
    Subacute painful thyroiditis, painless/silent thyroiditis, postpartum thyroiditis—এগুলোতে stored hormone release হয়; antithyroid drug সাধারণত মূল চিকিৎসা নয়, supportive treatment বেশি দরকার। NICE thyrotoxicosis with hyperthyroidism ও transient thyroiditis আলাদা করতে TRAb ও প্রয়োজনে technetium scan বিবেচনা করতে বলেছে।
  4. Exogenous thyroid hormone intake
    Levothyroxine বেশি খাওয়া বা ভুল dose।
  5. Iodine / amiodarone-induced thyrotoxicosis
    Iodine load বা amiodarone thyroid hormone imbalance করতে পারে।

C. Goitre / Nodule-এর কারণ

  1. Iodine deficiency
  2. Multinodular goitre
  3. Graves disease
  4. Hashimoto thyroiditis
  5. Thyroid cyst / benign adenoma
  6. Thyroid cancer — কমন নয়, কিন্তু red flag থাকলে জরুরি evaluation দরকার

NICE thyroid enlargement-এর red flags হিসেবে shortness of breath, rapid growth, hoarse voice, swallowing difficulty উল্লেখ করেছে।

2. Symptoms — লক্ষণসমূহ

A. Hypothyroidism symptoms

  1. অতিরিক্ত ক্লান্তি ও ঘুম ঘুম ভাব
  2. ওজন বৃদ্ধি, appetite কম হলেও
  3. ঠান্ডা বেশি লাগা
  4. Constipation
  5. শুষ্ক ত্বক, চুল পড়া, ভ্রু পাতলা হওয়া
  6. মুখ/চোখ ফুলে যাওয়া — myxoedema look
  7. Depression, memory কমে যাওয়া, slow thinking
  8. Bradycardia, low exercise tolerance
  9. Menorrhagia, infertility, libido কমে যাওয়া
  10. Hoarse voice, carpal tunnel syndrome
  11. Delayed ankle jerk reflex
  12. Severe হলে: myxoedema coma — hypothermia, altered consciousness, bradycardia; emergency

B. Hyperthyroidism symptoms

  1. ওজন কমে যাওয়া, appetite বেশি থাকতে পারে
  2. Heat intolerance, অতিরিক্ত ঘাম
  3. Palpitation, tachycardia, atrial fibrillation
  4. হাত কাঁপা — fine tremor
  5. Anxiety, irritability, insomnia
  6. Frequent stool / diarrhoea
  7. Muscle weakness, বিশেষ করে proximal myopathy
  8. Oligomenorrhoea / amenorrhoea, infertility
  9. Diffuse goitre, thyroid bruit — Graves-এ
  10. Eye symptoms — lid lag, exophthalmos, diplopia, gritty eye, photophobia
  11. Severe হলে: thyroid storm — fever, severe tachycardia, confusion, heart failure; emergency

C. Thyroiditis symptoms

  1. গলার সামনে ব্যথা, jaw/ear-এ pain যেতে পারে
  2. Fever, malaise
  3. শুরুতে hyperthyroid symptoms
  4. পরে transient hypothyroid phase
  5. অনেক ক্ষেত্রে কয়েক মাসে recovery

D. Nodule / Goitre symptoms

  1. গলায় lump বা swelling
  2. Dysphagia — গিলতে কষ্ট
  3. Dyspnoea — শ্বাসকষ্ট
  4. Hoarseness — recurrent laryngeal nerve involvement suspicious
  5. Rapid growth, hard fixed node, cervical lymph node — malignancy red flag

3. Clinical Diagnosis & Investigation

Step-1: History

  • Weight change, heat/cold intolerance, bowel habit
  • Palpitation, tremor, anxiety, sleep
  • Menstrual/fertility history
  • Neck swelling, pain, dysphagia, hoarseness
  • Drug history: amiodarone, lithium, iodine contrast, interferon, immunotherapy
  • Past thyroid surgery/RAI
  • Family history autoimmune disease
  • Pregnancy/postpartum status
  • Biotin supplement intake

Step-2: Examination

  • Pulse, BP, temperature
  • Tremor, sweating, skin/hair changes
  • Eye signs: lid lag, exophthalmos, ophthalmoplegia
  • Thyroid: size, tenderness, nodule, bruit, movement with swallowing
  • Cervical lymph node
  • Reflex: delayed relaxation in hypothyroidism
  • Heart failure / AF signs

Step-3: Specific laboratory diagnosis

PatternDiagnosis meaning
TSH high + FT4 lowPrimary hypothyroidism
TSH high + FT4 normalSubclinical hypothyroidism
TSH low + FT4/FT3 highOvert hyperthyroidism / thyrotoxicosis
TSH low + FT4/FT3 normalSubclinical hyperthyroidism
TSH low/normal + FT4 lowCentral hypothyroidism / severe non-thyroidal illness

TSH is the best initial screening test in most non-pituitary adult cases; ATA also describes TSH as an early warning marker, with high TSH usually suggesting underactive thyroid and low TSH usually suggesting overactive thyroid.

Step-4: Antibody test

  1. Anti-TPO antibody
    Hashimoto thyroiditis বা autoimmune hypothyroidism support করে। NICE raised TSH হলে adult-এ TPOAb consider করতে বলেছে।
  2. TRAb / TSI
    Graves disease confirm করতে useful।
  3. Anti-thyroglobulin antibody
    Selected cases, especially autoimmune thyroiditis / thyroid cancer follow-up context.

Step-5: Imaging

  1. Ultrasound thyroid
    Palpable nodule, goitre, asymmetry, suspicious lymph node থাকলে।
    Routine abnormal TFT alone-এ ultrasound করা উচিত নয় যদি palpable thyroid abnormality না থাকে।
  2. FNAC
    Suspicious ultrasound features বা size criteria অনুযায়ী। ATA thyroid nodule guideline অনুযায়ী ultrasound pattern + size combined করে FNA decision নেওয়া হয়।
  3. Radionuclide scan / Technetium scan
    Low TSH + nodule হলে toxic adenoma/multinodular goitre differentiate করতে।
  4. ESR/CRP
    Painful subacute thyroiditis-এ high হতে পারে।
  5. Baseline CBC + LFT
    Antithyroid drug শুরু করার আগে দরকার; NICE antithyroid drug-এর আগে full blood count ও liver function test করতে বলেছে।

4. Differential Diagnosis

Hypothyroid-like symptoms-এর differential

  • Anaemia
  • Depression
  • Chronic kidney disease
  • Chronic liver disease
  • Vitamin B12 deficiency
  • Sleep apnoea
  • Menopause
  • Drug-induced fatigue
  • Non-thyroidal illness

Hyperthyroid-like symptoms-এর differential

  • Anxiety / panic disorder
  • Pheochromocytoma
  • Cardiac arrhythmia
  • Tuberculosis / malignancy-related weight loss
  • Diabetes mellitus
  • Drug-induced tremor
  • Menopause hot flush

Thyroid nodule differential

  • Benign colloid nodule
  • Thyroid cyst
  • Multinodular goitre
  • Hashimoto pseudonodule
  • Thyroid adenoma
  • Thyroid carcinoma
  • Cervical lymph node / thyroglossal cyst

5. Complications — জটিলতা

Hypothyroidism complications

  1. Hyperlipidaemia
  2. Coronary artery disease risk বৃদ্ধি
  3. Bradycardia, pericardial effusion
  4. Infertility, miscarriage risk
  5. Depression, cognitive slowing
  6. Peripheral neuropathy / carpal tunnel
  7. Myxoedema coma — life-threatening emergency
  8. শিশুতে untreated হলে growth ও neurodevelopment impairment

Hyperthyroidism complications

  1. Atrial fibrillation
  2. Heart failure
  3. Osteoporosis
  4. Muscle wasting
  5. Weight loss, malnutrition
  6. Thyroid eye disease
  7. Infertility / menstrual disorder
  8. Thyroid storm — life-threatening emergency
  9. Long-standing toxic goitre-এ compressive symptoms

6. Treatment Management — Guideline-based

A. Hypothyroidism treatment

Main drug: Levothyroxine

NICE adult, children ও young people-এর primary hypothyroidism-এ levothyroxine first-line treatment বলেছে। Adult <65 years without cardiovascular disease: starting dose about 1.6 mcg/kg/day; age ≥65 বা cardiovascular disease থাকলে 25–50 mcg/day দিয়ে titration।

Dose shortcut

  • Young healthy adult: 1.6 mcg/kg/day
  • Elderly / CAD / severe long-standing hypothyroid: 12.5–25 or 25–50 mcg/day
  • Dose increase: 12.5–25 mcg every 6–8 weeks
  • Monitoring: TSH 6–8 weeks after dose change; stable হলে বছরে ১ বার
  • Duration: Hashimoto, post-surgery, post-RAI হলে usually lifelong
  • Timing: সকালে খালি পেটে, breakfast-এর 30–60 min আগে

Drug profile

  1. Generic name: Levothyroxine sodium
  2. Therapeutic category: Thyroid hormone replacement
  3. Pharmacological class: Synthetic T4 hormone
  4. Purpose: শরীরে কম থাকা T4 replace করে TSH normalize করা
  5. Side effects: Dose বেশি হলে palpitation, tremor, insomnia, weight loss, AF, angina, osteoporosis
  6. Interaction: Calcium, iron, antacid, sucralfate, cholestyramine, soy, coffee absorption কমায়; warfarin effect বাড়তে পারে; phenytoin/carbamazepine/rifampicin metabolism affect করতে পারে
  7. Bangladesh available brands: Euthycin 50 mcg, Euthyrox 25/50/100 mcg, Leroid 25/50 mcg tablet/capsule, Synroid 50 mcg, Synthox 25/50/75/100 mcg, T4 25/50 mcg, Thormon 50 mcg, Thynor 50 mcg, Thyrin 25/50/75/100 mcg, Thyrolar 50 mcg, Thyronor 12.5/25/50/75/100 mcg, Thyrotab 50 mcg, Thyrox 25/50/75/100 mcg, Tyroid 50 mcg. MedEx lists Thyrox 12.5 as “mg”; clinically levothyroxine dose is microgram, so pack label should be verified before prescribing.

B. Hyperthyroidism / Graves disease treatment

Treatment options

  1. Symptom control: beta-blocker
  2. Antithyroid drug: carbimazole / methimazole / PTU
  3. Definitive treatment: radioactive iodine or surgery
  4. Thyroid storm: ICU emergency management

NICE Graves disease-এ selected mild uncomplicated patient-এ antithyroid drug 12–18 months বা radioactive iodine option দেয়; antithyroid drug শুরু করলে carbimazole 12–18 months titration/block-replace regimen ব্যবহার করা যায়। PTU consider করা হয় carbimazole adverse reaction, pregnancy/trying pregnancy, বা pancreatitis history থাকলে।

B1. Carbimazole

  1. Generic name: Carbimazole
  2. Therapeutic category: Antithyroid drug
  3. Pharmacological class: Thionamide; methimazole prodrug
  4. Dose:
    • Mild–moderate: 10–20 mg/day
    • Severe: 30–40 mg/day
    • Maintenance: 5–15 mg/day
    • Duration: usually 12–18 months in Graves disease
  5. Purpose: Thyroid peroxidase inhibit করে T3/T4 synthesis কমায়
  6. Side effects: Rash, pruritus, arthralgia, GI upset, agranulocytosis, hepatitis/cholestasis, rarely pancreatitis
  7. Danger sign: Fever, sore throat, mouth ulcer হলে drug stop + urgent CBC
  8. Interaction: Warfarin effect thyroid state change-এর সাথে vary করতে পারে; iodine excess response কমাতে পারে
  9. Bangladesh available brands: Carbiroid 5 mg/10 mg, Carbizol 5 mg/10 mg.

B2. Methimazole

  1. Generic name: Methimazole
  2. Therapeutic category: Antithyroid drug
  3. Pharmacological class: Thionamide
  4. Dose:
    • Mild: 5–10 mg/day
    • Moderate: 10–20 mg/day
    • Severe: 30–40 mg/day
    • Maintenance: 5–10 mg/day
    • Duration: usually 12–18 months
  5. Purpose: T3/T4 synthesis কমানো
  6. Side effects: Rash, itching, arthralgia, agranulocytosis, hepatotoxicity; pregnancy 1st trimester-এ avoid unless specialist-directed
  7. Interaction: Warfarin, digoxin, beta-blocker dose requirement thyroid status normalize হলে বদলাতে পারে
  8. Bangladesh available brands: Methiroid 5 mg/10 mg, Tapazol 5 mg/10 mg, Thyzol 5 mg/10 mg/20 mg.

B3. Propylthiouracil — PTU

  1. Generic name: Propylthiouracil
  2. Therapeutic category: Antithyroid drug
  3. Pharmacological class: Thionamide
  4. Dose:
    • Initial: 100 mg every 8 hourly = 300 mg/day
    • Severe: 400–600 mg/day divided
    • Maintenance: 50 mg 2–3 times/day
    • Duration: specialist-directed; Graves-এ 12–18 months course হতে পারে
  5. Purpose: T4/T3 synthesis কমায় এবং peripheral T4→T3 conversion কিছুটা কমায়; thyroid storm ও pregnancy early phase-এ specialist setting-এ বেশি useful
  6. Side effects: Rash, agranulocytosis, severe hepatotoxicity, ANCA vasculitis
  7. Danger sign: Jaundice, dark urine, severe fatigue, fever/sore throat হলে stop + urgent CBC/LFT
  8. Interaction: Warfarin effect বাড়তে পারে; beta-blocker dose adjust লাগতে পারে
  9. Bangladesh available brands: PTU 50 mg, Thiocil 50 mg.

B4. Beta-blocker for symptom control

Propranolol

  1. Generic name: Propranolol hydrochloride
  2. Therapeutic category: Symptomatic control in thyrotoxicosis
  3. Pharmacological class: Non-selective beta-blocker
  4. Dose: 10–40 mg orally 3–4 times/day; severe symptomsে higher specialist dose
  5. Purpose: Palpitation, tremor, anxiety, tachycardia কমায়
  6. Side effects: Bradycardia, hypotension, bronchospasm, fatigue, sleep disturbance
  7. Avoid/caution: Asthma/COPD, heart block, severe bradycardia
  8. Interaction: Verapamil/diltiazem, digoxin, insulin/sulfonylurea masking hypoglycaemia
  9. Bangladesh brands: Propranol 10/20/40 mg, Indever 10/40 mg, Adlock 10/40 mg, Betacap TR 40 mg.

Metoprolol alternative

  • Generic: Metoprolol tartrate
  • Class: Beta-1 selective beta-blocker
  • Dose: 25–50 mg 2–4 times/day depending on pulse/BP
  • Bangladesh brands: Betaloc 25/50 mg, Betacard 50 mg, Betaone 25/50 mg, Metaloc 50/100 mg, Lopresor 50 mg; MedEx hyperthyroidism indication-এ metoprolol 50 mg four times daily উল্লেখ করেছে।

Atenolol alternative

  • Generic: Atenolol
  • Class: Beta-1 selective beta-blocker
  • Dose: 25–50 mg once daily
  • Bangladesh brands: Tenoren 25/50/100 mg, Tenoloc 50/100 mg, Betanol 25/50/100 mg, Lonet 50/100 mg, Cardisef 50/100 mg, Tenocard 50 mg.

C. Thyroiditis treatment

Subacute painful thyroiditis

  1. Mild pain: NSAID
  2. Severe pain: Prednisolone
  3. Hyperthyroid symptoms: Beta-blocker
  4. Antithyroid drug: সাধারণত লাগে না, কারণ hormone synthesis বেশি নয়—stored hormone release হয়
  5. Temporary hypothyroid phase: symptomatic/marked TSH high হলে temporary levothyroxine

NSAID options

Ibuprofen

  • Dose: 200–400 mg 6–8 hourly after food; max OTC range usually 1200 mg/day
  • Side effects: gastritis, GI bleeding, renal injury, BP rise
  • Avoid/caution: peptic ulcer, CKD, anticoagulant, uncontrolled HTN
  • Bangladesh brands: Flamex 200/400 mg, Flam 400 mg, Profen 400 mg, Intaflam 400 mg, Reumafen 200/400 mg.

Naproxen

  • Dose: 250–500 mg twice daily after food
  • Side effects/interactions: same NSAID class; anticoagulant/steroid/CKD caution
  • Bangladesh brands: Naprox 250/500 mg, Naprosyn 250/500 mg, Naproxin 250/500 mg, Naxo 500 mg, Nipoxen 250 mg.

Prednisolone

  1. Generic: Prednisolone
  2. Therapeutic category: Corticosteroid
  3. Pharmacological class: Glucocorticoid
  4. Dose: Subacute thyroiditis severe painে commonly 20–40 mg/day, then gradual taper over 2–6 weeks according to pain/ESR/CRP
  5. Purpose: Inflammation ও severe thyroid pain কমানো
  6. Side effects: Hyperglycaemia, gastritis, mood change, insomnia, weight gain, infection risk, hypertension
  7. Interaction: NSAID + steroid = GI bleed risk; warfarin, diabetes drugs adjustment may be needed
  8. Bangladesh brands: Cortan 2/5/20 mg, Deltasone 5/10/20 mg, Pednisol 5/10/20 mg, Pred 5/10/20 mg, Predimax 5/10/20 mg, Precodil 2/10 mg and oral solution, Inflagic 20 mg.

D. Goitre / Nodule management

  1. TSH first
    TSH low হলে toxic nodule exclude করতে scan।
  2. Ultrasound thyroid
    Nodule size, echogenicity, margin, calcification, taller-than-wide, lymph node দেখা।
  3. FNAC
    Suspicious US pattern/size criteria অনুযায়ী।
  4. Benign nodule
    Follow-up USG; compressive symptoms থাকলে surgery।
  5. Toxic multinodular goitre / toxic adenoma
    RAI বা surgery definitive; antithyroid drug symptom control/bridge হিসেবে।
  6. Cancer suspected
    Urgent ENT/endocrine surgery referral।

7. Prevention — কীভাবে প্রতিরোধ করবেন

  1. Iodized salt ব্যবহার
    Iodine deficiency area-তে goitre কমাতে iodized salt গুরুত্বপূর্ণ। WHO iodine deficiency control-এ salt iodization-কে preferred strategy বলে।
  2. অতিরিক্ত iodine supplement নিজে থেকে নয়
    Excess iodine hyperthyroidism বা hypothyroidism দুটোই trigger করতে পারে।
  3. High-risk patient screening
    Type 1 diabetes, autoimmune disease, new-onset AF, depression/anxiety with suspicion, infertility/menstrual disorder, postpartum symptoms — TFT করা যুক্তিযুক্ত। NICE autoimmune disease ও new-onset AF-এ thyroid test offer করতে বলেছে।
  4. Drug monitoring
    Amiodarone, lithium, immune therapy, iodine contrast নেওয়া রোগীতে baseline ও follow-up TFT।
  5. Pregnancy planning
    Known thyroid disease থাকলে conception-এর আগে TSH optimize করা দরকার।
  6. Levothyroxine নিয়ম মেনে খাওয়া
    একই brand/strength maintain করা ভালো; calcium/iron/antacid থেকে 4 ঘণ্টা gap।
  7. Antithyroid drug warning education
    Fever, sore throat, mouth ulcer, jaundice হলে urgent CBC/LFT।
  8. Smoking stop
    Graves ophthalmopathy worsen করতে পারে।

Quick Clinical Shortcut

  • TSH ↑ + FT4 ↓ = Hypothyroid → Levothyroxine
  • TSH ↓ + FT4/FT3 ↑ = Hyperthyroid → Beta-blocker + cause-specific treatment
  • TRAb positive + diffuse goitre/eye sign = Graves
  • Painful tender thyroid + high ESR/CRP = Subacute thyroiditis → NSAID/steroid, not routine antithyroid
  • Nodule + low TSH = scan first
  • Nodule + hoarseness/rapid growth/lymph node = urgent referral

Overview / Summary

Thyroid disease mainly presents as hypothyroidism, hyperthyroidism, thyroiditis, or goitre/nodule. Diagnosis should be biochemical first: TSH, FT4, FT3, followed by TPOAb/TRAb, ultrasound, scan, or FNAC depending on clinical scenario. Hypothyroidism-এর main treatment levothyroxine; Graves/hyperthyroidism-এ beta-blocker + antithyroid drug, এবং definitive option হিসেবে RAI/surgery। Thyroiditis-এ সাধারণত NSAID/steroid supportive treatment লাগে।

Actionable Plan / Steps

  1. Patient-এর symptoms অনুযায়ী TSH first করুন।
  2. TSH high হলে FT4 + TPOAb; TSH low হলে FT4 + FT3 + TRAb।
  3. Antithyroid drug শুরু করার আগে CBC + LFT করুন।
  4. Palpable nodule/goitre হলে USG thyroid ± FNAC করুন।
  5. Levothyroxine শুরু করলে 6–8 weeks পরে TSH repeat।
  6. Carbimazole/methimazole/PTU দিলে fever/sore throat/jaundice warning লিখে দিন।
  7. Pregnancy, AF, heart failure, thyroid storm, eye disease, suspected cancer হলে endocrinologist/ENT referral।

Reference List

Textbooks

  1. Harrison’s Principles of Internal Medicine, 21st ed. Endocrinology section: Disorders of the Thyroid Gland.
  2. Davidson’s Principles and Practice of Medicine, 24th ed. Endocrinology chapter: Thyroid disease.
  3. Robbins & Cotran Pathologic Basis of Disease, 10th ed. Endocrine System: Thyroid gland pathology.
  4. Guyton and Hall Textbook of Medical Physiology, 14th ed. Thyroid metabolic hormones chapter.

Guidelines

  1. NICE NG145: Thyroid disease—assessment and management, updated/reviewed 2023–2025.
  2. American Thyroid Association 2014 Hypothyroidism Treatment Guideline — levothyroxine as standard therapy. DOI: 10.1089/thy.2014.0028.
  3. American Thyroid Association 2016 Hyperthyroidism Guideline. DOI: 10.1089/thy.2016.0229.
  4. American Thyroid Association 2015 Thyroid Nodule/Differentiated Thyroid Cancer Guideline. DOI: 10.1089/thy.2015.0020.
  5. WHO Guideline: Fortification of food-grade salt with iodine for prevention and control of iodine deficiency disorders.

Peer-reviewed journals with DOI

  1. Chaker L, et al. Hypothyroidism. Lancet. 2017;390:1550–1562. DOI: 10.1016/S0140-6736(17)30703-1.
  2. De Leo S, Lee SY, Braverman LE. Hyperthyroidism. Lancet. 2016;388:906–918. DOI: 10.1016/S0140-6736(16)00278-6.
  3. Jonklaas J, et al. Guidelines for the Treatment of Hypothyroidism. Thyroid. 2014;24(12):1670–1751. DOI: 10.1089/thy.2014.0028.
  4. Ross DS, et al. 2016 ATA Guidelines for Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016;26(10):1343–1421. DOI: 10.1089/thy.2016.0229.
  5. Haugen BR, et al. 2015 ATA Management Guidelines for Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26(1):1–133. DOI: 10.1089/thy.2015.0020.

Md.Rafiqul Islam Lipu Date:-27-05-2026 Wednesday Time:-06-16-29 Pm

Leave a Comment

Your email address will not be published. Required fields are marked *

Scroll to Top