🧬 ICD-10 E03.9 · Endocrinology

Hypothyroidism Billewicz Score

Clinical scoring tool for hypothyroidism diagnosis with ICMR STW-guided Levothyroxine dosing and TSH targets for Indian clinical practice.

📋 ICMR STW Guidelines 2022 🏥 Primary · Congenital · Central ⚡ Billewicz et al., 1969
🩺
Billewicz Scoring Tool
Select all present symptoms and signs — each scores +1 point
Female < 55 yrs earns +1 bonus point
Symptoms
Physical Signs
0
/ 12

🔍
Symptoms
Primary hypothyroidism
  • Fatigue, weight gain with poor appetite
  • Dry skin and cold intolerance
  • Hair loss, diffuse alopecia
  • Constipation
  • Hoarseness of voice
  • Dyspnea, muscle weakness & cramps
  • Menorrhagia → oligomenorrhea / amenorrhea
  • Infertility
  • Difficulty concentrating, poor memory
  • Paraesthesia, impaired hearing
👁
Signs
Clinical examination
  • Dry, coarse skin; cool peripheries
  • Puffy face, hands, feet (myxoedema)
  • Goitre
  • Bradycardia
  • Peripheral oedema
  • Delayed ankle tendon reflex
  • Periorbital puffiness
  • Carpal tunnel syndrome
  • Serous cavity effusions
  • Slow movements
🧪
Investigations & Interpretation
Confirming clinical suspicion
TypeTests to OrderInterpretation
Primary Hypothyroidism TSH · FT4 or Total T4 · TPO antibodies (if available) Overt: TSH ↑ + FT4 ↓
Subclinical: TSH ↑ + normal FT4/T4
Congenital TSH · FT4 or T4 · USG neck · Nuclear imaging (after 72 hrs, do not delay treatment) Screening: TSH > 30 mU/L; T4 < 10th centile
Confirmatory: TSH > 9 mU/L; FT4 < 0.6 ng/ml
Central (Secondary) FT4 or T4 · TSH · Other pituitary profile · Imaging of sella TSH normal or low + FT4/T4 low
💊
Levothyroxine Dosing — ICMR STW
Initiation and titration guidance
TypeStarting DoseSpecial Notes
Primary Hypothyroidism 1.6 – 1.8 mcg/kg/day (single dose, fasting, no calories for 1 hr) Elderly / CAD: start 12.5–25 mcg/day; increase 12.5–25 mcg every 3–4 weeks
Congenital Hypothyroidism 10 – 15 mcg/kg/day; single daily dose with breast milk (powdered) Titrate on FT4 + TSH initially, then TSH alone
Central (Secondary) 1.3 mcg/kg/day ⚠ Must treat coexisting adrenal insufficiency with Hydrocortisone first — risk of adrenal crisis
⚠️ Consider treating subclinical hypothyroidism if: large goitre, positive TPO antibody, ASCVD, heart failure, dyslipidaemia, infertility, depression, refractory anaemia, or personal/family history of autoimmune disease.
🎯
Target TSH Ranges
Primary hypothyroidism — age-adjusted
Young Adults
1.0 – 2.5 mU/L
Middle-Aged
1.5 – 3.0 mU/L
Elderly < 60 y
> 4.5 mU/L
Elderly 60–70 y
> 6.0 mU/L
Elderly 70–80 y
> 7.0 – 8.0 mU/L
Congenital Hypothyroidism Targets
Target T4
10 – 16 mcg/dl
Target FT4
1.4 – 2.3 ng/dl
Target TSH
0.5 – 2 mU/L
📅
Follow-up Schedule
Monitoring post-initiation

Primary / Central

  • TSH every 3–6 months initially
  • Annual follow-up once stable dose achieved
  • Central: titrate on FT4/T4 levels (not TSH)

Congenital Hypothyroidism

  • Initial: 2 weeks then 4 weeks
  • Every 1–2 months in first 6 months
  • Every 3–4 months from 6 months to 3 years
  • Every 6–12 months till growth is complete
Source: ICMR Standard Treatment Workflow — Hypothyroidism (ICD-10: E03.9), Department of Health Research, MoHFW, Government of India, July 2022.
Scoring Reference: Billewicz WZ, Chapman RS, Crooks J, et al. Statistical methods applied to the diagnosis of hypothyroidism. Q J Med. 1969;38:255–266.
This tool is for clinical decision support only. Individual patient management is at treating physician's discretion. Not a substitute for clinical judgment.