🧬 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
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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

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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
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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
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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
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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.
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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
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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

Frequently Asked Questions

What are the symptoms of hypothyroidism?
Classic symptoms: fatigue and lethargy (most common), weight gain, cold intolerance, constipation, dry skin and hair, hair loss, bradycardia, myalgia, depression, cognitive slowing ('brain fog'), menstrual irregularity (heavy periods), and facial puffiness (periorbital oedema). In severe hypothyroidism: myxoedema — non-pitting oedema, hoarse voice, carpal tunnel syndrome, pleural/pericardial effusions, and ultimately myxoedema coma.
What is the most common cause of hypothyroidism in India?
Hashimoto thyroiditis (autoimmune thyroiditis) is the most common cause in iodine-sufficient urban India, characterised by elevated anti-TPO and anti-thyroglobulin antibodies and lymphocytic infiltration of the thyroid. Iodine deficiency remains a significant cause in remote and hilly regions (Himalayan belt, northeast India) where iodised salt use is suboptimal. Iatrogenic causes: post-thyroidectomy and post-radioiodine ablation for hyperthyroidism.
What is the starting dose of levothyroxine?
Standard dose: 1.6 mcg/kg/day actual body weight in young healthy adults. Elderly (>65 years) or ischaemic heart disease: start low at 12.5–25 mcg/day, uptitrate by 12.5–25 mcg every 6–8 weeks. Severe hypothyroidism or myxoedema coma: IV levothyroxine 200–500 mcg stat (hospital setting) + exclude adrenal insufficiency before giving T4. Recheck TSH after 6–8 weeks of any dose change.
What TSH level confirms hypothyroidism?
Overt hypothyroidism: TSH >10 mIU/L with low free T4 — always treat. Subclinical hypothyroidism: TSH 4–10 mIU/L with normal free T4. Treat subclinical if: TSH >10, symptoms present, positive anti-TPO antibodies, pregnant or planning pregnancy, or age <65 with cardiovascular risk factors. Do not routinely treat asymptomatic TSH 4–10 in elderly >65 — TRUST trial showed no benefit.
How is levothyroxine taken correctly?
Take on an empty stomach 30–60 minutes before breakfast (or at bedtime, consistently). Calcium supplements, iron tablets, PPIs, and antacids reduce levothyroxine absorption — take 4 hours apart. Drug interactions increasing T4 requirement: rifampicin, phenytoin, carbamazepine. Consistency in timing and brand matters — avoid switching brands without TSH monitoring. Recheck TSH 6–8 weeks after any dose change; annually when stable.
What is myxoedema coma?
Myxoedema coma is a life-threatening complication of severe untreated hypothyroidism: hypothermia, bradycardia, hypotension, hypoventilation, altered consciousness, and hyponatraemia. Precipitants: cold exposure, infection, sedatives, surgery. Management: IV levothyroxine 200–500 mcg stat (penetrates blood-brain barrier faster) ± IV T3, IV hydrocortisone (adrenal insufficiency may co-exist), rewarming, supportive ICU care. Mortality 20–50% even with treatment.
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.

Frequently Asked Questions

What are the symptoms of hypothyroidism?
Common symptoms: fatigue, weight gain, cold intolerance, constipation, dry skin, hair loss, bradycardia, depression, cognitive slowing, and menstrual irregularity. Severe cases cause myxoedema — non-pitting oedema, hoarse voice, pleural/pericardial effusions, and myxoedema coma.
What is the most common cause of hypothyroidism in India?
Hashimoto thyroiditis (autoimmune) is the most common cause in urban India, with positive anti-TPO antibodies. Iodine deficiency remains significant in remote hilly regions. Iatrogenic causes include post-thyroidectomy and post-radioiodine ablation.
What TSH level confirms hypothyroidism?
Overt hypothyroidism: TSH >10 mIU/L with low free T4 — always treat. Subclinical: TSH 4–10 with normal T4. Treat subclinical if TSH >10, symptomatic, anti-TPO positive, pregnant, or age <65 with cardiovascular risk. Avoid treating asymptomatic TSH 4–10 in elderly >65 — TRUST trial showed no benefit.
What is the starting dose of levothyroxine?
Standard: 1.6 mcg/kg/day in young healthy adults. Elderly or ischaemic heart disease: start 12.5–25 mcg/day, uptitrate every 6–8 weeks. Take on empty stomach 30–60 minutes before breakfast. Calcium, iron, and PPIs reduce absorption — take 4 hours apart. Recheck TSH after 6–8 weeks of any dose change.
What is myxoedema coma?
Life-threatening complication of severe untreated hypothyroidism: hypothermia, bradycardia, hypotension, hypoventilation, altered consciousness, hyponatraemia. Precipitants: cold exposure, infection, sedatives. Management: IV levothyroxine 200–500 mcg stat, IV hydrocortisone (exclude adrenal insufficiency), rewarming, ICU support. Mortality 20–50% even with treatment.
How is hypothyroidism monitored on treatment?
Recheck TSH 6–8 weeks after starting or changing dose. Once stable, check TSH annually. Target TSH 0.5–2.5 mIU/L for most patients; 1–4 mIU/L in elderly. In pregnancy: increase levothyroxine dose by 25–30% immediately on confirming pregnancy, target TSH <2.5 mIU/L in first trimester.