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Thyroid function tests should also be done to rule out overt hypothyroidism as a cause of the patients symptoms.31,32 Various types of hypothyroid states exist, including the following: primary (disease of the thyroid gland itself), secondary or pituitary (from the lack of thyroid stimulating hormone), late Hashimotos thyroiditis (autoimmunity against the thyroid), iodine deficiency goiter, genetic thyroid enzyme defects, conversion of T4 to T3 defects, thyroid receptor insensitivity, and drug-induced hypothyroidism (ie, lithium, sulfonamides, phenylbutazone, or oral contraceptives).33-35 All of these disorders can result in a functional hypothyroidism and a very similar clinical presentation