Hashimoto's thyroiditis: two decades on.

Hashimoto's thyroiditis is the leading cause of primary hypothyroidism in iodine-sufficient regions, progressing from euthyroid autoimmunity to subclinical or overt disease with variable clinical course.

• Why it matters: Immune-mediated thyroid follicular cell injury and disrupted immune tolerance drive heterogeneous progression, yet diagnosis and management still rely largely on monitoring rather than disease-modifying treatment.
• What they did: This Review synthesizes two decades of evidence on epidemiology, natural history, aetiopathogenesis, diagnosis, and management, integrating genetic, environmental, and epigenetic mechanisms with clinical assessment, thyroid function tests, autoantibodies, and ultrasonography when indicated.
• The result: Levothyroxine replacement is established for overt hypothyroidism and individualized care is used for subclinical disease, while immunomodulatory strategies remain investigational and precision approaches are proposed for future therapies.

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