Thyroid disorders represent one of the most common yet under-recognized endocrine issues affecting women, particularly during their reproductive years. The thyroid gland, although small, plays a critical role in regulating metabolism, hormonal balance, menstrual health, and fertility. Disorders such as hypothyroidism (underactive thyroid) and hyperthyroidism (overactive thyroid) can significantly influence menstrual irregularities, ovulation patterns, pregnancy outcomes, and overall reproductive health. Despite the availability of effective screening tools and treatments, awareness about thyroid health among women remains insufficient, especially in semi-urban and rural regions [1-5].

In India, thyroid disorders are highly prevalent, with hypothyroidism disproportionately affecting women, particularly those aged 15 to 45 years. Studies have shown that untreated or poorly managed thyroid dysfunction can lead to infertility, miscarriage, menstrual disturbances, and increased risk of complications during pregnancy, including preeclampsia, low birth weight, and preterm delivery. Alarmingly, many women remain undiagnosed due to the vague nature of symptoms such as fatigue, weight changes, and mood disturbances, which are often misattributed to lifestyle stressors or ignored altogether [6-9].

In Shimla, a district with a unique blend of urban and semi-rural populations, geographical constraints and variations in health literacy pose additional challenges in timely diagnosis and management of thyroid conditions. Limited health-seeking behavior, misconceptions about symptoms,  and   lack   of   proactive  screening,  especially among women of reproductive age, contribute to the silent burden of thyroid disease in the community. Additionally, awareness about the interconnection between thyroid health and reproductive well-being—including its impact on fertility, pregnancy, and postpartum recovery—remains critically low.

This study aims to assess the level of public knowledge, perceptions, and practices regarding thyroid disorders among women in Shimla, with a particular focus on their awareness of symptoms, reproductive health implications, and the importance of early diagnosis and treatment. By identifying existing knowledge gaps and misconceptions, the study intends to guide community-level health education initiatives and contribute to the broader goal of improving endocrine and reproductive health outcomes in women across varying socio-demographic groups in the district.

Study Design

A descriptive, cross-sectional online survey was conducted to assess awareness, understanding, and practices related to thyroid disorders and their implications on reproductive health among women in Shimla. The study was designed to gather data from a diverse female population across different reproductive life stages using a structured questionnaire disseminated via digital platforms.

Study Area and Target Population

The study was carried out among women residing in Shimla district, Himachal Pradesh. The target population included adolescent girls (≥15 years), young women, women of reproductive age (15–45 years), and post-reproductive women, regardless of their pregnancy status or parity.

Inclusion Criteria:

• Female participants aged 15 years and above.

• Residents of Shimla district (minimum 1 year).

• Ability to comprehend and respond in Hindi or English.

• Access to a smartphone, tablet, or computer with internet connectivity.

• Willingness to provide informed electronic consent.

Exclusion Criteria:

• Healthcare professionals specializing in endocrinology or gynecology (to avoid bias).

• Women with a previously diagnosed and professionally managed thyroid disorder (if focus is on public awareness and undiagnosed cases).

Study Duration

The study was conducted over a six-week period, from Jan 1st  to Feb 15th , 2025, aligning with World Thyroid Awareness Month campaigns to improve participation and visibility.

Sampling Technique and Sample Size

A non-probability convenience sampling method was used, given the online nature of the study. The survey link was distributed through:

• Women-specific WhatsApp and Facebook groups,

• Educational institution forums and health clubs,

• Local NGOs and community health workers,

• Online networks of primary health centers and women’s self-help groups.

A target sample size of 400 participants was set based on assumed 50% baseline awareness prevalence, 95% confidence level, and 5% margin of error, allowing for subgroup analysis across age and residence categories.

Data Collection Tool

A pre-validated, bilingual (Hindi and English) structured questionnaire was developed using Google Forms. The questionnaire was designed based on literature review and expert inputs from endocrinologists and public health specialists. It consisted of the following sections:

• Demographics: Age, education level, marital status, occupation, residence (urban/semi-urban/rural).

• Knowledge of Thyroid Function and Disorders: Understanding of thyroid gland role, symptoms of hypothyroidism and hyperthyroidism, awareness of thyroid tests.

• Thyroid and Reproductive Health: Knowledge about how thyroid disorders affect menstruation, fertility, pregnancy, and postpartum health.

• Health-Seeking Behavior: Past thyroid testing experience, source of health information, openness to screening, barriers to care.

• Attitudes and Beliefs: Perceived seriousness of thyroid disorders, misconceptions (e.g., infertility myths, weight-related stigma), and trust in medical treatment.

The tool underwent pilot testing with 25 participants (excluded from final analysis) to ensure clarity, relevance, and cultural appropriateness.

Data Collection Procedure

An introductory screen provided background information, purpose, confidentiality assurances, and consent form. Participation was anonymous, and only one response per device was allowed. The form was designed to be mobile-friendly to increase accessibility.

Data Analysis

Responses were exported to Microsoft Excel and analyzed using SPSS (version 26.0). Descriptive statistics (frequencies and percentages) were used to summarize participant characteristics and awareness levels. Chi-square tests and cross-tabulations were used to explore associations between awareness levels and demographic variables.

Ethical Considerations

The study received approval from an Institutional Ethics Committee. Informed electronic consent was obtained from all participants. Data were stored anonymously and securely, with no personally identifiable information collected at any stage

Socio-Demographic Characteristics of Participants

A total of 410 women participated in the online survey. The majority of participants were aged 25–34 years (43.4%), followed by those in the 15–24 (23.4%) and 35–45 (22.9%) age groups. Most respondents were married (68.3%), and more than half had completed graduate-level education or above (57.6%). The sample was diverse in residence, with 62.4% living in urban/semi-urban areas and 37.6% from rural Shimla. Employment status revealed that 51.2% were employed, while others identified as homemakers (27.3%), students (14.6%), or unemployed (6.8%). These varied demographics offer a representative overview of women across life stages in the district (Table 1).

Table 1: Socio-Demographic Characteristics of Participants (N = 410)

Awareness of Thyroid Disorders and Reproductive Health

Participants were assessed through 20 structured questions covering symptoms of hypothyroidism and hyperthyroidism, the relationship between thyroid function and reproductive health, awareness of diagnostic tools, and treatment misconceptions. While general awareness about common symptoms such as fatigue, weight gain, and irregular menstruation was moderate, fewer participants understood the reproductive implications, such as its role in infertility, miscarriage, and pregnancy complications. Knowledge about TSH screening, iodine deficiency, and postpartum thyroiditis was limited (Table 2).

Table 2: Awareness of Thyroid and Reproductive Health (N = 410)

Knowledge Score Classification

Based on their responses, participants were classified into four knowledge categories. The majority (36.1%) fell into the ‘Fair’ category (40–59% correct), indicating moderate understanding. 32.2% demonstrated ‘Good’ knowledge,  while  only   12.7%   achieved   a   ‘Very Good’  score  (≥80% correct). Notably, 19.0% scored below 40%, signaling a concerning lack of awareness and highlighting the need for expanded educational efforts related to thyroid health and its reproductive consequences (Table 3).

Table 3: Knowledge Score Classification (N = 410)

This study offers vital insights into the current level of awareness and understanding of thyroid disorders and their reproductive health implications among women in Shimla district. The findings suggest a mixed pattern of knowledge—with moderate familiarity concerning general thyroid function and symptoms, but substantial gaps in understanding its reproductive and hormonal consequences. These results echo prior literature from similar semi-urban Indian populations where the silent burden of thyroid dysfunction remains largely under-recognized due to the non-specific nature of symptoms and prevailing misconceptions.

The fact that only 12.7% of women demonstrated a 'Very Good' awareness level, and a significant 19% scored in the 'Poor' category, underscores a pressing public health concern. Many participants were unaware of the impact thyroid imbalance can have on menstrual regularity, ovulation, infertility, and miscarriage, highlighting an urgent need to integrate thyroid health into broader reproductive education initiatives. Moreover, while over two-thirds of women recognized TSH as a diagnostic marker and understood the importance of iodine, only 51.5% knew the optimal screening period was before conception, a critical missed opportunity given the role of maternal thyroid hormones in fetal development.

Notably, awareness was relatively higher among women with higher education levels and those residing in urban/semi-urban areas, which reinforces the link between access to health information and accurate knowledge. Still, misconceptions—such as the belief that birth control pills cure thyroid disorders or that only overweight women are affected—were observed across all demographic categories, indicating that cultural myths persist regardless of educational attainment.

The online nature of the study, while inclusive in terms of digital reach, may have slightly favored participants with better health literacy and internet access. However, the inclusion of homemakers, students, and rural residents helped ensure a balanced representation. The findings should prompt both public health stakeholders and primary care providers to develop targeted campaigns—leveraging local language media, community health workers, and maternal health platforms—to spread awareness about thyroid screening, especially among adolescent girls and women of reproductive age.

In conclusion, while foundational knowledge about thyroid health exists in Shimla, critical reproductive health linkages remain poorly understood. Bridging this gap through culturally tailored, accessible education could improve fertility outcomes, reduce maternal complications, and promote earlier diagnosis and management of thyroid disease in women.

This study reveals that while basic knowledge of thyroid function is present among women in Shimla, significant gaps remain in understanding its impact on reproductive health, fertility, and pregnancy outcomes. With nearly one in five women demonstrating poor awareness, urgent, stage-specific educational interventions are warranted to address misconceptions, promote timely screening, and integrate thyroid awareness into reproductive health services—ultimately enhancing the quality of care and long-term endocrine well-being for women in the district.

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