Thyroid and parathyroid disorders

​​​​​​​Emergency

If any of the following are suspected, seek emergency medical advice or refer the patient to the emergency department (via ambulance if necessary)

  • Agranulocytosis or neutropenic sepsis in patient taking carbimazole or propylthiouracil
  • Any symptoms suggestive of hypocalcaemia post-thyroid or post-parathyroid surgery
  • Thyroid mass with any of the following features:
    • Airway compromise
    • Breathing difficulty
    • Drooling
    • Haemoptysis
    • Severe odynophagia
    • Stridor
    • Sudden increase in size or pain over days to weeks
    • Sudden voice change
  • Corrected serum calcium > 3.0 mmol/L with symptomatic hypercalcaemia (e.g. nausea
    and vomiting or volume depletion, alteration in mental status, or acute kidney injury)
  • Corrected serum calcium > 3.5 mmol/L
  • Corrected serum calcium < 1.9 mmol/L with symptomatic hypocalcaemia (e.g. seizures or tetany)
  • Hyperthyroidism complicated by cardiac or respiratory compromise, or other indications of severe illness (i.e. fever, vomiting, labile blood pressure or altered mental state)
  • Hyperthyroidism with hypokalaemia and paralysis
  • Reduced visual acuity in Graves' disease
    Note: refer to ophthalmology state-wide referral criteria
  • Suspected myxoedema coma​​

When public outpatient services are not routinely provided

  • Asymptomatic, stable thyroid nodule(s) which are classified as benign by ultrasound (ACR TR 1-2) or by combination of low-risk ultrasound (ACR TR 1-4) and biopsy (Bethesda Category II)
  • Mildly elevated parathyroid hormone levels with normal serum calcium levels
  • Unexplained fatigue without an endocrine disorder\

  • Uncomplicated primary hypothyroidism, including sub-clinical hypothyroidism in the absence of pregnancy or pregnancy planning​

Criteria to access public outpatient services

CategoryCriteria
Category 1
Recommended to be seen within 30 calendar days.
  • Asymptomatic hypercalcaemia with corrected serum calcium > 3.0 mmol/L
  • Cervical lymphadenopathy associated with a thyroid mass
  • Clinically suspected, or cytologically confirmed or suspected thyroid malignancy (Bethesda Category V
    or VI)
    Note: for any malignancy, concurrent referral to a thyroid surgeon is highly recommended
  • Following surgery for thyroid cancer, where radioactive iodine treatment is being considered
    Note: consider referral to nuclear medicine, where appropriate
  • Hyperthyroidism due to amiodarone or checkpoint inhibitors
  • Hypocalcaemia with corrected serum calcium
    1.8 – 2.0 mmol/L
  • Pre-pregnancy, pregnant or post-pregnancy with hypothyroidism or hyperthyroidism
  • Pregnant with any degree of hypocalcaemia or hypercalcaemia
  • Severe, symptomatic hyperthyroidism
  • Sub-acute thyroiditis (i.e. hyperthyroidism with thyroid pain), where glucocorticoid therapy is being considered
  • Thyroid function tests suggestive of hypothalamic or pituitary pathology (central hypothyroidism)​​
​​Category 2
Recommended to be seen within 90 calendar days.
  • ​​Hypercalcaemia with corrected serum calcium 2.8 – 3.0 mmol/L
  • Following surgery for thyroid cancer (or where surgery
    is not indicated) where specialist surveillance is recommended by the treating team
  • Graves' ophthalmopathy or Thyroid Eye Disease (TED)
    Note: if vision threatening, urgent ophthalmology review is required
  • Overt hyperthyroidism
  • Pre-pregnancy counselling for a thyroid or blood calcium disorder
  • Primary hyperparathyroidism with persistent mild hypercalcaemia (i.e. corrected calcium 2.5 – 2.8 mmol/L on repeat testing) with any of the following features during monitoring:
    • Progressive rise in calcium levels
    • Declining renal function (eGFR reduction > 10 mL/min/1.73m²)
    • New fragility fracture
  • Significant bone density loss (> 3.0% per year or T-score decline > 0.5)
  • Thyroid nodules with any of the following features:
    • Bethesda Category III or IV
    • Size > 4 cm (regardless of imaging characteristics or cytology results)
    • Significant growth (i.e. > 20.0% increase in diameter or > 2.0 mm) in a previously identified nodule > 1 cm with TI-RADS score > 3
    • > 2 non-diagnostic fine needle aspirate (FNA) results

Note: consider referral to either a thyroid surgeon or an endocrinologist​

Category 3
Recommended to be seen within 365 calendar days.

  • Long-term requirement for anti-thyroid therapy
    where review of treatment strategy is required
  • Multinodular goitre or generalised thyroid enlargement with evidence of growth or development symptoms
  • Permanent hypoparathyroidism to review or develop
    a long-term management plan
  • Persistent abnormal thyroid stimulating hormone elevation despite attempts at optimal therapy
  • Sub-clinical hyperthyroidism aged > 65 years with multinodular goitre

Information to include within a referral

Required

  • Reason for referral
  • Details of the presenting condition, including symptoms and their duration
  • Provisional diagnosis
  • Patient health summary (such as relevant medical history, relevant investigations, current medications and dosages, immunisations, allergies and/or adverse reactions), including specifically:
    • Specific thyroid history (e.g. thyroiditis, thyroid disease in pregnancy, management of hyperthyroidism, any history of surgery or Graves' disease)
    • Personal or family history of thyroid cancer or familial endocrine neoplasia syndromes
    • Neck radiation exposure
    • Osteoporotic therapy
    • Physical examination findings
    • Investigations
    • Full blood count (FBC)
    • Electrolytes, urea and creatinine (EUC)
    • Liver function tests (LFTs)
    • Fasting lipids
    • C-reactive protein (CRP)

If a thyroid condition:

    • Thyroid stimulating hormone (TSH)
    • Free thyroxine (fT4) (where TSH is abnormal)
    • Free triiodothyronine (fT3) (where TSH is low)
    • Thyroid antibodies
      • If hypothyroidism – anti-TPO antibody, anti-Tg antibody
      • If hyperthyroidism – anti-TPO antibody, anti-Tg antibody, TRAB/TSI

If a thyroid nodule:

    • Diagnostic thyroid ultrasound +/- fine needle aspirate (FNA) biopsy result (include copy of results, test location and date)
      Note: neck ultrasound is not required for investigation of uncomplicated thyroid hormone dysfunction in the absence of a proven or suspected thyroid nodule

If calcium or parathyroid condition:

    • Corrected calcium, magnesium, phosphate, 25-OH vitamin D and parathyroid hormone (PTH) on two occasions
    • Concurrent spot urine or 24-hour calcium:creatinine
    • Electrophoresis (EPG), immunofixation electrophoresis (IEPG) (to exclude myeloma)
    • Bone mineral density within last 2 years
    • Thoracolumbar spine X-ray

If available

  • Weight, height, body mass index and weight history (i.e. weight loss or weight gain)
  • Use of complementary medicines (e.g. herbs, supplements, Biotin)
  • Computed tomography (CT) scan for chest, abdomen, and pelvis as screening for occult malignancy, granulomatous, or inflammatory process (if non-PTH mediated hypercalcaemia)​

Important information for referring health professionals

If there is a change to a patient’s condition while waiting for their appointment, referring health professionals may further investigate and manage the situation, or send an updated referral to the outpatient service. Where there are significant concerns about a patient's condition, referring health professionals may check HealthPathways for urgent/same day advice or contact the relevant clinical team.​

Current as at: Monday 23 March 2026
Contact page owner: System Purchasing