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This hormone nuclear receptor complex activates gene transcription and synthesis of messenger RNA and cytoplasmic proteins. Secondary (Pituitary) and Tertiary (Hypothalamic) Hypothyroidism Adequacy of therapy should be assessed by measuring serum free- T4 levels, which should be maintained in the upper half of the normal range in these patients. Carcinogenesis, Mutagenesis, And Impairment Of Fertility Animal studies have not been performed to evaluate the carcinogenic potential, mutagenic potential or effects on fertility of levothyroxine. Specific indications include: primary (thyroidal secondary ( pituitary and tertiary (hypothalamic) hypothyroidism and subclinical hypothyroidism. A portion of the conjugated hormone reaches the colon unchanged and is eliminated in the feces. 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