Thyroid function testing

Last Updated: 2014-10-20

Introduction
Thyroid hormones thyroxine (T4) and triiodothyronine (T3) are produced, stored, and secreted by the thyroid gland. These
hormones, particularly T3, play a major role in multiple biologic and metabolic processes. They act by binding to thyroid
receptors that are distributed in almost every organ. Typically, this process regulates gene transcription and the subsequent
production of various proteins that are involved in development, growth, and cellular metabolism. [1] Thyroid function tests
(TFTs) are the most commonly used endocrine test. [American Thyroid Association: thyroid function tests]

Thyroid hormone production

Thyroid hormone production is regulated by the hypothalamus and pituitary gland. Hypothalamic thyrotropin-releasing hormone
(TRH) stimulates pituitary thyrotropin (TSH) synthesis and secretion. In turn, TSH stimulates production and release of T4 and
T3 from the thyroid gland. Once released, T4 and T3 exert a negative feedback mechanism on the production of TRH and
TSH. [1]

Hypothalamic-pituitary-thyroid axis

From the collection of Dr Sheikh-Ali

The protein thyroglobulin (Tg) is produced and used by the thyroid gland to produce T4 and T3. T3 is the biologically active form
of thyroid hormone whereas T4 is considered a prohormone to T3. The thyroid gland produces 100% of circulating T4 but only
20% of circulating T3. The remaining 80% of T3 is produced by the conversion of T4 to T3 in the peripheral tissues. Acute
illnesses, as well as certain drugs, may inhibit the process of converting T4 to T3 and, therefore, affect their serum levels.

Thyroid hormone-binding proteins

T3 and T4 circulate in peripheral blood bound to proteins (thyroxine-binding globulin [TBG], prealbumin [transthyretin], and
albumin). Approximately, 99.98% of T4 and 97% of T3 are protein-bound. Only the unbound or "free" portion, free T3 (FT3) and
free T4 (FT4), are active. Therefore, any changes in the quantity or quality of thyroid-binding proteins will produce changes in
circulating thyroid hormone levels. [1]

Indications for TFTs: general considerations

According to population studies in the US and the UK, the prevalence of overt hypothyroidism varies from 0.1% to 2%, and of
subclinical hypothyroidism from 4% to 10% of adults, with possibly a higher frequency in older women. In the US, the prevalence
of hyperthyroidism is approximately 1.2% (0.5% overt and 0.7% subclinical); the most common causes include Graves disease,
toxic multinodular goiter, and toxic adenoma. [2] [3]

In the US, the American Thyroid Association suggested that all adults should have serum TSH concentration measured at 35
years of age and every 5 years thereafter. [4] However, the US Preventive Services Task Force found that evidence was
insufficient to recommend for or against routine screening for thyroid disease in adults. [5] In the UK, screening the healthy adult
population for thyroid disease is not currently practiced. [6]

Screening may be appropriate in people at higher risk of developing thyroid dysfunction. Screening and further surveillance
should be considered in patients: [7] [8] [9] [10]

With a goiter
Who have had surgery or radiation therapy affecting the thyroid gland
Who have pituitary or hypothalamic disease, surgery, or irradiation
With diabetes mellitus type 1
With Addison disease
With first-degree relative with autoimmune thyroid disease
With vitiligo
With pernicious anemia
With leukotrichia (prematurely gray hair)
With psychiatric disorders
Receiving medications and iodine-containing compounds (e.g., amiodarone hydrochloride, radiocontrast agents,
expectorants containing potassium iodide, kelp, interferon alpha, and tyrosine-kinase inhibitors, most notably
sunitinib).
With Down or Turner syndrome.

Known thyroid dysfunction and preconception

In patients with known history of hypothyroidism who are trying to conceive, thyroxine levels should be increased to achieve
serum TSH values to <2.5 mIU/mL. This increase will reduce the risk of TSH elevation during the first trimester. [11]

Screening for thyroid dysfunction during pregnancy

In pregnancy, estrogen levels increase and thyroid-binding globulin concentrations rise, which leads to an increase in T4 and T3.
In the first trimester, serum TSH also falls due to the effect of hCG, which may be associated with a slight and transient increase
in FT4. These changes are small and in most of the pregnant women, FT4 concentrations remain within the normal range for
nonpregnant women. [12] In the second and third trimesters, FT4 and FT3 decrease, sometimes below the nonpregnant
women's reference level. There is insufficient evidence to recommend for or against screening in pregnant women.

Universal screening compared with case finding for detection and treatment of thyroid hormonal dysfunction during pregnancy
did not result in a decrease in adverse outcomes. [13] However, the Endocrine Society recommends screening groups at high
risk for thyroid dysfunction - that is, women with: [14]

Age >30 years

Currently receiving levothyroxine replacement
Living in a region presumed with iodine deficiency
History of hyperthyroid or hypothyroid disease, postpartum thyroiditis, or thyroid lobectomy
Family history of thyroid disease
Goiter
Thyroid antibodies (when known)
Symptoms or clinical signs suggestive of thyroid under-function or over-function, including anemia, elevated cholesterol,
or hyponatremia
Type 1 diabetes
Other autoimmune disorders
History of therapeutic head or neck irradiation
Prior history of miscarriage or preterm delivery
Infertility: should have screening with TSH as part of infertility workup.
TFTs should be monitored closely in pregnant women with hypothyroidism because thyroxine replacement often needs to be
increased by 30% to 50% during the first trimester. Thyroxine dosage should be titrated to maintain serum TSH concentrations
of 0.1 to 2.5 mIU/mL in the first trimester, 0.2 to 3 mIU/mL in the second trimester, and 0.3 to 3 mIU/mL in the third
trimester.[11] [13] Monitoring during pregnancy should consist of measuring TSH every 4 weeks for up to 20 weeks' gestation,
and then at least once at 26 and 32 weeks of gestation. After delivery, thyroxine should be reduced to prepregnancy dose and
TSH rechecked at 6 weeks to further adjust thyroxine if needed. [11]

TFTs
TSH assay

A serum TSH assay is the test of choice to screen for thyroid function disorders in the absence of hypothalamic or a
pituitary pathology. [4] [15] [16] In most reference laboratories, the normal range for TSH is 0.45 to 4.5
mIU/L. [17]TSH is sensitive to any change in the plasma concentration of thyroid hormones. [18] TSH may require an
average of 6 to 8 weeks to adjust to changes in thyroid hormone levels. Therefore, it is recommended to check TSH
levels 6 to 8 weeks after thyroxine adjustment or any antithyroid drug treatment. A subnormal TSH level should
trigger the measurement of FT4. If this is not elevated, FT3 should be measured to identify cases of T3-
thyrotoxicosis. Suppressed or elevated TSH confirms presence of thyroid dysfunction but not its cause.

Free T4 (FT4) and Free T3 (FT3) assays

FT4 assay is the test of choice to evaluate an abnormal TSH level. It is used in preference to a total T4 assay. A free T3
assay would be the preferred test over a total T3 assay; however, some commercially available free T3 assays are
variable and unreliable. Free T3 should be measured in evaluating patients with thyrotoxicosis, and when the FT4 is
not elevated in the presence of a subnormal TSH. FT4 and FT3 assays are a good measure of thyroid gland output
and are independent of thyroid hormone-binding protein concentrations. Typical normal range for FT4 is 0.9 to 2.3
nanograms/dL (12 to 30 picomol/L) and for FT3 is 230 to 420 picograms/dL (2 to 7 picomol/L). [1]

Total T4 and total T3 assays

Previously, before improved FT4 and FT3 assays, total T4 and total T3 assays were ordered to evaluate an abnormal
TSH assay. However, total T4 and total T3 levels can be affected by changes in the levels of circulating thyroid
hormone-binding protein levels. They measure both free and protein-bound hormones. Normal range for total T4 is
5.5 to 12.5 microgram/dL (206 to 309 nanomol/L) and normal range for total T3 is 60 to 180 nanograms/dL (0.92 to
2.76 nanomol/L).
Conditions associated with elevated total T4 and total T3 levels secondary to increased thyroxine-binding globulin
(TBG) levels include pregnancy, estrogen use, liver diseases (e.g., hepatitis), drug use (e.g., tamoxifen or
methadone), or rarely, hereditary TBG excess. [19] [20] Other rare conditions resulting in elevated total T4 and total
T3 levels are increased albumin or transthyretin binding.
Conditions associated with decreased total T4 and total T3 levels secondary to decreased TBG levels include androgen
excess, glucocorticoid excess, nephrotic syndrome, hereditary TBG deficiency, and drug use (e.g., niacin or
danazol). [20] [21] [22]
Illness, starvation, and poor nutrition may also decrease total T4 and total T3 levels by decreasing albumin and
transthyretin levels and possibly interfering with the binding capacity of the carrier proteins.

Thyroid autoantibodies

TSH-receptor antibodies (TRAb) are not routine tests but may be of use in selected cases where diagnosis is equivocal.
The results are useful in identifying thyroid disease etiology. TRAb can be either stimulatory or blocking to the TSH
receptor. Thyroid-stimulating immunoglobulin (TSI) is an example of a stimulatory TRAb and is usually elevated in
Graves disease.
Thyroid peroxidase antibodies (TPOAb) are also helpful in identifying thyroid disease etiology. TPOAb are usually
present in Hashimoto disease and other autoimmune thyroid diseases.
Tg antibody test is used primarily to help diagnose autoimmune conditions involving the thyroid gland.
Because TRAbs freely cross the placenta and stimulate the fetal thyroid gland, TRAb should be measured by 22 weeks
of gestational age in a mother with current or a history of Graves disease, previous neonate with Graves disease, or
previously elevated TRAb. [14]

Tg assay
 Usually ordered for surveillance in patients with differentiated thyroid cancer when the patient does not have Tg
autoantibodies in the serum.
In addition, it may be ordered when investigating the underlying cause of hyperthyroidism. Tg is usually elevated in
primary hyperthyroidism and thyroiditis but not in factitious thyrotoxicosis (excessive use of thyroid hormone
medication causing thyrotoxicosis).
An increase in serum Tg occurs in 33% to 88% of patients who undergo thyroid fine needle biopsy (FNB). Serum Tg
concentrations typically return to baseline about 2 to 3 weeks after FNB. The degree of increase in serum Tg after
FNB is highly variable (ranging from 35% to 341%) and not a predictor of whether the biopsied nodule is benign or
malignant. [23]

Radioactive iodine uptake (RAIU) and scan

Usually ordered in the setting of thyrotoxicosis to help identify the underlying etiology. It measures the amount of
radioactive iodine (usually I-123) that is taken up by the thyroid gland. High uptake may indicate hyperthyroidism. The
increased uptake may be diffuse and homogeneous as seen in Graves disease, or take on the appearance of hot
nodules, as seen in multinodular toxic goiter. Low uptake may indicate thyroiditis or factitious thyrotoxicosis in the
appropriate clinical setting.
RAIU cannot be performed in certain patients (e.g., pregnant or nursing women or iodine-contaminated patients); in
such cases, serum TRAb measurement is helpful in identifying Graves disease.

TRH stimulation test

Used to evaluate TSH response to TRH stimulation in the setting of central hypothyroidism. It may also help
differentiate TSH secretory tumor from resistance to thyroid hormone syndrome (RTH). In RTH, the TSH response is
normal. TRH stimulation test is not a specific test and is not commonly available in the US.

Calcitonin

Calcitonin is usually a marker of medullary thyroid cancer. [24] However, calcitonin levels may also be increased,
although infrequently, in other clinical conditions such as C-cell hyperplasia, pulmonary and pancreatic
neuroendocrine tumors, renal failure, and hypergastrinemia (use of proton-pump inhibitors). [25]
A single, unstimulated calcitonin measurement can be used in the initial workup of thyroid nodules. [25] However, this
practice is not done routinely in the US.

Low TSH - associated with a high FT4 and/or FT3

Suggestive of hyperthyroidism. The most common causes include Graves disease, toxic multinodular goiter, toxic
adenoma, and thyroiditis. [26] Radioactive iodine uptake (RAIU) helps to differentiate between these conditions. In
cases of Graves disease, RAIU is diffusely increased. For toxic nodules: uptake is increased in the area of a single
nodule, or in multiple areas in cases of toxic multinodular goiter; the remaining thyroid tissue uptake is suppressed.
Furthermore, in Graves disease, thyroid stimulating immunoglobulins (TSI) are present in about 90% of patients,
though usually not required for diagnosis.
In subacute or granulomatous thyroiditis, RAIU is low. Patients with subacute thyroiditis have elevated thyroid hormone
levels initially, secondary to excessive release of stored T4 and T3 from the thyroid gland. Later, thyroid hormone
levels decrease below normal, before returning to normal when inflammation subsides.
Other causes include factitious thyrotoxicosis (caused by excessive use of thyroid hormone medication), in which case
thyroglobulin levels and RAIU are low, or iodine-induced hyperthyroidism (e.g., following use of amiodarone or
exposure to radiocontrast agents), where RAIU is also low.
 Differentiating causes of low TSH and high free T4 (FT4) and/or free T3 (FT3)

From the collection of Dr Sheikh-Ali

Low TSH - associated with a low FT4 and/or FT3

Suggests secondary (central) hypothyroidism, which is associated with pituitary or hypothalamic dysfunction. TSH can
be low, normal, or slightly elevated. Evaluation for deficiencies in other pituitary hormones should be obtained before
imaging (i.e., pituitary MRI). Hormone tests should include: ACTH with cortisol, FSH, LH, estradiol (female),
testosterone (male), prolactin, GH, and insulin-like growth factor 1 (IGF1). For this condition, thyroid replacement
therapy is monitored by checking the levels of FT4 and FT3. [27]
Other causes of these results include nonthyroid illness (sick euthyroid syndrome) where abnormalities in thyroid tests
secondary to acute systemic illness are observed with no true thyroid dysfunction. TSH can be normal or low
followed by rebound elevation during recovery from acute illness. [17] FT4 can be normal, low, or high. FT3 is usually
low secondary to decreased conversion of T4 to T3. Thyroid hormone replacement is not recommended in this
condition.[28] [29]
In the second and third trimesters of pregnancy, FT4 and FT3 decrease, sometimes below the nonpregnant woman's
reference level.

Differentiating causes of low TSH and low free T4 (FT4) and/or free T3 (FT3)

From the collection of Dr Sheikh-Ali

Low TSH - associated with a normal FT4 and/or FT3

In the absence of nonthyroidal illness or relevant drug therapy, these results suggest subclinical (or mild)
hyperthyroidism. In this case radioactive iodine uptake (RAIU) can be slightly elevated or normal.
 In nonthyroid illness (sick euthyroid syndrome), TSH can be normal or low followed by rebound elevation during
recovery from acute illness. [17] FT4 can be normal, low, or high. FT3 is usually low secondary to decreased
conversion of T4 to T3.
The following drugs may cause these results: dopamine, dopaminergic agonists, glucocorticoids, cytokines, or
octreotide, because they inhibit pituitary TSH secretion. Similar results may also occur following exposure to
radiocontrast agents. [30] [31]
Recent treatment of hyperthyroidism with antithyroid medication may also cause these results. It may take up to 6 to 8
weeks for TSH to adjust after initiating therapy. [32]
In the first trimester of pregnancy, serum TSH falls due to the effect of hCG. This may be associated with a slight and
transient increase in FT4. [12]

Differentiating causes of low TSH and normal free T4 (FT4) and/or free T3 (FT3)

From the collection of Dr Sheikh-Ali

High TSH - associated with a high FT4 and/or FT3

If this result is found then assay artifact/laboratory error should be considered first. Changing laboratory method may
help in identifying the problem. [33]
If assay results are correct, the major diagnoses are a TSH-secreting pituitary tumor (TSH-oma) or a syndrome of
resistance to thyroid hormone. The finding of an elevated serum sex hormone-binding globulin (SHBG) and
circulating free alpha subunit may support the diagnosis of TSH-oma, as may the finding of hyper- or hyposecretion
of other pituitary hormones. [34] Pituitary imaging (MRI) usually confirms the diagnosis but should not be undertaken
until the appropriate biochemical confirmation has been made. Radioactive iodine uptake (RAIU) shows diffusely
increased uptake.
Thyroid hormone resistance syndrome can be confirmed by positive family history, absence of adenoma on pituitary
MRI, and normal levels of serum alpha subunit glycoprotein. By contrast, with a TSH-oma where TSH production is
autonomous, T4 or T3 administration eventually suppresses the high TSH in thyroid hormone resistance
syndrome.[35] [36] [37]
Thyroxine replacement therapy (for possible hypothyroidism) taken within a few hours of TFT can raise FT4 levels.
However, FT3 is almost always normal in these situations. [38]
Abnormal thyroid function has been found in patients with acute psychiatric disorders. [39]
 Differentiating causes of high TSH and high free T4 (FT4) and/or free T3 (FT3)

From the collection of Dr Sheikh-Ali

High TSH - associated with a low FT4 and/or FT3

Suggests primary hypothyroidism. Underproduction of the thyroid hormones (T4 and T3) may occur with autoimmune
thyroiditis (Hashimoto disease), which is the most common cause of primary hypothyroidism. More than 90% of
patients with Hashimoto thyroiditis have positive TPOAb.
Other causes include thyroidectomy or radioactive iodine treatment of the thyroid without adequate thyroid hormone
replacement.

Differentiating causes of high TSH and low free T4 (FT4) and/or free T3 (FT3)

From the collection of Dr Sheikh-Ali

High TSH - associated with a normal FT4 and/or FT3
Subclinical (or mild) hypothyroidism occurs when TSH is above reference range with a normal FT4 and FT3. The risk of
progression to overt hypothyroidism is 2% to 5% per year. [40] The risk is higher in patients with positive
TPOAb.[41] The decision to treat these patients is controversial. Generally, thyroxine replacement is not
recommended when TSH is below 10 mIU/L. [42] TSH and FT4 should be repeated at 6- to 12-month intervals to
monitor for improvement or worsening in thyroid status in untreated patients. [40]
Differentials include the recovery from nonthyroid illness (sick euthyroid syndrome). TSH can be normal or low followed
by rebound elevation during recovery from acute illness. [17]
Other differentials include poor adherence to thyroxine replacement therapy or its malabsorption: for example, in celiac
sprue, or as a result of interference from other co-administered medications, such as calcium carbonate, ferrous
sulfate, and cholestyramine.
Concomitant medication that promotes increased metabolism of thyroid hormone (e.g., rifampin, phenytoin,
carbamazepine, barbiturates) can also cause these results. [17]
In addition, problems with assay procedures (e.g., interference of abnormal antibodies in serum) can cause false
elevation in TSH. Changing the laboratory method may help identify the problem. [33]

Differentiating causes of high TSH and normal free T4 (FT4) and/or free T3 (FT3)

From the collection of Dr Sheikh-Ali

Normal TSH - associated with a low FT4 and/or FT3

These results may occur following secondary (central) hypothyroidism, which is associated with pituitary or
hypothalamic dysfunction. TSH can be low, normal, or slightly elevated. Evaluation for deficiencies in other pituitary
hormones should be obtained before imaging (i.e., pituitary MRI). Hormone tests should include: ACTH with cortisol,
FSH, LH, estradiol (female), testosterone (male), prolactin, GH, and (insulin-like growth factor 1 (IGF1). For this
condition, thyroid replacement therapy is monitored by checking the levels of FT4 and FT3. [27]
Other causes include drug use (e.g., phenytoin, rifampin, carbamazepine, barbiturates) and assay error when interfering
substances are present.
 Differentiating causes of normal TSH and low free T4 (FT4) and/or free T3 (FT3)

From the collection of Dr Sheikh-Ali

Drug effects
Many commonly used medications affect thyroid function. [42] Therefore, the possible effect of these drugs both on the results of
TFTs and on the effectiveness of treatment should always be considered in decisions regarding patient care.

Iodine, amiodarone, or lithium increase or decrease thyroid hormone secretion.

Dopamine and its agonists, as well as glucocorticoids, cytokines, or octreotide, decrease TSH secretion.
Rifampin, phenytoin, carbamazepine, or barbiturates increase hepatic metabolism.
Carbimazole, propylthiouracil, or lithium decrease thyroid hormone synthesis.
Beta-blockers, glucocorticoids, amiodarone, propylthiouracil, or radiocontrast dyes impair T4 to T3 conversion.
Furosemide, NSAIDs, mefenamic acid, carbamazepine, or beta-blockers displace T4/T3 from plasma proteins.
Estrogens, tamoxifen, heroin, methadone, or raloxifene increase thyroxine-binding globulin (TBG), total T4, and total T3
levels.
Androgens, anabolic steroids, or glucocorticoids decrease TBG, total T4, and total T3 levels.
Cholestyramine, aluminum hydroxide, ferrous sulfate, sucralfate, calcium carbonate, or proton-pump inhibitors impair
absorption of thyroxine.
Interleukin-1, interferon-alfa, interferon-beta, and TNF-alpha are associated with risk of autoimmune thyroid dysfunction.
Amiodarone may also modify thyroid hormone action.
Drug effects on the thyroid