Unfortunately a misdiagnosis can happen in the management of hypothyroidism and other thyroid disorders. If you go to a doctor with hypothyroid symptoms, you may be given replacement hormones without first determining what’s causing your thyroid issues.
Or, if you have hypothyroid symptoms but your lab tests are normal, your doctor may not realize you’re experiencing thyroid issues in the first place. You may even receive treatment or medication to deal with the symptoms you’re experiencing—like an antidepressant to address depressive symptoms—but you won’t receive anything that will help your thyroid disorder.
The problem with this approach is that thyroid physiology is complex.
The production, conversion, and uptake of thyroid hormone in the body involves several steps. A malfunction in any of these steps can cause hypothyroid symptoms, but may not show up on standard lab tests.
All cases of hypothyroidism do not share the same cause—and, as you might guess, they require different treatments.
In this article, I’ll present five patterns of thyroid dysfunction that may not show up on standard lab tests. If you have one of these patterns, your thyroid isn’t functioning properly and you will have symptoms. But depending on the tests your doctor runs, you may not get a diagnosis of hypothyroidism; and, if that’s the case, you won’t receive the treatment you need.
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A standard thyroid panel usually includes TSH and T4 only (while some panels will also look at free T3, free T4, and check for thyroid antibodies). The ranges for these markers vary from lab to lab, which is one of two main problems with standard lab ranges. The other problem is that lab ranges are not based on research that tells us what a healthy range might be, but on a bell curve of values obtained from people who come to the labs for testing.
Now, follow me on this. Who goes to labs to get tested? Sick people. If a lab creates its “normal” range based on test results from sick people, is that really a normal range? Does that tell us anything about what the range should be for health? (For more on the problems with standard lab ranges, watch this great presentation by Dr. Bryan Walsh)
Are you experiencing hypothyroidism symptoms even though your lab work is normal? You may still have hypothyroidism, though it may not show up on standard labs. Check out this article for more. #functionalmedicine #chriskresser
The Five Thyroid Patterns
1. Hypothyroidism Caused by Pituitary Dysfunction
This pattern is caused by elevated cortisol, which is in turn caused by active infection, blood sugar imbalances, chronic stress, pregnancy, hypoglycemia, or insulin resistance. (1) These stressors fatigue the pituitary gland at the base of the brain so that it can no longer signal the thyroid to release enough thyroid hormone. There may be nothing wrong with the thyroid gland itself. The pituitary isn’t sending it the right messages.
With this pattern, you’ll have hypothyroid symptoms and a TSH below the functional range (1.8 – 3.0) but within the standard range (0.5 – 5.0). The T4 will be low in the functional range (and possibly the lab range too).
2. Under-Conversion of T4 to T3
T4 is the inactive form of thyroid hormone. It must be converted to T3 before the body can use it. More than 90 percent of thyroid hormone produced is T4.
This common pattern is caused by inflammation and elevated cortisol levels. T4 to T3 conversion happens in cell membranes. Inflammatory cytokines damage cell membranes and impair the body’s ability to convert T4 to T3. (2) High cortisol also suppresses the conversion of T4 to T3. (3)
With this pattern you’ll have hypothyroid symptoms, but your TSH and T4 will be normal. If you have your T3 tested, which it rarely is in conventional settings, it will be low.
3. Hypothyroidism Caused by Elevated TBG
Thyroid binding globulin (TBG) is the protein that transports thyroid hormone through the blood. When thyroid hormone is bound to TBG, it is inactive and unavailable to the tissues. When TBG levels are high, levels of unbound (free) thyroid hormone will be low, leading to hypothyroid symptoms. (4)
With this pattern, TSH and T4 will be normal. If tested, T3 will be low, and T3 uptake and TBG will be high.
Elevated TBG is caused by high estrogen levels, which are often often associated with birth control pills or estrogen replacement (i.e. Premarin or estrogen creams). To treat this pattern, excess estrogen must be cleared from the body.
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4. Hypothyroidism Caused by Decreased TBG
This is the mirror image of the pattern above. When TBG levels are low, levels of free thyroid hormone will be high. You might think this would cause hyperthyroid symptoms. But too much free thyroid hormone in the bloodstream causes the cells to develop resistance to it. So, even though there’s more than enough thyroid hormone, the cells can’t use it and you’ll have hypothyroid—not hyperthyroid—symptoms.
With this pattern, TSH and T4 will be normal. If tested, T3 will be high, and T3 uptake and TBG will be low.
Decreased TBG is caused by high testosterone levels. (5) In women, it is commonly associated with PCOS and insulin resistance. Reversing insulin resistance and restoring blood sugar balance is the key to treating this pattern.
5. Thyroid Resistance
In this pattern, both the thyroid and pituitary glands are functioning normally, but the hormones aren’t getting into the cells where they’re needed. This causes hypothyroid symptoms.
Note that all lab test markers will be normal in this pattern, because we don’t have a way to test the function of cellular receptors directly.
Thyroid resistance is usually caused by chronic stress and high cortisol levels. It can also be caused by high homocysteine and genetic factors. (6)
Thyroid Treatment Depends on the Right Diagnosis
The five patterns above are only a partial list. Several others also cause hypothyroid symptoms and don’t show up on standard lab tests. If you have hypothyroid symptoms, but your lab tests are normal, it’s likely you have one of them.
Not only do these patterns fail to show up on standard lab work, they don’t respond well to conventional thyroid hormone replacement. If your body can’t convert T4 to T3, or you have too much thyroid binding protein, or your cells are resistant, it doesn’t matter how much T4 you take; you won’t be able to use it.
Unfortunately, if you have one of these patterns and tell your doctor your medication isn’t working, all too often the doctor’s response is to simply increase the dose. When that doesn’t work, the doctor increases it yet again.
As I said at the beginning of this article, the key to a successful treatment is an accurate diagnosis. Without understanding precisely what’s causing the problem, you may end up with a treatment that isn’t well-suited to your specific situation.
The good news is that, once the correct diagnosis is made, patients respond very well to treatment.
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Following brain aneurysym have metal clip next to my pituitary gland. Since then have gone from being extremely hypo to
being extremely hyper with thyroid readings according to
my GP as being “like a galloping horse” . Also had extreme
weight loss and barely able to function followed by adrenal
failure.
Since then my thyroid functioning has been extremely labile
with both hypo/hyper symptoms for the past 20 years.
Constantly have had my thyroid meds adjusted – major
weight loss almost 20 lbs. despite truckdrivers appetite –
Intense fatigue forcing my eyelids to close and again
being forced to sleep. I also have IBS and with my now
current very low TSH have gone to the other extreme
of my IBS – constipation.
Having coped with this misery for more than 20 years
wonder why surgical removal of diseased multinodular
goitre not being recommended – resolving the thyroid
having any further influence on the pituitary gland
obviously being effected by the brain aneurysm metal
clip positioned beside it.
Would like quality of life which my erratic thyroid
functioning persists in denying to me – thankfully
I am positive thinking and sure hope that a
competent thyroid expert will be able to figure
out the complexity of my symptoms.
Thanks for listening.
Marnie
So I can see myself in two of these scenarios, but I don’t see where it says what the treatment that works so well would be if my doctor won’t prescribe Armour because my blood tests have me within a “normal” range even though I have been suffering symptoms for a long time and they are getting worse.
Hi, Chris,
I admit I did not read every comment … but I have Hashimoto’s and am working to find a cure for IT instead of simply treating my thyroid. I have been on Armour for about 4 years now (Synthroid did nothing to alleviate my symptoms) and would LOVE to get off of all the medication if I could. I have other complications as well: insulin resistance – pre diabetes. Bummage. I am using a (mostly) gluten-free diet, selenium, and iodine supplements. Any other advice you have for me regarding Hashimoto’s would be welcome.
Meanwhile, I love proofing – I would happily proofread your articles before you post them for free. Let me know if you’re interested in that. 🙂
God bless!
-C
Hi I’m sitting in an exotic country where I cannot get T3 and my pharmacist miscalculated how many tablets I’d need and I’ve now had to take 1/4 of the dose to make it last til I get back to reorder back home. My husband has noticed my brain has “turned to mush” (his words) and of course I’ve noticed. My conservative doctor (I see two) didn’t believe in it, nor it seems do some other countries. All I can say is: I regained back a life with them, and without them I cannot function properly. Can someone explain in a quasi scientific manner at least, why it effects one’s brain functioning, so we both know?! Why this reluctance to acknowledge its benefits? Why does the mainstream research not back up people’s experiences?! I very much doubt it’s psychological…
Chris- I would be really interested to read a companion article on hyperthyroidism.
Trying to get the insurance company to cover the screening for resistance to thyroid hormone is near impossible. Has anyone been able to get this passed through? Its $1000 test!
Please help!!! So what is the solution? I have been to so many doctors and had so much blood work done, only (as you have stated) for them to come back completely normal. Yet, i have still have MANY symptoms of thyroid diseases. What type of doctor do I need to go to or is there a specific type of blood work that i should request? PLEASE HELP!!
Dr. Bryan Walsh is Da Bomb! He will educate you above most endos in just a few hrs!! Thyroid physiology is very understandable for the average layman. Even an endo could get it ~wickedgrin~
The problem is finding doctors covered by health insurance and then paying for the pricey bloodwork and supplements needed. Especially as you try different treatments—needed even with the bloodwork (out of pocket again as not covered by insurance). Getting it exactly right off the first labs is unusual. Then more labs and more supplements.
It’s out of the pocketbook of the average American and that is very frustrating. Dr. Walsh has the best model I’ve seen though…I noticed Chris is using it in his article 🙂 Very familiar info!
All of my thyroid hormones came back normal but I was very symptomatic. Sleepy, swollen face hands feet, etc., weight gain even with calorie counting. Ends up on a routine physical i had nodules on my thyroid (large ones) that I didn’t even know about. They all came back as Papillary Carcinoma. In surgery it was found that the Papillary Carcinoma had metastasized to the lymph nodes on both sides of my neck. I just went through radiation treatment two days ago. Strange is that I have been feeling better than I have for a LONG TIME just being on 25 mcg of Cytomel. Also I have lost 21 pounds! I have yet to start permanent thyroid hormone replacement because of my recent radiation treatment. Hopefully my body will be able to convert t4 to t3, since Cytomel is t3 and appears my body has responded well to it.
Also! I lost all 4 of my parathryoids due to lose of blood supply from the cancer around my thyroid..i hade deficiency in Vit. D and my nails started falling off.
Hi Dr. Kresser,
I’m a 40 yr old woman, who lives in India, and currently weigh 260 lbs. I have battled the bulge for the past 20 years… and do have PCOD and Diabetes… I was diagnosed with Hypothyroid when I was 12, and was cured of it by the time I turned 16…however, at 17 I was diagnosed with a growth / tumor in my pituitary gland, however when I reached London for the surgery, which disappeared in 2 months on it’s own. after which, I did get tested every 6 months for 3 yrs, however, I was told it was all good since.
I also am convinced that I do have Hypothyroid for the past 10 yrs, since I do have all the symptoms that define it…however, since all the usual tests, T3, T4 & TSH, always come back within the normal range, the Doctors here keep telling me that I’m normal and that my weight is only a result of my diet & lethargy! That all I have to do is eat less & exercise. Like I haven’t done that!!!
What they don’t seem to grasp is that I actually do eat pretty healthy (NO sodas, fried foods, sweets, carbs and processed foods) and I do try and work out at least 3 times a week… and in spite of all that, my weight just doesn’t come off!!!
My current medication is: I take glycomet (metformin) 1gm twice a day, glucobay-50mg thrice a day & glynase 5mg twice a day For my Diabetes. Since my periods come on time, I have not been given anything for my PCOD.
Dr. Kresser, I really need your help and advice.
Please write in to me at: [email protected]
Just had thyroid testing done and was told I was not in the optimal range, but was in the “normal” range. Endocrinologist tested my TSH, Free T3, Free T4, cortisol, glucose serum, and several other things. He’s prescribed Armour Thyroid (60mg) daily, but if my levels are fine why am I being told to take this drug? I’m confused. Here are my results: cortisol 6.5 ug/dL, Free T3 2.5, Free T4 1.14, and TSH 2.18, glucose serum 112. My blood work was done in the late afternoon w/o fasting.
Any help would be great!!
I have a T3 deficiency as a result of non-conversion of T4 into T3. My TSH and T4 levels are normal. My question is, how do I reduce my cortisol levels? I have alopecia areata as well which is an auto-immune disorder and probably as a result of elevated cortisol levels too. I have been taking synthetic thyroid hormone for the past 4 years which makes me feel alot better, however, my hair loss has not improved and I’m guessing this is because the underlying cause has not been addressed.
If a T3 to T4 conversion is your issue, then you need to be on Armor (which is cheaper) because it is a natural thyroid and helps you with this conversion. None of the synthetic thyroid give you the T3 to T4 conversion. There is a great doctor in Fredericksburg, VA called Dr. Hill. His office is by the hospital. He is fairly good. It was a free clinic doctor who without seeing my test results, told me I was on a synthetic. and prescribed Armor. It made a hugh difference and it worked. Also, Silkence Shampoo volumnizer that helps my hair grow back. Rogaine for women did not work for me. Also, Witch Hazel is a great medicine for skin cleanser(acne), blemish and itch reduction. Great stuff.
Where do you go to get definitive answers? What other test are needed or what type of Doctor to get help? I want to sleep around the clock, have lost my eye brows on the corners on both sides. In desperation I went to a weight clinic for diet pills. Not losing weight but I can at least get out of bed a few hours like a normal person. I am at wits end.
I am 44 and been dealing with this same problem for over 10 years now. I have been through the gammit of testing as you spoke of by a few Endocrinologists and was told that ALL my levels were “normal” yet I still struggle to lose weight/keep it off, my hair is thin and falls out constantly, my skin is dry and seems tough and nothing helps. I developed KP on my upper arms which I never had before and have no family history of. I have stripped my diet down to 1200-1400 calories a day and only eat natural protien from lean meat/fish, fresh vegatables, fresh fruit, brown rice, moderate dairy in the form of greek yogurt or small amounts of milk in coffe or cereal and not every day. I only drink water and the occasional ice tea and coffee. THis seems to only help in mantaining my weight where it is at but that is all. I admit that I do not get the proper amount of exercise that I should as I am a night shift nurse so going to the gym or even taking walks etc is a challenge since I sleep during the day but my job does offord me to be physical 75% of the time as I work with ALS patients and am doing 100% care from meds to the physical so by the time I have finished a 12 hour shift I am pretty well worked out just from that. I wear a pedometer and walk the equivalent of 6 miles or more a day just at my job alone. Yes, I know I need more variety and I am working on this aspect. Also I will point out that this problem started long before I became a nurse or worked night shift. My delima is how do I get an MD to listen to me when I tell him that this is more than an activity/diet problem regardless of my tests coming back “normal”. This started when my children were very young and I was extremely active. I have gone through 2 Dr.’s now and 1 specialist. Both of which get back normal test results. The specialist and 1 MD put me on phentermine or phendimetrizine to solve the weight issue rather than trying to get to the bottom of the issue. This DRUG FIX only ever helped me loose 10 to 15 because it made me not want to eat anything since both drugs are and anorexic/stimulants. Well Duh! Starvation of course will make you loose weight. This was a temporary fix and never helps solve any of my other issues including the weight problem since I need to loose 50 pounds not 15. My problem is not my eating habits or how much I consume it is something else. Clearly that is and was not the answer and I feel like they were treating me like a diet drug seeker (which by the way I didn’t ask, suggest or hint that I wanted diet drugs). I wanted answers as to why my hair was falling out and I keep gaining more and more weight year after year without increasing my dietary intake and my activity level staying the same. This problem actually started back when I was in my late 20’s just after having my gallbladder removed but got increasingly worse after I hit my 30’s and now 40’s. Another lovely side effect of whatever is going on is I now have been growing very coarse man like facial hair on and under my chin which is multiplying bit rapidly. I read this suggests increased testosterone but when I have brought this symptom up they just ignore me. I’m no expert but I just wish I could find an MD who actually cares and wants to get to the bottom of the problem rather than prescribe “diet pills” as an answer since all my blood work is normal? Being a nurse this makes it more frustrating because I know something is wrong and if you try and rationalize the symptoms verses the tests and that there must be something underlying that the tests are not showing they tell me its not possible? Um not possible? Hello that is a nice way of saying “I don’t want to try and get to the bottom of it, now run along and deal with your weight problem since you obviously just eat too much”. Ok but ALL my test results are normal so if I eat too much and all the wrong things why is my BG levels, A1C etc.. normal? Liids, cholesterol, trigycerides etc…. NORMAL….. When I say all my test were normal it was like reading a chart of a very healthy early 20’s something year old with no diet issues who gets ample exercise etc… One of the endo’s said if even one of these were on the low side he at least could start there but there not? How do you move forward from there? This is also the MD that prescribed me phendimetrizine by the way? I am so frustrated. I am also so tired of feeling tired, gaining weight for even stepping out of my diet box for 5 minutes and sometimes even when I do not step out of my diet box I still gain. Any advice, help, direction etc.. would be SO appreciated. A guide/list if you will that I can take to an MD or Specialist that tells them what I want tested and done and followed up on etc…. HELP PLEASE…… Here is a list of my symptoms: Thin hair that falls out constantly and never grows beyond my shoulder area before it breaks off and or falls out, dry and pale skin that seems like it has thickened with patches of KP like rashes on upper arms, flank pain on my right side under my rib cage where my kidney is that comes and goes (had sonogram, checked and tested for stones, infections etc… with negative results) , fatigue, constipation, thin brittle nails, depression, joint pain, muscle pain, unexplained weight gain, thin eybrows and eye lashes. Puffy face at times, painful reaction to consumption of alcohol ( if I drink 1 oz of liquor I get a burning red flush on my face and chest. It feel like I have acid under my skin and then I start to itch on my face and chest)I almost never drink because of this. Any guidance or help would be greatly appreciated. I have always been very in tune with my body and I know something is wrong. I’m tired of feeling tired, depressed and having horribly thin hair on my head and dry skin that looks like a red bumpy dry war zone. I struggle everyday with remaining positive and persisting through all these problems but I’m starting to lose this battle as it has been a 15 year struggle and I am so tired of being told to watch what I eat and exercise as a solution. There has to be more to it than that if those recommendations are not working. Ok I will stop ranting now and hope for some advice and help. Thank you in advance to whomever responds. P
Hello Tracie….I just found this website and it’s AMAZING how much I have in common with most people here. Did you ever receive a response from anyone regarding your thyroid problem? I’m new to this site so I’m not sure if someone actually responds or what? How are you doing now?? Hope you have received the help you need!! Thanks!
Donna
I am sending you good luck for proper diagnosis and treatment – it just got “real” for me – as my hair has been falling out at an alarming rate now – I am going to try to find an endocrinologist and get all the tests run I can (of course the generic thyroid test came back “normal” – it’s going to put me in debt – but I can’t live like this anymore – I am praying for us all…
Hi Tracie. I certainly don’t have all the answers related to thyroid but the weight part and chin hair actually sounds like estrogen dominance. I would suggest getting your hormone levels checked by a naturapath. It has to be the spit test one, not the kind regular docs run. If you’re not in a state that recognizes holistic practioners you can order the test and do it yourself. It’s spendy but not crazy expensive like some of the tests they’re talking about here. Check out John R Lee’s website http://www.johnleemd.com/. He’s actually an MD. There’s lots of info and a symptom checklist and you can order the hormone test kit from there. It’s possible that you may get some relief from progesterone cream or by taking vitex which helps the body make more of it’s own and supports pms, perimenopause and menopause as well as the parathyroid. Vitex takes about three months to work fully though. Vitanica is an excellent brand. There are also some products like DIM that help with clearing up excess bad estrogens. All of these things are pretty inexpensive and you can get them from Amazon. The hormone issue may not be the main issue but it might help with some other stuff. My irregular periods and feeling cold all the time has cleared up since I started using natural progesterone cream. I too have a super weird acidic reaction to alcohol as well as soda of any kind. Good luck and I hope some if this may help!
Hi my tsh was 27 last Wednesday then checked it again on Friday to be sure and it was 2.58 & they also tested T4 this time which was also what they called normal at 9,9!
Hello, I have all the classic symptoms of hypothyroid, I have seen 3 doctors, this last doctor is a surgeon, I have had the right part of my thyroid removed in 2004 due to a nodule. I have never been on any medicine for it. Now all of the sudden I have all these symptoms and the doctors do not know what to do. All my labs came out fine, I had a sonogram that showed my left thyroid is alittle bit swollen. I have now lost my voice. Now the surgeon wants to put a camera in my throat to see what is going on and why I am so hoarse in my voice. My gut is saying he wont find anything. I am very lost now. I dont no what to do. And yet I still have all the symptoms.
Interesting talk by Sherry Tenpenny explaining all the thyroid hormones and relationship between thyroid iodine & selenium that your Dr. probably never told you and may not even be aware of: https://www.youtube.com/watch?v=hMjKmi12UX0
I have kind of a weird thing going on – after a total thyroidectomy in August 2012 (multinodular goiter, and the pathologist found an encapsulated papilloma), my endo started me on 150mcg levothyroxine. I felt OK on this dose, but my TSH was still 0.0 (don’t recall my T3/T4 numbers). He proceeded to decrease the dose to, eventually 112. That dose brought my thyroid numbers into range, but everything else collapsed into a perfect hypothyroid presentation – weight gain, depression, brain fog, chills, etc. Against his orders, I started taking 1.5 112 pills daily. My weight started going back down, the fatigue and depression lifted, the shivers went away, and I felt genuinely good for the first time in years. The problem is that, yep, my thyroid numbers now indicated *hyper*, which made doc very angry. I stopped the 168, and sure enough, hypo. Now he’s threatening to reduce the levo to 100mcg, just for the sake of good thyroid numbers at the expense of everything else. How do I make him understand what he’s doing to me?
I recently found this page and I’m so thrilled. I’m 43 and have been dealing with what I think are thyroid issues for years despite my doctor saying “everything is normal.” I’m NOT normal. I’m textbook thyroid and it doesn’t matter to even try to treat the symptoms instead of my bloodwork! How do I get someone to listen to me. I have a 1 inch nodule on my thyroid, cells are fine from biopsy. I’ve read about deiodinases and am trying to find out more research on that subject. Again, how do I get them to take me seriously instead of just thinking I want a weight loss pill (that would be nice, lol) but it is SO much more than me spending 4 months at the gym and only losing 4 pounds. My endo told me years ago that I had PCOS, however, I truly felt she was just giving me a diagnosis to give me a diagnosis. My ob/gyn checked my ovaries due to diagnosis but they were not cystic and I had no problem conceiving. I’m at a loss and so frustrated. Just had bloodwork done with PCP and of course “everything is within normal range.” Then WHY do I feel like this?
Go to different Dr. or several different Drs if you have to. I was recently disappointed with endocrinologist for not running full thyroid panel, only to get full lab script from family MD during recent physical.