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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I have recently started having symptoms of some form of thyroid issue. I had blood work done and my levels for my ths levels were “normal” but my doctor said no way he said he is convinced due to my symptoms that I have some form of thyroid issue and has set up for more labs. I am so very thankful for him I was terrified that he would just say everything is fine and leave it at that all the while I would be feeling rather miserable.
I so understand Sara. You are lucky you have a doctor like that. I have seen so many doctors, and not one would keep on trying with me.
I hope you find out and get on what you need in order to feel better. I still hope to find out as well 🙂
What about an elevated TSH, but normal T3 and T4? Once I saw that my TSH was high, I expected to see some variation in my other levels. Is this a typical combination?
excellent article, as usual!!
How about high TSH (8), normal Ft3, Ft4 and negative antibodies??
thanks!!
Erika,
That pattern can be seen in someone who is already taking thyroid hormone but did not take it on the morning of the blood test. It may also be seen in someone who recently started high doses of iodine supplementation, or perhaps just went on an intense Detox program of some kind. I would just re-test it and make sure the patient takes their thyroid hormone the morning of the test.
Last year my mother was diagnosed with diabetes. I took her to an endo doctor and asked him to please run tests on her thyroid because she seemed symptomatic to thyroid issues. i.e. weight gain, fatigue, etc. He ran the normal tests and proceeded to treat her for the diabetes. After a year of diabetes meds, she went into the hospital for heart issues. A doctor there ran more extensive testing and, guess what? She had a thyroid problem! They put her on meds and is no longer taking diabetic medication. Now I am going through the same thing! Blood tests show normal, but I know with my other symptoms I have a thyroid issue. They are, instead, checking me for diabetes!
I appreciate finding this site and the info however I notice that there are many many people here who are having similar issues but their doctors seem to be discounting them and or their concerns. This sounds like an epidemic and why isn’t something being done about that? Also, I noticed there weren’t any responses to the many posts made here. Is there a reason for this? It would be just as helpful to hear the responses to the posts. As many of us know, it’s hard to find a good doctor to deal with these concerns. How does one find a good recommendation, within their geographical area? I live in the Minneapolis, Minnesota area.
I believe – for best results – look for a MD that practices holistic medicine specifically thyroid. This is my next step. My family doc said my labs are normal, my gyn said I was on the hypo side but she doesn’t treat thyroid issues. I have all the symptoms, plus more.
I agree 100% this should be looked into further so that people can be properly diagnosed at the onset of symptoms
Dr. Chris great Article will be taking it to my Doctor next month.
Have been on Thyroid medicine for 19 years. Currently taking Cytomel 50 mg and Levoxly 50 mg my blood work shows that I am having too much thyroid medicine, but my symptoms are still the same no energy , cold. Have a feeling my thyroid is not converting the medicine properly what do you suggest?
thank you.
The way to test people who have normal labs is through symptoms, body temperature and heart rate, which are direct consequence of absorbing the hormones.
Just had my TT removed. My first thyroid panel came back at TSH .78, FreeT4 1.4. And Free T3 at 2.7. These numbers see a little out is sync with your past conversation but I do feel great and no longer have any of the medical symptoms before the surgery.
Has a multi benign nodule substernal thyroid that was massive and grew to 12.5 cm RT lobe and LT Lobe 8.5 all within 6 months due to subacute thyroidistis.
I was wondering if the TSH should be higher?
C
I also am confused. My blood tests are normal, although i have cysts on my thyroid. I have the symptoms of hypothyroidism. The front of my neck will feel swollen then go down. what do I do?
I have all of the symptoms and I’ve been tested, and each time I’m told that I’m okay. My Mother and my grandma had hypothyroidism. What can I do if the doctor can’t see the symptoms? Is there a dr. With a cure? I need help
I too have been having similar struggles. I found Dr. Steven F Hotze in the Houston, Texas area and that is who I suggest checking out. I ordered a book called Hypothyroidism, Health & Happiness written by Dr. Hotze and it explains so much. I highly suggest you check it out. Its definitely an interesting read. Hope this helps!
I had symptoms of a thyroid problem for more then 15 years on and off before a doctor caught it on a blood test. My family had a history of high diagnosis of thyroid and diabetes. I went through years and years of hell, and still get told I don’t know what I am talking about from endocrinologist specialists. Yet I know what I have had to deal with symptom wise. Turns out after having a total thyroidectomy during the dissection of my thyroid papillary cancer was found. This had not shown on any of the tests used to diagnose hyperthyroidism. If I hadn’t insisted on having my thyroid out instead put on medication treatment for 3 years the cancer could have spread. Over and over I have had misdiagnosis, doctor’s trying to tell me it was a mental illness, or that I was just over weight. I can not tell you how many doctor’s should be without a license to practice, but I was to ill for such a long time to pursue their incompetence. I will tell you that you should keep a medical diary, always keep track of your symptoms, get copies of your medical records, ask for second opinions, and believe in yourself because if you don’t you can end up dead. Seriously.
I have numerous symptoms of hypothyroidism, I’m losing my hair and eyebrows ,dizziness weight gain , terrible bone pain , exhausted and cold all the time , I having a pain in the front of my neck and swelling comes and goes ,my doctor checked my tsh level which is 3.52 but was 1.6 this time last year , she said that was normal so i paid private for free T3 and free T4 test the results are fT3 4.4 and FT4 15.2 my doctor has now dismissed that my symptoms have anything to do with my thyroid , she hasnt yet felt my neck for any bumps , I’ve had vit d and ferritin blood tests done today but I feel like I’m banging my head off a brick wall can anyone shed some light on these results or has had similar symtoms with similar results
I have a strange thyroid issue – mine swells then goes down. there’s no set pattern to it, but when it does swell up quite a bit, my heart races and I get really tired. When it goes back down, all is good. Been to two different endocs, both did biopsy and told me that I had multi-nodule goiter, all bloodwork (that they did) came back normal. They put me on replacement hormones for my thyroid as they said maybe it was being “overworked” – didn’t help any with the swelling. Anyways, when I told the two endos that it goes up and down, they said it doesn’t do that! Also my GP said the same thing. The biopsies were non cancerous, but the first one said “it was full of blood” they said they could remove it if it’s bothering me, but I don’t want to have to take meds for the rest of life and the whole process of trying to get everything figured out as far as levels. Any idea on what this could be? thanks!
I’m 23 and I have had hypothyroidism symptoms for 3 years. I’m not at all a professional, but that sounds like hashimoto’s. It is an autoimmune disease that cause your thyroid to swing back and forth between hyper and hypo. This results in the thyroid swelling and shrinking. I would research that and see if the symptoms fit. Good luck!
I am 43 and last year started having symptoms of what I would think would be hypothyroidism. Staying cold all the time, lack of concentration, feeling tired, some dizziness and at times anxiety. I went to one doctor and the only test he performed was the TSH. Result came back normal. Finally after the persistent symptoms TSH, free T3 and free T4 was performed. Results are TSH – 1.78, free T4 – 1.00 and free T3 – 2.9. LDL was slightly elevated at 120. Doctor tells me results are normal. Can anyone please help with interpreting results? Thanks
Hi Melissa,
My thyroid levels are close to yours. TSH = 1.30, T4 = 1.0, T3 = 2.8. I’m so cold so often that my ability to function as a substitute teacher is no longer there. I’ve been at home playing the sleuth and listening to every summit for the past several months! It’s been fascinating and thankfully, I think I’m finally figuring some things out. I love to check my ideas against Chris’ articles because I feel that he is such an authority on so many topics. Also, he explains things well.
I’d like to pass along a link to some info about functional thyroid levels and what they might indicate presented by Andrea Maxim. She’s a naturopathic doctor in Canada who I also find to be very knowledgeable and a good teacher.
thanks for sharing the video ; i learned alot!!
Dr. Chris my Mom had her thyroid removed a little over a year ago. She is tired, breathing is labor and she at her all time weight. He endo Dr. says here levels are where they were prior to them removing he thyroid. Any advise?
Meant to say her weight is more than she’s ever weighted in her life. Forgot to say she now has hypertension as well. Her blood pressure before surgery was lower than normal.
Wow! I guess I stumbled on the right doctor! I had my first visit with her yesterday and told her I wasn’t sleeping and have zero energy. She ordered labs and will then do a physical. She included the T3 test right off the bat! Sounds like she knows her stuff. She is an internist and not a family doctor.
10 out of my dads 14 siblings and my grandmother all had hypothyroid , alot of my cousins have it, and on my mothers side 2 of her siblings had pituitary tumors ..I have been wrestling with thyroid issues for yrs but always comes back normal..even my doc is surprised ..time to get more into the reason because I can literally check almost all the symptoms off .its so frustrating
Me too, it recently took everything out of me and I can’t even keep up with my children. I have some symptoms that I don’t see listed on many pages such as sore soles of feet or can’t stand for a long period of time… I walk across the house and suddenly I’m so tired I want to lay down on the floor and sleep. I just want my life back… I miss my energy and if I scratch my legs anymore they will bleed! My Dr doesn’t even believe me when I tell him all my symptoms.
I have a lot of symptoms for a thyroid problem. I went to my Dr he ordered the standard lab test for thyroid. They came back normal. I asked him to order additional thyroid tests to test T3. He said it would be inappropriate to order more tests since the last one came back normal. What can I say to get these tests? It is frustrating to me that he wont just order them. I’m the patient I want them done!
Get a new doctor
I just got home from seeing an endocrinologist because my basic thyroid tests came back normal and my primary care provider was stumped. It was great. She listened and agreed that my body wasn’t doing what it was supposed to do and is going to order a series of tests that my PCP wouldn’t be comfortable ordering. General practitioners just kind of throw up their hands and say there’s nothing wrong with you.
If you can, get in to see an endocrinologist because they’re the people who know what’s appropriate and what isn’t when it comes to your thyroid.
I’m in the same boat, Rebecca. I have asked for a complete panel for months. I told the doctor I still didn’t feel up to par, and would like more than just the TSH done. I get the order in the mail….she only added T4 and free T4. I don’t understand why it is so difficult for a doctor to order complete profiles.
Or to leave me be on my original thyroid, which I did well on since I was 6 weeks old. Tweaking dosages now and then kept me going till a dr. switched me to Synthroid. Their choice, not mine
Then I get a phone call from the office manager. Dr. terminates my being a patient there! Right when I’m trying to get help! All she had to do is test, and adjust.
All I want is to ENJOY my life, hike and bike with my family & friends, and keep up with my grandkids.
My insurance helped me find a DO. Hopefully now, I can get some help.
T3 is the active hormone that T4 is supposed to be converted into. Sometimes for various reasons the conversion doesn’t go the way its supposed to and that’s why you want to check T3 and free T3, and sometimes reverse T3 (RT3) which also reduces the effectiveness of T3. You can find another Dr. and/or report this Dr. to the state medical board for leaving you hanging. I would do both. In my case, I’m having difficulty getting the full thyroid panel from endocrinologist. When family physician found out, she ordered all the proper blood work pronto!
Go to a Lab Express, or Any Lab Test now and order them yourself!
Do you know anything about hyperconversion of T4? I have been on block and replace therapy for hyperthyroidism for years now, and my TSH has NEVER been normal. My typical numbers are: TSH: 26, Free T4, .79 (normal .7 to 1.5), T3, 160 (87 – 178 normal). Even when I had a high T3 and was severely hyperthyroid (with low TSH), I never had a high T4. It was always low to low-normal.
No matter how much synthroid (T4) I take, the T4 numbers don’t go up. They are always in the low to low normal range.
So my assumption is that my body converts the majority of my T4 to T3, so I have both hypothyroid symptoms (depression, fatigue, body aches, hair loss, weight gain no matter what I do) and hyperthyroid symptoms (heart palpitations (especially when I wait too long to take medicine or when I try to go down on my methimazole thyroid blocker), shakes, etc.
I now have a thyroid nodule that they want to remove, and the surgeons recommend having the whole thing taken out. However, I am concerned that I will hyperconvert the T4 (synthroid) into T3, and I will still have all of the same problems I am having now. I have gained a lot of weight (for me), and though I am eating a very healthy, low calorie diet and exercising regularly, I can’t lose it.
Do you know of any doctors who might be able to help with this?
I am going crazy I can’t control my weight no matter what I do no matter the amount if physical activity my diet I regulate strictly as I am celiac I am in my 50’s and already went through menopause I pee up to 36 times a day I can’t sleep I am sleep deprived all tests come back normal but there is a history of thyroid disease in my family so I was wondering if I should pursue these other tests and are these symptoms part of that
Could be Lyme Disease or another related infection.
Which will not show up on standard tests.
Did they do a biopsy of the nodule? I have 3 nodules. The biopsy didn’t show anything. But when I lost weight, they became smaller.
This is a fantastic article, I am printing it off to take to my Dr’s tomorrow. Totally sick of the NHS and their pesky lab ref ranges, Dr’s have no idea how to think outside of the box. I was undiagnosed with crohns for 4 years – nearly died – twice and had to pay privately for treatment, now that is in remission I have MS and accepted this speedy diagnosis with grace, now for the last two years I have suffered ‘globus’, extreme anxiety, heart pains, palpitations, hoarse voice, sore glands, hair falling out by the handful and apparently I need anti-depressants because this is all a bad reaction to my last diagnosis and my thyroid markers are fine. I am stressed to the point I am in a constant state of angst all the while working full time with absolutely no recognition for these symptoms, except to be made to feel neurotic for mentioning them to my GP. I have just changed GP and hope to get somewhere with this one, now see a holistic Dr as well but nothing is happening quickly enough for my liking. I have spent my whole adult life battling my Dr’s knowing something is wrong, the whole health system is a mess and has no leaning towards health – just medicine. They are in the ‘illness’ business, not the happy healthy people business.
Hi Angie,
Just a quick question. Did you go over your blood work your self? Do you see any items that are close to the high or low of the lab ranges? Hows your calcium?
Hi Tamsyn,
I completely understand where you are coming from! I have seen doctors since I was little trying to find the answer to my symptoms. I believe I have Hypothyroid and my last naturopath (as I have see so many normal doctors) in America ordered standard tests came back ‘normal’ and dropped the whole subject. My mother has hypo and my father had hyper and now he has hypo. I am convinced what I have been battling for so long is finally becoming clear.
I have just moved to the UK to settle and now am nervous how the doctors on NHS will accept me. They have never liked me much, and when it comes time for me to ask them to add more tests to the chart, they will dismiss it quickly.
Haven’t had the best experience with UK doctors in the past (student).
Totally agree with the medicine bit. It gets hard to trust that a new doctor has your best interest at heart when they all seem to conduct their business that way.
I wish you the best of luck!
Was a great article. Too bad people get caught up in bickering so that the point is pushed to the background.