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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Can someone please direct me to the foods to eat and avoid lists that are referred to (above in post of “Joyce
March 13, 2014 at 5:55 am”) ….. I searched the site and was not able to find them.
Thank you SO much.
Chris,
One thing you said does not sound right.
You say that lab reference values are based on the values of sick people. Yet the medical director of Quest Diagnostics says the opposite. That “normal” values are based on the results of healthy people who do not have illness.
Which one of you is right?
Oh my goodness!!! This makes me angry. Just now read this. No FREAKING wonder I haven’t improved on levothyroxine. I told my doc felt a bit better at first for about a week then felt just the same almost as bad as before! Of course she upped my dose which did nothing but increase palpitations. So I made no more complaints because I knew it would do no good.
I’m going to copy this, if I may, and send it to her. I wonder if she will be offended? If so, I will find another doctor! I want a correct diagnosis!
Ginny,
I found out that levoxyl did not work for me as well. Try Armour thyroid instead. As a natural thyroid base it converts T3- T4. Levoxyl is a synthetic that does not,. Also, Armour 30 mg costs about 5.50 for 30 day supply at CVS.
w.r
So if normal lab results do not show these, where do suggest get test done? My allergist says there are NO (yes she said No)tests for food sensitivities. Is that correct if not who do you suggest I turn to?
There test for food sensitivities… Period.
I’m SO glad to find this article, yet still wonder where I fall. I’ve been miserable with hypo symptoms for months. The first test was only TSH which was “normal”. 5 months later and I still feel lousy, so I asked for more testing. T3 is normal but T4 is low. How does that happen? He’s putting me on synthroid, but I wonder if that’s the solution or just a band-aid. Should I ask for additional tests to find a root cause? Thanks so much.
Thank you for everyone’s comments, its wonderful to see I am not alone in this 10 year struggle to find answers.
Heavy Periods, Fatigue, loss of energy, depressed, full body rashes lasting months, weight gain no matter low calorie count, natural whole foods with natural herbs and regular exercise.
I am strongly opposed to medications, coffee, alcohol, soda, or beverage with color dyes, sugar or sugar substitutes. Only minimal amount of sea salt in the kitchen and dinner table…
The human body is obviously very complex….most times trying to find balance feels impossible…
I found bentonite clay simply mixed with water clears away rashes, lots of water (without chlorine or flouride), fresh lemon assists in ongoing cleansing- removal of toxins…
But as of January 2014 have discovered essential oils- therapeutic grade, that addresses every symptom typed into the internet 🙂 included thyroid issues, liver, kidney function and more.
Join me in this journey of learning how naturally to heal our bodies, without the medications offered to us in every office and over each counter.
Chris – I have symptoms of thyroid problems. Low heart rate, cool body temperature, fine brittle hair. Plus both my mother and brother take synthroid. Yet my blood tests don’t show any problem. Who can I see in the Miami, Florida area that can perform more comprehensive testing? Thanks.
Good Morning Chris ~
I’ve been diagnosed with hypothyroidism for a little over three years now. I have no symptoms nor have I ever.
When first diagnosed, I inquired about managing with diet and was told it wasn’t possible. The doctor allowed me three months to try on my own, but offered no suggestions where to go for information. Obviously, I was unsuccessful.
He also gave no indication or information about the effects of chronic stress. I was diagnosed at a time when my marriage was falling apart, my mother had been diagnosed with a terminal illness, and there were signifiant issues at work. All of these had been long term, on-going issues of which the doctor was aware (and for which had tried to prescribe me anti-depressents). After reading a considerable amount in the past few weeks, I’ve begun to suspect I am actually experiencing your point #1 in this article.
I’ve recently been introduced to Paleo/Primal and was sent some of your writings on Thyroid. I want to thank you for giving me an avenue to begin research of my own self and personal reactions to food and stimuli.
I’ve printed your foods to avoid and (shocker) a good majority of them were favorites of mine. Artichokes, asparagus, coffee just to name a few were in my diet multiple times weekly. Asparagus fills my freezer in the summer.
I now have a new doctor due to insurance change. I see her for the first time later this month. I’ll be walking in armed with many of your articles as well as articles from some of the others associated with the Paleo movement who research this area. I will have been on the Whole30 elimination diet, including avoiding FODMAP foods, for slightly more than three weeks at that point, four weeks off of the foods you recommend avoiding for hypothyroidism.
With any luck, I will not be renewing my Synthroid prescription. It’s out of stock half the time anyway, which is an indicator to me that this condition is not well managed by the medical community.
I wanted to thank you for your research and for sharing it with the world at large. Please keep it up so that we can continue to educate our medical practitioners or at the very least be more self-aware.
Thank you.
Joyce, can you please direct me to the foods to eat and avoid lists that you refer to….. I searched the site and was not able to find them.
Thank you SO much.
I have no symptons other than a one off week where I had a few heart palpitations and I have as a result of bloods being taken been diagnosed with Hypothyroidism. Not tired, slim very very active and sporty. Been prescribed levoflaxine but don’t want to take it as don’t feel I need anything and taking the hormone will make me too hyper. Looking to try and find out exactly what is going on. My TSH level was 24.8 and T4 10.4. Perhaps it is early diagnosis and the tiredness etc will be coming soon? Lauren.
I have a lot of Hypothyroid symptoms, but the blood tests have come back normal and after another trip to the Doctor I was nearly escorted off the premises for wasting their time.
I’m almost at breaking point with not being able to cope with the symptoms, and want to go back to the doctors to insist on further tests or to see a Expert on Thyroid problems.
what tests or expert do i ask the doctor to refer me to?
sorry if that question has already been answered above, i notice there are a lot of comments, and is a relief to actually know there are other people suffering out there.
i’m now being avoided as being the complete nutter in my work place.
thanks for your help.
i have been diagnosed with everything but hypothroid even though I have been to numerous doctors with numerous tests and nothing in the blood. I was tested as a new born because as a newborn I was born with constipation issues which I guess is not right and have had all the symptoms of a thyroid issue my enitre life. Finally, my regular doctor put me on a very low dose of levothroxine which did absolutely nothing. Now I am on numerous anti depressandt drugs and more of the like as I have all the mood indicators, aniexiety, lifelong depression, panic attacks etc….. Both my children and I have suffered from severe migraine headaches since age 3-4. Mine have gotten somewhat better after a hystorecotomy at age 36. I am now 45. So the end result is the diagnosis of fibromyalgia which to me looks exactly like a thyroid issue. I feel that this diagnosis has been given to me as they can’t “find” anything else with test results but i don’t remeber fibro making your hair fall out among other symptoms of thyroid that I have. I don’t have the money to keep running from my regular doc and endochronologist and back to my regular doc. back and forth all the time and I am now on disability due to my “Fibro” and some issues with my back and neck. i never feel good even with all the meds from the phych doc. I take adderal so that I have a little energy and dont sleep my life away. It helps a little. I take 2 anti depressants and 1 anexiety medication. So, in other words it is all in my head ans therefore stick me on all these phych drugs that dont really help much at all…. Oh what to do what to do… my whole life i have been told by family and friends how they think I have thyroid issues. One even bought me a book about it and it was me completely. Now my daughter just recently did get the diagnosis of hypo with her blood test. She gained a huge amount of weight and was so tired she was missing more work that working along with her migraines. We both have very low basil temps. In fact she says that if she ever hits a normal 98.6 she knows she is getting sick. She is 26 now but has had high cholestorol since she was 20 or so. I have worked out 5 days a week which is hard to do when you feel so crappy. I can loose a bit of weight that way as long as I dont eat anything but i have battled my weight my whole life. I have only lost weight even with diet and exerciise with the help of phentermine or adderall. When the body gets used to those they stop working and the weight comes back even if I continue to follow a workout regimin and a diet. I am at a loss. My daughter is now on a dose of levothyroxine but she is still super tired and still getting headaches of which of course she takes a pill for. Seems like we complain and end up with another drug to take. My maternal grandmother had thyroid issues as well as paternal family members. Some no longer have a thyroid and are on complete replacement drugs. I have had gout and both my daughter and i have vitimin d deficiencies. I am in the sun alot as it feels good on my sore body but she is very fair skinned and almost looks aniemic. She also has an iron deficiency and my mother has hematchromotosis as do all of her siblings. My mother has all the signs of thyroid as well but she was a nurse and is old school so the test didnt show anything therefore she she doesnt believe anthing that a test cant prove. Her hair is also extremely thin, weight issues, mood issues, gout in big toe, loss of most of her eyebrows. Mine too. I guess is what I am trying to get at here is that there is a definate history of thyroid issues in our family. I have almost every symptom there is from my nails to my hair to my skin to my weight and my moods. EVERYTHING matches…. I dont know what to do….
Hi, I was diagnosed with a underactive thyroid when I was 13 (after experiencing excessive hair loss, fatigue/lethargic- don’t know whats the correct term for very very tired all the time, and rapid weight gain) my mother also has hypothyroidism- and I was on medication for a while, I had to go for test every 6 months to check the levels, I cannot remember everything they tested. However after 3 years on Eltroxin 0.1mg, the doctor stopped my medication because she said that my tests show as normal. Since I have stopped it I had a sudden increase of weight gain to the point where I did not even lose weight when on a diet and I have been on a number of diets. I did not really notice that being overly tired as a result of stopping the medication but thought of it as just being due to stress from exams and later stress from work. Last year I once again tried to lose weight and have successfully lost 25kgs, the first 13kgs I lost in a period of 9 months and the other 12kgs in the past 3 months after a drastic diet and hectic exercise program and using “Duromine” 30mg (Since last year December). Where my question comes in is; I still have 10kgs to lose to be what I need to be according to my BMI, however it is becoming very difficult to lose that last bit, I have not deviated from my diet or exercise program and still on Duromine. Now Duromine helps to give you more energy, the first month on it was great I didn’t feel tired anymore like I used to, but then around the second month I was once again forced to rely on energy boosters to get me through the day, I use a multivitamin (Spectrum Hi-performance), which also helped but also only for a while. I have lately noticed that I am also experiencing excessive hair loss, constantly. Has my under-active thyroid really stabilized, is my weight problem, fatigue and hair loss enough symptoms to get retested and if I do test and they show normal how will I know for sure that they really are, because as I understand your article, the doctors and labs don’t really then know what they are talking about??
In conclusion; I don’t want to waste my time and money going through all of this just so that at the end the doctor can tell me I’m fine, when she actually has no idea of what she’s talking about. What can I do to make sure I’m correctly diagnosed because I can’t tell her shes wrong, if my symptoms are due to my thyroid, I will need a prescription from my doctor.
This is such a great article. I help my clients heal their thyroid completely using nutritional balancing science. It uses a hair mineral analysis to reveal your thyroid functioning and feed it with minerals to heal it. Learn how to heal the thyroid naturally. http://www.liveto110.com/thyroid-conditions
Sensitivity to Synthroid! When my Hyper converted to Hypo, I was placed on Synthroid. I had an incredibly bad reaction to it, I had vomiting, nausea, my hair fell out in clumps and I had steady weight gain. I was changed to Tirosint and had positive results. Most recently I had my dosage increased, my TSH numbers are super high and my T4 is low. However, I was not given Cytomel for the weight gain which is my biggest problem.
Has anyone had any success with Tirosint/Cytomel combo?
for all of those with these problems you should also have vitamin levels checked low D3 causes depression, low B12 will cause you to be tired. There are more effects than I have mentioned but these are I feel are the worst because if you have these you do not want to go outside and by not going outside and not taking D3 supplement will make your mood lower because we get natural D3 from the Sun. If you Fybromyalgia by it’s self or in combination with low vitamin levels and a Thyroid problem makes finding exactly what meds you need very hard also it is still hard sometimes to find out you ha Fybromyalgia because many in the medical world still do not accept it as a real condition. there is also another problem mentioned on here was “leaky Gut” which is a condition not recognized by the medical community as yet but my Gastroenterologist says sounds right is from a woman named J.J. Virgin who is a nutritionist and dietitian she explains about food sensitivities which are very mild allergic reactions which you are often told its your age or your not getting enough sleep etc. this can cause leaky gut I can only remember one of the symptoms right now and that is when you eat a regular meal with in 2 hours you feel hungry again (it might be 2-3 hrs.) not sure that is how mine goes. The best thing about the Virgin diet is you take out 7 categories of food for 3 weeks and then add them back one at a time to see if first the problems all or partly go away and when you add the items back what problems come back. Then you choose to limit intake or cut out the category. these sensitivities can also cause many of the other symptoms so like with vitamins check out every option available to make sure of every issue you have so you can get to feeling better. And please don’t just take my word for it with these issues search for yourself because as much as I am trying to help it is always possible I am not remembering everything correctly. I always tell people knowledge is power and I would add especially when it comes to your or your families health.
Dear colleague. I am a cardiologist, so these issues about rare causes of hypothyroidism are pretty unusual for me. But the fact is, that I have a daughter turning 34 who has been going to several doctors, experts in Endocrinologist, but none of them have given her a solution. Lets go to the point. She has all the symptoms of hypothyroidism, as gaining weight, fragil and lis of hair , weaknesses from time to time. She refers this symptom like an on and off. The blood test she was run were absolutely normal. In case the cause is a matter of high resistance of tissues, wich is the best treatment? To take T4 or T3 orally? And which will be the accurate dossis of T3 for her. Tnanks a lot. Best regards
I’ve been battling hypothyroid for 3 years and before that hyperthyroid for 4 years. My problem is weight management. I live a very active lifestyle and have a very healthy diet and I am afflicted with no other illnesses. I take my medicine and am in the normal hormonal range for hypo management, but I keep gaining weight. I have put on a total of 25 pounds in the last 18 months and cant get it off. I am within my weight class for my height but not for the amount of physical activity and diet that I carry. I am also not comfortable with the additional weight. Has anyone else done everything right and still have trouble with weight gain not associated to overeating? What helped you overcome?
Thank you so much for this. Now I can check what was tested and go back to the doctor if TS3 levels weren’t checked. This totally makes sense why blood results are normal when I am so sleepy. A sleepiness which does seem to get worse with stress, though not ruling out Chronic Fatigue Syndrome yet either.
So, any idea how to or what doctor to go to that will listen? I have had thyroid disease as a child, and was on Synthroid for 6 years. Now my thyroid levels have been from 5.3 to 3.5 to last week 4.7. I have gained over 100 lbs without eating much. I am so tired all the time. I sleep 90% of the day, not wanting to I Have to. I am fatigued. I am freezing all the time to the point I Have 2 heaters in my apartment in addition to my regular heat being turned up to 90. I also need heating pads and blankets…because I am always cold. My hair and eyebrows are thinning. My skin is dry, I am light headed. My voice recently has started to get hoarse. But because my damn levels are withing the 5.0 normal range save for once no one will help me. I am seriously about to buy synthroid online or find another way to obtain it to get some relief. I KNOW what is wrong with me, no doctors listen and this is upsetting me. Do I have to die before they listen?
Hello,
Thank you for this great article; However I wasn’t able to find the answer to my question, maybe you would have advice?
I have Hashimoto’s and my TSH is normal, T4 as well and T3 is low. I tested my cortisol levels, they are normal, and my oestrogen/testosterone levels as well. Selenium is within normal range but more on the high side, vitamin A and D are under-range. Iodine is under-range too.
I still have thyroid symptoms, more than before.
Could my symptoms be due only to the vitamins and iodine deficiencies? Or could it be something else?
Many thanks for your help 🙂
Celine
My numbers are similar to yours except I wanted to be tested for Hashi’s and Thyroglobulin numbers are OK. My D3 is 47 which is in range but I would like it higher (and this is with supplementing 4000 units/day) and I live in Florida! My T3 is LOW! I take supplements including one for Thyroid that has selenium and iodine and L-tyrosine. How do I get my T3 up? Do I take Cytomel?
I do a regular blood test once a year and i realized that my TSH level has gone lower this time but my T3 & T4 are the same and according to the lab test they are within the normal range. should i be concerned that my TSH level has gone down?