There are a couple of ways to answer this question, but first, let’s run through an all too common scenario. You are tired all the time, you have gained 30 lbs, your hair is falling out, and have struggled with constipation for years.

Of course, you Googled your symptoms and are pretty sure that you have a thyroid problem. You decide to make an appointment with your doctor to get a blood test to find out once and for all if you have hypothyroidism. Below is a list some of the common and not so common hypothyroid related symptoms.

Common Hypothyroid Symptoms:

• Low energy / Fatigue / Drowsiness
• Weight gain
• Constipation
• PMS / Heavy periods
• Infertility
• Low mood / depressed
• Anxiety
• Enlarged thyroid (Goiter)
• Puffy eyes/face
• Swollen hands and feet
• Dry skin
• Brittle nails
• Hair loss
• Loss of eyebrow hair (lateral ⅓ = Queen Anne’s Sign)
• Cold feeling 

Going into the appointment, you feel optimistic that you might get some answers as to how you have been feeling and excited to feel better.  You tell your doctor the situation, and he draws some blood to run a few tests. About a week later, you get a call from his office saying you that your tests were “normal” and your thyroid is fine.  

You are disappointed. How can you feel this lousy and your thyroid tests be normal? You feel lost, a bit hopeless and not sure what to do next.  

This is an all too common situation that many of our patients have gone through. So, do you have hypothyroidism? You seem to have all of the classic symptoms of hypothyroidism, but your doctor says your fine.  

From a conventional perspective, If your Thyroid Stimulating Hormone Level (TSH) is above the reference range, then your doctor will diagnose you with Hypothyroidism. If your TSH is within the reference range, your doctor will not diagnose you with Hypothyroidism.

This seems very simple and straightforward; however, we have had many patients over the years go to their doctor, suspecting they have a thyroid issue only to be told they don’t.  You might have had a similar experience. How can so many people, especially women be wrong about how they feel and the symptoms they have on a daily basis.

Why is a hypothyroidism diagnosis contingent only on a single TSH level? Why are a  patient’s symptoms routinely ignored during the evaluation process?

TSH Test:

The Thyroid Stimulating Hormone test is a screening assessment of the hormonal communication between the brain and the thyroid gland. The anterior pituitary gland in the brain releases TSH, which then enters the bloodstream and ends at the thyroid gland. The TSH hormones then “stimulates” the thyroid gland to produce T4 (Thyroxine). Once an adequate amount of T4 is in the bloodstream, it signals the pituitary to stop producing TSH.  

In physiology, this is referred to as a Negative Feedback Loop. Many factors influence the thyroid feedback loop. Genetics, nutrition, sleep quality, stress, and environmental toxins are some of the factors that affect thyroid function.  

If your thyroid is low or underactive, the TSH tends to be high normal, which we consider anything higher then 2.0 ng/dL to 2.5 ng/dL. If the TSH is greater than 4.5 ng/dL, this is diagnostic for Hypothyroidism.

TSH Reference Range:

• 0.45 ng/dL to 4.5 ng/dL

The TSH test is often the only “screening” test that will be done to assess thyroid function. Conventionally, it is black and white, either you are Hypothyroid, or you are not. If your TSH test is greater than 4.5 ng/dL, then you are hypothyroid and if it below 4.5 ng/dL you are not considered to be hypothyroid regardless of your symptom picture.  

Obviously, this begs the question, is a TSH test really that reliable to be the only criteria to diagnose someone with Hypothyroidism?

We feel the TSH should not be the only test used to diagnose a patient accurately. Many people have a TSH level below 4.5 ng/dL that could easily be considered to have hypothyroidism based on symptoms alone.

We think the TSH only approach is severely inadequate to assess and diagnose someone with Hypothyroidism. Thyroid issues are much more complicated and should not be reduced down to a single test.

Some Endocrinology Associations have proposed that the TSH reference range should be reduced from 4.5 ng/dL down to 2.5 ng/dL. This certainly narrows the reference range so that fewer people would go undiagnosed. Even still, this puts too much of an emphasis on just the TSH level alone.

The tests we routinely run for our patients are listed below. We never just run a TSH alone, but we do include it in our panel as it does help to make decisions about medication dosage adjustments. We prefer to run a Free T3 and Free T4, as opposed to Total T3 and Total T3. We find that most everyone typically falls within the reference range as well. In our opinion, a Free T3 level is the most clinically relevant test. We also include both the Anti-TPO and Antithyroglobulin antibody tests as well because we want to know if the patient has Hashimoto’s Thyroiditis or not.  

Ideal Hypothyroidism Testing:

• TSH
• Free T3
• Free T4
• Anti-TPO
• Anti-Thyroglobulin
• Reverse T3 (if currently on medication) 

If you are interested in getting testing done, you can purchase labs directly from our online store. Use the discount code: THYROID to get 25% off your order.

It is estimated that about 70% of all hypothyroid cases are of the Hashimoto’s type. Plus, it helps formulate a comprehensive treatment plan, beyond just medication. We consider many other factors.

Factors that Influence Thyroid Function:

• Genetics
• Diet (sugar / gluten)
• Stress
• Sleep (lack of)
• Liver function (caffeine & alcohol)
• Environmental toxins 

Is Subclinical Hypothyroidism Treated?

One rule we have always stuck by is to treat the patient, not a blood test. Unfortunately, there is way too much emphasis placed on blood tests in general, especially a TSH level.

In some situations, lab testing is crucial and has to be used to make necessary clinical decisions. Lab work is also essential in the diagnosis of Hypothyroidism, but the patient’s symptom picture is also relevant to the diagnosis.  

If your thyroid test is “normal,” but you have some or many of the Hypothyroid symptoms, then you could be classified as having Subclinical Hypothyroidism. This is when your labs are “normal,” but you are experiencing some of those classic hypothyroid symptoms.

Subclinical Hypothyroidism is something we see all the time with our patients. Their labs are “technically” normal, but have many of the classic symptoms.

For example, a patient named Cindy, who was a 37-year-old mother of two, came to see me a few years ago to get a different opinion about her thyroid. She was at her wit’s end because she had many of the common hypothyroid symptoms, but her doctor kept telling her that her thyroid was fine. She was not happy with response considering how she felt.

Cindy was tired all the time and had gained about 40 lbs after her second child. She had terrible PMS with really heavy periods, which made her anemic. After doing some updated blood work, her TSH was high normal at 3.4 ng/dL. Technically this is a “normal” level and the reason why her doctor did not diagnose her as hypothyroid, despite her symptoms.
I also ran a Free T3 level was 2.2 pg/mL, which is a below normal level. The reference range for Free T3 is 2.3 to 4.4 pg/mL. We like to see this number at least above 3.0 pg/mL if not higher.

For Cindy, I prescribed 65 mg of Nature Throid, which is considered desiccated thyroid medication. I also prescribed a 100 mg Bioidentical Progesterone capsule. We always prescribe thyroid medications that contain both T4 and T3 because patients often feel better as opposed to prescribing a medication with only T4, such as Synthroid or Levothyroxine.

After about three months, we did some, and Cindy’s TSH came down to 1.6 ng/dL, and her Free T3 increased to 3.5 pg/mL. Not to mention, her energy improved significantly, and she lost about 12 pounds. Also, her PMS and heavy periods improved considerably. Cindy was happy with how she felt but was confused why her doctor didn’t treat her in the past after repeated requests.

Unfortunately, this is somewhat of a controversial issue in medicine. If the TSH is normal, then it is concluded that thyroid function is normal. Again, we don’t agree because the TSH test does not tell a full thyroid story. As a result, many people end up falling through the cracks that could benefit if appropriately diagnosed.

When we diagnose someone with Subclinical Hypothyroidism, it is based on lab results and clinical presentation. We will often start them on thyroid medication. We usually prescribe Compounded Thyroid or in some cases Nature Throid, or WP Thyroid. We prefer to use medicine that contains both T4 and T3 hormones.  

One thing to understand, T4 (Thyroxine) is an inactive thyroid hormone. It has no real effect on the body and is simply converted into T3 (Triiodothyronine). Most of this conversion by the body occurs in the liver, roughly 60%, about 20% of T4 is converted to T3 by flora in the colon and about 20% by the peripheral tissues such as skeletal muscle.  

Taking medications that only contain T4 sounds good in theory, but in our experience does not always make the patient feel better.  The TSH level will improve, but symptoms often do not resolve, so the patient is still suffering from the same symptoms.

We know there is a great deal of information and opinions about what thyroid medication is best, so we will We will discuss more on that issue soon.

We hope you found this article helpful. Feel free to leave a comment below or send us an email at [email protected].