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Thyroid Function Tests

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What is the thyroid gland?

The thyroid is a small, butterfly-shaped gland located in the front of the neck below the larynx, or voice box. The thyroid gland makes two thyroid hormones, triiodothyronine (T3) and thyroxine (T4), which circulate in the bloodstream and act on virtually every tissue and cell in the body. Thyroid hormones affect metabolism, brain development, breathing, heart and nervous system functions, body temperature, muscle strength, skin dryness, menstrual cycles, weight, cholesterol levels, and more.

Thyroid hormone production in the thyroid is regulated by another hormone called thyroid-stimulating hormone (TSH). TSH is made by the pituitary gland, which is located in the brain. From the pituitary gland, TSH travels to the thyroid where it stimulates the production of T3 and T4 and their release into the bloodstream.

Drawing of the head and neck with the thyroid and pituitary glands labeled. The hormones TSH, T3, and T4 are also labeled. Arrows indicate the flow of these hormones between the two glands.
The thyroid gland's production of thyroid hormones (T3 and T4) is regulated by thyroid-stimulating hormone (TSH), which is made by the pituitary gland.

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Why are thyroid function tests performed?

Thyroid function tests are used to evaluate the thyroid's functioning and to diagnose and help determine the cause of thyroid diseases.

Sometimes the body produces too much or too little thyroid hormone. Too much thyroid hormone in the bloodstream causes hyperthyroidism, which results in increased metabolic rate, weight loss, sweating, rapid heart rate, and high blood pressure, among other symptoms. Too little thyroid hormone causes hypothyroidism, which slows down bodily functions and leads to fatigue, weight gain, cold intolerance, and related symptoms.

Hyperthyroidism and hypothyroidism are most often caused by autoimmune diseases. Normally, the immune system produces antibodies that defend the body against foreign substances such as bacteria. In autoimmune diseases, however, the immune system produces "autoantibodies" that attack the body's own healthy cells and tissues-in this case, the thyroid. Graves' disease is the most common cause of autoimmune hyperthyroidism. Hashimoto's disease is the most common cause of autoimmune hypothyroidism. Both Graves' disease and Hashimoto's disease are due to an immune attack on the thyroid. In Graves' disease, the attacking antibodies stimulate thyroid hormone production.

Blood tests assess thyroid function by measuring TSH and thyroid hormone levels and detecting certain autoantibodies present in autoimmune thyroid disease. Radiologic tests either assess thyroid function or detect abnormalities in the thyroid gland.

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What blood tests are used to assess thyroid function?

Usually the first blood test performed is the TSH test. TSH is the key hormone for diagnosing hyperthyroidism and hypothyroidism. If results of the TSH test are abnormal, one or more additional tests are needed to help determine the cause of the problem.

TSH Test

This blood test is the most sensitive test of thyroid function available. The TSH test can detect TSH blood levels as low as 0.01 milli-international units per liter (mIU/L). The normal range for TSH is between 0.3 and 4 mIU/L, although the range varies from one laboratory to another.

The TSH test is based on the way TSH and thyroid hormones work together. Normally, the pituitary boosts TSH production when thyroid hormone levels in the blood are low. The thyroid responds by making more hormone. Then, when the body has enough thyroid hormone circulating in the blood, TSH output drops. The cycle repeats continuously to maintain a healthy level of thyroid hormone in the body. The TSH test measures the amount of TSH being secreted by the pituitary.

In people whose thyroid produces too much thyroid hormone, the pituitary shuts down TSH production, leading to low or even undetectable TSH levels in the blood. An abnormally low TSH level suggests hyperthyroidism.

In people whose thyroid is not functioning normally and produces too little thyroid hormone, the thyroid cannot respond normally to TSH by producing thyroid hormone. As a result, the pituitary keeps making TSH, trying to get the thyroid to respond. An abnormally high TSH level suggests hypothyroidism.

Occasionally, however, a low TSH level can indicate a type of hypothyroidism called secondary hypothyroidism. Instead of a problem with the thyroid gland, this type of hypothyroidism is caused by an abnormality in the pituitary that prevents it from making enough TSH to stimulate thyroid hormone production.

Very rarely, hyperthyroidism can result from a problem with the pituitary rather than the thyroid. Noncancerous, or benign, pituitary tumors may overproduce TSH and cause thyroid hormone levels to rise. However, such tumors are extremely rare. The usual cause of a high TSH level is an underfunctioning thyroid gland or inadequate dosage of thyroid hormone medication in patients taking replacement hormone.

T4 Tests

T4 is the principal thyroid hormone and exists in two forms-T4 that is bound to proteins in the blood and kept in reserve until the body needs it, and a small amount of unbound or "free" T4 (FT4), which is the active form of the hormone and is available to body tissues. The normal range for total T4-bound and free together-is usually about 4.5 to 12.6 micrograms per deciliter (µg/dL), although the range varies from one laboratory to another. The normal FT4 range is about 0.7 to 1.8 nanograms per deciliter (ng/dL).

Elevated total T4 or FT4 suggests hyperthyroidism, and low total T4 or FT4 suggests hypothyroidism. Sometimes total T4 levels are abnormal because the protein-bound T4 is abnormally high or low due to elevated or low concentrations of the protein that binds T4. Therefore, FT4 must be calculated separately.

Measuring FT4 directly requires complicated laboratory procedures, so FT4 is usually estimated based on the ratio of binding protein to total T4. Normal FT4 levels, when the total T4 is high or low, indicate the issue is the binding protein, not the thyroid. For example, pregnancy or the use of oral contraceptives increases levels of binding protein in the blood. In this case, the total T4 will be high due to the binding protein but the person does not have hyperthyroidism. Severe illness or the use of corticosteroids-a class of medications that treat asthma, arthritis, and skin conditions, among other health problems-can decrease binding protein levels. The total T4 measurement will be low as a consequence, but the person does not have hypothyroidism. In either case-having high binding protein or having low binding protein-the FT4 will be normal and the person has normal thyroid function-also called euthyroid.

T3 Test

Only about 20 percent of the T3 circulating in the blood comes from the thyroid gland, while all of the circulating T4 comes from the thyroid. The remaining 80 percent of circulating T3 comes from various cells all over the body where T4 is converted to T3. T3 is far more active than T4 and, like T4, exists in both bound and free states. In some cases of hyperthyroidism, FT4 is normal but free T3 (FT3) is elevated, so measuring both forms is useful if hyperthyroidism is suspected. The normal FT3 range is about 0.2 to 0.5 ng/dL. The T3 test is not useful in diagnosing hypothyroidism because levels are not reduced until the hypothyroidism is severe.

Thyroid-stimulating Immunoglobulin (TSI) Test

TSI is an autoantibody present in Graves' disease, the most common cause of hyperthyroidism. TSI mimics TSH by stimulating the thyroid cells, causing the thyroid gland to secrete excess hormone. The TSI test detects TSI circulating in the blood and is usually measured in specific instances in people with Graves' disease-when the diagnosis is obscure, during pregnancy, and to determine if remission has occurred.

Antithyroid Antibody Test

Antithyroid antibodies are present in Hashimoto's disease, the most common cause of hypothyroidism. Antithyroid antibodies are markers in the blood, and their presence is extremely helpful in diagnosing Hashimoto's disease. Two principal types of antithyroid antibodies are

  • anti-TG antibodies, which attack a protein in the thyroid called thyroglobulin
  • anti-thyroperoxidase, or anti-TPO, antibodies, which attack an enzyme in thyroid cells called thyroperoxidase

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What radiologic tests are used to assess thyroid function?

Two radiologic tests-the radioactive iodine uptake (RAIU) test and a thyroid scan-may be used to aid diagnosis and treatment.

RAIU Test

The thyroid uses iodine from food to make thyroid hormone. The RAIU test measures the amount of iodine the thyroid collects from the bloodstream. The test helps doctors evaluate how the thyroid is functioning and determine the cause of hyperthyroidism. The RAIU is not used to assess hypothyroidism.

For this test, the patient swallows a small amount of radioactive iodine in liquid or capsule form. After 4 to 6 hours and again at 24 hours, the patient returns to the testing center, where the doctor measures the amount of radioactive iodine taken up by the thyroid. The measurement is taken with a small device called a gamma probe, which resembles a microphone. The gamma probe is positioned near the patient's neck over the thyroid gland. Measurement takes only a few minutes and is painless.

In the diagnosis of hyperthyroidism, a high RAIU reading usually indicates an overactive thyroid that produces too much thyroid hormone, as seen in Graves' disease or toxic nodular goiter, an enlargement of the thyroid gland. A low RAIU reading suggests the thyroid is not overactive.

Thyroiditis may cause leakage of thyroid hormone and iodine out of the thyroid gland into the bloodstream, which can lead to high T4 levels. Because the thyroid is inflamed, it does not take up the radioactive iodine given as part of the RAIU test. Hyperthyroidism seen in Graves' disease would be marked by high blood T4 and a high RAIU. In thyroiditis, temporary hyperthyroidism may exist because of the release of T4 into the blood, but the RAIU is low because of the inflammation. Temporary hyperthyroidism in thyroiditis is often followed by a period of hypothyroidism before the thyroid heals.

The radioactive compound used in the RAIU test is safe to ingest in the small amount given. Pregnant and nursing women should not undergo this test, however, because the radioactive material can travel across the placenta to the baby's bloodstream or be transmitted to the baby via breast milk.

Thyroid Scan

A thyroid scan does not test thyroid function per se, but instead uses radioactive material to create a picture of the thyroid. The scan shows the size and shape of the thyroid and provides images of irregularities such as nodules. Nodules are tumors in the thyroid that can either be benign or cancerous and can sometimes produce excess thyroid hormone. The scan does not identify whether the nodules are benign or cancerous.

For the scan, radioactive iodine or radioactive technetium is either injected into the patient's vein or swallowed in liquid or capsule form. The scan takes place 30 minutes after an injection or 6 to 24 hours after the radioactive substance is swallowed. The patient lies on an examining table for the scan, which takes about 30 minutes. A device called a gamma camera is suspended over the table or may be located within a large, doughnut-shaped machine that resembles a computerized tomography (CT) scanner.

The gamma camera detects the radioactive material and sends images to a computer that show how and where the radioactive substance has been distributed in the thyroid. Nodules that produce excess thyroid hormone-so-called "hot," or toxic, nodules-show up clearly because they absorb more radioactive material than normal thyroid tissue. Graves' disease shows up as a diffuse, overall increase in radioactivity rather than a localized spot.

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What do thyroid function test results tell doctors?

The pattern of test results in people with hyperthyroidism or hypothyroidism can help doctors determine the underlying cause of the condition. The following tables give the usual pattern of thyroid function test results.

Table 1. Typical thyroid function test results: Hyperthyroidism

Cause
Test
     TSH          T3/T4           TSI            RAIU      
Graves' Disease +
Thyroiditis (early stage) -
Thyroid nodules (hot, or toxic) - ↑ or N

Table 2. Typical thyroid function test results: Hypothyroidism

Cause
Test
    TSH         T3/T4         Antithyroid Antibody    
Hashimoto-s (thyroiditis) disease ↓ or N +
Hashimoto-s (thyroiditis)
disease (later stage)
+
Pituitary abnormality -

Key:     N = Normal    ↑ = Above Normal    ↓ = Below Normal    + = Positive    - = Negative

Because many complex factors affect thyroid function and hormone levels, doctors must take the patient's full medical history into account when interpreting thyroid function tests.

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Points to Remember

  • Hyperthyroidism occurs when the thyroid gland produces too much thyroid hormone or hormone leaks out of the inflamed gland. Hypothyroidism occurs when the thyroid gland does not produce enough thyroid hormone.

  • Blood tests are used to diagnose hyperthyroidism and hypothyroidism and help determine the cause of these disorders.

  • Thyroid-stimulating hormone (TSH) is the key hormone for diagnosing hyperthyroidism and hypothyroidism.

  • Radiologic tests that use radioactive materials evaluate how the thyroid is functioning and create pictures of the gland to further pinpoint the cause of thyroid disorders.

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Hope through Research

Researchers are investigating the development, signs and symptoms, and genetics of thyroid function disorders to better understand thyroid diseases. Scientists continue to study treatment options for hyperthyroidism, hypothyroidism, and other thyroid disorders.

Participants in clinical trials can play a more active role in their own health care, gain access to new research treatments before they are widely available, and help others by contributing to medical research. For information about current studies, visit www.ClinicalTrials.gov.

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For More Information

American Association of Clinical Endocrinologists
245 Riverside Avenue, Suite 200
Jacksonville, FL 32202
Phone: 904-353-7878
Fax: 904-353-8185
Email: info@aace.com
Internet: www.aace.com click to view disclaimer page

American Thyroid Association
6066 Leesburg Pike, Suite 550
Falls Church, VA 22041
Phone: 1-800-THYROID (1-800-849-7643) or 703-998-8890
Fax: 703-998-8893
Email: admin@thyroid.org
Internet: www.thyroid.org click to view disclaimer page

The Endocrine Society
8401 Connecticut Avenue, Suite 900
Chevy Chase, MD 20815
Phone: 1-888-363-6274 or 301-941-0200
Fax: 301-941-0259
Email: societyservices@endo-society.org
Internet: www.endo-society.org click to view disclaimer page

Graves' Disease Foundation
400 International Drive
Williamsville, NY 14221
Phone: 1-877-NGDF123 (1-877-643-3123) or 716-631-2310
Fax: 706-631-2822
Email: gravesdiseasefd@gmail.com
Internet: www.ngdf.org click to view disclaimer page

The Hormone Foundation
8401 Connecticut Avenue, Suite 900
Chevy Chase, MD 20815-5817
Phone: 1-800-HORMONE (1-800-467-6663)
Fax: 301-941-0259
Email: hormone@endo-society.org
Internet: www.hormone.org click to view disclaimer page

You may also find additional information about this topic by visiting MedlinePlus at www.medlineplus.gov

This publication may contain information about medications. When prepared, this publication included the most current information available. For updates or for questions about any medications, contact the U.S. Food and Drug Administration toll-free at 1-888-INFO-FDA (1-888-463-6332) or visit www.fda.gov. Consult your doctor for more information.

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Acknowledgments

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This publication was reviewed by Lewis Braverman, M.D., Boston Medical Center, and Leonard Wartofsky, M.D., M.A.C.P., Washington Hospital Center.

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National Endocrine and Metabolic Diseases Information Service

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The National Endocrine and Metabolic Diseases Information Service is an information dissemination service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health, which is part of the U.S. Department of Health and Human Services.

The NIDDK conducts and supports biomedical research. As a public service, the NIDDK has established information services to increase knowledge and understanding about health and disease among patients, health professionals and the public.

This publication is not copyrighted. The NIDDK encourages users of this publication to duplicate and distribute as many copies as desired.


NIH Publication No. 10-6284
May 2010

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Page last updated April 6, 2012


The National Endocrine and Metabolic Diseases Information Service is a service of the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.

National Endocrine and Metabolic Diseases Information Service
6 Information Way
Bethesda, MD 20892–3569
Phone: 1–888–828–0904
TTY: 1–866–569–1162
Fax: 703–738–4929
Email: endoandmeta@info.niddk.nih.gov
Internet: www.endocrine.niddk.nih.gov

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