Hypothyroid Testing: What You Need To Know and Ask For

Hypothyroid Testing: What You Need To Know and Ask For

6 hypothyroid tests can unlock the mystery of your thyroid health. A Yale-trained board-certified family physician with a specialty in women’s health and obstetrics shares how she tests for hypothyroidism. Sadly I hear from many readers that their doctors REFUSE to do these tests.The reality for hypothyroid sufferers –  you must be an advocate for yourself. If your doctor refuses to run these tests, you can also order your own lab tests.

Written by Aviva Romm M.D.

Just recently a patient came into my practice feeling fatigued, moody, was having heavy periods, no libido, and was bothered by constipation. She also wasn’t sleeping well – waking up too early in the morning and unable to fall back to sleep, and she’d gained 7 pounds in just a couple of months even though she hadn’t changed her eating habits.

All are signs of hypothyroidism.

We talked. She really didn’t feel that stress was causing her symptoms – nothing in her life was really that troublesome. She had no outlier symptoms that suggested another diagnosis. She was pretty sure something was wrong with her thyroid so she’d asked her primary doctor to check her thyroid labs before scheduling to come see me for a more integrative medicine consult. He’d checked her thyroid stimulating hormone (TSH) test only, and told her that since it was still in the normal range, even though it was at the upper end of normal, she did not have a thyroid problem. He sent her on her way suggesting that maybe an antidepressant would be good to consider.

But her labs weren’t normal. One step over a very thin line and she’d have had a slam dunk diagnosis of the most common thyroid problem: hypothyroidism. And in fact, this is what I diagnosed. She started appropriate treatment and her energy and symptoms quickly began to improve!

This is a typical story.

Getting to The Bottom of Hypothyroid Testing

While not all hypothyroid-like symptoms turn out to be a problem with the thyroid or thyroid hormones, we do know that statistically, hypothyroidism is an under-diagnosed condition. In fact, only about half of Americans with a thyroid problem know they have one, and it is estimated that this can be as many as 4-10% of Americans

Hypothyroidism is the most common thyroid problem, and Hashimoto’s disease, an autoimmune form of hypothyroidism, is the most common form of all. Women are much more likely than men to have thyroid problems. Hypothyroidism can appear at anytime but is especially common after childbirth and is prevalent in woman in their 40s and 50s.

Yet so many doctors seem reluctant to do an adequate work-up of thyroid function. Some even refuse! This seems strange given how common thyroid problems are, and yet they are quite willing to freely prescribe antidepressants. My patient’s doctor was doing just what we were all told to do in medical school – check the TSH and if that’s within what we were told is the normal range, there’s no problem. But there’s much more complexity to thyroid testing than that! Sadly, so many women are left believing that their symptoms of depression, fatigue, joint aches, weakness, weight gain and more are all in their head! Perhaps this has even happened to you.

In reality, your symptoms could be due to hypothyroidism.

What is the Thyroid?

The thyroid is a butterfly-shaped gland that sits at front of your neck and sets your entire metabolic rate. Thus it controls your weight, whether you feel sluggish or energetic, mentally crisp or foggy, cheerful or blue, and is involved in the control of everything from your cholesterol to your female hormones.

When your thyroid is not functioning optimally, you can feel dull, tired, constipated, gain weight, your skin gets dry, your hair can become dry and even fall out, your muscles and joints might ache, your periods become irregular, you might have fertility problems, brain fog, sugar and carb cravings (because your body is desperate for energy!), high cholesterol even if your diet is amazing, and a host of other large and small symptoms.

What is Hypothyroidism?

Hypopthyroidism is a term used to describe a decreased metabolic state that is due to inadequate amounts of – or functioning of – thyroid hormone. Ninety-five percent of all cases are due to what is called “primary hypothyroidism.” This means that the thyroid gland is acting sluggish – or sometimes barely responding at all. This can be due to a number of reasons ranging from leaky gut to autoimmune disease.

Alternatively, we can be producing thyroid hormones effectively, but we can have “thyroid hormone resistance” similar to the way we can have insulin resistance. Our cells are not picking up and effectively using the active thyroid hormone we are making. We can also be making enough of the inactive form of thyroid hormone but not be effectively converting it to the active form.

While hypothyroidism can also be due to more serious problems in the hypothalamus and pituitary, this is rare. However, chronic or substantial stress can suppress the pituitary gland enough to interfere with thyroid hormone production.

Symptoms of hypothyroidism include:

  • Fatigue
  • Increased sensitivity to cold
  • Constipation
  • Dry skin
  • Unexplained weight gain
  • Cravings for sugar and carbohydrates
  • Puffy face
  • Muscle weakness
  • Elevated blood cholesterol level
  • Muscle aches, tenderness and stiffness
  • Pain, stiffness or swelling in your joints
  • Heavier than normal or irregular menstrual periods
  • Thinning hair
  • Slowed heart rate
  • Depression
  • Impaired memory (“Brain fog”)

Because these symptoms are so common to so many women, hypothyroidism is often dismissed as “just normal symptoms” or depression! One patient of mine was accused of overeating by her primary doctor as the cause of her weight problem when she actually had a thyroid problem!

The 6 Key Hypothyroid Tests

There are 6 key tests that can unlock the mystery of your thyroid function and are what your doctor should be looking at. Thyroid testing should be simple to obtain from your primary doctor or local lab. However, the nuances may take some skill to interpret, depending on the results, and your doctor might be resistant to ordering more than the TSH test. That’s where an open-minded endocrinologist or a skilled integrative or functional medicine doctor can be of help.

In my practice, if my patient’s symptoms are highly suggestive of hypothyroidism, I will run the entire thyroid panel described below right up front. If there are other diagnoses that are equally likely, I will run just the first 3 tests (Panel 1), and if these come back borderline or positive for thyroid or thyroid hormone problems, I will then add in the remainder of the test panel (Panel 2). I will also sometimes recheck test results for TSH, FT3, and FT4, if normal in a newly symptomatic patient, in 6-12 weeks, because I’ve occasionally seen initial testing be normal then a short time later, voila – the tests come back confirming the problem.

Thyroid Stimulating Hormone (TSH)

Thyroid Stimulating Hormone (TSH) is produced in a part of your brain called the pituitary gland. The job of TSH is to tell the thyroid gland that it’s time to get busy producing more thyroid hormone. When the healthy thyroid gets this chemical message, it produces two hormones: triiodothyronine (T3) and thyroxine (T4).

The normal range for TSH is somewhat controversial. Most labs consider the upper range to be between 4 and 5 mU/L. However, many experts – even in conventional endocrinology – believe that the upper end of normal is actually more like 2.5-3 mU/L. This is based on the fact that when Americans without any hypothyroid symptoms have this test done, that is the most usual upper range.

Many integrative and functional medicine doctors find that their patients feel their best at an upper limit of 1.5-2 mU/L.

My patient was one of these people. At a TSH of 4 she was really at the upper limit of normal, over the preferred upper limit according to some docs, and well over the 1-2 mU/L upper range! This controversy and discrepancy of opinion over the normal upper range for TSH is one of the most common reasons that women get under-diagnosed for hypothyroidism and suffer with unnecessary symptoms that can seriously interfere with health and quality of life.

In most cases hypothyroidism occurs because the thyroid gland is sluggish – that is, it is having trouble producing T3 and T4. This can be due to a variety of reasons ranging from nutritional deficiencies to autoimmunity. So TSH gets pumped out in a higher amount to try harder to stimulate the thyroid gland into action. Think of it like this: You are TSH. Your best friend’s house is the thyroid gland. When you go to visit your friend you knock on her front door. If she doesn’t answer, what do you do? You knock louder to get a response. In just the same way, the TSH amps up to knock louder, hoping to get an answer. That’s why an under-functioning thyroid shows up as high TSH on lab tests. However, TSH can be normal in the presence of hypothyroidism in some cases, and you can still be having the symptoms of low thyroid when TSH is normal because of poor conversion of T4 to T3 (see below) or because of thyroid hormone resistance at the level of your cells.

When stress is suppressing the pituitary gland enough to interfere with producing TSH, you might see low or normal TSH levels in the presence of low thyroid hormone production (T3 or T4), and hypothyroid symptoms.

Thyroid Hormones (T3 and T4)

Triiodothyronine (T3) and thyroxine (T4) are the hormones produced by your thyroid gland. T4 is produced in a much larger amount and is then converted to T3, the active form of the hormone, as needed to up-regulate metabolic functions. T3 and T4 are sent out into your bloodstream where they are responsible for the thyroid’s actual work of controlling your metabolism. Free T3 (FT3) and Free T4 (FT4) are called this because they are not bound to proteins in your blood, making them free to perform their work in your cells – keeping your metabolism appropriately revved up for your optimal health.

Measuring FT3 and FT4 is important because they are the indicators of thyroxine and triiodothyronine activities in the body. A high TSH and low FT4 and FT3 indicate hypothyroidism. A normal TSH, normal FT4, and low FT3 can indicate T4 to T3 conversion problems, and a normal or high TSH, normal FT4 and high FT3 can indicate cellular resistance to FT3 which can still lead to hypothyroid symptoms because the active hormone can’t get to the cell to do its job.

Thyroid Antibodies

Thyroid antibody testing is ordered to diagnose the autoimmune thyroid disease Hashimoto’s Thyroiditis and distinguish it from other forms of thyroid dysfunction.

The two thyroid antibody tests that I order are Thyroid Peroxidase Antibody (TPOAb) and Thyroglobulin Antibody (TgAb). Some people do have an autoimmune thyroid condition but don’t initially test positive. If positive, antibody testing can be repeated every six months to trend improvement while you are working with an integrative physician to address possible underlying causes.

Reverse T3 (rT3)

Reverse T3 is the third most abundant form of thyroid hormone. When your body wants to conserve – rather than “burn” – energy, it will divert the active T3 into an inactive “reserve” form. This might happen when you are sick, under stress, or undernourished. If TSH and FT4 look ok, but FT3 is low this can be because it is being diverted into rT3 – which will be elevated. It is worth checking rT3 if there are obvious symptoms suggesting hypothyroidism, but the typical tests aren’t demonstrating low TSH or low FT4. There is some controversy amongst conventional doctors about the utility of this test – I personally find it very useful.

 Thyroid tests and optimal levels

Additional Testing

If labs return showing that there is hypothyroidism, then I also test for deficiencies of selenium, iron, and zinc and make sure there is adequate dietary intake or supplementation if needed, and look for environmental factors that can interfere with iodine utilization, for example, fluoride and bromide exposures from water and flame-retardant products, respectively. I will then also start to look more closely for other underlying causes, for example, gluten intolerance, heavy metal exposure, and other environmental triggers.

Adrenal stress is a biggie for hypothyroidism patients, that few mainstream doctors consider. Our bodies, in their infinite wisdom, work very hard to protect us from overwhelm, fatigue, stress, and even the challenges of environmental toxins, inflammatory foods, and hidden infections. They do this through a set of tiny but powerful glands called the adrenals, that sit one on top of each kidney, that produce a hormone called cortisol. The thyroid’s job is to regulate how much energy we burn or conserve. When we’re under a lot of stress, or other exposures that we need a lot of energy to manage or repair from, the adrenals, through cortisol as a messenger, tell the thyroid to save energy – and voila! The thyroid slows down to protect those precious energy resources and we end up with hypothyroidism. Also, because the adrenals control inflammation and our response to infection, when we are overdriving the adrenal system, or have depletion in that system, our ability to control our immune system becomes compromised and we can get both reactivation of old infections like EBV that can affect thyroid function, as well as autoimmune reactions that can lead to Hashimoto’s.

Talking with Your Doctor About Thyroid Testing (or Switching Doctors)

As a doctor, I can tell you that in medical school we are taught that doctors know best. But this is often not the case. You are your body’s best expert. After all, you live with you all the time! And you have a right to ask for basic testing and receive it. We’re not talking about tens of thousands of dollars in MRI’s and CT scans here – we’re talking about modest amounts of blood work.

That said, do discuss your symptoms with your doctor because there’s a lot of hype in the natural medicine and natural products world, and your doctor is possibly just trying to protect your from the opposite problem – getting OVER-diagnosed or misdiagnosed with a thyroid problem – and believe me, I’ve also had many patients who were put on thyroid medications by integrative practitioners when these meds were not needed.

If you are unable, however, to have an honest conversation with your doctor, if you feel your doctor is not listening or is condescending, then that’s another issue. You should be able to have mutually respectful conversations with your care provider, to get the answers you are seeking, and to be able to explore your concerns. If you can’t, then figure out whether the obstacle is in your being unable to speak up because of a perceived power differential (many of us become weak in the knees when we face our doctors, especially if we feel vulnerable about our health) or whether your doctor is just not communicating respectfully. And make the change!

About Aviva Romm M.D.

Dr. Aviva Romm is the mother of four grown children, a Yale-trained physician specializing in integrative medicine for women and children, a midwife, an herbalist, and an award-winning author of 8 books. Aviva is the recent Past President of the American Herbalists Guild and a founder of the Yale Integrative Medicine program. avivaromm.com

READ NEXT: 11 Common Medical Conditions Often Caused By Thyroid Disease

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I appreciate every share! Thank you.

About Dana Trentini

Dana Trentini founded Hypothyroid Mom October 2012 in memory of the unborn baby she lost to hypothyroidism. This is for informational purposes only and should not be considered a substitute for consulting your physician regarding medical advice pertaining to your health. Hypothyroid Mom includes affiliate links including the Amazon Services LLC Associates Program.


  1. Sue A Whiteman says

    I was diagnosed with hypothyroidism when I was 14, and told at that time I would have to be on medication the rest of my life. I took it for many years, but had my thyroid fiction checked thru out my life. I’m now 69. About 30years ago they took me off thyroid medication, saying I didn’t require it any more, but continued to have my levels checked periodically. About 5 years ago, my doctor ordered a TSH test, my insurance company (Blue Cross) rejected the claim, stating they will only cover that test for a newborn. Recently a doctor ordered it for my husband, and received the same denial. We had to pay $170.00 for those 2 tests….just FYI. As a nurse, it makes no sense to me, whatsoever, but thought others should be aware.

  2. I was finally dx’ed when *I* asked for all the proper lab tests. My TSH was “in range,” and my Free T4 was at the bottom, but again “in range.” I was tested for Hashi’s and Graves – no antibodies (I was retested for Hashi’s 10 years later – still no antibodies). I pointed to my TSH and Free T4 and how one was somewhat high and the other low and asked him to test my Free T3. He agreed.

    When I came back for the results, my T3 levels were in the basement (nowhere near even the bottom of the range). I started treatment that day, but I didn’t feel well until I got a a combo of natural thyroid plus levothyroxine. That was a lot of trial and error, but I had a great doc who helped me get back to my old self. I was just sad I couldn’t take him with me when we moved 1800 miles away. Finding a new one hasn’t been easy.

    • Julie Baeskens says

      Hi Victoria-
      Got my results today and I also have a high TSH and low end free T4 and have been on levothyroxine but still don’t feel like myself! What kind of natural thyroid do you use with your levothyroxine?

      Thank you,

  3. My TSH LEVELS ARE 8.6 DO I HAVING Thyroid

  4. Kelly wuest says

    Yep, this is the case for me. I have every single marker for hypothyroid (except crazy periods because I have had a total hysterectomy) also to add genetics to that list, my mother and my maternal grandmother both had hypothyroidism but cannot for the life of me get the right testing!😠 I feel like any doctor including my gp and ob/gyn my complaints fall on deaf ears. I’m miserable!😣

  5. This article was extremely helpful. I have every one of these issue and have not been properly diagnosed in 35 years. I’m in my early 50’s and I find life completely unbearable at times. I’m extremely frustrated with both my regular MD and my OBGYN. Both are older men. Both put me on anti depressants through out those 35 years as well as sleeping aids. These medications made my weight fluctuate so bad I would gain or lose between 30 to 80 lbs in 12 months. Not to mention being sent to psychiatrists and neurologists because no one could properly diagnose me. I’m at my worst now. It’s all I can do to get out of bed each day and go to work. I come home, energy depleted, don’t sleep well at all, depressed, irritated, anxious, belly pain, dizzy, heart racing….etc. I have all those problems and I feel completely cheated because those physicians that I trusted all these years let me down!
    I switched OBGYN last year, excellent improvement but still gaining weight like crazy. Just switched MD and waiting for lab results to come in. T3 & T4 are doing better, but still have the tiredness, fatigue, anxious, cold all the time, heart racing ( you get the picture). So she’s looking for an endocrinologist and I’m also doing an in home sleep study.
    Doesn’t address the massive weight gain though. Any thoughts about that? I hate working out, but I do eat fairly clean.

    • Kay Northington says

      My problem started when I was 31. I was a normal weight, started falling asleep if I got still & was gaining weight at an alarming rate. I was in the normal range, so was just dismissed. After discovering that I had multi-modular goiter, I was put on Synthroid. When I started having symptoms of being hyperthyroid, my medications were adjusted and eventually stopped. Over the years, I had had the hyper symptoms off & on & have gained & lost weight, with no change in eating habits.
      After having MRSA, in 2011 & again in 2013, I underwent several CAT scans to find fluid in my abdomen. I kept having symptoms of hyperthyroidism that was so bad I thought I was going to die. My TSH level at dropped from 2.3 to .63. I was still in the range so was denied treatment.
      In 2017 my doctor wanted to have a CAT scan on my sinuses. I told him of the problems I had with it before, but he insisted. I started having the same symptoms. Then in 2017 I broke my femur, fibula & tibia in my left leg. Subjected to CAT scans again, & have been a mess ever since. This time I went into AFib, but all the doctors want to do is fill me full of rhythm medication, blood thinners, & blood pressure pills. What does it take to get them to listen? I am not a bit shy around doctors. I have argued my car to several doctors & have not gotten any results.

    • Jan Gate – My daughter in 20’s was put on
      antidepressants to control cyclic vomiting syndrome and gained 30 lbs in 2 months! Was never overweight before. She’s put on whopping total of 120 lbs in a few years , developed OCD and lost her love for life. Has always been a struggle to get thyroid properly tested and treated. New functional dr today thinks antidepressant is messing up her thyroid. We are starting from scratch for evaluation of systems, but its the antidepressant for sure causing weight gain.

  6. Does anyone know of an Endocrinologist in Houston, Texas that is good? I have been to 3. Supposedly, i have something called Thyroiditis. I feel like crap all the time, have dizzy spells and my levels are supposedly within normal levels. So confused!!

  7. I have a 21 month old granddaughter who at 1 had a TSH level of 7 and sent to a Endocrinologist who put her on Levothyroxine for possible Hypothyroidism 3 months later her TSH was 1.79 and Free t4 was 1.52 and then 3 months after that TSH was 2.78 and T4 was 1.58 and now TSH is 1.71 and T4 is 1.69 Dr says this is all normal and too continue medication until she is 2 and a half 3 years old but unable to say if she has hypothyroid or will in the future the numbers seem all over the place, Any thoughts??

  8. I have been taking levothyroxin for over twenty years with no relief from symptoms. I fear I have adrenal issues now from the on going stress of living with a narcissist for years without realizing it. What tests should I ask for, and what things can I do to reverse this. I also suspect leaky gut.

    • THIS COULD BE ME EXACTLY! Find a good doctor. If they blow you off, find a better doctor. Get your health under control, and then determine whether you can get rid of your narcissist. AND beware. I divorced mine and married another one. Choose very wisely. And God bless you.

  9. Norma Leingang says

    Hi. I had my thyroid panel done 7 years ago and I never done anything about it! My doctor suggest I see an Endo but didn’t cuz I thought that it was a fluke thing. My TSH was very low 0.07 but my T3 and T4 were on the high side. Now I’m approaching 60 and I’m thinking I should get this checked out!!! What do you think?????

  10. Hello,
    I am a 46 yo female with a high TSH, ,but the T3 & T4 levels are normal. My sonogram indicated that I have an enlarged Thyroid on the right side.
    I thought I was experiencing premenopausal symptoms, but my pcp said it is due to my thyroid.
    Now that the tests show a normal T3 n T4, now im told it’s nothing and to exercise and to watch what I eat.
    I feel like there is something missing and not getting to a real answer to the solution. Is it really in my mind now?
    Is it normal or not having a high tsh and normal t3 and t4 levels?

  11. Gary Adams says

    I am a 54 male with all the symptoms of hypo, wt gain , tired, joint and muscle pain, etc
    My TSH is normal 3.0 and my free t4 is border line low at 0.7……. 0.8 is normal
    Could my symptoms be hypo ? of course Endo says no way 🙁

  12. Hi I’m a 42 yo male with many a health issues for the past 12 years. Now I just had labs done on my thyroid. It says the antibodies were in range the free T3, free T4, and TSH were all within range but the reverse T3 was at 38 ng/dL which was way above range. I looked at one site and it said you have to figure the ratio between the free T3 and the reverse T3 . Depending on the ratio it could be I’m pooling reverse T3 and it need to be flushed out. My question is how do you flush it out and how do I figure the ratio. The 38 reverse T3 was in ng/dL and the free T3 is 2.7 in pg/mL. Any help would be great. Sorry for such a long message.

    • Hi Brian, There are several common causes of high reverse T3 that need to be checked such as high stress, chronic infections, inflammation, gut infections, abnormal iron levels, and even certain medication like blood pressure medication, diabetic medications and antidepressants. Chronic stress turned out to be the reason for my elevated Reverse T3 as showed up when my doctor did saliva testing of my cortisol levels, also high inflammation showed up when my CRP (C-reactive protein) was tested. My doctor’s strategy was a combination of supplementation with adaptogenic herbs like ashwagandha, a prescription for NDT and time-release T3, liver supplements like milk thistle and 200mcg of selenium. This is to give you an idea of strategies that can be used by your doctor. Here are two helpful articles that give you more ideas of what to discuss at your next appointment. Good to have you at Hypothyroid Mom.



  13. Carol Leashefski says

    I am trying to figure out the difference between T3 Free Tracer Dialysis and Total T3. My labs are back and I can’t seem to figure this one out. T3 Free was 289 pg/dL and Total T3 was 151. Free T4 was 1.3. I am trying to figure out what is going on.

  14. I have been sick for three and doctors can’t found nothing. So tired of being exhausted and have lot of pain my legs. Please advise

  15. james nyari says

    I was seeing a urologist, (for symptems of hypothyrodism) when during routine urine test, I showed elevated salt. It was a hyperparathyroid, which could cause kidney stones. When I was referred to an head/neck surgeon, during the nuclear MRI to locate the over-active parathyroid, said there were nodules in my thyroid, which could indicate cancer,so during surgery, removed it. Pathology later confirmed cancer, and with parathyroid removed calcium levels are normal.

  16. Ok I can’t seem to find anything to tell me what my condition may be. My Tsh is low and my FT3 is low but my FT4 is normal. This has happened my last two work ups. It seems to be a mystery it doesn’t fit any diagnosis. Any help or direction will be greatly appreciated. I’m a 42 year old female with two basically grown children. Help ………

  17. My husband has lost weight for no reason,craved sweets,has extremely dry skin, and cyclic cognitive decline. Drs. Checked tsh and of course all is well except the patient. He has skin bruising-like discoloration on arms, vision and hearing problems..this is 74 yr old man on no meds,no illness, other than kidney stones and 3 blasting surgeries. His memory and day to day functioning is declining. He thinks he is fine and says it is because he is getting old. Changed completely within a yr. Help, could this be thyroid,

    • DOLORES DIAZ says

      PLEASE have him checked out for hyperparathyroidism. U can read about it at parathyroid.com. I had it and had the surgery and all my symptoms went away, especially my cognitive issues I had

      • james nyari says

        I was seeing a urologist, (for symptems of hypothyrodism) when during routine urine test, I showed elevated salt. It was a hyperparathyroid, which could cause kidney stones. When I was referred to an head/neck surgeon, during the nuclear MRI to locate the over-active parathyroid, said there were nodules in my thyroid, which could indicate cancer,so during surgery, removed it. Pathology later confirmed cancer, and with parathyroid removed calcium levels are normal.

  18. Thanks!!!!

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