Essential Thyroid Labs

Thyroid Labs

Thyroid Labs.  When I worked in the clinical setting I often observed physicians ordering TSH and Total T4 ONLY to assess a patient’s thyroid.  Naturally, I would debate the issue with them time and time again, and only a few listened to the point that they changed their orders.  I even posed the question to one new resident “if this were your wife, are these really the only two tests you would order?”  My question seemed to resonate with him and he listened by ordering a couple additional tests but that was it.  This situation  occurred in an inpatient hospital setting and of course, I understand there are protocols for lab orders physicians must follow; however, I was thankful that even only a handful of doctors listened to me in my attempts to advocate for high-quality thyroid care. You have much more control over your healthcare in the outpatient setting, e.g. you have the autonomy to hire your own doctor – one of your choosing as a part of your wellness team. You also have the right to request or self-order your own thyroid labs.  Where thyroid health is concerned, we want our lab values to be “optimal,” not low-normal or high-normal.

Most women receive a phone call from their doctor or nurse reporting that they don’t have a thyroid problem because TSH and Total T4 are “normal” and that’s the end of it (you may have gotten really lucky and were also tested for Total T3, Free T4, and Free T3, but these tests usually require persistence on your part).  Well, there a couple of problems here, when the TSH and T4 tests are the only tests ordered.  First of all, these two panels are not sufficient tests to assess thyroid health or a potential thyroid autoimmune disease such as Hashimoto’s or Graves’.  Secondly, what does the reference “normal” mean exactly?  

Where thyroid health is concerned, we want our thyroid labs to be “optimal,” not low-normal or high-normal. Not to mention various lab facilities report normal ranges that conflict with other labs (because they’re not standardized) and outdated.

In Order to Manage Your Thyroid Health You Must Know What Tests to Ask For ~ and You Must Request COPIES of Your Lab Reports FOREVER.

The TSH test is a very hot topic. Thyroid advocates all over the world are pushing for better thyroid care.  This marker misses a lot of thyroid disease cases and to rely on the TSH test as the only tool to diagnose and treat is simply outdated.  TSH is an indicator of what your pituitary gland is doing.  Think of it like this: the pituitary gland is an alarm clock and the thyroid gland is your brain.  You’re asleep in bed and come morning the alarm (pituitary) is sounding repeatedly to awaken you and yet your brain (the thyroid) doesn’t respond to the signal.  We can assume in this scenario the pituitary is working fine – but the thyroid isn’t.  Before putting someone on replacement thyroid hormone, doesn’t it seem logical to run a complete thyroid panel? 

Another issue with the TSH test is the range values used by various labs and doctors.  Conventional medicine practitioners typically follow a range of 0.5 to 5.0, whereas functional and integrative practitioners view a healthy TSH value as anywhere from 0.3 to 3.0.  You can see how this might leave many people with classic thyroid symptoms undiagnosed.

I often had an optimal TSH level all those years I was struggling with thyroid disease but didn’t know I had the condition at the time. My body was a complete mess and aging quickly.  I discuss my health challenges in detail in my ebook Thyroid Bundle eBook Cover ImageHashimoto’s: Finding Joy in the Journey. I hope you get a chance to read it soon.

Triiodothyronine (T3) is the thyroid hormone usable by the body for metabolic energy. Without sufficient T3 available to the cells, you are lacking in energy, quality sleep, digestion, healthy skin, hair, nails, mental focus, and mood.  Thyroid skin & hair is no fun I can assure you – but these outward manifestations are also a mirror of what’s going on inside the body and it is not pleasant.  Our body – head to toe, inside and out, needs optimal Free T3 available 24/7.

Levothyroxine (T4) is the thyroid hormone which T3 is derived from after it loses an atom of iodine.  T4 must be converted to T3 because it cannot be used by the body.  It happens during a metabolic conversion in the GI tract and the liver.  I remember when I was on Synthroid (a T4-only medication) and how HORRIBLE I felt – I was getting worse as time went on and the only wisdom my “world-renowned” endocrinologist had to offer was to continue raising the dose –  and as he raised my Synthroid dose the sicker, fatter, and more tired and achy I became.  Why?  It was because, like many autoimmune thyroid patients, my body could not convert T4 to T3 due to underlying issues with the liver and the gut.  However, my labs still showed an optimal TSH and ample supply of T4 – the only two tests my doctor at the time would even order. He said I was normal and optimal and that I must be depressed.  He even wanted to put me on anti-anxiety medication which I refused.

 Thyroid Labs – Testing Free T4 & Free T3

This is really a major issue – your lab report must say the word “free” before T4 and T3, otherwise, it means the test measured “bound” T4 and T3.  It is important to know what is free and available to the cells.  The word “free” means that which isn’t bound to a protein molecule and is available to enter those T3 receptors on the cells, or how much “free” T4 is available for conversion in the first place.  “So what” if it’s riding around on a protein molecule – this is not of much use in diagnosis or treatment. We mostly want to know what is free and available to the cells and for conversion.


One thing that baffles me most is referring to Hashimoto’s or Graves’ as “thyroid” diseases

These diagnoses are an autoimmune condition, just like rheumatoid arthritis, multiple sclerosis, lupus, scleroderma, pernicious anemia, hemolytic anemia, Crohn’s disease, ulcerative colitis, celiac disease, and more.  There are 80-100 autoimmune diseases that attack various body systems and tissues, so regardless of what “label” we give each one.  Autoimmune disease is a condition of a confused and chaotic immune system…NOT the other way around. 

In the case of Hashimoto’s and Graves’ and all autoimmune disease, it is our immune system causing the disease, not our thyroid.

The thyroid labs to confirm Hashimoto’s or Graves’disease is by testing Thyroperoxidase (TPO) and anti-Thyroglobulin (TGB) antibodies.  To learn what additional tests you need to request from your doctor review my post on Thyroid Basics.

If for some reason your doctor won’t order the correct thyroid labs for you, you can pay out of pocket and order them yourself very inexpensively through a company like Direct Labs. To view a list of recommended thyroid labs click HERE.  

Read Next:

Can Stress Trigger Thyroid Autoimmunity?

Holistic Thyroid Care Newsletter


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