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Can You Have Normal Thyroid Levels And Still Be Hypothyroid

Hypothyroidism Caused By Elevated Tbg

Why You Still Have Thyroid Symptoms With Normal TSH and T4

Thyroid-binding globulin is the protein that transports thyroid hormone through the blood. When thyroid hormone is bound to TBG, it is inactive and unavailable to tissues. High levels of TBG reduce levels of free thyroid hormone, causing hypothyroid symptoms. 59363-7/abstract” rel=”nofollow”> 13) Patients with this pattern have normal TSH and T4, low T3, high T3 uptake and high TBG.

Elevated estrogen can raise TBG and cause hypothyroidism. Estrogen may become elevated due to the use of birth control pills and estrogen hormone replacement therapy. The treatment for this pattern is to clear excess estrogen from the body.

Your Labs Aren’t Optimized

You can really think of this as an extension of #2 which has to do with your dose of thyroid medication.

Your dose of thyroid medication directly influences your thyroid lab tests.

And when I am talking about thyroid lab tests I am referring to much more than just the TSH.

I am referring to the combination of TSH, free T3, free T4, and reverse T3 .

Any thyroid medication that you take by mouth will have a direct influence on these lab tests either for the positive or for the negative.

For instance:

As you take thyroid medication you should notice that your TSH decreases.

This decrease is more prominent with medications which contain T3 thyroid hormone but any and all thyroid medications will cause a decrease in the TSH.

But in addition to influencing your TSH, your thyroid medication will also have an influence on the other thyroid lab metrics I’ve listed above.

If you are taking the thyroid medication levothyroxine then this medication should be causing all of the following changes to your labs:

  • A reduction in the TSH
  • An elevation in free T3
  • No effect on reverse T3
  • An elevation in total T3

Taking this medication SHOULD impact your thyroid lab tests in the following way. But just because it can impact them does not tell you anything about the degree with which it impacts them.

And the degree to which levothyroxine impacts your lab tests has to do with the dose that you are taking.

This optimization is complex but it is nonetheless very important.

What Are Normal Thyroid Hormone Levels

The thyroid itself is regulated by another gland that is located in the brain, called the pituitary. In turn, the pituitary is regulated in part by the thyroid and by another gland called the hypothalamus.

The hypothalamus releases a hormone called thyrotropin releasing hormone , which sends a signal to the pituitary to release thyroid stimulating hormone . In turn, TSH sends a signal to the thyroid to release thyroid hormones. If a disruption occurs at any of these levels, a defect in thyroid hormone production may result in a deficiency of thyroid hormone .

Hypothalamus – TRH

Thyroid – T4 and T3

The rate of thyroid hormone production is controlled by the pituitary gland. If there is an insufficient amount of thyroid hormone circulating in the body to allow for normal functioning, the release of TSH is increased by the pituitary gland in an attempt to stimulate more thyroid hormone production. In contrast, when there is an excessive amount of circulating thyroid hormone, TSH levels fall as the pituitary attempts to decrease the production of thyroid hormone.

  • In persons with hypothyroidism , there is a continuously decreased level of circulating thyroid hormones.
  • In persons with hyperthyroidism , there is a continuously elevated level of circulating thyroid hormones.

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How Is Hyperthyroidism Diagnosed

There are signs and symptoms of hyperthyroidism that can be identified by a physician. Signs and symptoms of hyperthyroidism are often non-specific and can also be associated with many other causes. Laboratory tests are used to confirm the diagnosis of hyperthyroidism and probable cause. A primary care physician may make the diagnosis of hyperthyroidism, but help may be needed from an endocrinologist, a physician who is a specialist in thyroid and other endocrine diseases.

The best test to determine overall thyroid function is the thyroid stimulating hormone level. TSH is produced in the brain and travels to the thyroid gland to stimulate the thyroid to produce and release more thyroid hormone. A high TSH level indicates that the body does not have enough thyroid hormone. A TSH level lower than normal indicates there is usually more than enough thyroid hormone in the body and may indicate hyperthyroidism. When hyperthyroidism develops, free thyroxine and free triiodothyronine levels rise above normal. Other laboratory studies may help identify the cause of hyperthyroidism. Thyroid-stimulating immunoglobulins can be identified in the blood when Graves’ disease is the cause of hyperthyroidism. Thyroid peroxidase antibodies and other anti-thyroid antibodies are also seen in some disorders leading to hyperthyroidism.

What Are Thyroid Hormones

Optimal TSH T3 &  T4 levels

The thyroid gland produces hormones that are essential for normal body metabolism. Blood testing is now commonly available to determine the adequacy of the levels of thyroid hormones. These blood tests can define whether the thyroid gland’s hormone production is normal, overactive, or underactive.

The thyroid gland is located in the lower part of the neck, below the Adam’s apple.The gland wraps around the windpipe and has a shape that is similar to a butterfly – formed by two wings and attached by a middle part .

The thyroid gland uses iodine to produce thyroid hormones.

  • The two most important thyroid hormones are thyroxine and triiodothyronine , which account for 99.9% and 0.1% of thyroid hormones present in the blood respectively.
  • However, the hormone with the most biological activity is T3.
  • Once released from the thyroid gland into the blood, a large amount of T4 is converted into T3 – the active hormone that affects the metabolism of cells.

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Avoid Generics Or Get A Stable Multiple

Some HMOs and insurance companies will automatically override your doctor’s requested brand and supply you with a generic levothyroxine made by one of many different manufacturers.

There is nothing inherently wrong with generic drugs. The problem with this practice, however, is that you may be switched from one generic brand to the next every month without even knowing it. And, each time you are, you may receive a product that has a slightly different potency or is closer to the expiration date that you might otherwise prefer.

To ensure medication consistency, ask your doctor to write “no generic substitution” or “DAW” on the prescription. If your insurer threatens a higher drug copay, ask your doctor to write a motivation outlining why the specific brand is necessary.

If your insurer denies your request, try asking doctor to write a prescription for a six-month drug supply. Once received, check to ensure the drugs are all from the same manufacturer and are within the expiration date for at least the next six months.

What Were The Study Results

7% of the subjects were diagnosed with Hashimotoâs disease with 14 men and 173 females which syncs with previous data that Hashimotoâs disease is more prevalent in women.

Those diagnosed with Hashimotoâs disease did not show any differences in age, body mass index, waist to hip ratio, blood pressure, liver tests, blood glucose, or cholesterol. Creatinine and uric acid levels were lower in the Hashimotoâs disease group but his is due to the higher prevalence of women in this group who tend to have lower levels of these markers compared to men.

The proportion of participants with Hashimotoâs disease was 4% when the TSH was below 2.6 compared to 14% when the TSH was above 2.6. They grouped the participants into three categories of 2.6, 2.9 and 4.5 TSH cutoff values and found some interesting results.

TSH values of 2.6 and 2.9 cutoff values were able to detect more people with abnormal triglycerides and LDL cholesterol. The authors did find that a TSH value of 4.2 to the be the upper limit of normal in their analysis.

However, the authors used a âprevalence of Hashimotoâs thyroiditisâ factor to determine the upper limit of TSH and found a range of 2.6-2.9 to be more appropriate. They state that this correlates with the National Academy of Clinical Biochemists findings of a 2.5 upper limit for TSH levels.

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You Are Not Absorbing Your Medication

It’s possible for you to take your thyroid medication faithfully each and every day, even if it’s at the right dose, and still experience thyroid symptoms.

One reason for this has to do with the absorption of thyroid medication in the intestinal tract.

You can take all of the thyroid medication in the world but if it isn’t being absorbed into your body then it won’t do any good for you.

And this problem is actually quite common, especially among thyroid patients who have a very high incidence of intestinal issues.

Hypothyroidism slows down intestinal function and alters the population/concentration of healthy bacteria in your gut.

These factors can all influence medication absorption of both thyroid hormone and other medications.

People who have issues with thyroid absorption remain symptomatic despite taking their thyroid medication each and every day.

Several factors can influence how well you do absorb your medication and I’ve listed several below:

What More Should I Know About Thyroid Blood Tests

Why Your TSH Is Normal Yet You Still Have Hypothyroid Symptoms

Ranges noted here are approximate your providers may differ slightly. Its important that you remember abnormal readings do not necessarily mean a thyroid disorder is present, as each test can be affected by a variety of factors.

No preparation is required for these tests. They can be taken any time of day without fasting.

Last reviewed by a Cleveland Clinic medical professional on 12/27/2019.


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What Are The Types Of Thyroid Disorders

    Blood tests are used to diagnose hypothyroidism or hyperthyroidism. They do not point to a specific cause. In order to determine a cause of the thyroid abnormality, the doctor will consider the patient’s history, physical examination, and medical condition. Further testing might be used to isolate an underlying cause. These tests might include more blood testing for

    • thyroid antibodies,
    • ultrasound of the thyroid gland, or
    • others.

    If thyroid cancer is suspected and surgery may be required, your physician may ask for a blood test known as thyroglobulin.

    • Thyroglobulin is a protein made only by thyroid cells.
    • If the thyroglobulin level at baseline is detectable or elevated it can be used as a tumor marker.
    • After a total thyroidectomy for cancer the level should fall to an undetectable range since the cells that make thyroglobulin have been removed.
    • If the level remains detectable after surgery, there is a possibility of thyroid tissue elsewhere in the body, and metastatic disease should be considered.
    • If the level is undetectable for a period of time after surgery and then starts to climb, a recurrence of the cancer – either at the primary site or elsewhere in the body should be considered.

    Hypothyroidism Caused By Decreased Tbg

    Low levels of TBG cause free thyroid hormone levels to rise because there are fewer proteins available to bind thyroid hormones. The high circulating levels of T4 and T3 induce cellular resistance to thyroid hormone, much like how cells develop insulin resistance upon continuous exposure to high levels of insulin. This problem means that even though there is plenty of thyroid hormone, cells cant use it. As a result, symptoms of hypothyroidism develop. Patients with this pattern of thyroid dysfunction have normal TSH and T4, high T3, low T3 uptake, and low TBG.

    Low TBG can be caused by a high testosterone level. This thyroid pattern often occurs in women with PCOS and insulin resistance because these two conditions lead to elevated testosterone. Insulin sensitivity and blood sugar balance need to be restored to treat this pattern of thyroid dysfunction.

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    Do I Need To Stop Taking My Thyroid Pills For These Tests

    Since Euthyrox or Synthroid behave exactly as normal human thyroid hormone, they are not rapidly cleared from the body as other medications are. Most thyroid pills have a half life of 6.7 days which means they must be stopped for four to five weeks before accurate thyroid testing is possible. An exception to the long half life of thyroid medication is Cytomel – a thyroid pill with a half life of only forty-eight hours. Therefore it is possible to change a person’s thyroid replacement to Cytomel for one month to allow time for his regular pills to clear the body. Cytomel is then stopped for ten days and the appropriate test can then be done. Usually patients, even those who have no remaining thyroid function, tolerate being off thyroid replacement only ten days quite well.

    You Are Not Taking Enough Thyroid Medication

    What If Your TSH Is Normal but You

    The next most obvious reason for persistent hypothyroid symptoms has to do with your dose .

    Your dose refers to the actual amount of thyroid medication that you are taking.

    You might be thinking that taking the right dose is easy given how many doctors approach dosing, but that couldn’t be farther from the truth.

    Dosing thyroid medication is an incredibly complex situation which requires evaluation of more than just the TSH lab test.

    We will touch on some of the important points related to thyroid testing in other sections here, so I won’t go into it now, but you should understand that your dose plays an important role in how you feel.

    If your dose is insufficient then you are simply not taking enough thyroid medication to have any lasting impact on your symptoms.

    And, in my experience, I find that doctors do tend to underdose patients more than they overdose them.

    But why is that?

    It’s actually quite simple.

    The reason is multi-factorial but the main reason has to do with the potential risk of side effects and symptoms.

    The closer you are to your “ideal” dose the closer you are to taking too much medication.

    Imagine this scenario to help you grasp this concept:

    Imagine your ideal dose is 75mcg of Synthroid.

    Taking anything less than 75mcg may cause hypothyroid symptoms while on the flip side taking anything more than 75mcg may cause symptoms of excess thyroid hormone .


    This same concept is applied to people who take insulin .

    Just remember:

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    Is Medication Necessary For Normal Tsh Levels

    Not necessarily. People with normal TSH and T4 levels typically do not need to be treated with thyroid hormone replacement medication for hypothyroidism, even if their lab results show positive TPO antibodies. Normal TSH and T4 levels indicate that the thyroid is still functioning well. The body is not suffering from a lack of thyroid hormone.

    Hashimoto’s often progresses into hypothyroidism, which requires treatment with a thyroid hormone replacement medication like levothyroxine. Your thyroid doctor works with you to determine the type and dose of medication you need depending on subclinical or overt hypothyroidism.

    Need To Check Your Thyroid Maybe Not

      As medical science advances, we have more tests and biomarkers available to help identify illnesses. Yet overdiagnosis and overtreatment that may occur following abnormal results can cause dangerous adverse effects and costly consequences. Hypothyroidism a lower than normal range of thyroid hormones may be the poster child for this problem because it is such a common condition.

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      Normal Thyroid Blood Test Despite Low Thyroid Symptoms

      Comments: 9 | December 4th, 2017

      Do you have symptoms of hypothyroidism but your doctor told you your blood work was normal? Learn why you can have a normal thyroid blood test despite low thyroid symptoms, and how you can get the RIGHT diagnosis. Watch as Dr. Hotze explains why a blood test often fails to detect hypothyroidism.

      Video Highlights

      0:42: The best way to determine whether or not an individual has hypothyroidism, thats low thyroid function, is to listen to them. To listen to them tell you their symptoms.

      1:09: The thyroid gland in the neck produces the thyroid hormones. The thyroid hormones are secreted in the blood. They dont do anything in the blood, they have to enter the cells. In the cells, they go to an area of the cell where you make energy.

      1:49: if you dont get enough thyroid hormone into your cells, then the energy production in your cells is low and your metabolism is low.

      2:27: Commonly, people with joint and muscle aches and pains go to see the doctor and he tells them they have fibromyalgia. Has anybody ever told you that? Fibromyalgia is not a diagnosis, its description of a symptom. Its a Latin term for Joint and muscle aches and pains

      3:15: It also affects womens menstrual cycles so that oftentimes women have irregular menstrual cycles when theyre low thyroid. They oftentimes have an inability to conceive so theyre infertile.

      Video Transcript

      How to Properly Diagnose Hypothyroidism

      Thyroid Hormones Needed for Energy

      What Is Thyroid Medication

      Hidden Secret #8 Why You STILL Have Low Thyroid Symptoms TSH Immunoglobulin

      Thyroid Hormone Treatment Levothyroxine is thestandard of care in thyroid hormone replacement therapy and treatment of hypothyroidism. Levothyroxine is equivalent to the T4 form of naturally occurring thyroid hormone and is available in generic and brand name forms.

      How do I take levothyroxine? To optimize absorption of your thyroid medication, it should be taken with water at a regular time each day. Multiple medications and supplements decrease absorption of thyroid hormone and should be taken 3-4 hours apart, including calcium and iron supplements, proton pump inhibitors, soy, and multivitamins with minerals. Because of the way levothyroxine is metabolized by the body, your doctor may ask you to take an extra pill or skip a pill on some days of the week. This helps us to fine tune your medication dose for your body and should be guided by an endocrinologist.

      For patients with celiac disease or gluten sensitivity, a gluten free formulation of levothyroxine is available.

      Some individuals may have genetic variant that affects how the body converts T4 to T3 and these individuals may benefit from the addition of a small dose of triiodothyronine.

      Liothyronine is replacement T3 thyroid hormone. This medication has a short half-life and is taken twice per day or in combination with levothyroxine. Liothyronine alone is not used for treatment of hypothyroidism long term.

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