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Could Your Thyroid Be Causing Your Symptoms?

Could Your Thyroid Be Causing Your Symptoms?

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Updated June 19, 2006

Physical Exam

Having your physician perform a physical exam looking explicitly for:

_____ Thinning hair (especially the lateral third of your eyebrows)
_____ Dry skin or signs of eczema or psoriasis
_____ Thick tongue with “scalloping" of the tongue (caused by edema and swelling of the tongue squeezing it against your teeth making teeth marks around the tongue’s edge)
_____ Enlarged thyroid gland or discrete nodules palpated – if so – you may need to have a Thyroid Ultrasound to rule out the potential of thyroid cancer (solid nodules larger than 10 mm are suspect and need further evaluation).
_____ Bradycardia (slow heart rate)
_____ Carotoderma (yellow skin) – this is caused by the inability to convert beta-carotene into vitamin A (you need adequate thyroid hormone to do this)
_____ Bumps on the back of the upper arms - caused by buildup of beta-carotene under the skin)
_____ Myxedema / “non-pitting" edema or swelling of the ankles that “bounces" right back when you push on it similar to the way a balloon would bounce back if you pushed on it. This is not the same thing as “pitting-edema" that stays “indented" for a few seconds after you remove your finger from the skin (like the Pillsbury doughboy). Pitting edema is caused by water retention (which has multiple causes that aren’t relevant to discuss here).
_____ Decreased deep tendon reflexes (such as when your doctor bangs on your knees with a reflex hammer). A “delayed return phase" of the ankle jerk reflex is a pretty sensitive indicator of low thyroid.
Blood Tests

Have your physician order the following blood tests:
  • TSH (thyroid stimulating hormone) – Though the reference range according to the lab I work with is 0.5 – 5.5 mIU/L, I consider anything over 3.0 mIU/L suspect for low thyroid. (Important Note: The recommended reference range for TSH is now .3 to 3.0, according to National Academy of Clinical Biochemistry's revised testing guidelines issued in late 2002).
  • Free T4 (not total T4 and not a “reflex T4" if the TSH is abnormal) – those other tests are thrown off for various reasons so the directly measured Free T4 is the most accurate measure. Quest Diagnostics’ normal range is 0.8 to 1.8 ng/dL and I aim to keep my patients greater than 1.4 ng/dL.
  • Free T3 (not total T3 or T3RU) – as discussed above, I also like to be in the higher end of the normal range (Quest 230-420 pg/dL) and I shoot for a value greater than 300 pg/dL.
  • Thyroid Peroxidase Antibodies AND Thyroglobulin Antibodies – for Quest’s Nichols Institute, any value greater than 2 IU for either test is positive for Hashimoto’s Thyroiditis.
  • Reverse T3 – there is debate on whether any lab reliably tests this hormone. I have been “underwhelmed" by the reliability of every lab I have tried to use, so I have discontinued ordering this test for now.
  • You will not be able to order a “TSH following TRH test" as Thryel (the brand name for TRH) is no longer being made by Ferring Laboratories and there is no other supplier of this test substance.
  • It is not necessary to order a thyroglobulin as we are testing free levels of T3 and T4. Thyroglobulin, however, is important to follow in patients recovering from thyroid cancer, and would be ordered in such cases.
If You Have Normal Laboratory Tests, Could Your Thyroid Still Be Causing Your Symptoms?

There are many things that can cause weight gain and inability to lose weight. There are many things that can cause fatigue. There are many things that can cause cold hands and cold intolerance. In fact, there are many things that can cause many of the symptoms commonly associated with low thyroid. When my patients come in with a constellation of symptoms, I use my patient’s clinical history more than anything else to figure out where the true problems lie.

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