Thyroid Testing and Diagnosis (2022)

Getting a diagnosis of thyroid disease is a process that incorporates a number of different types of examinations, including clinical evaluation, blood tests, imaging tests, biopsies, and other tests. Let's take a look at the various components of the thyroid diagnosis process.

Thyroid Testing and Diagnosis (1)

Clinical Evaluation

An important baseline element in the detection and diagnosis of thyroid disease is clinical evaluation. A clinical evaluation of your thyroid function should be conducted by a healthcare provider. You might be referred to an endocrinologist, which is a doctor who specializes in treating endocrine disorders, like thyroid diseases.

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Thyroid Testing and Diagnosis (2)

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As part of a thorough clinical evaluation, your healthcare provider typically will perform the following assessments:

  • Feel (also known as “palpating”) your neck for enlargement, lumps, or irregularity in the shape of your thyroid.
  • Listen to your thyroid using a stethoscope to detect blood flow abnormalities.
  • Test your reflexes. A hyper-response is often present with an overactive thyroid, and a blunted reflex response can occur with hypothyroidism.
  • Check your heart rate, heart rhythm, and blood pressure. Lower heart rate and/or blood pressure can be associated with an underactive thyroid, and elevated heart rate and/or blood pressure can occur due to hyperthyroidism.
  • Measure your weight and discuss any changes. Unexpected weight gain often accompanies hypothyroidism, while unintentional weight loss can occur due to hyperthyroidism.
  • Measure body temperature. Low body temperature and feeling cold all the time can develop due to an underactive thyroid. And feeling too hot, with a slightly elevated temperature may occur due to hyperthyroidism.
  • Examine your face for thyroid-related signs, including loss of the outer eyebrows, puffiness in the eyes, and unusual rashes.
  • Examine your eyes, looking for signs of thyroid eye disease, including bulging eyes, a prominent stare, and dry eyes.
  • Observe the general quantity and quality of your hair. Changes in the texture of hair, as well as hair loss and breakage, are associated with both hyperthyroidism and hypothyroidism.
  • Examine your skin. Dry, rough skin can be a sign of hypothyroidism, and unusually smooth skin can be a sign of hyperthyroidism.
  • Examine your nails and hands. Dry, brittle nails can result from an underactive thyroid.

Blood Tests

Blood tests that measure thyroid hormone levels are not a standard part of a routine physical, but they can be ordered if you have any symptoms, signs, or risk factors of thyroid disease.

Before you have blood tests done, you will want to understand your options in terms of the timing of testing, and whether to fast and/or take medications prior to testing.

Common thyroid blood tests include the following:

  • Thyroid-stimulating hormone (TSH) test
  • Total T4/total thyroxine
  • Free T4/free thyroxine
  • Total T3/total triiodothyronine
  • Free T3/free triiodothyronine
  • Reverse T3
  • Thyroglobulin/thyroid-binding globulin (TBG)
  • Thyroid peroxidase antibodies (TPOAb)/antithyroid peroxidase antibodies
  • Thyroglobulin antibodies/antithyroglobulin antibodies
  • Thyroid-receptor antibodies (TRAb)
  • Thyroid-stimulating immunoglobulins (TSI)

These tests can measure thyroid hormones in their different forms, as well as proteins that can increase or decrease your thyroid hormone production. Your healthcare provider will look at the combination of results to determine the type and cause of your thyroid condition.

What Do Your Thyroid Blood Test Results Mean?

Interpreting Your Results

The pattern of the thyroid blood test results helps your healthcare provider understand your thyroid disease.

Normal ranges may vary by lab, so keep that in mind if you are looking at your results.

Examples of test results and their significance in thyroid disease:

  • Elevated antibody levels may indicate underlying autoimmune thyroid disease. Different antibodies can indicate hyperthyroidism, hypothyroidism, nodules, or goiter. With Hashimoto's disease, you can have high TPO antibodies, and with Graves' disease, you can have high TSI antibodies.
  • The more controversial reverse T3 test detects overproduction of an inactive form of the T3 hormone and may be used by some integrative healthcare providers.

Your healthcare team can help you understand what your results mean in relation to your unique situation.

(Video) Thyroid function test - Hypo and hyperthyroidism || symptoms & diagnosis

The TSH Test

The thyroid-stimulating hormone (TSH) test is considered an important thyroid test. If your thyroid hormones are low, sometimes TSH can be elevated as your body attempts to compensate. And sometimes TSH is low if your thyroid hormones are too high.

For example:

  • An elevated TSH—along with lower T4/free T4 and lower T3/free T3 levels—is associated with hypothyroidism.
  • Low TSH—along with higher T4/free T4 and higher T3/free T3 levels—is associated with hyperthyroidism.

However, sometimes thyroid disease can be complicated, so the results aren't always so straightforward.

Ordering Your Own Thyroid Blood Tests

In most states in the U.S., and some areas outside the U.S., you can order and pay for your own thyroid tests. Some people use this approach to get testing done.

It may be more affordable to have your tests done through your healthcare provider, however. Sometimes, your insurance plan may limit the tests they will pay for.

Imaging Tests

Imaging tests can be used to identify thyroid enlargement, atrophy, or nodules.

These tests include the following.

  • Thyroid ultrasound: Thyroid ultrasound can visualize nodules, lumps, and enlargement of your gland. Ultrasound can be used to help your healthcare provider see whether your thyroid nodule is a fluid-filled cyst or a mass of solid tissue.
  • Nuclear scan/radioactive iodine uptake: This test, also known as RAI-U, can identify signs of Graves' disease, toxic multinodular goiter, or thyroiditis. This test should not be performed during pregnancy.
  • CT scan: A CT scan can provide a picture that shows a goiter or larger thyroid nodules.
  • MRI/magnetic resonance imaging: MRI can help evaluate the size and shape of your thyroid gland.

Thyroid Testing and Diagnosis (3)

Biopsy

A needle biopsy, also known as a fine needle aspiration (FNA) biopsy, is used to help evaluate suspicious thyroid lumps and nodules. During a needle biopsy, a thin needle is inserted directly into the nodule, and cells are withdrawn and evaluated in a laboratory for signs of cancer. Some healthcare providers use ultrasound while conducting a biopsy to guide the needle position.

While 95% of thyroid nodules are not cancerous, FNA, along with some additional tests such as the Veracyte Afirma test, can make the results of your biopsy more accurate and may spare you unnecessary surgery for nodules that turn out to be benign.

Evaluating Thyroid Nodules With Fine Needle Aspiration

Other Diagnostic Tests

Healthcare providers sometimes use other tests and procedures to identify thyroid dysfunction. The use of these tests is considered controversial to mainstream practitioners, but some of these tests are accepted and in use among alternative, integrative, and holistic physicians.

These tests include:

  • Iodine patch tests
  • Saliva testing
  • Urinary testing
  • Basal body temperature testing

The reliability and value of these tests have not been established. If your healthcare provider recommends a specific type of test, they should help you understand what information it will provide them and how you can best prepare for it.

Neck Check Self-Test

While it is not considered diagnostic, you can perform a self-check of your neck to look for lumps and enlargement.

In general, a neck check is not considered to be reliable or accurate compared to other available testing methods. It may provide a false negative—you can have thyroid disease even if your neck feels completely normal. However, a self-check doesn't hurt to do and is simple and straightforward.

With your fingers, you'll gently feel for lumps in your neck as you swallow a sip of water.

(Video) Thyroid Hormones and Thyroid Function Tests

Thyroid Testing and Diagnosis (4)

How to Perform a Thyroid Neck Check

A Word From Verywell

Based on the results of a clinical examination, blood tests can detect key signs of thyroid conditions, including hypothyroidism (insufficient thyroid hormone) and hyperthyroidism (excess thyroid hormone). For nodules and goiter, imaging tests can help to identify whether nodules could be cancerous. An FNA biopsy is performed to obtain a tissue sample that can be assessed with a microscope for cancer cells. With this combination of tests, a healthcare provider can make an accurate diagnosis and provide you with treatment.

Frequently Asked Questions

An Overview of Thyroid Disease Treatments

9 Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

  1. Thyroid Disease. Cleveland Clinic. What are the symptoms of hypothyroidism and hyperthyroidism?

  2. American Thyroid Association. Thyroid Function Tests

  3. American Thyroid Association. Hyperthyroidism FAQs

  4. National Institute of Diabetes and Digestive and Kidney Diseases. Thyroid Tests

  5. American Cancer Society. Tests for Thyroid Cancer

  6. Thyroid Awareness. Neck Check

  7. MedlinePlus. TSH (Thyroid-stimulating hormone) test.

  8. Sachan A, Naresh S, Bitla AR. Utility of saliva for measurement of thyroid hormones. Indian journal of Medical Biochemistry. 2018;22(1):36-40. doi:10.5005/jp-journals-10054-0051

  9. Johns Hopkins Medicine. Thyroid Fine Needle Aspiration Biopsy.

Additional Reading

Thyroid Testing and Diagnosis (5)

By Mary Shomon
Mary Shomon is a writer and hormonal health and thyroid advocate. She is the author of "The Thyroid Diet Revolution."

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FAQs

Can thyroid problems be wrongly diagnosed? ›

The most common misdiagnoses were hyperthyroidism in euthyroid patients (1.9%), hypothyroidism in euthyroidism (0.8%), non-recognition or non-aspiration of cold nodules (0.9%), missing a goitre (0.6%). Among diagnostic methods the radio-iodine test was reason for a wrong diagnosis most commonly (66%).

Is TSH enough to diagnose hypothyroidism? ›

While a simple TSH blood test is a very accurate way to screen for hypothyroidism, an elevated TSH alone may not be enough to confirm the diagnosis.

How accurate is a thyroid blood test? ›

Tests also check levels of the thyroid hormones triiodothyronine (T3) and thyroxine (T4), and the proteins that affect thyroid hormone production. Thyroid blood tests are usually simple and accurate. A few things can affect your results, though. You may have ongoing fluctuations in thyroid hormone levels.

What is the gold standard for diagnosing hypothyroidism? ›

Assessment of TSH is the single most useful test of thyroid function in the vast majority of patients. Primary care providers should seldom need to order any other biochemical thyroid test.

What can hypothyroidism be mistaken for? ›

Hypothyroidism often begins slowly. Symptoms can be mistaken for stress, depression, or other health problems.
...
Common symptoms include:
  • Fatigue.
  • Unplanned weight gain.
  • Muscle weakness.
  • Muscle aches, cramps, tenderness, or stiffness.
  • Increased sensitivity to cold.
  • Constipation.
  • Pale, dry skin.
  • Puffy face.
27 Apr 2020

Why is thyroid disease misdiagnosed? ›

Counterfeit hormones – those that do not perfectly match the molecular structure of hormones in one's body – can be dangerous, he says. “Hypothyroidism and aging share an important common denominator – diminished or faulty hormone production — so it's easy to see how doctors can miss a diagnosis,” Hotze says.

Can you still have a thyroid problem if your TSH is normal? ›

Can you have hypothyroidism with normal TSH? Yes, it is possible to have hypothyroidism and normal TSH levels in the blood. Most people with hypothyroidism have high TSH because their thyroid gland is not releasing enough hormones. In response to this, the body produces more TSH in order to get the thyroid to work.

What is the most accurate test for hypothyroidism? ›

Blood tests for your thyroid include: TSH - measures thyroid-stimulating hormone. It is the most accurate measure of thyroid activity. T3 and T4 - measure different thyroid hormones.

Can thyroid test be normal but still have symptoms? ›

Some people treated for hypothyroidism may still experience symptoms even if blood tests show that their thyroid stimulating hormone (TSH) levels are well within the normal range.

What can mess up a thyroid test? ›

You change your diet.

Certain foods, like walnuts, soy, and foods high in fiber, can interfere with the absorption of your thyroid medication. Cruciferous vegetables, such as Brussels sprouts, cauliflower, cabbage, and kale, may interfere with the production of thyroid hormone in people with an iodine deficiency.

What is the best time to do thyroid test? ›

I recommend getting your thyroid function tests done first thing in the morning, bringing your medications with you, and taking them right after you have your thyroid function tests to ensure that you get accurate test results.

Can underactive thyroid be misdiagnosed? ›

Hypothyroidism is one of the most misunderstood and misdiagnosed conditions in the U.S. It is estimated that approximately 10 million Americans have it - and I'm one of them.

Which is more important T4 or TSH? ›

Across many clinical studies it seems clear that the physiologic effects of low or high thyroid function correlate much more strongly to free T4 and free T3 levels than to TSH levels. In fact, correcting for changes in T4 and T3 levels there appeared to be no correlation between TSH level and body function.

What is a full thyroid panel? ›

The tests included in a thyroid panel measure the level of thyroid hormones in the blood. A thyroid panel usually includes tests for: TSH (thyroid-stimulating hormone) Free T4 (thyroxine) Free T3 or total T3 (triiodothyronine)

Which is more important T3 T4 or TSH? ›

Because T4 is converted into another thyroid hormone called T3 (triiodothyronine), free T4 is the more important hormone to measure.

What disease has the same symptoms as hypothyroidism? ›

  • Angioedema.
  • Bronchitis.
  • Bulimia Nervosa.
  • Chronic Obstructive Pulmonary Disease.
  • Congestive Heart Failure.
  • Depression.
  • Menopause.
  • Preeclampsia.

What has the same symptoms as thyroid problems? ›

Disorders of red or white blood cells can mimic thyroid disorders with symptoms like fatigue, weakness, feeling cold, excessive sweating, pale skin, easy bruising, shortness of breath, leg cramps, difficulty concentrating, dizziness and insomnia.

What are the mental symptoms of hypothyroidism? ›

Many symptoms of psychological dysfunction have been described with hypothyroidism. Those symptoms most commonly related to thyroid deficiency include forgetfulness, fatigue, mental slowness, inattention, and emotional lability. The predominant affective disorder experienced is depression.

Why don't doctors treat Hashimoto's? ›

Thyroid disease is easy to diagnose

Or you may have Hashimoto's disease, but since your thyroid stimulating hormone (TSH) is in the reference range, your doctor won't treat you.

Can hyperthyroidism be mistaken for anxiety? ›

Yes, thyroid disease can affect your mood — primarily causing either anxiety or depression. Generally, the more severe the thyroid disease, the more severe the mood changes. If you have an overactive thyroid (hyperthyroidism), you may experience: Unusual nervousness.

Can graves be misdiagnosed? ›

The symptoms of panic disorder and Graves' disease often overlap, which makes it difficult to distinguish between the two conditions. There is a high risk of misdiagnosis, especially on weekend or holiday shifts where medical resources are scarce and when fatigue and exhaustion set in.

Can stress affect thyroid levels? ›

The Connection Between Chronic Stress and Thyroid Health

Under stress, your body releases the hormone cortisol. Too much cortisol can interfere with thyroid hormone production: It can stimulate the thyroid to work harder to create sufficient amounts of thyroid hormone.

Does everyone with hypothyroidism gain weight? ›

Massive weight gain is rarely associated with hypothyroidism. In general, 5-10 pounds of body weight may be attributable to the thyroid, depending on the severity of the hypothyroidism.

What levels indicate Hashimoto's? ›

Hashimoto thyroiditis is an autoimmune disorder of inadequate thyroid hormone production. The biochemical picture indicates raised thyroid-stimulating hormone (TSH) in response to low free T4. Low total T4 or free T4 level in the presence of an elevated TSH level confirms the diagnosis of primary hypothyroidism.

Can TSH levels change quickly? ›

Thyroid levels and TSH, in particular, can change along with the seasons. 8 For example, TSH naturally rises somewhat during colder months and drops back down in the warmest months.

How can I get my thyroid test more accurate? ›

The best way to initially test thyroid function is to measure the TSH level in a blood sample. Changes in TSH can serve as an “early warning system” – often occurring before the actual level of thyroid hormones in the body becomes too high or too low.

Can hypothyroidism go away? ›

For those with particularly low levels of thyroid hormones, hypothyroidism is a life-long condition that will need to be controlled with medication on a regular schedule. It can be controlled very well and you can live a normal life with hypothyroidism.

What can be mistaken for hyperthyroidism? ›

In older adults, hyperthyroidism is sometimes mistaken for depression link or dementia link. Older adults may have different symptoms, such as loss of appetite or withdrawal from people, than younger adults with hyperthyroidism.

What are the symptoms of an underactive thyroid in females? ›

Symptoms of an underactive thyroid
  • tiredness.
  • being sensitive to cold.
  • weight gain.
  • constipation.
  • depression.
  • slow movements and thoughts.
  • muscle aches and weakness.
  • muscle cramps.

Is hyperthyroidism hard to diagnose? ›

Hyperthyroidism can mimic other health problems, which can make it difficult for your doctor to diagnose. It can also cause a wide variety of signs and symptoms, including: Unintentional weight loss, even when your appetite and food intake stay the same or increase.

What medications can affect your thyroid? ›

Which drugs can cause thyroid dysfunction and should this be treated?
  • Amiodarone. Amiodarone can cause transient alterations of thyroid function tests, as well as overt hypothyroidism or hyperthyroidism. ...
  • Lithium. ...
  • Interferons (IFN) ...
  • Tyrosine Kinase Inhibitors (TKIs) ...
  • Alemtuzumab. ...
  • Iodine-containing medications and agents.

Can caffeine affect thyroid test? ›

Caffeine in coffee and other caffeinated beverages can affect the absorption of the thyroid drug levothyroxine by making the drug pass through your gut too quickly. This can cause your T4 hormone levels to drop or fluctuate.

Can lack of sleep affect TSH levels? ›

Sleep loss can also affect the function of the human hypothalamo-pituitary-thyroid axis. In contrast to the effects of sleep deprivation in rodents, acute sleep loss in humans is associated with increased TSH, T4, and T3,6,7 and human sleep is believed to have an acute inhibitory effect on overnight TSH secretion.

How many hours fasting is required for thyroid test? ›

Usually,no special precautions including fasting need to be followed before taking a thyroid test. However, your pathologist can guide you better. For example, if you have to undergo some other health tests along with thyroid hormone levels, you may be asked to fast for 8-10 hours.

Should thyroid test be done fasting? ›

You don't need any special preparations for a TSH blood test. If your health care provider has ordered other blood tests, you may need to fast (not eat or drink) for several hours before the test.

Can I drink water before thyroid test? ›

Can I drink water before Thyroid Test? "Yes, you can have water before a Thyroid Test."

Can you have normal thyroid levels and still have Hashimoto's? ›

It's possible to have Hashimoto's disease but not yet have a severe enough case that your thyroid function has been impacted. In these cases, you can have Hashimoto's disease with normal TSH. If your TSH levels aren't normal, there are also possible other causes.

Is Hashimoto's often misdiagnosed? ›

Hashimoto's thyroiditis can manifest in many different ways, and early symptoms can be nonspecific. As a result, a person may receive a misdiagnosis. Conditions that can be confused with Hashimoto's include: chronic fatigue syndrome.

Can hypothyroidism cause heart palpitations? ›

Excess thyroid hormone also causes the heart to beat harder and faster and may trigger abnormal heart rhythms. One is atrial fibrillation, a disorganized rhythm in the heart's upper chambers. A related symptom is palpitations, a sudden awareness of your heartbeat.

Can hypothyroidism be misdiagnosed? ›

Hypothyroidism is one of the most misunderstood and misdiagnosed conditions in the U.S. It is estimated that approximately 10 million Americans have it - and I'm one of them.

What if my thyroid levels are normal but I still have symptoms? ›

Additionally, it is important to realize that levels that are sometimes considered “normal” are actually a sign of a thyroid problem. Most doctors consider TSH levels that are between 0.5 and 5.0 normal. However, a patient who is still experiencing a range of thyroid symptoms may be hyperthyroid or hypothyroid.

What can be mistaken for hyperthyroidism? ›

In older adults, hyperthyroidism is sometimes mistaken for depression link or dementia link. Older adults may have different symptoms, such as loss of appetite or withdrawal from people, than younger adults with hyperthyroidism.

What are the mental symptoms of hypothyroidism? ›

Many symptoms of psychological dysfunction have been described with hypothyroidism. Those symptoms most commonly related to thyroid deficiency include forgetfulness, fatigue, mental slowness, inattention, and emotional lability. The predominant affective disorder experienced is depression.

Can stress bring on hypothyroidism? ›

Cortisol, the main hormone produced in response to stress, can suppress pituitary function and keep the thyroid-stimulating hormone (TSH) from being released, thereby inducing hypothyroidism, according to Dr.

Can TSH be normal and still have hypothyroidism? ›

Can you have hypothyroidism with normal TSH? Yes, it is possible to have hypothyroidism and normal TSH levels in the blood. Most people with hypothyroidism have high TSH because their thyroid gland is not releasing enough hormones. In response to this, the body produces more TSH in order to get the thyroid to work.

Does caffeine affect the thyroid? ›

Per a study in the journal Thyroid, caffeine has been found to block absorption of thyroid hormone replacement. "People who were taking their thyroid medication with their morning coffee had uncontrollable thyroid levels, and we couldn't figure it out," says Dr. Lee.

Does sleep affect thyroid? ›

One study9 found that people who sleep fewer than seven hours per day are at greater risk of developing hyperthyroidism, while sleeping more than eight hours per day may increase the risk of both overactive and underactive thyroid function.

What does a thyroid storm feel like? ›

Common signs and symptoms of thyroid storm include: Having a high fever — a temperature between 104 degrees to 106 degrees Fahrenheit is common. Having a rapid heart rate (tachycardia) that can exceed 140 beats per minute. Feeling agitated, irritable and/or anxious.

What medications can affect your thyroid? ›

Which drugs can cause thyroid dysfunction and should this be treated?
  • Amiodarone. Amiodarone can cause transient alterations of thyroid function tests, as well as overt hypothyroidism or hyperthyroidism. ...
  • Lithium. ...
  • Interferons (IFN) ...
  • Tyrosine Kinase Inhibitors (TKIs) ...
  • Alemtuzumab. ...
  • Iodine-containing medications and agents.

What is the best time to do thyroid test? ›

I recommend getting your thyroid function tests done first thing in the morning, bringing your medications with you, and taking them right after you have your thyroid function tests to ensure that you get accurate test results.

Can caffeine affect thyroid test? ›

Caffeine in coffee and other caffeinated beverages can affect the absorption of the thyroid drug levothyroxine by making the drug pass through your gut too quickly. This can cause your T4 hormone levels to drop or fluctuate.

What are 4 major clinical symptoms of hyperthyroidism? ›

Symptoms
  • Unintentional weight loss, even when your appetite and food intake stay the same or increase.
  • Rapid heartbeat (tachycardia) — commonly more than 100 beats a minute.
  • Irregular heartbeat (arrhythmia)
  • Pounding of your heart (palpitations)
  • Increased appetite.
  • Nervousness, anxiety and irritability.
14 Nov 2020

Which one is worse hypothyroidism or hyperthyroidism? ›

Neither is worse than the other. Both can lead to death in the most severe cases. However, hypothyroidism is 5 times more common than hyperthyroidism. In severe cases, hypothyroidism can lead to heart disease and myxedema coma, both of which can lead to death.

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