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Part three of our series on hypothyroidism discusses how hypothyroidism is diagnosed. While it’s estimated that some 27 million Americans have hypothyroidism many people (especially women) with thyroid deficiencies face difficulty in getting tested for thyroid irregularities and/or go undiagnosed. Patients who complain of unexplained weight gain, a chief symptom of hypothyroidism, are often dismissed by doctors with platitudes to eat less and move more. Some women have even had doctors flat out refuse to administer thyroid tests, despite the fact that one in eight women will develop thyroid irregularities in her lifetime. And even those people who are diagnosed with hypothyroidism usually have about a fifty-fifty chance of getting proper treatment. Read more about the diagnosis of hypothyroidism after the jump.

T4, T3 – Hormones produced by the thyroid. The numbers refer to the number of iodine molecules in each thyroid hormone molecule. A healthy functioning thyroid produces about 80 percent T4 and 20 percent T3. T3 is stronger than T4.

T4 to T3 Conversion – The thyroid produces some T3, but the bulk of T3 needed by the body is formed from the mostly inactive T4 by the removal of one iodine molecule, a process known as T4 to T3 conversion.

TSH – Thyroid-stimulating hormone released by the pituitary gland. TSH is sent to the thyroid gland, where it causes production, storage and release of more T3 and T4. If you don’t have enough thyroid hormone, more TSH will be produced in order to encourage the thyroid to produce more. This is why TSH levels are high when your thyroid levels are low.

TRH – Thyrotropine-releasing hormone; TRH is released by the hypothalamus gland in response to environmental factors like cold, heat and stress. TRH is sent from the hypothalamus to the pituitary gland, which then produces TSH.

Hypothyroidism – Caused when the body doesn’t produce enough thyroid hormone.

Most conventional doctors rely on the TSH test to diagnose hypothyroidism, although there are several other blood tests that can also be done. The TSH test measures the amount of thyroid-stimulating hormone (TSH) in your bloodstream. Elevated TSH is considered indicative of hypothyroidism. Sounds pretty simple, right? Wrong. Thyroid normal ranges can vary from lab to lab, compounded by the fact that thyroid normal ranges are in tremendous flux right now. During the 1980s and 1990s, the “normal” TSH range was from 0.3 - 0.5 to 4.7 – 5.5. Anywhere in between and you were considered “normal.”

In November 2002, the National Academy of Clinical Biochemistry (NACB) issued new lab medicine practice guidelines for the diagnosis and treatment of hypothyroidism. The organization recommended reducing the upper limit of the normal range to 2.5, with a range between 0.5 and 2.0 as the “therapeutic target.” A year later, based on these findings, the American Association of Clinical Endocrinologists (AACE) encouraged doctors to reduce normal thyroid ranges from 0.5 – 5.0 to 0.3 – 3.0. Despite the NACB and AACE announcements, many labs have not yet adopted the new guidelines and some physicians are still unaware of the revisions or they refuse to change their procedures until the lab revises their standards.

TSH tests are usually done in your doctor’s office or at a lab. They can run anywhere from $30 - $100, or more depending on the markup of either your doctor or the lab. You can now test your TSH levels at home with Biosafe. Here’s how it works: You prick your finger with a provided lancet and put the results in a special collection device to mail back to the company for analysis. The company then mails you your results. The entire test costs about $35.

Antibodies Test – An antibodies test checks for antithyroid antibodies, which can determine if you have an autoimmune thyroid problem in which the body attacks itself. When this happens with your thyroid, antibodies are developed against the thyroid to make it less able to function (Hashimoto’s hypothyroidism) or send it into hyperfunction (Graves’ disease/hyperthyroidism). Hypothyroidism most commonly results from Hashimoto’s disease, but its important to note that hypothyroidism can result from a number of causes and diseases.

TRH Test – Measures the level of thyrotropin-releasing hormone in the blood stream and is generally accepted to be reliable in detecting subtle underactive thyroid problems. Dr. Rafael Kellerman has even called it the “gold standard for accurately detecting an underactive thyroid.” He found that when patients had three or more common symptoms of hypothyroidism, some 35 – 40 percent tested normal for TSH, but evidenced hypothyroidism on the TRH test. Still, this is not available in the U.S. because production of the TRH drug for injection has been discontinued.

Imaging/Evaluation Tests

Nuclear Scans/Radioactive Iodine Reuptake (RAI) – This test involves taking a pill containing a small amount of radioactive iodine. Several hours later, an X-ray is done to detect iodine concentration in the thyroid. Overactive thyroids will take up higher amounts of iodine and those that do not are considered underactive.

Thyroid Ultrasound – Ultrasound of the thyroid to evaluate for nodules, lumps and enlargements of the gland.

CT Scan/Computed Tomography – Special type of X-ray is not often used, but is occasionally used to evaluate an enlarged thyroid or goiter.

MRI/Magnetic Resonance Imaging – An MRI is done when the size and shape of the thyroid needs to be evaluated. May be done in conjunction with blood tests and is sometimes preferable to X-rays or CT scans, because it doesn’t require injections of contrast dyes or exposure to radiation.

Needle Biopsy/Fine Needle Aspiration – Helps to evaluate lumps or nodules; a thin needle is inserted directly into the lump and cells are withdrawn and evaluated.

Thyroid Neck Check – Hold a mirror so that you can see your neck just below the Adam’s apple and above the collarbone. This is the general location of your thyroid gland. Tilt your head back, while keeping a view of your neck in the mirror. Take a drink of water and swallow. As you swallow, examine your neck for any bulges or lumps. This test isn’t conclusive, but is helpful in identifying an enlarged thyroid or masses in the thyroid.

Basal Body Temperature Test – Thyroid hormones have a direct result on the basal, or resting, metabolic rate. While hypothermia (lowered body temperature) is a known and medically accepted symptom of hypothyroidism, the use of body temperature as a diagnostic tool is somewhat controversial. The late Dr. Broda Barnes pioneered this diagnostic test, which is still used by complementary and alternative practitioners. To measure your BBT, use an oral glass/mercury thermometer or a special BBT thermometer available at some pharmacies. Leave the thermometer near your bed so that as soon as you wake up, you can put the thermometer in your armpit and leave it for 10 minutes. Record the readings for three to five consecutive days. Women who have menstrual periods should not test on the first five days of their period. Others can test anytime of the month.

If the average BBT is 97.6 degrees Fahrenheit, some complementary practitioners would consider a diagnosis of an underfunctioning thyroid. An average BBT between 97.8 and 98.2 is considered normal. Temperatures below 98.0 degrees are considered evidence of possible hypothyroidism. While the test remains controversial, many practitioners recommend it as a tool to help one better manage their treatment plan.

Finding the Right Doctor – If your hypothyroidism responds well to levothyroxine (Synthroid), your family doctor is usually able to administer tests and prescribe medication. Others who want to explore other treatments may need to seek out the services of an endocrinologist, an osteopathic physician or a holistic doctor. Endocrinologists specializes in diseases of the endocrine system, specifically diabetes and thyroid problems. Osteopathic physicians are similar to doctors in that they are fully trained and licensed to prescribe medication and to perform surgery. The primary difference lies in their philosophy; osteopaths typically address people holistically. These doctors are more likely than a general practitioner or even an endocrinologist to work with nontraditional prescription thyroid medications. Holistic doctors focus on the whole person and how he/she interacts with the environment, rather than illness, disease or specific body parts. Holistic doctors are most likely to work with nontraditional prescription thyroid medicines, such as a natural thyroid replacement or the T3-related therapies. They are also more likely to treat you with herbs, supplements and vitamins.

Communicating with Your Doctor – Once you’ve settled on a doctor and made the appointment, it’s important to know how to communicate with them. Prepare an agenda in advance noting your particular symptoms, any medications you are on and their dosages, and questions and concerns you’d like your doctor to address. Doctors can sometimes inspire “white coat fear,” so if you’re worried you might be too nervous to speak with the doctor or that you might not be assertive enough to demand answers, bring a friend or family member with you to the appointment. Take notes during your appointment or jot down instructions or test readings. And be sure to ask the doctor about the lab he/she uses, and what scale they use to determine normal thyroid ranges. If

When to Switch Doctors – In a doctor-patient relationship, you are the client and the doctor is providing a service. If you are not satisfied with that service for whatever reason, you are perfectly within your rights to seek out the services of another doctor. Remember, it’s your health at stake. If your doctor dismisses your concerns or symptoms and/or refuses to consider your questions, find a new doctor. If your doctor is rude, arrogant, and interruptive or doesn’t appear to be listening to you, find a new doctor. If your doctor’s staff is disorganized and makes billing, appointment or paperwork mistakes, find a new doctor. And if your doctor has lots of drug company perks (mousepads, tissues, pens, calendars, prescription pads, etc…) at least be concerned.

Gender Bias – Women are five to seven times more likely than men to have hypothyroidism and it’s estimated that one in eight women will develop thyroid problems in her lifetime, but nonetheless there still exists a gender bias in the treatment of women, which may result in a misdiagnosis of the disorder. It’s the old hearkening back to the Victorian assumptions that women are more emotional or “hysterical” than men, and so exaggerate or overdramatize their symptoms. Plus, because depression (a chief symptom of hypothyroidism) doesn’t require a lab test, many people are more likely to walk away with a prescription for an antidepressant than with a thyroid test. Some researchers estimate that as many as 15 percent or more of people with a diagnosis of depression are actually suffering from undiagnosed hypothyroidism. There’s also the assumption that changes in mood, energy and weight are the result of normal and cyclical hormonal changes in a woman’s body or their concerns about unexplained weight gain are chalked up to gluttony and sloth. If you suspect that you’re not being taken seriously or your symptoms are being dismissed by your doctor, be persistent and/or find a new doctor.

If you’ve had a TSH test and been told you’re normal but are still experiencing symptoms of hypothyroidism, obviously you aren’t well. Ask for your specific test results and the lab’s normal ranges. Since you have paid for these tests, they belong to you and your doctor’s office must oblige your request. Check your own health records to see if your thyroid has ever been tested in the past, before you started to develop thyroid symptoms. If your TSH levels were 1.0 before your thyroid symptoms and they’re at 3.0 now, your new TSH may be higher than normal for you even though it falls within the normal range for everyone else. You might also want to ask for a Free T3 or antibodies test to get a true diagnosis of hypothyroidism. Sometimes the problem is not with T4 itself, but with T3 or the T4 to T3 conversion. In February of 1999, a study published in the New England Journal of Medicine (“Effects of Thyroxine s Compared with Thyroxine plus Triiodothyronine in Patients with Hypothyroidism”) found that adding T3 to standard T4 therapy improved the quality of life and mental functioning for most hypothyroid patients. The report, known as the Bunevicius-Prange Studies, studied 33 hypothyroid patients for a five-week period. At the end of the study, only two patients said they preferred T4 only treatment.

Medication can sometimes take a month before you start to see effects from it, so be patient. But If you’re diagnosed with hypothyroidism and your treatment plan isn’t working, there are alternate treatment plans available outside of the standard T4 hormone replacement. Treatments and medications for hypothyroidism will be the topic of discussion tomorrow.