26/8/2014

Interpretation of Thyroid Tests - Common Tests to Examine

Thyroid Gland Function

Common Tests to Examine
Wri tten by Jam es N orm an MD, FA CS, FA CE (/author/485/norman)

Som e inform ation on this page is a little m ore adv anced. If y ou hav e trouble understanding the process of norm al thy roid function,
(h ttp://www.en docri n eweb.com /con di ti on s/th y roi d/h ow-y ou r-th y roi d-works) please

go to our page describing this process first.

As we hav e seen from our ov erv iew of norm al thy roid phy siology (h ttp://www.en docri n eweb.com /con di ti on s/th y roi d/h ow-y ou r-th y roi dworks) ,

the thy roid gland produces T4 and T3 . But this production is not possible without stim ulation from the pituitary gland

(TSH) which in turn is also regulated by the hy pothalam us's TSH Releasing Horm one. Now, with radioim m unoassay
techniques it is possible to m easure circulating horm ones in the blood v ery accurately . Knowledge of this thy roid phy siology is
im portant in knowing what thy roid test or tests are needed to diagnose different diseases. No one single laboratory test is 1 00%
accurate in diagnosing all ty pes of thy roid disease; howev er, a combinat ion of t wo or more t est s can usually det ect even
t he slight est abnormalit y of t hy roid funct ion.
For exam ple, a low T4 level could m ean a diseased thy roid gland ~ OR ~ a non-functioning pituitary gland which is not
stim ulating the thy roid to produce T4 . Since the pituitary gland would norm ally release TSH if the T4 is low, a high TSH lev el
would confirm that the thy roid gland (not the pituitary gland) is responsible for the hy pothy roidism .
If t he T4 level is low and TSH is not elevat ed, the pituitary gland is m ore likely to be the cause for the hy pothy roidism . Of course, this would drastically
effect the treatm ent since the pituitary gland (h ttp://www.en docri n eweb.com /en docri n ol ogy /i n trodu cti on -en docri n ol ogy -en docri n e-su rgery ) also regulates the body 's
other glands (adrenals, ov aries, and testicles) as well as controlling growth in children and norm al kidney function. Pituitary gland failure m eans that the
other glands m ay also be failing and other treatm ent than just thy roid m ay be necessary . The m ost com m on cause for the pituitary gland failure is a tum or
of the pituitary and this m ight also require surgery to rem ov e.
Modern m easurem ent of thy roid horm ones is done by a new technique, radioim m unoassay (RIA), discov ered by Dr. Solom on Berson and Dr. Rosaly n
Yallow. They were awarded the 1 9 7 7 Nobel Prize in Medicine for this discov ery which rev olutionized the study of thy roid disease as well as the entire field
of endocrinology .
The following are commonly used thyroid tests
Measurement of Serum Thy roid Hormones: T4 by RIA
T4 by RIA (radioim m unoassay ) is the m ost used thy roid test of all. It is frequently referred to as a T7 which m eans that a
resin T3 uptake (RT3 u) has been done to correct for certain m edications such as birth control pills, other horm ones, seizure
m edication, cardiac drugs, or ev en aspirin that m ay alter the routine T4 test. The T4 reflect s t he amount of
t hy roxine in t he blood. If the patient does not take any ty pe of thy roid m edication, this t est is usually a good measure of t hy roid funct ion.
Measurement of Serum Thy roid Hormones: T3 by RIA
As stated on our thy roid horm one production page, thy roxine (T4 ) represents 80% of the thy roid horm one produced by the norm al gland and generally
represents the ov erall function of the gland. The ot her 20% is t riiodot hy ronine measured as T3 by RIA. Som etim es the diseased thy roid gland will
start producing v ery high lev els of T3 but still produce norm al lev els of T4 . Therefore m easurem ent of both horm ones prov ides an ev en m ore accurate
ev aluation of thy roid function.
Thy roid Binding Globulin
Most of the thy roid horm ones in the blood are attached to a protein called thy roid binding globulin (TBG). If there is an excess or deficiency of this protein it
alters the T4 or T3 measurement but does not affect the action of the horm one. If a patient appears to hav e norm al thy roid function, but an unexplained
high or low T4 , or T3 , it m ay be due to an increase or decrease of TBG. Direct m easurem ent of TBG can be done and will explain the abnorm al v alue. Excess
TBG or low lev els of TBG are found in som e fam ilies as an hereditary trait. It causes no problem except falsely elev ating or lowering the T4 lev el. These people

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Interpretation of Thyroid Tests - Common Tests to Examine

are frequently m isdiagnosed as being hy perthy roid or hy pothy roid, but they hav e no thy roid problem and need no treatm ent.
Measurement of Pit uit ary Product ion of TSH
Pituitary production of TSH is m easured by a m ethod referred to as IRMA (im m unoradiom etric assay ). Norm ally , low lev els (less than 5 units) of TSH are
sufficient to keep the norm al thy roid gland functioning properly . When the thy roid gland becom es inefficient such as in early hy pothy roidism , the TSH
becom es elev ated ev en though the T4 and T3 m ay still be within the "norm al" range. This rise in TSH represent s t he pit uit ary gland's response t o a
drop in circulat ing t hy roid hormone; it is usually t he first indicat ion of t hy roid gland failure. Since TSH is norm ally low when the thy roid gland
is functioning properly , the failure of TSH to rise when circulating thy roid horm ones are low is an indication of im paired pituitary function. The new
"sensitiv e" TSH test will show v ery low lev els of TSH when the thy roid is ov eractiv e (as a norm al response of the pituitary to try to decrease thy roid
stim ulation). Int erpret at ions of t he TSH level depends upon t he level of t hy roid hormone; therefore, the TSH is usually used in com bination with
other thy roid tests such as the T4 RIA and T3 RIA.
TRH Test
In norm al people TSH secretion from the pituitary can be increased by giv ing a shot containing TSH Releasing Horm one (TRH...the horm one released by the
hy pothalam us which tells the pituitary to produce TSH). A baseline TSH of 5 or less usually goes up to 1 0-2 0 after giv ing an injection of TRH. Patients with
too m uch thy roid horm one (thy roxine or triiodothy ronine) will not show a rise in TSH when giv en TRH. This "TRH test" is presently the m ost sensitiv e test in
detecting early hy perthy roidism . Patients who show too m uch response to TRH (TSH rises greater than 4 0) m ay be hy pothy roid. This test is also used in
cancer patients who are taking thy roid replacem ent to see if they are on sufficient m edication. It is som etim es used to m easure if the pituitary gland is
functioning. The new "sensit ive" TSH t est (above) has eliminat ed t he necessit y of performing a TRH t est in most clinical sit uat ions.
Iodine Upt ake Scan
A m eans of m easuring thy roid function is to m easure how m uch iodine is taken up by the thy roid gland (RAI uptake). Rem em ber, cells of the thy roid
norm ally absorb iodine from our blood stream (obtained from foods we eat) and use it to m ake thy roid horm one (described on our thy roid function page
(h ttp://www.en docri n eweb.com /con di ti on s/th y roi d/h ow-y ou r-th y roi d-works) ).

Hy pothy roid patients usually take up too little iodine and hy perthy roid patients take up

too m uch iodine. The test is perform ed by giv ing a dose of radioactiv e iodine on an em pty stom ach. The iodine is concentrated in the thy roid gland or excreted
in the urine ov er the next few hours. The am ount of iodine that goes into the thy roid gland can be m easured by a "Thy roid Uptake". Of course, patients who
are taking thy roid m edication will not take up as m uch iodine in their thy roid gland because their own thy roid gland is turned off and is not functioning. At
other tim es the gland will concentrate iodine norm ally but will be unable to conv ert the iodine into thy roid horm one; therefore, interpretation of the iodine
uptake is usually done in conjunction with blood tests.
Thy roid Scan
Taking a "picture" of how well the thy roid gland is functioning requires giv ing a radioisotope to the patient and letting the
thy roid gland concentrate the isotope (just like the iodine uptake scan abov e). Therefore, it is usually done at t he
same t ime t hat t he iodine upt ake t est is performed. Although other isotopes, such as technetium , will be
concentrated by the thy roid gland; these isotopes will not m easure iodine uptake which is what we really want to know
because the production of thy roid horm one is dependent upon absorbing iodine. It has also been found that thy roid nodules that concentrate iodine are rarely
cancerous; this is not true if the scan is done with technetium . Therefore, all scans are now done with radioactiv e iodine. Both of the scans abov e show norm al
sized thy roid glands, but the one on the left has a "HOT" nodule in the lower aspect of the right lobe, while the scan on the right has a "COLD" nodule in the
lower aspect of the left lobe (outlined in red and y ellow). Pregnant wom en should not hav e thy roid scans perform ed because the iodine can cause dev elopm ent
troubles within the baby 's thy roid gland.
Two ty pes of thy roid scans are av ailable. A cam era scan is perform ed m ost com m only which uses a gam m a cam era operating in a fixed
position v iewing the entire thy roid gland at once. This ty pe of scan takes only fiv e to ten m inutes. In the 1 9 9 0's, a new scanner called a
Com puterized Rectilinear Thy roid (CRT) scanner was introduced. The CRT scanner utilizes com puter technology to im prov e the clarity of
thy roid scans and enhance thy roid nodules. It m easures both thy roid function and thy roid size. A life-sized 1 :1 color scan of the thy roid is
obtained giv ing the size in square centim eters and the weight in gram s. The precise size and activ ity of nodules in relation to the rest of the gland is also
m easured. CTS of the norm al thy roid gland In addition to m aking thy roid diagnosis m ore accurate, the CRT scanner im prov es the results of thy roid biopsy .
The accurate sizing of the thy roid gland aids in the follow-up of nodules to see if they are growing or getting sm aller in size. Knowing the weight of the thy roid
gland allows m ore accurate radioactiv e treatm ent in patients who hav e Grav es' disease.
Thyroid Scans are used for the following reasons:
Identify ing nodules and determ ining if they are "hot" or "cold".
Measuring the size of the goiter prior to treatm ent.
Follow-up of thy roid cancer patients after surgery .
Locating thy roid tissue outside the neck, i.e. base of the tongue or in the chest.
Thy roid Ult rasound
Thy roid ultrasound refers to the use of high frequency sound wav es to obtain an im age of the thy roid gland and identify nodules. It tells if a nodule is "solid" or
a fluid-filled cy st, but it will not tell if a nodule is benign or m alignant. Ultrasound allows accurate m easurem ent of a nodule's size and can determ ine if a
nodule is getting sm aller or is growing larger during treatm ent. Ultrasound aids in perform ing thy roid needle biopsy by im prov ing accuracy if the nodule
cannot be felt easily on exam ination. Sev eral m ore pages are dedicated to the use of ultrasound in ev aluating thy roid nodules
(h ttp://www.en docri n eweb.com /con di ti on s/th y roi d/th y roi d-n odu l e-u l trasou n d) .

Thy roid Ant ibodies

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The body norm ally produces antibodies to foreign substances such as bacteria; howev er, som e people are found to hav e antibodies against their own thy roid
tissue. A condition known as Hashim oto's Thy roiditis (h ttp://www.en docri n eweb.com /con di ti on s/th y roi d/h ash i m otos-th y roi di ti s) is associated with a high lev el of these
thy roid antibodies in the blood. Whether the antibodies cause the disease or whether the disease causes the antibodies is not known; howev er, the finding of a
high lev el of thy roid antibodies is strong ev idence of this disease. Occasionally , low lev els of thy roid antibodies are found with other ty pes of thy roid disease.
When Hashim oto's thy roiditis presents as a thy roid nodule rather than a diffuse goiter, the thy roid antibodies m ay not be present.
Thy roid Needle Biopsy
This has becom e the m ost reliable test to differentiate the "cold" nodule that is cancer from the "cold" nodule that is benign ("hot" nodules are rarely
cancerous). It prov ides inform ation that no other thy roid test will prov ide. While not perfect, it will prov ide definitiv e inform ation in 7 5% of the nodules
biopsied. A v ery extensiv e discussion of Thy roid Needle Biopsy is found on another page. (h ttp://www.en docri n eweb.com /con di ti on s/th y roi d/fi n e-n eedl e-bi opsy -th y roi dn odu l es)

Do I need to stop taking my thyroid pills for these tests?

Since Euthy rox or Sy nthroid (and m ost other thy roid pills) behav e exactly as norm al hum an thy roid horm one, they are not rapidly cleared from the body as
other m edications are. Most thy roid pills hav e a half life of 6 .7 day s which m eans they m ust be stopped for four to fiv e weeks (fiv e half liv es) before accurate
thy roid testing is possible. An exception to the long half life of thy roid m edication is Cy tom el - a thy roid pill with a half life of only forty -eight hours.
Therefore it is possible to change a person's thy roid replacem ent to Cy tom el for one m onth to allow tim e for his regular pills to clear the body . Cy tom el is then
stopped for ten day s (fiv e half liv es) and the appropriate test can then be done. Usually patients, ev en those who hav e no rem aining thy roid function, tolerate
being off thy roid replacem ent only ten day s quite well.

Quick look at Norm al Ranges (h ttp://www.en docri n eweb.com /con di ti on s/th y roi d/th y roi d-fu n cti on -tests) for thy roid function tests
Return to Thy roid Introduction (h ttp://www.en docri n eweb.com /con di ti on s/th y roi d/y ou r-th y roi d-gl an d)
More about the basics of the Regulation of Thy roid Horm one Production
(h ttp://www.en docri n eweb.com /con di ti on s/th y roi d/h ow-y ou r-th y roi d-works)

More about Thy roid Ultrasound (h ttp://www.en docri n eweb.com /con di ti on s/th y roi d/th y roi d-n odu l e-u l trasou n d)
More about Thy roid Nodules (h ttp://www.en docri n eweb.com /con di ti on s/th y roi d/th y roi d-n odu l es)
More about Thy roid Needle Biopsy (h ttp://www.en docri n eweb.com /con di ti on s/th y roi d/fi n e-n eedl e-bi opsy -th y roi d-n odu l es)
Updated on : 10/13/10

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