Data Klinik

Glucose Tests
Also known as: Blood Sugar; Fasting Blood Sugar; FBS; Fasting Blood Glucose; FBG; Fasting
Plasma Glucose; FPG; Blood Glucose; Oral Glucose Tolerance Test; OGTT; GTT; Urine
Glucose
Formal name: Blood Glucose; Urine Glucose
Related tests: A1c; Urinalysis; Insulin; C-peptide; Urine Albumin; Comprehensive Metabolic
Panel; Basic Metabolic Panel; Fructosamine
At a Glance
Why Get Tested?
To determine if your blood glucose level is within a healthy range; to screen for and diagnose
diabetes and prediabetes and to monitor for high blood glucose (hyperglycemia) or low blood
glucose (hypoglycemia); to check for glucose in your urine
When to Get Tested?
Blood glucose: when you are older than 45 years or have risk factors for diabetes; when you have
symptoms suggesting high or low blood glucose; during pregnancy; when you are diabetic, self-
checks up to several times a day to monitor blood glucose levels
Urine glucose: usually as part of a urinalysis
Sample Required?
A blood sample drawn from a vein in your arm or a drop of blood from a skin prick; sometimes a
random urine sample is used. Some diabetics may use a continuous glucose monitor, which uses
a small sensor wire inserted beneath the skin of the abdomen to measure blood glucose at
frequent intervals and provides a result.
Test Preparation Needed?
In general, it is recommended that you fast (nothing to eat or drink except water) for at least 8
hours before having a blood glucose test. For people with diabetes, glucose levels are often
checked both while fasting and after meals to provide the best control of diabetes. For random,
timed, and post-meal glucose tests, follow your health practitioner's instructions.
The Test Sample
What is being tested?
Glucose is the primary energy source for the body's cells and the only energy source for the brain
and nervous system. A steady supply must be available for use, and a relatively constant level of
glucose must be maintained in the blood. A few different protocols may be used to evaluate the
glucose level in the blood. See "How is it used?" for more information on these. Sometimes,
glucose may be tested in urine.
During digestion, fruits, vegetables, breads and other dietary sources of carbohydrates are broken
down into glucose (and other nutrients); they are absorbed by the small intestine and circulated
throughout the body. Using glucose for energy production depends on insulin, a hormone
produced by the pancreas. Insulin facilitates transport of glucose into the body's cells and directs
the liver to store excess energy as glycogen for short-term storage and/or as triglycerides in
adipose (fat) cells.
Normally, blood glucose rises slightly after a meal and insulin is released by the pancreas into
the blood in response, with the amount corresponding to the size and content of the meal. As
glucose moves into the cells and is metabolized, the level in the blood drops and the pancreas
responds by slowing, then stopping the release of insulin.
If the blood glucose level drops too low, such as might occur in between meals or after a
strenuous workout, glucagon (another pancreatic hormone) is secreted to induce the liver to turn
some glycogen back into glucose, raising the blood glucose level. If the glucose/insulin feedback
mechanism is working properly, the amount of glucose in the blood remains fairly stable. If the
balance is disrupted and the glucose level in the blood rises, then the body tries to restore the
balance, both by increasing insulin production and by eliminating excess glucose in the urine.
There are a few different conditions that may disrupt the balance between glucose and the
pancreatic hormones, resulting in high or low blood glucose. The most common cause is
diabetes. Diabetes is a group of disorders associated with insufficient insulin production and/or a
resistance to the effects of insulin. People with untreated diabetes are not able to process and use
glucose normally. Those who are not able to produce any or enough insulin (and typically have
diabetes autoantibodies) are diagnosed as having type 1 diabetes. Those who are resistant to
insulin and may or may not be able to produce sufficient quantities of it may have prediabetes or
type 2 diabetes.
Severe, acute changes in blood glucose, either high (hyperglycemia) or low (hypoglycemia), can
be life-threatening, causing organ failure, brain damage, coma, and, in extreme cases, death.
Chronically high blood glucose levels can cause progressive damage to body organs such as the
kidneys, eyes, heart and blood vessels, and nerves. Chronic hypoglycemia can lead to brain and
nerve damage.
Some women may develop gestational diabetes, which is hyperglycemia that occurs only during
pregnancy. If untreated, this can cause these mothers to give birth to large babies who may have
low glucose levels. Women who have had gestational diabetes may or may not go on to develop
diabetes.
How is the sample collected for testing?
A blood sample is obtained by inserting a needle into a vein in the arm or a drop of blood is
taken by pricking a finger with a small, pointed lancet (fingerstick). Sometimes, a random urine
sample is collected. Some diabetics may use a continuous glucose monitor, which uses a small
sensor wire inserted beneath the skin of the abdomen and held in place with an adhesive patch.
The sensor measures blood glucose levels at frequent intervals and sends the results to a device
that is attached to the person's clothing. A digital readout on the device lets the person know the
blood glucose level in real time.
NOTE: If undergoing medical tests makes you or someone you care for anxious, embarrassed, or
even difficult to manage, you might consider reading one or more of the following articles:
Coping with Test Pain, Discomfort, and Anxiety, Tips on Blood Testing, Tips to Help Children
through Their Medical Tests, and Tips to Help the Elderly through Their Medical Tests.
Another article, Follow That Sample, provides a glimpse at the collection and processing of a
blood sample and throat culture.
Is any test preparation needed to ensure the quality of the sample?
For screening purposes, fasting is generally recommended (nothing to eat or drink except water)
for at least 8 hours before a blood glucose test. Those who have been diagnosed with diabetes
and are monitoring their glucose levels are often tested both while fasting and after meals. For
random and timed tests, follow the health practitioner's instructions. A glucose tolerance test
requires that the person fast for the first blood sample and then drink a liquid containing a
specified amount of glucose; subsequent blood samples are drawn at specified times.
The Test
1. How is it used?
2. When is it ordered?
3. What does the test result mean?
4. Is there anything else I should know?
How is it used?
The blood glucose test may be used to:
 Detect high blood glucose (hyperglycemia) and low blood glucose (hypoglycemia)
 Screen for diabetes in people who are at risk before signs and symptoms are apparent; in
some cases, there may be no early signs or symptoms of diabetes. Screening can therefore
be useful in helping to identify it and allowing for treatment before the condition worsens
or complications arise.
 Help diagnose diabetes, prediabetes and gestational diabetes
 Monitor glucose levels in people diagnosed with diabetes
A few different testing protocols may be used to evaluate blood glucose levels, depending on the
purpose.
Screening and Diagnosis

The following tests may be used for screening and diagnosis of type 1, type 2 or prediabetes.
(Gestational diabetes testing is different—see below.) If the initial screening result from one of
the tests is abnormal, the test is repeated on another day. The repeat result must also be abnormal
to confirm a diagnosis of diabetes.
 Fasting glucose (fasting blood glucose, FBG) – this test measures the level of glucose in
the blood after fasting for at least 8 hours.
 2-hour glucose tolerance test (GTT) – for this test, the person has a fasting glucose test
done (see above), then drinks a 75-gram glucose drink. Another blood sample is drawn 2
hours after the glucose drink. This protocol "challenges" the person's body to process the
glucose. Normally, the blood glucose level rises after the drink and stimulates the
pancreas to release insulin into the bloodstream. Insulin allows the glucose to be taken up
by cells. As time passes, the blood glucose level is expected to decrease again. When a
person is unable to produce enough insulin, or if the body's cells are resistant to its effects
(insulin resistance), then less glucose is transported from the blood into cells and the
blood glucose level remains high.
 A different test called hemoglobin A1c may be used as an alternative to glucose testing
for screening and diagnosis. (For more, see the article on A1c.).
Sometimes a blood sample may be drawn and glucose measured when a person has not been
fasting, for example, when a comprehensive metabolic panel (CMP) is performed. If the result is
abnormal, it is typically followed up with a fasting blood glucose test or a GTT.
Glucose blood tests are also used to screen pregnant women for gestational diabetes between
their 24th and 28th week of pregnancy. The American Diabetes Association and the U.S.
Preventive Services Task Force recommend that pregnant women not previously known to have
diabetes be screened and diagnosed, using either a one-step or two-step approach. The American
College of Obstetricians and Gynecologists (ACOG) recommends the two-step approach.
 One-step 2-hour oral glucose tolerance test (OGTT). After a fasting glucose level is
measured, a woman is given a 75-gram dose of glucose to drink and her glucose levels
are measured at 1 hour and 2 hours after the dose. Only one of the values needs to be
above a cutoff value for diagnosis.
 Two-step
o Perform a glucose challenge test as a screen: a woman is given a 50-gram glucose
dose to drink and her blood glucose level is measured after 1 hour.
o If the challenge test is abnormal, perform a 3-hour oral glucose tolerance test.
After a woman's fasting glucose level is measured, she is given a 100-gram
glucose dose and her glucose is measured at timed intervals. If at least two of the
glucose levels at fasting, 1 hour, 2 hour, or 3 hour are above a certain level, then a
diagnosis of gestational diabetes is made.
Glucose testing is also used to test women who were diagnosed with gestational diabetes 6-12
weeks after they have delivered their baby to detect persistent diabetes.
Monitoring
Diabetics must monitor their own blood glucose levels, often several times a day, to determine
how far above or below normal their glucose is and to determine what oral medications or
insulin(s) they may need. This is usually done by placing a drop of blood from a skin prick onto
a glucose strip and then inserting the strip into a glucose meter, a small machine that provides a
digital readout of the blood glucose level.
Urine
Urine glucose is one of the substances tested when a urinalysis is performed. A urinalysis may be
done routinely as part of a physical or prenatal checkup. The health practitioner may follow up
an elevated urine glucose test with blood glucose testing. Urine glucose testing is a screening
tool, but it is not sensitive enough for diagnosis or monitoring.
Other tests, such as diabetes autoantibodies, insulin, and C-peptide, may sometimes be
performed along with these tests to help determine the cause of abnormal glucose levels, to
distinguish between type 1 and type 2 diabetes, and to evaluate insulin production.
When is it ordered?
Several health organizations, including the American Diabetes Association (ADA) and the U. S.
Preventive Services Task Force (USPSTF), recommend diabetes screening when a person is age
45 or older or when a person of any age has risk factors. Examples of risk factors include:
 Overweight, obese, or physically inactive

 A close (first degree) relative with diabetes
 A woman who delivered a baby weighing more than 9 pounds or with a history of
gestational diabetes
 A woman with polycystic ovarian syndrome
 High-risk race or ethnicity such as African American, Latino, Native American, Asian
American, Pacific Islander
 High blood pressure (hypertension) or taking medication for high blood pressure
 Low HDL cholesterol level (less than 35 mg/dL or 0.90 mmol/L) and/or a high
triglyceride level (more than 250 mg/dL or 2.82 mmol/L)
 A1c equal to or above 5.7%
 Prediabetes identified by previous testing
 History of cardiovascular disease (CVD)
If the screening test result is within normal limits, the ADA recommends retesting within 3 years,
while the USPSTF recommends yearly testing. People with prediabetes may be monitored with
annual testing.
See the screening articles for Children, Teens, Young Adults, Adults and Adults 50 and Up for
additional details.
A blood glucose test may also be ordered when someone has signs and symptoms of high blood
glucose (hyperglycemia), such as:
 Increased thirst, usually with frequent urination

 Fatigue
 Blurred vision
 Slow-healing wounds or infections
or symptoms of low blood glucose (hypoglycemia), such as:
 Sweating
 Hunger
 Trembling
 Anxiety
 Confusion
 Blurred vision
Diabetics are often required to self-check their glucose, up to several times a day, to monitor
glucose levels and to determine treatment options as prescribed by their health practitioner. The
healthcare provider may order blood glucose levels periodically in conjunction with other tests
such as A1c to monitor glucose control over time.
Pregnant women are usually screened for gestational diabetes between their 24th and 28th week
of pregnancy, unless they have early symptoms or have had gestational diabetes with a previous
pregnancy. A woman may be tested earlier in her pregnancy if she is at risk of type 2 diabetes
(overt diabetes), says the ADA. When a woman has type 1, type 2 or gestational diabetes, her
health practitioner will usually order glucose levels throughout the rest of her pregnancy and
after delivery to monitor her condition.
What does the test result mean?
Blood Glucose
High levels of glucose most frequently indicate diabetes, but many other diseases and conditions
can also cause elevated blood glucose.
In a person with signs and symptoms of diabetes or hyperglycemia, a non-fasting glucose level
(random blood sample) that is equal to or greater than 200 mg/dL (11.1 mmol/L) indicates
diabetes.
The following information summarizes the meaning of other test results.
Fasting Blood Glucose
Glucose Level Indication

From 70 to 99 mg/dL (3.9 to 5.5 mmol/L) Normal fasting glucose
Prediabetes (impaired fasting
From 100 to 125 mg/dL (5.6 to 6.9 mmol/L)
glucose)
126 mg/dL (7.0 mmol/L) and above on more than one testing
Diabetes
occasion
2-Hour Oral Glucose Tolerance Test (OGTT)
Levels applicable except during pregnancy. Sample drawn 2 hours after a 75-gram glucose drink.
Less than 140 mg/dL (7.8 mmol/L) Normal glucose tolerance
Prediabetes (impaired glucose
From 140 to 199 mg/dL (7.8 to 11.1 mmol/L)
tolerance)
Equal to or greater than 200 mg/dL (11.1 mmol/L) on more than
Diabetes
one testing occasion
Gestational Diabetes One-Step Approach (as one option recommended by the ADA)
Samples drawn fasting and then 1 hour and 2 hours after a 75-gram glucose drink. Diagnosis of
GDM is made when any of the values exceed the limit.
Time of sample collection glucose level
Fasting Equal to or greater than 92 mg/dL (5.1 mmol/L)
1 hour Equal to or greater than 180 mg/dL (10.0 mmol/L)
2 hour Equal to or greater than 153 mg/dL (8.5 mmol/L)
Gestational Diabetes Two-Step Approach (as currently recommended by ACOG and as one option from
the ADA): Step One
Step One: Glucose Challenge Screen. Sample drawn 1 hour after a 50-gram glucose drink.
Less than 140* mg/dL (7.8 mmol/L) Normal screen
140* mg/dL (7.8 mmol/L) and over Abnormal, needs OGTT (see Step two below)
*Some experts recommend a cutoff of 130 mg/dL (7.2 mmol/L) because that identifies 90% of
women with gestational diabetes, compared to 80% identified using the threshold of 140 mg/dL
(7.8 mmol/L). ACOG recommends a lower threshold of 135 mg/dL (7.5 mmol/L) in high-risk
ethnic groups with higher prevalence of gestational diabetes.
Gestational Diabetes Two-Step Approach (as currently recommended by ACOG and as one option from
the ADA): Step Two
Step Two: Diagnostic OGTT. Samples drawn at fasting and then 1, 2 and 3 hours after a 100-
gram glucose drink. If two or more values meet or exceed the target level, gestational diabetes is
diagnosed. One of two sets of criteria may be used to establish a diagnosis.
Time of sample collection target levels**
Fasting (prior to glucose load) 95 mg/dL (5.3 mmol/L)
1 hour after glucose load 180 mg/dL (10.0 mmol/L)
2 hours after glucose load 155 mg/dL (8.6 mmol/L)
3 hours after glucose load 140 mg/dL (7.8 mmol/L)
**Some labs may use different numbers.
Some other diseases and conditions that can result in an elevated blood glucose level include:
 Acromegaly
 Acute stress (response to trauma, heart attack, and stroke for instance)
 Chronic kidney disease
 Cushing syndrome
 Excessive consumption of food
 Hyperthyroidism
 Pancreatic cancer
 Pancreatitis
A low level of glucose may indicate hypoglycemia, a condition characterized by a drop in blood
glucose to a level where first it causes nervous system symptoms (sweating, palpitations, hunger,
trembling, and anxiety), then begins to affect the brain (causing confusion, hallucinations,
blurred vision, and sometimes even coma and death). A diagnosis of hypoglycemia uses three
criteria known as the Whipple triad. (See the Common Questions section.)
A low blood glucose level (hypoglycemia) may be seen with:
 Adrenal insufficiency
 Drinking excessive alcohol
 Severe liver disease
 Hypopituitarism
 Hypothyroidism
 Severe infections
 Severe heart failure
 Chronic kidney (renal) failure
 Insulin overdose
 Tumors that produce insulin (insulinomas)
 Starvation
 Deliberate use of glucose-lowering products
Urine Glucose
Low to undetectable urine glucose results are considered normal. Any condition that raises blood
glucose such as diabetes or the other conditions listed above also has the potential to elevate the
concentration of glucose in the urine.
Increased urine glucose may be seen with medications, such as estrogens and chloral hydrate,
and with some forms of kidney disease. Some people naturally leak glucose in their urine when
blood levels are normal. Some medications used to treat diabetes work by increasing the
elimination of glucose in the urine.
Is there anything else I should know?
Extreme stress can cause a temporary rise in blood glucose. This can be a result of, for example,
trauma, surgery, heart attack or stroke.
Drugs, including corticosteroids, tricyclic antidepressants, diuretics, epinephrine, estrogens (birth

control pills and hormone replacement), lithium, phenytoin, and salicylates, can increase glucose
levels, while drugs such as acetaminophen and anabolic steroids can decrease levels.
Common Questions
1. Can I test myself at home for blood glucose levels?
2. Can I test my urine glucose instead of my blood?
3. What are the usual treatments for diabetes?
4. How can a diabetic educator help me?
5. How is hypoglycemia diagnosed?
6. How is glucose different from table sugar?
1. Can I test myself at home for blood glucose levels?
If you are not diabetic or prediabetic, there is usually no reason to test glucose levels at home.
Screening done as part of your regular physical should be sufficient.
If you have been diagnosed with diabetes or gestational diabetes, however, your health
practitioner or diabetes educator will recommend a home glucose monitor (glucometer, or one of
the newer methods that use very tiny amounts of blood or tests the interstitial fluid -- the fluid
between your cells -- for glucose). You will be given guidelines for how high or low your blood
sugar should be at different times of the day. By checking your glucose regularly, you can see if
the diet and medication schedule you are following is working properly for you.
2. Can I test my urine glucose instead of my blood?
Not in most cases. Glucose will usually only show up in the urine if it is at sufficiently high
levels in the blood so that the body is "dumping" the excess into the urine, or if there is some
degree of kidney damage and the glucose is leaking out into the urine. Urine glucose, however, is
sometimes used as a rough indicator of high glucose levels and the urine indicator strip (dipstick)
that measures the glucose is occasionally useful for tracking the presence of protein and ketones
in the urine.
3. What are the usual treatments for diabetes?
For type 2 diabetes, which is the most common type of diabetes, losing excess weight, eating a
healthy diet that is high in fiber and restricted in carbohydrates, and getting regular amounts of
exercise may be enough to lower your blood glucose levels. In many cases, however, oral
medications that increase the body's secretion of and sensitivity to insulin are necessary to
achieve the desired glucose level. With type 1 diabetes (and with type 2 diabetes that does not
respond well enough to oral medications), insulin injections several times a day are necessary.
See the article on Diabetes for more on treatment.
4. How can a diabetic educator help me?

If you are diabetic, a diabetic educator (often a nurse with specialized training) can make sure
that you know how to:
 Recognize and know how to treat both high and low blood sugar
 Test and record your self-check glucose values
 Adjust your medications
 Administer insulin (which types in which combinations to meet your needs)
 Handle medications when you get ill
 Monitor your feet, skin, and eyes to catch problems early
 Buy diabetic supplies and store them properly
 Plan meals; diet is extremely important in minimizing swings in blood glucose levels. A
registered dietician can help you learn how to plan meals and a diabetic educator can help
with this as well.
5. How is hypoglycemia diagnosed?
An actual diagnosis of hypoglycemia requires satisfying the "Whipple triad." These three criteria
include:
 Documented low glucose levels (less than 40 mg/dL (2.2 mmol/L), often tested along
with insulin levels and sometimes with C-peptide levels)
 Symptoms of hypoglycemia when the blood glucose level is abnormally low
 Reversal of the symptoms when blood glucose levels are returned to normal
Primary hypoglycemia is rare and often diagnosed in infancy. People may have symptoms of
hypoglycemia without really having low blood sugar. In such cases, dietary changes such as
eating frequent small meals and several snacks a day and choosing complex carbohydrates over
simple sugars may be enough to ease symptoms.
6. How is glucose different from table sugar?
Table sugar (sucrose) is a combination of two simple sugars, glucose and fructose, that are both
released when table sugar is digested. Because glucose is the body's primary energy source, the
blood glucose test is often informally referred to as a "blood sugar" test.
Hemoglobin
Also known as: Hgb; Hb; H and H (Hemoglobin and Hematocrit)
Formal name: Hemoglobin
Related tests: Complete Blood Count (CBC), Hematocrit, Red Blood Cell Count, Blood Smear,
Iron Tests, Reticulocyte Count, Vitamin B12 and Folate, Red Cell Indices, Bone Marrow
Aspiration and Biopsy, G6PD, Erythropoietin, Hemoglobinopathy Evaluation
At a Glance
Why Get Tested?
To evaluate the hemoglobin content of your blood as part of a general health checkup; to screen
for and help diagnose conditions that affect red blood cells (RBCs); if you have anemia or
polycythemia, to assess the severity of these conditions and to monitor response to treatment
When to Get Tested?
With a hematocrit or as part of a complete blood count (CBC), which may be ordered as part of a
general health screen; when your doctor suspects that you have a condition such as anemia
(decreased hemoglobin) or polycythemia (increased hemoglobin); at regular intervals to monitor
disease or response to treatment
Sample Required?
A blood sample drawn from a vein in your arm or by a fingerstick (children and adults) or
heelstick (newborns)
None
The Test Sample

Hemoglobin is the iron-containing protein found in all red blood cells (RBCs) that gives the cells
their characteristic red color. Hemoglobin enables RBCs to bind to oxygen in the lungs and carry
it to tissues and organs throughout the body. It also helps transport a small portion of carbon
dioxide, a product of cell metabolism, from tissues and organs to the lungs where it is exhaled.
The hemoglobin test measures the amount of hemoglobin in a person's sample of blood. A
hemoglobin level can be performed alone or with a hematocrit, a test that measures the
proportion of blood that is made up of RBCs, to quickly evaluate an individual's red blood cells.
Red blood cells, which make up about 40% (ranging 37-49%) of the blood's volume, are
produced in the bone marrow and are released into the bloodstream after they mature. The
typical lifespan of an RBC is 120 days, and the bone marrow must continually produce new
RBCs to replace those that age and degrade or are lost through bleeding.
Several diseases and conditions can affect RBCs and consequently the level of hemoglobin in the
blood. In general, the hemoglobin level and hematocrit rise when the number of red blood cells
increases. The hemoglobin level and hematocrit fall to less than normal when there is a drop in
production of RBCs by the bone marrow, an increase in the destruction of RBCs, or if blood is
lost due to bleeding. A drop in the RBC count, hemoglobin and hematocrit can result in anemia, a
condition in which tissues and organs in the body do not get enough oxygen, causing fatigue and
weakness. If too many RBCs are produced, the blood can become thickened, causing sluggish
blood flow and related problems.

A blood sample is obtained by inserting a needle into a vein in the arm or by a fingerstick (for
children and adults) or heelstick (for newborns).
No test preparation is needed.
The Test
1. How is it used?
How is it used?
The hemoglobin test may be used to screen for, diagnose, or monitor a number of conditions and
diseases that affect red blood cells (RBCs) and/or the amount of hemoglobin in blood. It is often
used with a hematocrit as a quick evaluation of the number of RBCs or is performed as part of a
complete blood count (CBC) as an integral part of a health evaluation. The test may be used to:
 Screen for, diagnose, and measure the severity of anemia (low RBCs, hemoglobin and
hematocrit) or polycythemia (high RBCs, hemoglobin and hematocrit)
 Monitor the response to treatment of anemia or polycythemia
 Help make decisions about blood transfusions or other treatments if the anemia is severe
Some conditions affect RBC production in the bone marrow and may cause an increase or
decrease in the number of mature RBCs released into the blood circulation. Other conditions
may affect the lifespan of RBCs in the circulation. If there is increased destruction of RBCs
(hemolysis) or loss of RBCs (bleeding) and/or the bone marrow is not able to produce new ones
fast enough, then the overall number of RBCs and hemoglobin will drop, resulting in anemia.
This test can indicate if there is a problem with red blood cell production and/or lifespan, but it
cannot determine the underlying cause. In addition to the full CBC, some other tests that may be
performed at the same time or as follow up to establish a cause include a blood smear,
reticulocyte count, iron studies, vitamin B12 and folate levels, and in more severe conditions, a
bone marrow examination.
When is it ordered?
The hemoglobin test may be ordered by itself, with a hematocrit, or as a part of the complete
blood count (CBC) during a general health examination. These tests are also often ordered when
a person has signs and symptoms of a condition affecting RBCs such as anemia or polycythemia.
Some signs and symptoms of anemia include:
 Weakness or fatigue
 Lack of energy
 Fainting
 Paleness (pallor)
 Shortness of breath
Some signs and symptoms of polycythemia include:
 Disturbed vision
 Dizziness
 Headache
 Flushing
 Enlarged spleen
This test may be performed several times or on a regular basis when someone has been
diagnosed with ongoing bleeding problems or chronic anemias or polycythemia to determine the
effectiveness of treatment. It may also be ordered routinely on patients undergoing treatment for
cancer that is known to affect the bone marrow.
Since a hemoglobin level is often performed as part of a CBC, results from other components are
taken into consideration. A rise or drop in the hemoglobin level must be interpreted in
conjunction with other parameters, such as RBC count, hematocrit, reticulocyte count, and/or red
blood cell indices. Age, sex, and race are other factors to be considered. In general, hemoglobin
mirrors the results of the RBC count and hematocrit.
Some causes of a low hemoglobin level include:
 Excessive destruction of red blood cells, for example, hemolytic anemia caused by
autoimmunity or defects in the red cell itself; the defects could be hemoglobinopathy
(e.g., sickle cell anemia), abnormalities in the RBC membrane (e.g., hereditary
spherocytosis) or RBC enzyme (e.g., G6PD deficiency).
 Decreased hemoglobin production (e.g., thalassemia)
 Acute or chronic bleeding from the digestive tract (e.g., ulcers, polyps, colon cancer) or
other sites, such as the bladder, uterus (in women, heavy menstrual bleeding, for
example), or with severe trauma
 Nutritional deficiencies such as iron, folate or B12 deficiency
 Damage to the bone marrow from, for example, a toxin, radiation or chemotherapy,
infection or drugs
 Kidney failure—severe and chronic kidney diseases lead to decreased production of
erythropoietin, a hormone produced by the kidneys that stimulates RBC production by
the bone marrow
 Chronic inflammatory diseases or conditions
 Bone marrow disorders such as aplastic anemia, myelodysplastic syndrome, or cancers
such as leukemia, lymphoma, multiple myeloma, or other cancers that spread to the
marrow
Some causes of a high hemoglobin level include:
 Polycythemia vera—a rare disease in which the body produces excess RBCs
inappropriately
 Lung (pulmonary) disease—if someone is unable to breathe in and absorb sufficient
oxygen, the body tries to compensate by producing more red blood cells
 Congenital heart disease—in some forms, there is an abnormal connection between the
two sides of the heart, leading to reduced oxygen levels in the blood. The body tries to
compensate by producing more red blood cells.
 Kidney tumors that produce excess erythropoietin
 Smoking—heavy smokers have higher hemoglobin levels than nonsmokers.
 Genetic causes (altered oxygen sensing, abnormality in hemoglobin oxygen release)
 Living at high altitudes (a compensation for decreased oxygen in the air)
 Dehydration—as the volume of fluid in the blood drops, the hemoglobin artificially rises.

A recent blood transfusion can affect a person's hemoglobin level.
Hemoglobin decreases slightly during normal pregnancy.
Common Questions
1. Can I test my hemoglobin at home?
2. Is anyone at greater risk of abnormal hemoglobin levels?
3. Are there warning signs for abnormally low hemoglobin levels?
4. Can a healthy diet and nutrition help keep optimal hemoglobin levels?
1. Can I test my hemoglobin at home?
Yes, there are some home tests currently available that have been approved by the U.S. Food and
Drug Administration (FDA). Home testing offers many benefits, but it's also important to
recognize the potential tradeoffs between quality and convenience and to take steps to protect
yourself against the possibility of false results, and your own lack of training. Talk to your doctor
about this type of testing and consult her about any questions or concerns you may have. For
more about these tests, see the article With Home Testing, Consumers Take Charge of Their Health.
2. Is anyone at greater risk of abnormal hemoglobin levels?
Women of childbearing age tend to have lower hemoglobin levels than men due to loss of iron
and blood during menstrual periods and increased need for iron during pregnancy. Others who
are at greater risk of a low hemoglobin level ( anemia) include people with poor nutrition and diets
low in iron or vitamins, people who have undergone surgery or have been severely injured,
people with chronic conditions such as kidney disease, cancer, HIV/AIDS, inflammatory bowel disease,
chronic infection or chronic inflammatory conditions (e.g., rheumatoid arthritis). Someone who has
family members with a genetic cause of anemia, such as sickle cell or thalassemia, also has a higher
risk of having the condition and a higher risk of anemia.
3. Are there warning signs for abnormally low hemoglobin levels?
Some warning signs are fatigue, fainting, pallor, and shortness of breath.
4. Can a healthy diet and nutrition help keep optimal hemoglobin levels?
Yes, to the extent that if you eat a well-balanced diet, you can prevent anemia due to a lack of
iron, vitamin B12, or folate in the foods you eat. Sometimes use of a supplement is
recommended if you are at risk of a vitamin deficiency. However, the most common cause
of vitamin B12 deficiency is malabsorption, and the most common cause of iron deficiency is
bleeding. These conditions and other RBC problems that are caused by diseases other than
nutritional deficiencies cannot be corrected by diet.
Fructosamine
Also known as: Glycated Serum Protein; GSP
Formal name: Fructosamine
Related tests: Glucose; A1c; Albumin; Total Protein; Hemoglobinopathy Evaluation
At a Glance
Why Get Tested?
To help monitor your blood glucose (sugar) levels over time if you have diabetes mellitus,
especially if it is not possible to monitor your diabetes using the A1c test; to help determine the
effectiveness of changes to your diabetic treatment plan that might include changes in diet,
exercise or medications, especially if they were made recently
When to Get Tested?
When you are diabetic and your healthcare provider wants to evaluate your average blood
glucose level over the last 2-3 weeks
Sample Required?
A blood sample drawn from a vein in your arm or sometimes from a fingerstick
None
The Test Sample

Fructosamine is a compound that is formed when glucose combines with protein. This test
measures the total amount of fructosamine (glycated protein) in the blood.
Glucose molecules will permanently combine with proteins in the blood in a process called
glycation. Affected proteins include albumin, the principal protein in the fluid portion of blood
(serum), as well as other serum proteins and hemoglobin, the major protein found inside red
blood cells (RBCs). The more glucose that is present in the blood, the greater the amount of
glycated proteins that are formed. These combined molecules persist for as long as the protein or
RBC is present in the blood and provide a record of the average amount of glucose that has been
present in the blood over that time period.
Since the lifespan of RBCs is about 120 days, glycated hemoglobin (hemoglobin A1c) represents
a measurement of the average blood glucose level over the past 2 to 3 months. Serum proteins
are present in the blood for a shorter time, about 14 to 21 days, so glycated proteins, and the
fructosamine test, reflect average glucose levels over a 2 to 3 week time period.
Keeping blood glucose levels as close as possible to normal helps those with diabetes to avoid
many of the complications and progressive damage associated with elevated glucose levels.
Good diabetic control is achieved and maintained by daily (or even more frequent) self-
monitoring of glucose levels in insulin-treated diabetics and by occasional monitoring of the
effectiveness of treatment using either a fructosamine or A1c test.
A blood sample is obtained by inserting a needle into a vein in the arm or from a fingerstick.
The Test
1. How is it used?
How is it used?
Fructosamine testing may be used to help a person with diabetes monitor and control his or her
blood glucose level. The level of fructosamine in the blood is a reflection of glucose levels over
the previous 2-3 weeks. (See the "What is being tested?" section for more on this.)
Both fructosamine and A1c tests are used primarily as monitoring tools to help people with
diabetes control their blood sugar. However, the A1c test is much more well-known and widely
accepted because there are firm data that a chronically elevated A1c level predicts an increased
risk for certain diabetic complications, such as problems with the eyes (diabetic retinopathy),
possibly leading to blindness, kidney disease (diabetic nephropathy), and nerve damage
(diabetic neuropathy).
The American Diabetes Association (ADA) recognizes the usefulness of both tests and states that
fructosamine may be considered as a substitute in situations where A1c cannot be reliably
measured. Instances where fructosamine may be a better monitoring choice than A1c include:
 Rapid changes in diabetes treatment – Fructosamine allows the effectiveness of diet or

medication adjustments to be evaluated after a few weeks rather than months.
 Diabetic pregnancy – In diabetic women who are pregnant, good glycemic control is
essential during pregnancy, and the needs of the mother frequently change during
gestation; fructosamine measurements may be ordered along with glucose levels to help
monitor and accommodate shifting glucose, insulin, or other medication requirements.
 Shortened RBC life span – An A1c test will not be accurate when a person has a
condition that affects the average lifespan of red blood cells (RBCs), such as hemolytic
anemia or blood loss. When the lifespan of RBCs in circulation is shortened, the A1c
result is falsely low and is an unreliable measurement of a person's average glucose over
time.
 Abnormal forms of hemoglobin – The presence of some hemoglobin variants, such as
hemoglobin S in sickle cell anemia, may affect certain methods for measuring A1c. In
these cases, fructosamine can be used to monitor glucose control.
When is it ordered?
Although not widely used, the fructosamine test may be ordered whenever a health practitioner
wants to monitor a person's average glucose levels over the past 2 to 3 weeks. It is primarily
ordered when a diabetic treatment plan is being started or adjusted in order to monitor the effect
of the change in diet, exercise, or medication.
Fructosamine levels also may be ordered periodically when a diabetic woman is pregnant or
when a person has an illness that may change their glucose and insulin requirements for a period
of time. The fructosamine test may be used when monitoring is required and an A1c test cannot
be reliably used, as in cases of a shortened RBC life span or in some cases where the person
being tested has an abnormal hemoglobin.
A high fructosamine means that a diabetic's average glucose over the previous 2 to 3 weeks has
been elevated. In general, the higher the fructosamine level, the higher the average blood glucose
level. Monitoring the trend of values may be more important than a single high value. A trend
from a normal to a high fructosamine level may indicate that a person's glucose control is not
adequate. This, however, does not pinpoint the cause. A review and adjustment to the person's
diet and/or medication may be required to help get the person's glucose under control. Acute
illness and significant stress can also temporarily raise blood glucose levels so these factors may
also be taken into account when interpreting results.
A normal fructosamine level may indicate that a diabetic has good diabetic control and that the
current treatment plan is effective for the individual. Likewise, a trend from high to normal
fructosamine levels may indicate that changes to a person's treatment regimen have been
effective.
Fructosamine results must be evaluated in the context of a person's overall clinical findings.
Falsely low fructosamine results may be seen with decreased blood total protein and/or albumin
levels, with conditions associated with increased protein loss in the urine or gastrointestinal tract,
or with changes in the type of protein produced by the body. In this case, a discrepancy between
the results obtained from daily glucose monitoring and fructosamine testing may be noticed.
Also, someone whose glucose levels swing erratically from high to low may have normal or near
normal fructosamine and A1c levels but still have a condition that requires frequent monitoring.
However, most people with such unstable diabetic control do have elevated fructosamine and
A1c concentrations.
Since the fructosamine levels of people with well-controlled diabetes may overlap with those of
people who are not diabetic, the fructosamine test is not useful as a screening test for diabetes.
High levels of vitamin C (ascorbic acid) and hyperthyroidism can interfere with test results.
Common Questions
1. Can I test for fructosamine at home?
2. Do I need to fast for a fructosamine test?
3. Shouldn't someone with a family history of diabetes have a fructosamine test?
4. If I have diabetes, should I have a fructosamine test?
1. Can I test for fructosamine at home?
No. Although a home test was available in the past, it was discontinued in 2002 after the
manufacturer was purchased by another company and amid concerns that the test strips were
producing falsely high results.
2. Do I need to fast for a fructosamine test?
No. Since it measures glycated protein and determines the average glucose over the past 2-3
weeks, the fructosamine test is not affected by food that you have eaten during the day. It can be
measured at any time during the day.
3. Shouldn't someone with a family history of diabetes have a fructosamine test?
Not usually. Unlike A1c, this test is not recommended for screening non-diabetic people, even if
they have a strong family history.
4. If I have diabetes, should I have a fructosamine test?
The vast majority of people with diabetes can be monitored using A1c tests that reflect their
glycemic control over the previous 2 to 3 months. Fructosamine testing can be useful during
pregnancy when the woman has diabetes, when a person's red blood cells have a shortened
lifespan, and in some cases of people with abnormal forms of hemoglobin. Most diabetics will
never need to have the test performed.
A1c
Also known as: Hemoglobin A1c; HbA1c; Glycohemoglobin; Glycated Hemoglobin;
Glycosylated Hemoglobin
Formal name: A1c
Related tests: Glucose Tests; Microalbumin; Microalbumin/Creatinine Ratio; Fructosamine
At a Glance
Why Get Tested?
To monitor a person's diabetes and to aid in treatment decisions; to diagnose diabetes; to help
identify those at an increased risk of developing diabetes
When to Get Tested?
When first diagnosed with diabetes and then 2 to 4 times per year; as part of a health checkup or
when you have symptoms of diabetes
Sample Required?
A blood sample drawn from a vein in your arm or from a fingerstick
None
The Test Sample

The A1c test evaluates the average amount of glucose in the blood over the last 2 to 3 months. It
does this by measuring the concentration of glycated (also often called glycosylated) hemoglobin
A1c.
Hemoglobin is an oxygen-transporting protein found inside red blood cells (RBCs). There are
several types of normal hemoglobin, but the predominant form – about 95-98% – is hemoglobin
A. As glucose circulates in the blood, some of it spontaneously binds to hemoglobin A. The
hemoglobin molecules with attached glucose are called glycated hemoglobin. The higher the
concentration of glucose in the blood, the more glycated hemoglobin is formed. Once the glucose
binds to the hemoglobin, it remains there for the life of the red blood cell – normally about 120
days. The predominant form of glycated hemoglobin is referred to as HbA1c or A1c. A1c is
produced on a daily basis and slowly cleared from the blood as older RBCs die and younger
RBCs (with non-glycated hemoglobin) take their place.
This test is used to monitor treatment in someone who has been diagnosed with diabetes. It helps
to evaluate how well the person's glucose levels have been controlled by treatment over time.
This test may be used to screen for and diagnose diabetes or risk of developing diabetes. In 2010,
clinical practice guidelines from the American Diabetes Association (ADA) stated that A1c may
be added to fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT) as an option
for diabetes screening and diagnosis.
For monitoring purposes, an A1c of less than 7% indicates good glucose control and a lower risk
of diabetic complications for the majority of diabetics. However, in 2012, the ADA and the
European Association for the Study of Diabetes (EASD) issued a position statement
recommending that the management of glucose control in type 2 diabetes be more "patient-
centered." Data from recent studies have shown that low blood sugar (hypoglycemia) can cause
complications and that people with risk of severe hypoglycemia, underlying health conditions,
complications, and a limited life expectancy do not necessarily benefit from having a stringent
goal of less than 7% for their A1c. The statement recommends that people work closely with
their doctor to select a goal that reflects each person's individual health status and that balances
risks and benefits.
A blood sample is obtained by inserting a needle into a vein in the arm or a drop of blood is
taken from a finger by pricking it with a small, pointed lancet.
The Test
1. How is it used?

How is it used?
The A1c test is used to monitor the glucose control of diabetics over time. The goal of those with
diabetes is to keep their blood glucose levels as close to normal as possible. This helps to
minimize the complications caused by chronically elevated glucose levels, such as progressive
damage to body organs like the kidneys, eyes, cardiovascular system, and nerves. The A1c test
result gives a picture of the average amount of glucose in the blood over the last few months.
This can help the diabetic person and his doctor know if the measures that are being taken to
control his diabetes are successful or need to be adjusted.
A1c is frequently used to help newly diagnosed diabetics determine how elevated their
uncontrolled blood glucose levels have been over the last 2-3 months. The test may be ordered
several times while control is being achieved, and then several times a year to verify that good
control is being maintained.
The A1c test may be used to screen for and diagnose diabetes. However, A1c should not be used
for diagnosis of gestational diabetes in pregnant women or for diagnosis of diabetes in people
who have had recent severe bleeding or blood transfusions, those with chronic kidney or liver
disease, or people with blood disorders such as iron-deficiency anemia, vitamin B12 deficiency
anemia, and some hemoglobin variants (e.g., patients with sickle cell disease or thalassemia). In
these cases, a fasting plasma glucose or oral glucose tolerance test should be used for screening
or diagnosing diabetes.
Only A1c tests that have been referenced to an accepted laboratory method (standardized) should
be used for diagnostic or screening purposes. Currently, point-of-care tests, such as those that
may be used at a doctor's office or a patient's bedside, are not accurate enough for use in
diagnosis but can be used to monitor treatment (lifestyle and drug therapies).
When is it ordered?
Depending on the type of diabetes that a person has, how well their diabetes is controlled, and on
doctor recommendations, the A1c test may be measured 2 to 4 times each year. The American
Diabetes Association recommends A1c testing in diabetics at least twice a year. When someone
is first diagnosed with diabetes or if control is not good, A1c may be ordered more frequently.
For diagnostic and screening purposes, A1c may be ordered as part of a health checkup or when
someone is suspected of having diabetes because of signs or symptoms of increased blood
glucose levels (hyperglycemia) such as:
 Increased thirst
 Increased urination
 Fatigue
 Blurred vision
 Slow-healing infections
For monitoring glucose control, A1c is currently reported as a percentage and, for most diabetics,
it is recommended that they aim to keep their A1c below 7%. The closer diabetics can keep their
A1c to the American Diabetes Association (ADA)'s therapeutic goal of less than 7% without
experiencing excessive hypoglycemia, the better their diabetes is in control. As the A1c
increases, so does the risk of complications.
An individual with type 2 diabetes, however, may have an A1c goal selected by the person and
his doctor. The goal may depend on several factors, such as length of time since diagnosis, the
presence of other diseases as well as diabetes complications (e.g., vision impairment or loss,
kidney damage), risk of complications from low blood glucose (hypoglycemia), and whether or
not the person has a support system and health care resources readily available. For example, a
person with heart disease who has lived with type 2 diabetes for many years without diabetic
complications may have a higher A1c target (e.g., 7.5%-8.0%) set by their doctor, while someone
who is otherwise healthy and just diagnosed may have a lower target (e.g., 6.0%-6.5%) as long
as low blood sugar is not a significant risk.
The A1c test report also may include the result expressed in SI units (mmol/mol) and an
estimated Average Glucose (eAG), which is a calculated result based on the A1c levels.
The purpose of reporting eAG is to help a person relate A1c results to everyday glucose
monitoring levels and to laboratory glucose tests. The formula for eAG converts percentage A1c
to units of mg/dL or mmol/L.
It should be noted that the eAG is still an evaluation of a person's glucose over the last couple of
months. It will not match up exactly to any one daily glucose test result. The ADA has adopted
this calculation and provides a calculator and information on the eAG on their DiabetesPro web
site.
In screening and diagnosis, some results that may be seen include:
 A nondiabetic person will have an A1c result less than 5.7% (39 mmol/mol).
 Diabetes: A1c level is 6.5% (47 mmol/mol) or higher.
 Increased risk of developing diabetes in the future: A1c of 5.7% to 6.4% (39-46
mmol/mol)
The A1c test will not reflect temporary, acute blood glucose increases or decreases, or good
control that has been achieved in the last 3-4 weeks. The glucose swings of someone who has
"brittle" diabetes will also not be reflected in the A1c.
If an individual has a hemoglobin variant, such as sickle cell hemoglobin (hemoglobin S), they
will have a decreased amount of hemoglobin A. This may limit the usefulness of the A1c test in
diagnosing and/or monitoring this person's diabetes, depending on the method used.
If a person has anemia, hemolysis, or heavy bleeding, A1c test results may be falsely low. If
someone is iron-deficient, the A1c level may be increased.
If a person has had a recent blood transfusion, the A1c may be inaccurate and may not accurately
reflect glucose control for 2 to 3 months.
Common Questions
1. How is estimated Average Glucose (eAG) calculated?
2. Is there a home test for A1c?
3. Is A1c reported the same way around the world?
4. Why are my A1c and blood glucose different?
1. How is estimated Average Glucose (eAG) calculated?
The ADAG formula that is used to calculate the eAG from your A1c result is:
28.7 X A1c (%) – 46.7 = eAG (milligrams/deciliter, mg/dl)
An example of this is an A1c of 6%. The calculation for this would be:
28.7 X 6 – 46.7 = 126 mg/dl
for an estimated average glucose of 126 mg/dl.
What this means is that for every one percent that your A1c goes up, it is equivalent to your
average glucose going up by about 29 mg/dl.
2. Is there a home test for A1c?
Yes. If you have already been diagnosed with diabetes, a home test may be used to help monitor
your glucose control over time. However, a home test is not recommended for screening or
diagnosing the disease. There are FDA-approved tests that can be used at home. If you are
interested in learning more, visit the article on Home Tests and ask your doctor.
3. Is A1c reported the same way around the world?
For monitoring purposes, the way that the A1c is reported is in the process of changing.
Traditionally, in the United States, the A1c has been reported as a percentage, and the ADA has
recommended that people with diabetes strive to keep their A1c below 7%. While this is still
generally true, more than a decade of national and international efforts to improve and
standardize the A1c test and its reporting led to the release of a consensus statement in 2007 (and
an update in 2010) by the ADA, the European Association for the Study of Diabetes (EASD), the
International Federation of Clinical Chemistry and Laboratory Medicine (IFCC), the
International Society for Pediatric and Adolescent Diabetes, and the International Diabetes
Federation. These joint statements and the completion of a study called ADAG (A1c-Derived
Average Glucose) that further examined the relationship between blood glucose concentrations
and A1c led to a recommendation that A1c be reported worldwide in two ways:
• As a percentage (based upon National Glycohemoglobin Standardization Program (NGSP)

derived units) and
• In SI (Système International) units (mmol/mol)
An estimated Average Glucose (eAG) based upon a formula developed from the ADAG study
with either mg/dl or mmol/l as units that were recommended in the 2007 consensus statement
(but not in the 2010 update) may also be reported.
What this means for the diabetic person and his doctor in the U.S. is that the person's A1c results
will be reported as a percentage but may in addition to this be reported as mmol/mol and, in
some cases, also as an eAG with the same type of units (mg/dl) as are reported by home glucose
monitors and laboratory results.
4. Why are my A1c and blood glucose different?
Beyond the difference in units used to report them, the A1c represents an average over time
while your blood glucose reflects what is happening in your body now. Your blood glucose will
capture the changes in your blood sugar that occur on a daily basis, the highs and the lows. Each
blood glucose is a snapshot and each is different. The A1c is an indication that "in general" your
glucose has been elevated over the last few months or "in general" it has been normal. It is
inherently not a sensitive as a blood glucose. However, if your day-to-day glucose control is
stable (good or bad), then both the A1c and blood glucose should reflect this. It is important to
remember the time lag associated with the A1c. Good glucose control for the past 2-3 weeks will
not significantly affect the A1c result for several more weeks.
In addition to this, it is also important to remember that glycated hemoglobin and blood glucose
are two different but related things. For unknown reasons, some peoples' A1c may not accurately
reflect their average blood glucose
Insulin
Also known as: Fasting Insulin
Formal name: Insulin, serum
Related tests: C-peptide, Glucose Tests
At a Glance
Why Get Tested?
To help evaluate insulin production by the beta cells in the pancreas; to help diagnose the
presence of an insulin-producing tumor in the islet cells of the pancreas (insulinoma); to help
determine the cause of low blood glucose (hypoglycemia); to help identify insulin resistance, or
to help determine when a type 2 diabetic might need to start taking insulin to supplement oral
medications
When to Get Tested?
When you have low blood glucose levels with symptoms such as sweating, palpitations,
dizziness, fainting; when you have diabetes and your health practitioner wants to monitor your
insulin production; sometimes when it is suspected that you have insulin resistance
Sample Required?
A blood sample drawn from a vein in your arm
You may be asked to fast for 8 hours before the blood sample is collected, but occasionally a
health practitioner may do the test with, for example, a glucose tolerance test. In some cases, a
health practitioner may request that you fast longer.
The Test Sample

Insulin is a hormone that is produced and stored in the beta cells of the pancreas. It is vital for the
transportation and storage of glucose, the body's main source of energy. Insulin helps transport
glucose from the blood to within cells, helps regulate blood glucose levels, and has a role in lipid
metabolism. This test measures the amount of insulin in the blood.
Insulin and glucose blood levels must be in balance. After a meal, carbohydrates usually are
broken down into glucose and other simple sugars. This causes the blood glucose level to rise
and stimulates the pancreas to release insulin into the blood. As glucose moves into cells, the
level in the blood decreases and release of insulin by the pancreas decreases.
If an individual is not able to produce enough insulin, or if the body's cells are resistant to its
effects (insulin resistance), glucose cannot reach most of the body's cells and the cells starve,
while blood glucose rises to an unhealthy level. This can cause disturbances in normal metabolic
processes that result in various disorders and complications, including kidney disease,
cardiovascular disease, and vision and neurological problems.
Diabetes, a disorder associated with high glucose levels and decreased insulin effects, can be a
life-threatening condition. People with type 1 diabetes produce very little insulin and so
eventually require insulin supplementation therapy. Type 2 diabetes is generally related to insulin
resistance, which increases with time.
With insulin resistance, the body is unable to respond to the effects of insulin. The body
compensates by producing additional amounts of the hormone. This results in a high level of
insulin in the blood (hyperinsulinemia) and over-stimulation of some tissues that have remained
insulin-sensitive. Over time, this process causes an imbalance in the relationship between
glucose and insulin and, without treatment, may eventually cause health complications affecting
various parts of the body.
In addition to type 2 diabetes, insulin resistance may be seen in those with polycystic ovarian
syndrome (PCOS), prediabetes or heart disease, metabolic syndrome, and with disorders related
to the pituitary or adrenal glands.
Other than in insulin resistance, hyperinsulinemia is most often seen in people with tumor of the
islet cells in the pancreas (insulinomas) or with an excess amount of administered (exogenous)
insulin. Hyperinsulinemia causes low blood sugar (hypoglycemia), which can lead to sweating,
palpitations, hunger, confusion, blurred vision, dizziness, fainting, and seizures. Since the brain
is dependent on blood glucose as an energy source, severe glucose deprivation due to
hyperinsulinemia can lead fairly quickly to insulin shock and death.
A blood sample is obtained by inserting a needle into a vein in the arm.
Typically, a person will be asked to fast for 8 hours before blood is collected, but occasionally a
health practitioner may do testing when fasting is not possible, such as when a glucose tolerance
test (see Glucose) is done. In some cases, the health practitioner may request that a person fast
longer than 8 hours.
The Test
1. How is it used?
How is it used?
Insulin testing has several possible uses. Insulin is a hormone that is produced and stored in the
beta cells of the pancreas. Insulin helps transport glucose , the body's main source of energy,
from the blood to within cells. If a person makes too little insulin or is resistant to its effects,
cells starve. If someone makes too much, as may happen with an insulin-producing tumor
(insulinoma) for example, then symptoms of low blood glucose (hypoglycemia) emerge.
Insulin testing may be used to help:
 Diagnose an insulinoma, verify that removal of the tumor has been successful, and/or to
monitor for recurrence
 Diagnose the cause of hypoglycemia in an individual with signs and symptoms
 Identify insulin resistance
 Monitor the amount of insulin produced by the beta cells in the pancreas (endogenous); in
this case, a C-peptide test may also be done. Insulin and C-peptide are produced by the
body at the same rate as part of the conversion of proinsulin to insulin in the pancreas.
Both tests may be ordered when a health practitioner wants to evaluate how much insulin
in the blood is made by the body and how much is from outside (exogenous) sources such
as insulin injections. The test for insulin measures insulin from both sources while the C-
peptide test reflects insulin produced by the pancreas.
 Determine when a type 2 diabetic might need to start taking insulin to supplement oral
medications
 Determine and monitor the success of an islet cell transplant intended to restore the
ability to make insulin, by measuring the insulin-producing capacity of the transplant
Insulin testing may be ordered with glucose and C-peptide tests. Insulin levels are also
sometimes used in conjunction with the glucose tolerance test (GTT). In this situation, blood
glucose and insulin levels are measured at pre-established time intervals to evaluate insulin
resistance.
When is it ordered?
Insulin levels are most frequently ordered following a low glucose and/or when someone has
acute or chronic symptoms of low blood glucose (hypoglycemia) caused by, for example, an
insulinoma. Symptoms of hypoglycemia may include:
 Sweating
 Palpitations
 Hunger
 Confusion
 Blurred vision
 Dizziness
 Fainting
 In serious cases, seizures and loss of consciousness
These symptoms may indicate low blood glucose but may also be seen with other conditions.
An insulin test may also be done when an individual has or is suspected of having insulin
resistance. This may include people with type 2 diabetes, polycystic ovarian syndrome (PCOS),
prediabetes or heart disease, or metabolic syndrome.
A health practitioner also may order insulin and C-peptide tests after an insulinoma has been
successfully removed to verify the effectiveness of treatment and then order the tests periodically
to monitor for recurrence.
Periodic testing may also be used to monitor the success of an islet cell transplant by measuring
the insulin-producing capacity of the transplant.
Insulin levels must be evaluated in context.

Results seen:
fasting fasting glucose

Disorder
insulin level level
None Normal Normal
Normal or
Insulin resistance High somewhat
elevated
Not enough insulin produced by the beta cells (as seen in
Low High
diabetes, pancreatitis, for example)
Hypoglycemia due to excess insulin (may be seen in
Normal or
insulinomas, Cushing syndrome, excess administration of Low
high
exogenous insulin, etc.)
Elevated insulin levels are seen with:
1. Acromegaly
2. Cushing syndrome
3. Use of drugs such as corticosteroids, levodopa, oral contraceptives
4. Fructose or galactose intolerance
5. Insulinomas
6. Obesity
7. Insulin resistance, such as appears in type 2 diabetes and metabolic syndrome
Decreased insulin levels are seen with:
1. Diabetes
2. Hypopituitarism
3. Pancreatic diseases such as chronic pancreatitis (including cystic fibrosis) and pancreatic
cancer
Insulin for injection used to come strictly from animal sources (cow and pig pancreas cells).
Most insulin used today is synthetic, made by biochemical synthesis to identically match the
biological activity of the insulin produced by human cells.
There are different pharmaceutical formulations of insulin with different properties. Some are
rapid-release and quick-acting and others are slow-release preparations that act over a prolonged
period. Diabetics may take mixtures and/or different types of insulin throughout the day.
Insulin assays are designed to measure endogenous human insulin. However, different assays
react variably with exogenous (animal or synthetic) insulin. If someone is receiving insulin, these
effects should be clarified with the testing laboratory. If several or periodic insulin assays will be
performed, they should be analyzed by the same laboratory to ensure consistency.
The insulin tolerance test (ITT) is not widely used, but is one method for determining insulin
sensitivity (or resistance), especially in obese individuals and those with PCOS. This test
involves an IV-infusion of insulin, with subsequent measurements of glucose and insulin levels.
If someone has developed antibodies against insulin, especially as a result of taking non-human
(animal or synthetic) insulin, these can interfere with insulin testing. In this case, a C-peptide
may be performed as an alternative way to evaluate insulin production. Note also that most
people with type 1 diabetes will also have autoantibodies against insulin.
Common Questions
1. Can I do an insulin test at home?
2. Why does insulin have to be injected?
3. How is an insulinoma treated?
4. What else is important about insulin resistance?
1. Can I do an insulin test at home?
No. Although glucose levels can be monitored at home, insulin tests require specialized
instruments and training are are perforemd at laboratories.
2. Why does insulin have to be injected?
Insulin must be injected or given via an insulin pump. It cannot be given orally because it is a
protein and is broken down in the stomach before it can be absorbed.
3. How is an insulinoma treated?
Insulinomas are insulin-producing tumors that are usually benign. They are typically treated by
being located and removed. Once removed, generally they do not return.
4. What else is important about insulin resistance?

Insulin resistance is a warning signal that the body is having problems processing glucose and it
is characteristic of prediabetes. People with early or moderate insulin resistance often don't have
any symptoms, but if their condition is ignored, it puts them at a much greater risk of developing
type 2 diabetes, hypertension, hyperlipidemia, and/or heart disease several years down the road.
Abdominal obesity, insulin resistance, dyslipidemia, and hypertension form a set of risk factors
that are referred to as metabolic syndrome.
Risk factors for insulin resistance include:
 Obesity, especially abdominal obesity

 Family history of diabetes or insulin resistance
 Gestational diabetes
 Polycystic ovary syndrome
Treatment of insulin resistance involves changes in diet and lifestyle. The American Diabetes
Association recommends losing excess weight, getting regular amounts of moderate intensity
physical activity, and increasing dietary fiber to lower blood insulin levels and increase the
body's sensitivity to it.
C-peptide
Also known as: Insulin C-peptide; Connecting Peptide Insulin; Proinsulin C-peptide
Formal name: C-peptide
Related tests: Insulin; Glucose
At a Glance
Why Get Tested?
To help evaluate insulin production by the beta cells in the pancreas or to help determine the
cause of low blood glucose (hypoglycemia)
When to Get Tested?
When you have diabetes and your health practitioner wants to determine if you are producing
enough of your own insulin or if it is time to supplement oral medication with insulin injections
or an insulin pump; when your health practitioner suspects that you have insulin resistance; when
you have documented hypoglycemia
Sample Required?
A blood sample drawn from a vein in your arm and sometimes a 24-hour urine sample
Fasting for 8 to 10 hours before blood testing is usually required.
The Test Sample

C-peptide is a substance, a short chain of amino acids, that is released into the blood as a
byproduct of the formation of insulin by the pancreas. This test measures the amount of C-
peptide in a blood or urine sample.
In the pancreas, within specialized cells called beta cells, proinsulin, a biologically inactive
molecule, splits apart to form one molecule of C-peptide and one molecule of insulin. Insulin is
vital for the transport of glucose into the body's cells and is required on a daily basis. When
insulin is required and released from the beta cells into the blood in response to increased levels
of glucose, equal amounts of C-peptide are also released. Since C-peptide is produced at the
same rate as insulin, it is useful as a marker of insulin production.
In particular, C-peptide testing can be used to help evaluate the production of insulin made by the
body (endogenous) and to help differentiate it from insulin that is not produced by the body but
is taken in as diabetic medication (exogenous) and so does not generate C-peptide. This test may
be done in conjunction with an insulin test.
A blood sample is obtained by inserting a needle into a vein in the arm. If a 24-hour urine
sample is required, all urine produced over a 24-hour time period will be collected.
Fasting for 8 to 10 hours before blood testing is usually required.
The Test
1. How is it used?
How is it used?
C-peptide testing can be used for a few different purposes. C-peptide is a substance produced by
the beta cells in the pancreas when proinsulin splits apart and forms one molecule of C-peptide
and one molecule of insulin. Insulin is the hormone that is vital for the body to use its main
energy source, glucose. Since C-peptide and insulin are produced at the same rate, C-peptide is a
useful marker of insulin production.
The following are some purposes of C-peptide testing:
 A C-peptide test is not ordered to help diagnose diabetes, but when a person has been
newly diagnosed with diabetes, it may be ordered by itself or along with an insulin level
to help determine how much insulin a person's pancreas is still producing (endogenous
insulin).
 In type 2 diabetes, the body is resistant to the effects of insulin (insulin resistance) and it
compensates by producing and releasing more insulin, which can also lead to beta cell
damage. Type 2 diabetics usually are treated with oral drugs to stimulate their body to
make more insulin and/or to cause their cells to be more sensitive to the insulin that is
already being made. Eventually, because of the beta cell damage, type 2 diabetics may
make very little insulin and require injections. Any insulin that the body does make will
be reflected in the C-peptide level; therefore, the C-peptide test can be used to monitor
beta cell activity and capability over time and to help a health practitioner determine
when to begin insulin treatment.
 People who are on insulin therapy, regardless of the source of the insulin, may develop
antibodies to insulin. These typically interfere with tests for insulin, making it nearly
impossible to directly evaluate endogenous insulin production. In these cases, C-peptide
measurement is a useful alternative to testing for insulin.
 C-peptide measurements can also be used in conjunction with insulin and glucose levels
to help diagnose the cause of documented hypoglycemia and to monitor its treatment.
Symptoms of hypoglycemia may be caused by excessive supplementation of insulin,
alcohol consumption, inherited liver enzyme deficiencies, liver or kidney disease, or by
insulinomas.
 The C-peptide test may be used to help diagnose Insulinomas. These are tumors of the
islet cells in the pancreas that can produce uncontrolled amounts of insulin and C-peptide
and can cause acute episodes of hypoglycemia. C-peptide tests may be used to monitor
the effectiveness of insulinoma treatment and to detect recurrence.
 Sometimes a C-peptide test may be used to help evaluate a person diagnosed with
metabolic syndrome, a set of risk factors that includes abdominal obesity, increased blood
glucose and/or insulin resistance, unhealthy blood lipid levels, and high blood pressure
(hypertension).
 Rarely, when someone has had his pancreas removed or has had pancreas islet cell
transplants, intended to restore the ability to make insulin, C-peptide levels may be used
to verify the effectiveness of treatment and continued success of the procedure.
When is it ordered?
C-peptide levels may be ordered when a person has been newly diagnosed with type 1
diabetes as part of an evaluation of the person's "residual beta cell function."
With type 2 diabetes, the test may be ordered on a regular basis when a health practitioner wants
to monitor the status of a person's beta cells and insulin production over time and to determine
if/when insulin injections may be required.
C-peptide levels may be done when there is documented acute or recurring low blood glucose
(hypoglycemia) and/or excess insulin is suspected. Symptoms of hypoglycemia include:
 Sweating
 Palpitations
 Hunger
 Confusion
 Blurred vision
 Fainting
 In severe cases, seizures and loss of consciousness
However, many of these symptoms can occur with other conditions as well.
When a person has been diagnosed with an insulinoma, a C-peptide test may be ordered
periodically to monitor the effectiveness of treatment and to detect tumor recurrence.
Rarely, C-peptide levels may be monitored over time when someone has had his pancreas
removed or has had pancreas islet cell transplants.
A high level of C-peptide generally indicates a high level of endogenous insulin production. This
may be in response to a high blood glucose caused by glucose intake and/or insulin resistance. A
high level of C-peptide is also seen with insulinomas and may be seen with low blood potassium,
Cushing syndrome, and renal failure.
When used for monitoring, decreasing levels of C-peptide in someone with an insulinoma
indicate a response to treatment; levels that are increasing may indicate a tumor recurrence.
A low level of C-peptide is associated with a low level of insulin production. This can occur
when insufficient insulin is being produced by the beta cells, with diabetes for example, or when
production is suppressed by treatment with exogenous insulin.
C-peptide testing is not widely used and may not be available in every laboratory. If a series of
C-peptide tests are going to be performed, they should be done at the same laboratory using the
same method.
Even though they are produced at the same rate, C-peptide and insulin leave the body by
different routes. Insulin is processed and eliminated mostly by the liver, while C-peptide is
removed by the kidneys. Since the half-life of C-peptide is about 30 minutes compared to
insulin's 5 minutes, normally there will be about 5 times as much C-peptide in the blood as
insulin.
Common Questions
1. Can I do a C-peptide test at home like I can when I check my blood glucose?
2. If I need to go on the insulin pump, will I need a C-peptide test?
3. What else is C-peptide used for?
1. Can I do a C-peptide test at home like I can when I check my blood glucose?
No. The C-peptide test requires special equipment and training to perform.
2. If I need to go on the insulin pump, will I need a C-peptide test?
You may. Insulin pumps are usually recommended for those who are not producing sufficient
insulin. Sometimes a C-peptide test will be ordered during an initial evaluation to check the
3. What else is C-peptide used for?
Researchers are starting to better understand the role of C-peptide in the body. Some studies have
been conducted to evaluate the use of C-peptide as a therapy for those with diabetes. Results
have been promising, showing decreased diabetic complications with improvements in kidney
function, blood flow, and nerve function. However, further studies are needed.
Cortisol
Also known as: Urinary Cortisol; Salivary Cortisol; Free Cortisol; Dexamethasone Suppression
Test; DST; ACTH Stimulation Test
Formal name: Cortisol
Related tests: ACTH, Aldosterone, 17-Hydroxyprogesterone, Growth Hormone
At a Glance
Why Get Tested?
To help diagnose Cushing syndrome or primary or secondary adrenal insufficiency (Addison
disease); to detect conditions affecting the pituitary or adrenal glands
When to Get Tested?
When your healthcare provider suspects excess or deficient cortisol production
Sample Required?
A blood sample drawn from a vein in your arm or a random or 24-hour urine sample; sometimes
a saliva sample may be used
You may be required to rest before sample collection. For a salivary cortisol test, you may be
instructed to refrain from eating, drinking, or brushing your teeth for a period of time (may be
some time between 15 to 30 minutes) prior to the test. Follow any instructions you are given.
The Test Sample

Cortisol is a hormone that plays a role in the metabolism of proteins, lipids, and carbohydrates. It
affects blood glucose levels, helps maintain blood pressure, and helps regulate the immune
system. Most cortisol in the blood is bound to a protein; only a small percentage is "free" and
biologically active. Free cortisol is secreted into the urine and is present in the saliva. This test
measures the amount of cortisol in the blood, urine, or saliva.
The level of cortisol in the blood (as well as the urine and saliva) normally rises and falls in a
"diurnal variation" pattern. It peaks early in the morning, then declines throughout the day,
reaching its lowest level about midnight. This pattern can change when a person works irregular
shifts (such as the night shift) and sleeps at different times of the day, and it can become
disrupted when a disease or condition either limits or stimulates cortisol production.
Cortisol is produced and secreted by the adrenal glands, two triangular organs that sit on top of
the kidneys. Production of the hormone is regulated by the hypothalamus in the brain and by the
pituitary gland, a tiny organ located below the brain. When the blood cortisol level falls, the
hypothalamus releases corticotropin-releasing hormone (CRH), which directs the pituitary gland
to produce ACTH (adrenocorticotropic hormone). ACTH stimulates the adrenal glands to
produce and release cortisol. In order for appropriate amounts of cortisol to be made, the
hypothalamus, the pituitary, and the adrenal glands must be functioning properly.
The group of signs and symptoms that are seen with an abnormally high level of cortisol is called
Cushing syndrome. Increased cortisol production may be seen with:
 Administration of large amounts of glucocorticosteroid hormones (such as prednisone,

prednisolone, or dexamethasone) to treat a variety of conditions, such as autoimmune
disease and some tumors
 ACTH-producing tumors, in the pituitary gland and/or in other parts of the body
 Increased cortisol production by the adrenal glands, due to a tumor or due to excessive
growth of adrenal tissues (hyperplasia)
 Rarely, with tumors in various parts of the body that produce CRH
Decreased cortisol production may be seen with:
 An underactive pituitary gland or a pituitary gland tumor that inhibits ACTH production;
this is known as secondary adrenal insufficiency.
 Underactive or damaged adrenal glands (adrenal insufficiency) that limit cortisol
production; this is referred to as primary adrenal insufficiency and is also known as
Addison disease.
 After stopping treatment with glucocorticosteroid hormones, especially if stopped very
quickly after a long period of use

Typically, blood will be drawn from a vein in the arm, but sometimes urine or saliva may be
tested. Cortisol blood tests may be drawn at about 8 am, when cortisol should be at its peak, and
again at about 4 pm, when the level should have dropped significantly.
Sometimes a resting sample will be obtained to measure cortisol when it should be at its lowest
level (just before sleep); this is often done by measuring cortisol in saliva rather than blood to
make it easier to obtain the sample. Saliva for cortisol testing is usually collected by inserting a
swab into the mouth and waiting a few minutes while the swab becomes saturated with saliva.
Obtaining more than one sample allows the health practitioner to evaluate the daily pattern of
cortisol secretion (the diurnal variation).
Sometimes urine is tested for cortisol; this usually requires collecting all of the urine produced
during a day and night (a 24-hour urine) but sometimes may be done on a single sample of urine
collected in the morning.
Some test preparation may be needed. Follow any instructions that are given as far as timing of
sample collection, resting, and/or any other specific pre-test preparation.
A saliva test requires special care in obtaining the sample. You may be instructed to refrain from
eating, drinking, or brushing your teeth for a period of time (may be some time between 15 to 30
minutes) prior to the test. Follow any specific instructions that are provided.
A stimulation or suppression test requires that you have a baseline blood sample drawn and then
a specified amount of drug is given. Subsequent blood samples are drawn at specified times.
The Test
1. How is it used?

How is it used?
A cortisol test may be used to help diagnose Cushing syndrome, a condition associated with
excess cortisol, or to help diagnose adrenal insufficiency or Addison disease, conditions
associated with deficient cortisol. Cortisol is a hormone that plays a role in the metabolism of
proteins, lipids, and carbohydrates, among other functions. (See the "What is being tested?"
section for more.) Normally, the level of cortisol in the blood rises and falls in a "diurnal
variation" pattern, peaking early in the morning, then declining throughout the day and reaching
its lowest level about midnight.
Most cortisol in the blood is bound to a protein; only a small percentage is "free" and
biologically active. Blood cortisol testing evaluates both protein-bound and free cortisol while
urine and saliva testing evaluate only free cortisol, which should correlate with the levels of free
cortisol in the blood. Multiple blood and/or saliva cortisol levels collected at different times, such
as at 8 am and 4 pm, can be used to evaluate both cortisol levels and diurnal variation. A 24-hour
urine cortisol sample will not show diurnal variation; it will measure the total amount of
unbound cortisol excreted in 24 hours.
If an abnormal level of cortisol is detected, a health practitioner will do additional testing to help
confirm the findings and to help determine its cause:
Testing for Excess Cortisol Production

If a person has a high blood cortisol level, a health practitioner may perform additional testing to
confirm that the high cortisol is truly abnormal (and not simply due to increased stress or the use
of cortisol-like medication). This additional testing may include measuring the 24-hour urinary
cortisol, doing an overnight dexamethasone suppression test, and/or collecting a salivary sample
before retiring in order to measure cortisol at the time that it should be the lowest. Urinary
cortisol requires the collection of urine over a timed period, usually 24 hours. Since cortisol is
secreted by the pituitary gland in pulses, this test helps determine whether the elevated blood
level represents a real increase.
Dexamethasone suppression: The dexamethasone suppression test involves analyzing a

baseline sample for cortisol, then giving the person oral dexamethasone (a synthetic
glucocorticoid) and measuring cortisol levels in subsequent timed samples. Dexamethasone
suppresses ACTH production and should decrease cortisol production if the source of the excess
is stress.
Collecting a salivary sample for cortisol measurement is a convenient way to determine whether
the normal rhythm of cortisol production is altered. If one or more of these tests confirms that
there is abnormal cortisol production, then additional testing, including measuring ACTH,
repeating the dexamethasone suppression test using higher doses, and radiologic imaging may be
ordered.
Testing for Insufficient Cortisol Production

If a health practitioner suspects that the adrenal glands may not be producing adequate cortisol or
if the initial blood tests indicate insufficient cortisol production, the health practitioner may order
an ACTH stimulation test.
ACTH stimulation: This test involves measuring the level of cortisol in a person's blood before
and after an injection of synthetic ACTH. If the adrenal glands are functioning normally, then
cortisol levels will rise with the ACTH stimulation. If they are damaged or not functioning
properly, then the cortisol level will be low. A longer version of this test (1-3 days) may be
performed to help distinguish between adrenal and pituitary insufficiency.
When is it ordered?
A cortisol test may be ordered when a person has symptoms that suggest a high level of cortisol
and Cushing syndrome, such as
 High blood pressure (hypertension)

 High blood sugar (glucose)
 Obesity, especially in the trunk
 Fragile skin
 Purple streaks on the abdomen
 Muscle wasting and weakness
 Osteoporosis
Testing may be ordered when women have irregular menstrual periods and increased facial hair;
children may have delayed development and a short stature.
This test may be ordered when someone has symptoms suggestive of a low level of cortisol,
adrenal insufficiency or Addison disease, such as:
 Weight loss
 Muscle weakness
 Fatigue
 Low blood pressure
 Abdominal pain
 Dark patches of skin (this occurs in Addison disease but not secondary adrenal
insufficiency)
Sometimes decreased production combined with a stressor can cause an adrenal crisis that can be
life-threatening and requires immediate medical attention. Symptoms of a crisis may include:
 Sudden onset of severe pain in the lower back, abdomen, or legs

 Vomiting and diarrhea, resulting in dehydration
 Low blood pressure (hypotension)
 Loss of consciousness
Suppression or stimulation testing is ordered when initial findings are abnormal. Cortisol testing
may be ordered at intervals after a diagnosis of Cushing syndrome or Addison disease to monitor
the effectiveness of treatment.
Normally, cortisol levels are very low at bedtime and at their highest just after waking, though
this pattern will change if a person works rotating shifts and sleeps at different times on different
days.
An increased or normal cortisol level just after waking along with a level that does not drop by
bedtime suggests excess cortisol and Cushing syndrome. If this excess cortisol is not suppressed
after an overnight dexamethasone suppression test, or if the 24-hour urine cortisol is elevated, or
if the late-night salivary cortisol level is elevated, it suggests that the excess cortisol is due to
abnormal increased ACTH production by the pituitary or a tumor outside of the pituitary or
abnormal production by the adrenal glands. Additional testing will help to determine the exact
cause. (See the section "How is it used?" above.)
If insufficient cortisol is present and the person tested responds to an ACTH stimulation test, then
the problem is likely due to insufficient ACTH production by the pituitary. If the person does not
respond to the ACTH stimulation test, then it is more likely that the problem is based in the
adrenal glands. If the adrenal glands are underactive, due to pituitary dysfunction and/or
insufficient ACTH production, then the person is said to have secondary adrenal insufficiency. If
decreased cortisol production is due to adrenal damage, then the person is said to have primary
adrenal insufficiency or Addison disease.
Once an abnormality has been identified and associated with the pituitary gland, adrenal glands,
or other cause, then the health practitioner may use other testing such as CT (computerized
tomography) or MRI (magnetic resonance imaging) scans to locate the source of the excess (such
as a pituitary, adrenal, or other tumor) and to evaluate the extent of any damage to the glands.
Similar to those with adrenal insufficiency, people with a condition called congenital adrenal
hyperplasia (CAH) have low cortisol levels and do not respond to ACTH stimulation tests.
Cortisol measurement is one of many tests that may be used to help evaluate a person for CAH.
Heat, cold, infection, trauma, exercise, obesity, and debilitating disease can influence cortisol
concentrations. Pregnancy, physical and emotional stress, and illness can increase cortisol levels.
Cortisol levels may also increase as a result of hyperthyroidism or obesity. A number of drugs
can also increase levels, particularly oral contraceptives (birth control pills), hydrocortisone (the
synthetic form of cortisol), and spironolactone.
Adults have slightly higher cortisol levels than children do.
Hypothyroidism may decrease cortisol levels. Drugs that may decrease levels include some
steroid hormones.
Salivary cortisol testing is being used more frequently to help diagnose Cushing syndrome and
stress-related disorders but still requires specialized expertise to perform.
Common Questions
1. Do I need both tests (blood and urine) or is one better than the other?
2. How do I tell if a high cortisol level isn't just from stress?
1. Do I need both tests (blood and urine) or is one better than the other?
If your healthcare provider suspects Cushing syndrome, usually both blood and urine are tested
as they offer complementary information. Blood cortisol is easier to collect but is affected more
by stress than is the 24-hour urine test. Salivary cortisol may sometimes be tested instead of
blood cortisol.
2. How do I tell if a high cortisol level isn't just from stress?
There are several approaches that your healthcare provider can take. The simplest involves
repeating tests at a time when you feel less stressed. Your healthcare provider can also give you
varying doses of a medicine that replaces cortisol (usually dexamethasone) to see if this
decreases your cortisol level. Multiple tests are often needed to tell if stress or disease is causing
a high cortisol level.
TSH
Also known as: Thyrotropin
Formal name: Thyroid-stimulating Hormone
Related tests: Free T4, Free T3 and Total T3, Thyroid Panel, Thyroid Antibodies
At a Glance
Why Get Tested?
To screen for and help diagnose thyroid disorders; to monitor treatment of hypothyroidism and
hyperthyroidism
When to Get Tested?
For screening: Newborn screening is widely recommended; however, there is no consensus

within the medical community as to the age adult screening should begin or whether screening
should be done.
For monitoring treatment: as directed by your healthcare provider
Otherwise: when a person has symptoms of hyperthyroidism or hypothyroidism and/or an
enlarged thyroid
Sample Required?
A blood sample drawn from a vein in your arm or from pricking the heel of an infant
None needed; however, certain medications can interfere with the TSH test, so tell your health
practitioner about any drugs that you are taking. If you take thyroid hormone as treatment for
thyroid disease, it is recommended that your blood sample be drawn before you take your dose
for that day.
The Test Sample

Thyroid-stimulating hormone (TSH) is produced by the pituitary gland, a tiny organ located
below the brain and behind the sinus cavities. TSH stimulates the thyroid gland to release the
hormones thyroxine (T4) and triiodothyronine (T3) into the blood. These thyroid hormones help
control the rate at which the body uses energy. This test measures the amount of TSH in the
blood.
TSH, along with its regulatory hormone thyrotropin releasing hormone (TRH), which comes
from the hypothalamus, is part of the feedback system that the body uses to maintain stable
amounts of thyroid hormones in the blood. When thyroid hormone concentrations decrease, the
production of TSH by the pituitary gland is increased. TSH in turn stimulates the production and
release of T4 and T3 by the thyroid gland, a small butterfly-shaped gland that lies at the base of
the throat flat against the windpipe. When all three organs are functioning normally, thyroid
production turns on and off to maintain relatively stable levels of thyroid hormones in the blood.
If the thyroid releases inappropriately large amounts of T4 and T3, the affected person may
experience symptoms associated with hyperthyroidism, such as rapid heart rate, weight loss,
nervousness, hand tremors, irritated eyes, and difficulty sleeping. Graves disease is the most
common cause of hyperthyroidism. It is a chronic autoimmune disorder in which the affected
person's immune system produces antibodies that act like TSH, leading to the production of
excessive amounts of thyroid hormone. In response, the pituitary may produce less TSH, usually
leading to a low level in the blood.
If there is decreased production of thyroid hormones by the thyroid (hypothyroidism), the person
may experience symptoms such as weight gain, dry skin, constipation, cold intolerance, and
fatigue. Hashimoto thyroiditis is the most common cause of hypothyroidism in the U.S. It is a
chronic autoimmune condition in which the immune response causes inflammation and damage
to the thyroid as well as the production of autoantibodies. With Hashimoto thyroiditis, the
thyroid produces low levels of thyroid hormone. The pituitary may produce more TSH, usually
resulting in a high level in the blood.
However, the level of TSH does not always predict or reflect thyroid hormone levels. Some
people produce an abnormal form of TSH that does not function properly. They often have
hypothyroidism despite having normal or even mildly elevated TSH levels. In a variety of
thyroid diseases, thyroid hormone levels may be high or low, regardless of the amount of TSH
present in the blood.
Rarely, pituitary dysfunction may result in increased or decreased amounts of TSH. In addition to
pituitary dysfunction, hyperthyroidism or hypothyroidism can occur if there is a problem with
the hypothalamus (insufficient or excessive TRH).
A blood sample is obtained from a needle placed in a vein in the arm or from pricking the heel of
an infant.
No test preparation is needed. Certain medications can interfere with the TSH test, so tell your
health practitioner about any drugs that you are taking. If you take thyroid hormone as treatment
for thyroid disease, it is recommended that your blood sample be drawn before you take your
dose for that day.
The Test
1. How is it used?
How is it used?
The thyroid-stimulating hormone (TSH) test is often the test of choice for evaluating thyroid
function and/or symptoms of a thyroid disorder, including hyperthyroidism or hypothyroidism.
TSH is produced by the pituitary gland, a tiny organ located below the brain and behind the sinus
cavities. It is part of the body's feedback system to maintain stable amounts of the thyroid
hormones thyroxine (T4) and triiodothyronine (T3) in the blood and to help control the rate at
which the body uses energy.
A TSH test is frequently ordered along with or preceding a free T4 test. Other thyroid tests that
may be ordered include a free T3 test and thyroid antibodies (if autoimmune-related thyroid
disease is suspected). Sometimes TSH, free T4 and free T3 are ordered together as a thyroid
panel.
TSH testing is used to:
 Diagnose a thyroid disorder in a person with symptoms

 Screen newborns for an underactive thyroid
 Monitor thyroid replacement therapy in people with hypothyroidism
 Monitor anti-thyroid treatment in people with hyperthyroidism
 Help diagnose and monitor infertility problems in women
 Help evaluate the function of the pituitary gland (occasionally)
 Screen adults for thyroid disorders, although expert opinions vary on who can benefit
from screening and at what age to begin
When is it ordered?
A health practitioner may order a TSH test when someone has symptoms of hyperthyroidism or
hypothyroidism and/or when a person has an enlarged thyroid gland (goiter).
Signs and symptoms of hyperthyroidism may include:
 Increased heart rate

 Anxiety
 Weight loss
 Difficulty sleeping
 Tremors in the hands
 Weakness
 Diarrhea (sometimes)
 Light sensitivity, visual disturbances
 The eyes may be affected: puffiness around the eyes, dryness, irritation, and, in some
cases, bulging of the eyes.
Signs and symptoms of hypothyroidism may include:
 Weight gain
 Dry skin
 Constipation
 Cold intolerance
 Puffy skin
 Hair loss
 Fatigue
 Menstrual irregularity in women
TSH may be ordered at regular intervals when an individual is being treated for a known thyroid
disorder. When a person's dose of thyroid medication is adjusted, the American Thyroid
Association recommends waiting 6-8 weeks before testing the level of TSH again.
TSH screening is routinely performed in the United States on newborns soon after birth as part of
each state's newborn screening program.
In 2004, the U.S. Preventive Services Task Force found insufficient evidence to recommend for
or against routine screening for thyroid disease in asymptomatic adults. However, the American
Thyroid Association and the American Association of Clinical Endocrinologists released clinical
practice guidelines in 2012 that recommend that screening for hypothyroidism should be
considered in people over the age of 60. Because the signs and symptoms of both
hypothyroidism and hyperthyroidism are so similar to those seen in many common disorders,
health practitioners often need to rule out thyroid disease even though the patient has another
problem.
A high TSH result may mean that:
 The person tested has an underactive thyroid gland that is not responding adequately to
the stimulation of TSH due to some type of acute or chronic thyroid dysfunction
 A person with hypothyroidism or who has had their thyroid gland removed is receiving
too little thyroid hormone replacement medication and the dose may need to be adjusted
 A person with hyperthyroidism is receiving too much anti-thyroid medication and the
dose needs adjusting
 There is a problem with the pituitary gland, such as a tumor producing unregulated levels
of TSH
A low TSH result may indicate:
 An overactive thyroid gland (hyperthyroidism)

 Excessive amounts of thyroid hormone medication in those who are being treated for an
underactive (or removed) thyroid gland
 Insufficient anti-thyroid medication in a person being treated for hyperthyroidism;
however, it may take a while for TSH production to resume after successful anti-thyroid
treatment. This is why the American Thyroid Association recommends monitoring this
treatment with tests for thyroid hormones (T4 and T3) as well as TSH levels.
 Damage to the pituitary gland that prevents it from producing adequate amounts of TSH
Whether high or low, an abnormal TSH indicates an excess or deficiency in the amount of
thyroid hormone available to the body, but it does not indicate the reason why. An abnormal TSH
test result is usually followed by additional testing to investigate the cause of the increase or
decrease.
The following table summarizes some examples of typical test results and their potential meaning.
Free or
TSH Free T4 Probable Interpretation
total T3
High Normal Normal Mild (subclinical) hypothyroidism
Low or
High Low Hypothyroidism
normal
Low Normal Normal Mild (subclinical) hyperthyroidism
High or High or
Low Hyperthyroidism
normal normal
Low or Low or
Low Non-thyroidal illness; pituitary (secondary) hypothyroidism
normal normal
Thyroid hormone resistance syndrome (a mutation in the thyroid
Normal High High
hormone receptor decreases thyroid hormone function)
It is important to note that TSH, free T4, and free T3 tests are a "snapshot" of what is occurring
within a dynamic system. An individual person's thyroid testing results may vary and may be
affected by:
 Increases, decreases, and changes (inherited or acquired) in the proteins that bind T4 and
T3
 Pregnancy
 Estrogen and other drugs
 Liver disease
 Systemic illness
 Resistance to thyroid hormones
Many medications — including aspirin and thyroid-hormone replacement therapy — may affect
thyroid gland function test results and their use should be discussed with the health practitioner
prior to testing.
Illnesses not directly related to the thyroid, "nonthyroidal illnesses," can affect thyroid hormones
levels. In particular, the level of T3 can be low in nonthyroidal illness (NTI). Typically, the
thyroid hormone levels return to normal after a person recovers from the nonthyroidal illness.
Historically, this condition was referred to as "euthyroid sick syndrome" but that term is
controversial because there is some question as to whether those affected have a thyroid gland
that is functioning normally (euthyroid).
When a health practitioner adjusts a person's thyroid hormone replacement dosage, it is

important to wait at least one to two months before checking the TSH again so that the new dose
can have its full effect.
Extreme stress and acute illness may affect TSH test results. It is generally recommended that
thyroid testing be avoided in hospitalized patients or deferred until after a person has recovered
from an acute illness.
Results may be low during the first trimester of pregnancy.
Common Questions
1. Do health practitioners test TSH during pregnancy?
2. Are there things that I can do to raise or lower my TSH level?
3. What is a 3rd generation TSH and an ultrasensitive TSH?
1. Do health practitioners test TSH during pregnancy?
Health practitioners do not generally test asymptomatic women, but those with symptoms and/or
a known thyroid disorder may be tested at intervals to detect and evaluate hyperthyroidism or
hypothyroidism both during pregnancy and after. For more information, see the National
Endocrine and Metabolic Diseases Information Service webpage: Pregnancy and Thyroid
Disease.
2. Are there things that I can do to raise or lower my TSH level?
In general, TSH does not respond to lifestyle changes. What is important is that the pituitary and
thyroid glands are healthy and working together to produce appropriate amounts of thyroid
hormone.
3. What is a 3rd generation TSH and an ultrasensitive TSH?
The original immunoassays for TSH were not sensitive enough to differentiate the very low
levels seen in patients with hyperthyroidism from levels seen in normal euthyroid individuals. In
the 1980s, more sensitive assays ("second generation") were developed and these were able to
identify patients with TSH levels that were suppressed due to the excess amounts of free T4
present in hyperthyroidism. In the 1990s, TSH assays were made even more sensitive and,
although these were able to measure even lower levels, they were widely adopted because they
performed much better than the second generation assays in the range that was important for
differentiating normal from hyperthyroid. Almost all laboratories currently use so-called "third
generation" or "ultrasensitive" TSH assays today.
Free T4
Also known as: T4; Thyroxine
Formal name: Free Thyroxine
Related tests: TSH; Free T3 or Total T3; Thyroid Panel; Thyroid Antibodies; Calcitonin
At a Glance
Why Get Tested?
To help evaluate thyroid gland function; to help diagnose thyroid disease; to screen for
hypothyroidism in newborns; to monitor effectiveness of treatment
When to Get Tested?
When you have signs and symptoms of thyroid disease, usually after an abnormal result on a
TSH test; commonly performed as a screening test on newborns soon after birth; when you are
being treated for a thyroid disorder
Sample Required?
A blood sample drawn from a vein in your arm or from pricking the heel of an infant
None needed; however, certain medications can interfere with the free T4 test, so tell your
healthcare provider about any drugs that you are taking. If you take thyroid hormone as treatment
dose for that day.
The Test Sample

Thyroxine (T4) is one of two major hormones produced by the thyroid gland, a small butterfly-
shaped organ that lies flat across the windpipe at the base of the throat. The other major thyroid
hormone is called triiodothyronine (T3) and together they help control the rate at which the body
uses energy. Almost all of the T4 (and T3) found in the blood is bound to protein. The rest is free
(unbound) and is the biologically active form of the hormone. This test measures the amount of
free T4 in the blood.
T4 production is regulated by a feedback system. When the level of T4 in the bloodstream

decreases, the hypothalamus releases thyrotropin releasing hormone, which stimulates the
pituitary gland to produce and release thyroid-stimulating hormone (TSH). TSH then stimulates
the thyroid gland to make and/or release more T4. As the blood concentration of T4 increases,
TSH release is inhibited.
T4 makes up about 90% of thyroid hormones. When the body requires thyroid hormone, the
thyroid gland releases stored T4 into circulation. In the blood, T4 is either free (not bound) or
bound to protein (primarily bound to thyroxine-binding globulin). The concentration of free T4 is
only about 0.1% of that of total T4. T4 is converted into T3 in the liver or other tissues. T3, like
T4, is also mostly bound to protein, but it is the free forms of T3 and T4 that are biologically
active. Free T3 is 4 to 5 times more active than free T4 in circulation.
If the thyroid gland does not produce sufficient T4, due to thyroid dysfunction or to insufficient
TSH, then the affected person experiences symptoms of hypothyroidism such as weight gain, dry
skin, cold intolerance, irregular menstruation, and fatigue. Severe untreated hypothyroidism,
called myxedema, can lead to heart failure, seizures, and coma. In children, hypothyroidism can
stunt growth and delay sexual development.
If the thyroid gland produces too much T4, the rate of the person's body functions will increase
and cause symptoms associated with hyperthyroidism such as increased heart rate, anxiety,
weight loss, difficulty sleeping, tremors in the hands, and puffiness around dry, irritated eyes.
The most common causes of thyroid dysfunction are related to autoimmune disorders. Graves
disease causes hyperthyroidism and Hashimoto thyroiditis causes hypothyroidism. Both
hyperthyroidism and hypothyroidism can also be caused by thyroiditis, thyroid cancer, and
excessive or deficient production of TSH. The effect of these conditions on thyroid hormone
production can be detected and monitored by measuring the free T4.
A blood sample is obtained from a needle placed in a vein in the arm or from pricking the heel of
an infant.
No test preparation is needed. Certain medications can interfere with the free T4 test, so tell your
health practitioner about any drugs that you are taking. If you take thyroid hormone as treatment
dose for that day.
The Test
1. How is it used?
How is it used?
Free thyroxine (free T4) tests are used to help evaluate thyroid function and diagnose thyroid
diseases, including hyperthyroidism and hypothyroidism, usually after discovering that the
thyroid stimulating hormone (TSH) level is abnormal.
T4 and another hormone called triiodothyronine (T3) are produced by the thyroid gland. They
help control the rate at which the body uses energy and are regulated by a feedback system. TSH
stimulates the production and release of T4 (primarily) and T3 from the thyroid gland.
Most of the T4 and T3 circulates in the blood bound to protein, while a small percentage is free
(not bound). Blood tests can measure total T4, free T4, total T3, or free T3. The total T4 test has
been used for many years, but it can be affected by the amount of protein available in the blood
to bind to the hormone. Free T4 is not affected by protein levels and is the active form of
thyroxine. The free T4 test is thought by many to be a more accurate reflection of thyroid
hormone function and, in most cases, its use has replaced that of the total T4 test.
A free T4 test may be used along with or following a TSH test and sometimes with a free T3 test
to:
 Help detect too much or too little thyroid hormone (hyperthyroidism and
hypothyroidism) and diagnose the cause
 Distinguish between different thyroid disorders
 Help diagnose pituitary disorders
 Aid in the diagnosis of female infertility
 Monitor the effectiveness of treatment in a person with known thyroid disorder
 Monitor people with pituitary disease, to make sure that the thyroid is still working, and
to monitor thyroid hormone treatment if it is not
 Monitor individuals with thyroid cancer, in which the tumors respond to TSH. TSH and
T4 levels will be regularly checked to make sure that enough thyroid hormone is being
given to keep TSH low without making T4 too high.
 In the United States, newborns are commonly screened for T4 levels as well as TSH
concentrations to check for congenital hypothyroidism, which can cause mental
retardation if left untreated.
Free T4 along with TSH may sometimes be used to screen for thyroid disorders, but expert
opinions vary on who can benefit from screening and at what age to begin.
If a health practitioner suspects that someone may have an autoimmune-related thyroid

condition, then thyroid antibodies may be ordered along with a free T4 test.
When is it ordered?
A free T4 test may be ordered when a person has symptoms of hyperthyroidism or

hypothyroidism, particularly if the TSH test is out of range.
Signs and symptoms of hyperthyroidism may include:

 Anxiety
 Weight loss
 Weakness
Symptoms of hypothyroidism may include:
 Weight gain
 Dry skin
 Constipation
 Cold intolerance
 Puffy skin
 Hair loss
 Fatigue
 Menstrual irregularity in women
 Enlarged thyroid gland (goiter)
Free T4 testing may be ordered along with other thyroid tests on a regular basis when a person is
undergoing treatment for a thyroid disorder.
In pregnant women with thyroid disorders, the health practitioner is likely to order thyroid
testing early and late in the pregnancy and for a time period following delivery to monitor the
mother and baby.
Thyroid hormone screening is commonly performed on newborns in the United States as part of
newborn screening programs.

In general, high free T4 results may indicate an overactive thyroid gland (hyperthyroidism), and
low free T4 results may indicate an underactive thyroid gland (hypothyroidism). The test results
alone are not diagnostic but will prompt the health practitioner to perform additional testing to
investigate the cause of the excess or deficiency.
Both decreased and increased free T4 results are associated with a variety of temporary and
chronic thyroid conditions. Low free T4 results in conjunction with a low TSH level or high free
T4 results along with a high TSH may indicate a pituitary gland condition.
free or
TSH Free T4 probable Interpretation
Total T3
Low or
normal
High or High or
Low Hyperthyroidism
normal normal
Low or Low or
Low Non-thyroidal illness; rare pituitary (secondary) hypothyroidism
normal normal
Normal High High
When used for monitoring treatment for thyroid or pituitary disorders, results of thyroid tests will
inform the health practitioner whether treatment is effective and/or whether an adjustment to
dose is necessary. For example, in people with hyperthyroidism, free T4, free T3, and TSH are
regularly checked while they are on anti-thyroid drugs to assure that the drugs are working and to
decrease doses if thyroid hormone levels get too low. In people with hypothyroidism, TSH and
free T4 are regularly checked to assure that the right dose of thyroid hormone is being given to
make TSH normal.
It is generally recommended that thyroid testing be avoided in hospitalized patients or deferred

until after a person has recovered from an acute illness, as thyroid hormone levels may be
affected the stress of an illness.
It is important to note that thyroid tests are a "snapshot" of what is occurring within a dynamic
system. An individual person's results may vary and may be affected by:
T3
 Pregnancy
 Liver disease
Many medications—including estrogen, certain types of birth control pills, and large doses of
aspirin—can affect total T4 test results and their use should be discussed with the health
practitioner prior to testing. In general, free T4 levels are not affected by these medications.
Common Questions
1. How does pregnancy affect thyroid hormone levels?
2. What is FTI?
3. Are there things that I can do to raise or lower my free T4 level?
Pregnancy can increase free T4 levels, although this does not mean that thyroid disease exists.
For more information, see the Thyroid Foundation of America's web page Thyroid Problems
During and After Pregnancy - Are You At Risk?
2. What is FTI?
FTI stands for the Free Thyroxine Index and it is an estimation of the free T4 concentration. It is
sometimes referred to as T7. It is a calculated value determined from the total T4 test and some
estimation of the level of thyroid hormone binding proteins. The original test for estimating the
level of binding proteins was called the T3-uptake test and later versions were called T-uptake
methods. These are rarely used now that there are methods available to measure free T4 and T3
directly.
3. Are there things that I can do to raise or lower my free T4 level?
In general, free T4 does not respond to lifestyle changes. What is important is that the thyroid
gland is producing adequate amounts of free T4 and the body's feedback mechanism is
responding appropriately. For those who do not produce enough free T4, thyroid hormone
replacement medication can be given.
Free T3 and Total T3
Also known as: FT3; Triiodothyronine
Formal name: Free Triiodothyronine; Total Triiodothyronine
Related tests: TSH; Free T4; Thyroid Panel; Thyroid Antibodies
At a Glance
Why Get Tested?
To help evaluate thyroid gland function; to diagnose thyroid disease, including hyperthyroidism,
and determine the cause; to monitor effectiveness of treatment of a thyroid disorder
When to Get Tested?
When you have an abnormal TSH, particularly with a normal free T4 result, and/or signs and
symptoms of hyperthyroidism
Sample Required?
A blood sample taken from a vein in your arm
None needed; however, certain medications can interfere with the free T3 and total T3 tests, so
tell your health practitioner about any drugs that you are taking.
The Test Sample

Triiodothyronine (T3) is one of two major hormones produced by the thyroid gland, a small
butterfly-shaped organ that lies flat across the windpipe at the base of the throat. The other major
thyroid hormone is called thyroxine (T4) and together they help control the rate at which the
body uses energy. Almost all of the T3 (and T4) found in the blood is bound to protein. The rest
is free (unbound) and is the biologically active form of the hormone. Tests can measure the
amount of free T3 or the total T3 (bound plus unbound) in the blood.
T3 and T4 production is regulated by a feedback system. When blood levels of thyroid hormones
decline, the hypothalamus releases thyrotropin releasing hormone, which stimulates the pituitary
gland to produce and release thyroid-stimulating hormone (TSH). TSH then stimulates the
thyroid gland to produce and/or release more thyroid hormones. Most of the thyroid hormone
produced is T4. This hormone is relatively inactive, but it is converted into the much more active
T3 in the liver and other tissues.
If the thyroid gland produces excessive amounts of T4 and T3, then the person affected may have
symptoms associated with hyperthyroidism, such as nervousness, tremors of the hands, weight
loss, insomnia, and puffiness around dry, irritated eyes. In some cases, the person's eyes cannot
move normally and they may appear to be staring. In other cases, the eyes may appear to bulge.
If the thyroid gland produces insufficient amounts of thyroid hormones, then the person may
have signs and symptoms associated with hypothyroidism and a slowed metabolism, such as
weight gain, dry skin, fatigue, and constipation. The blood levels of thyroid hormones may be
low or high due to thyroid dysfunction or rarely due to insufficient or excessive TSH production
related to a pituitary disorder.
The most common causes of thyroid dysfunction are related to autoimmune disorders. Graves
disease causes hyperthyroidism, but it can also be caused by thyroiditis, thyroid cancer, and
excessive production of TSH. The effect of these conditions on thyroid hormone production can
be detected and monitored by measuring the free T3 or sometimes total T3.
A blood sample is obtained from a needle placed in a vein in the arm.
No test preparation is needed. Certain medications can interfere with the free or total T3 test, so
tell the health practitioner about any drugs being taken.
The Test
1. How is it used?
How is it used?
A free or total triiodothyronine (free T3 or total T3) test is used to assess thyroid function. It is
ordered primarily to help diagnose hyperthyroidism and may be ordered to help monitor
treatment of a person with a known thyroid disorder.
T3 and T4 (thyroxine) are hormones produced by the thyroid gland. They help control the rate at
which the body uses energy and are regulated by a feedback system. Thyroid-stimulating
hormone (TSH) stimulates the production and release of T4 (primarily) and T3. As needed, T4 is
converted into T3 by the liver and other tissues.
Most of the T4 and T3 circulates in the blood bound to protein, while a small percentage is free
(not bound). Blood tests can measure total T4 (unbound plus bound), free T4, total T3 (bound
plus unbound), or free T3.
Since most T3 is bound to protein, the total T3 can be affected by protein levels and protein
binding ability, but the free T3 is not. However, some professional guidelines recommend the
total T3, so either test may be used to assess thyroid function. For example, free T3 or sometimes
total T3 may be ordered along with thyroid antibodies to help diagnose Graves disease, an
autoimmune disorder that is the most common cause of hyperthyroidism.
The free or total T3 test is usually ordered following an abnormal TSH, particularly if the free T4
test is not elevated.
When is it ordered?
A free T3 or total T3 test may be ordered when someone has an abnormal TSH test result. It may
be ordered as part of the investigative workup when a person has symptoms suggesting
hyperthyroidism, especially if the free T4 level is not elevated.
Signs and symptoms may include:

 Anxiety
 Weight loss
 Weakness
Free or total T3 may sometimes be ordered at intervals to monitor a known thyroid condition and
to help monitor the effectiveness of treatment for hyperthyroidism.
Increased or decreased thyroid hormone results indicate that there is an imbalance between the
body's requirements and supply, but they do not tell the health practitioner specifically what is
causing the excess or deficiency.
free or
TSH free T4 probable Interpretation
total T3
Low or
normal
High or High or
Low Hyperthyroidism
normal normal
Low or Low or
Low Non-thyroidal illness; rare pituitary (secondary) hypothyroidism
normal normal
Normal High High
If someone is being treated with anti-thyroid medication for hyperthyroidism and the free or total
T3 (or more frequently, the free T4 or TSH) is normal, then it is likely that the medication is
effective in treating the condition. If the free or total T3 or free T4 is elevated, then the
medication is not effective in treating the condition and the person may be experiencing
symptoms associated with hyperthyroidism.
It is generally recommended that thyroid testing be avoided in hospitalized patients or deferred

until after a person has recovered from an acute illness since thyroid hormone levels may be
affected the stress of an illness. When someone is sick, the body decreases production of T3 from
T4. Most people who are sick enough to be in the hospital will have a low T3 or free T3 level.
For this reason, health practitioners usually only order T3 tests in outpatient settings.
It is important to note that thyroid tests are a "snapshot" of what is occurring within a dynamic
system. An individual person's total T3, free T3, total T4, free T4, and/or TSH results may vary
and may be affected by:
T3
 Pregnancy
 Liver disease
Many medications—including estrogen, certain types of birth control pills, and large doses of
aspirin—can affect total T3 test results and their use should be discussed with a health
practitioner prior to testing. In general, free T3 levels are not affected by these medications.
Common Questions
2. What is the T3 uptake test?
3. What is reverse T3?
Pregnancy can increase total and free T3 levels although it does not mean that thyroid disease
will develop. For more information, see the Thyroid Foundation of America's web page Thyroid
Problems During and After Pregnancy - Are You At Risk?
2. What is the T3 uptake test?
This test was once used to help calculate the Free Thyroxine Index (FTI), an estimation of the
free T4 concentration. It is determined from the total T4 test and some estimation of the level of
thyroid hormone binding proteins. The T3 uptake test was the original test for estimating the
level of binding proteins, and later versions were called T-uptake methods. These are rarely used
now that there are methods available to measure free T4 and free T3 directly.
3. What is reverse T3?
Reverse T3 (RT3 or REVT3) is a biologically inactive form of T3. Normally, when the liver
converts T4 to T3, it also produces a certain percentage of RT3. When the body is under stress,
such as during a serious illness, it tries to prevent many tissues that depend on T3 from being
metabolically active by producing more RT3 than T3. This is believed to be a way of conserving
energy until the stress is relieved and it causes a syndrome called non-thyroidal illness (NTI).
RT3 may also be elevated in hyperthyroidism. Use of the RT3 test remains controversial and it is
not widely requested.

Data Klinik

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Data Klinik

Uploaded by

Copyright:

Available Formats

Glucose Tests

When to Get Tested?

Urine glucose: usually as part of a urinalysis

Test Preparation Needed?

How is the sample collected for testing?

Is any test preparation needed to ensure the quality of the sample?

3. What does the test result mean?

4. Is there anything else I should know?

The blood glucose test may be used to:

Screening and Diagnosis

 Overweight, obese, or physically inactive

 Increased thirst, usually with frequent urination

or symptoms of low blood glucose (hypoglycemia), such as:

What does the test result mean?

The following information summarizes the meaning of other test results.

Fasting Blood Glucose

Glucose Level Indication

2-Hour Oral Glucose Tolerance Test (OGTT)

**Some labs may use different numbers.

A low blood glucose level (hypoglycemia) may be seen with:

Is there anything else I should know?

Drugs, including corticosteroids, tricyclic antidepressants, diuretics, epinephrine, estrogens (birth

3. What are the usual treatments for diabetes?

4. How can a diabetic educator help me?

5. How is hypoglycemia diagnosed?

6. How is glucose different from table sugar?

1. Can I test myself at home for blood glucose levels?

2. Can I test my urine glucose instead of my blood?

3. What are the usual treatments for diabetes?

4. How can a diabetic educator help me?

5. How is hypoglycemia diagnosed?

6. How is glucose different from table sugar?

Test Preparation Needed?

The Test Sample

How is the sample collected for testing?

Is any test preparation needed to ensure the quality of the sample?

No test preparation is needed.

3. What does the test result mean?

4. Is there anything else I should know?

Some signs and symptoms of anemia include:

Some signs and symptoms of polycythemia include:

What does the test result mean?

Some causes of a high hemoglobin level include:

Is there anything else I should know?

Hemoglobin decreases slightly during normal pregnancy.

3. Are there warning signs for abnormally low hemoglobin levels?

1. Can I test my hemoglobin at home?

2. Is anyone at greater risk of abnormal hemoglobin levels?

3. Are there warning signs for abnormally low hemoglobin levels?

When to Get Tested?

Test Preparation Needed?

The Test Sample

How is the sample collected for testing?

Is any test preparation needed to ensure the quality of the sample?

No test preparation is needed.

3. What does the test result mean?

4. Is there anything else I should know?

 Rapid changes in diabetes treatment – Fructosamine allows the effectiveness of diet or

What does the test result mean?

Is there anything else I should know?

3. Shouldn't someone with a family history of diabetes have a fructosamine test?

4. If I have diabetes, should I have a fructosamine test?

1. Can I test for fructosamine at home?