Interpretation

of Thyroid
Function Tests
Dhinesh M

Date ： 30.07.2021
 01 Introduction

02 TSH

03 Thyroid hormone assay

contents
04 Thyroid Antibodies

05 Thyroid Function in Pregnancy

06 Detecting thyroid dysfunction

07 Sick euthyroid syndrome

08 conclusion
Introduction
• Small butterfly shaped endocrine
organ
• Located anteriorly in the lower
part of neck
• 25–30 g in an adult.
• Chiefly synthesizes the hormone
thyroxine (T4) and small quantity
of triiodothyronine (T3).
TSH
• TSH is secreted by anterior
pituitary
• shows a diurnal variance,
presenting a peak soon after
midnight and a nadir by late
noon, with peak values
sometimes even twice the value
seen in nadir.
TSH
Conditions associated with high risk for thyroid
• TSH is now considered as the disease in which screening is recommended.
first diagnostic test for
assessment of thyroid condition.
• high sensitivity - 98%.
• specificity - 92%
• value of TSH is considered low
when less than 0.1 mU/L and
high when more than 6.5 mU/L.
TSH
• Using TSH as an ace standard does help to categorize patients in
over 95% cases.
• But, TSH alone can be used only if the pituitary thyroid axis is intact

• pituitary diseases
• non-thyroidal illness
• drugs (glucocorticoids, tyrosine kinase inhibitor,
octreotide, etc).
Screening of TSH
• The American Thyroid Association recommends routine screening
for thyroid disorders in all adults by measurement of serum TSH
starting from the age of 35 years and then every 5 years, with more
frequent screening in high risk or symptomatic person.
• The American Association of Clinical Endocrinologists recommend
routine measurement of serum TSH in all women of child bearing
age before they conceive or during the first trimester of pregnancy.
Conditions associated with abnormal TSH levels:
„ Decreased TSH levels
• — Primary hyperthyroidism
• — Pituitary or hypothalamic
disease—secondary or tertiary
hypothyroidism
• — Non-thyroidal illness
• — Drugs, e.g., glucocorticoids,
dopamine
„Increased TSH levels
• — Primary hypothyroidism
• — Pituitary adenoma (TSH producing)—
secondary hyperthyroidism
• — Pituitary resistance to thyroid hormone
(TSH unreliable)
• — Generalized thyroid hormone resistance
• — Old age
• — Drugs, e.g., amiodarone
• — Recovery phase after severe systemic
illness
Thyroid Hormone Assays
Serum Thyroxine
T4 levels ↑ - hyperthyroidism
• in the course of treatment their
levels are measured to ascertain
the degree of thyroid dysfunction
and titration of doses of anti-thyroid
medication
T4 (Serum thyroxine): 55–150
nmol/litre.
Secondary
hypothyroidism
Serum Triiodothyronine
• Not suggested routinely because of
its short half life .
• Despite this it is of values in cases
of T3 toxicosis, in which patients
have low TSH, normal T4, and
features of hyperthyroidism.
_Graves’ disease_
A ratio of T3:T4 > 20 ng/mL is
indicative of Graves’.
T3 (Serum tri-iodothyronine): 1.2–3.1
nmol/litre.
Free Thyroxine and Free Triiodothyronine
Conditions associated with altered TBG
• Small amount circulate in free
form not bound to protein
• Their quantification is of value in
conditions where levels of thyroid-
binding globulin (TBG) are altered.
• Levels of TBG influence the levels
of T3 and T4 in direct proportion
Free Thyroxine
Conditions associated with decreased fT4:
• „ Primary hypothyroidism (thyroid hypofunction)
• „ Secondary hypothyroidism (pituitary hypofunction)
• „ Tertiary hypothyroidism (hypothalamic hypofunction)

Conditions associated with increased fT4:

• „ Graves’ disease Normal range: 9-21pmol/L
• „ Plummer’s disease (toxic thyroid adenoma)
• „ Early phase of subacute thyroiditis
• „ Struma ovarii
Free Triiodothyronine
fT3 levels are rarely required.
Conditions associated with decreased fT3:
• „ Critically ill patients
• „ Patients on high dose steroids
• „ Patients on beta blockers
• „ Severe hypothyroidism
Conditions associated with increased fT3: Normal range: 2.6-6.2pmol/L
• „ T3 toxicosis
• „ Hyperthyroidism
 Thyroid Antibodies
• Anti Thyroperoxidase antibody
(Anti_x0002_TPO Ab),

• Antithyroglobulin antibody and

• TSH receptor antibody (TSH-RAb).

Anti-thyroperoxidase Antibody (Anti-TPO
Ab)
• Thyroid microsomal antibodies

• Hypothyroidism
blocking the thyroid peroxidase
thereby hindering the synthesis of T3
and T4

antibody dependent cell toxicity and

inflammation of thyroid gland

Anti-TPO Ab levels facilitate in the

diagnosis of subclinical hypothyroidism and helps in
evaluation of autoimmune thyroiditis.
TSH Receptor Antibody (TSH-RAb)
• Either stimulate or block the TSH receptor.

Grave’s disease hypothyroidism

and associated
ophthalmopathy

• helpful in confirming the cause of

hyperthyroidism
Thyroid Function in Pregnancy
• Shift in level of thyroid hormones leading to an increase in T4
levels and a reciprocal decrease in level of TSH
„→ HCG has an alpha subunit similar to TSH, which binds to TSH
receptor. This leads to an increased production of T4, which gives
a negative feedback to the pituitary resulting in eduction of TSH.
„→ Estrogen produced by the placenta leads to increased
secretion of sex hormone binding globulin (SHBG) by the liver.
This SHBG increases secretion of T4 from thyroid.
„→ Pregnancy being a hypermetabolic state leads to increased
glomerular filtration rate; hence, increased secretion of T4 by
thyroid due to augmented elimination by the kidneys.
Thyroid hormone values during pregnancy
Detecting Thyroid Dysfunction
• ↑TSH - hypothyroidism
• ↓TSH - hyperthyroidism

• Analysis of thyroid function test can be a challenge in case of

hypothalamic pituitary disease (low TSH, low T4), systemic
illness, starvation (low TSH, low T3)
Hyperthyroidism
• Elevated fT4 and low TSH is indicative of thyrotoxicosis.
Young - Grave’s
Elderly - Nodular thyroid disease

• Subclinical hyperthyroidism- TSH is borderline suppressed in presence of

normal fT3 and fT4.(increased age, cardiac condition like atrial fibrillation,
recent history of stroke, and osteoporosis)
• Temporary thyrotoxicosis-presented in the form of viral thyroiditis. Most
patients have a recent history of viral upper respiratory tract infection.(anti-
inflammatory medication)
• low TSH and normal fT4 thereby representing T3 toxicosis. T3 is done.
• During the course of treatment, TSH may remain suppressed for varied
amount of time; in this case fT4 is measured every 6–8 weeks to monitor
the treatment.
Hypothyroidism
• Elevated TSH levels with low fT4 suggest a diagnosis of primary
hypothyroidism, primarily autoimmune in nature

• Also be a result of previous surgery or radio iodine ablation of thyroid gland

• ↑TSH with normal ft4 - autoimmune thyroid condition

• TSH - >4 μIU/mL and < 10 μIU/mL , without clinical sign - Subclinical
hyperthyroidism (thyroperoxidase antibody, pregnancy, goitre, or dyslipidemia)

• TSH levels more that 10 μIU/mL require treatment.

Hypothyroidism
• Thyroxine replacement in hypothyroid patient should be titrated to maintain a
TSH of about 2 μIU/mL.

• Guidelines recommend that test for thyroid function and changes in dose of
thyroxine should not be done before 6 weeks unless clinically indicated.

• Patients suffering with differentiated thyroid cancers are given suppressive

doses of thyroxine to maintain TSH levels below 0.1 μIU/mL to prevent flare ups

• Those who initially had a high risk disease but are now disease free post-
treatment are advised to maintain TSH levels between 0.1 and 0.5 μIU/mL for at
least 5–10 years.
 Sick Euthyroid Syndrome (Iow T3 syndrome)

• A thyroid-related change that occurs during

systemic illness in the absence of an intrinsic
thyroid disease.
• T4 conversion to T3 via peripheral 5'
(outer ring) deiodination is impaired→rT3
• acute.
• reversible.
• occurs commonly after surgery, starvation
and in many acute febrile illnesses.
• low fT3(most common).
Sick Euthyroid Syndrome (Iow T3 syndrome)
Interpretation of thyroid function test
Conclusion
• Diseases of thyroid gland are common and initial test to be done for
assessment of this condition is Serum TSH.
• fT4 is indicated as a second line test, but the reference range for fT4 and
TSH are not universal and reference interval provided by the lab should be
acknowledged.
• Results of thyroid function test are interpreted in light of clinical status of
patients: hypothyroid, euthyroid, or hyperthyroid. Subclinical thyroid
diseases are commonly encountered and present with an abnormal TSH and
normal fT4.
• Awareness of associated conditions can serve as a guide for further
investigations and management.
References

• 1. Weeke J, Gundersen HJ. Circadian and 30 minutes variations in serum TSH and thyroid
hormones in normal subjects. Acta Endocrinol (Copenh). 1978;89(4):659-72.
• 2. National Academy of Clinical Biochemistry. Laboratory Support for the Diagnosis and
Monitoring of Thyroid Disease. Washington, DC: AACC Press; 2003.
• 3. Association for Clinical Biochemistry, British Thyroid Association, British Thyroid Foundation.
UK guidelines for the use of thyroid function tests. 2006. Available from: http://www.british-
thyroid_x0002_association.org/info-for-patients/Docs/
TFT_guideline_final_version_July_2006.pdf
• 4. Ladenson PW, Singer PA, Ain KB, et al. American Thyroid Association guidelines for detection of
thyroid dysfunction [erratum appears in Arch Intern Med. 2001;161(2):284]. Arch Intern Med.
2000;160(11):1573-5.
• 5. AACE Thyroid Task Force. American Association of Clinical Endocrinologists medical guidelines
for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism.
Endocrine Prac. 2002;8:457-69.
THANK YOU ！
Have a nice day!

Dhinesh M Date ： july 30

f
u
r
y