Individuals with ‘normal’ thyroid function may still have symptoms of low thyroid function

The thyroid gland is the ‘master regulator’ of the body’s metabolism. Should its function falter (hypothyroidism) it can give rise to a wide range of symptoms including dry skin, dry hair, fatigue, weight gain, sensitivity to cold, cold extremities and low mood or depression. Standard blood tests for thyroid function include thyroid stimulating hormone (TSH) and thyroxine (also known as T4). Thyroxine is one of the major hormones made by the thyroid. TSH is made by the pituitary gland, and stimulates the thyroid to make thyroid hormones. In the world of conventional medicine, a raised TSH coupled with low T4 would signal hypothyroidism, and would usually trigger treatment (with thyroxine, usually).

We doctors tend to rely quite heavily on TSH levels to make the diagnosis of low thyroid and monitor treatment. However, for a variety of reasons, I believe TSH is not to be utterly relied upon when making treatment decisions. I wrote about this a couple of years back here.

I was thinking about this today when I came across a study this week that focused individuals with a condition known as Hashimoto’s thyroiditis [1]. This condition is autoimmune in nature, which means its characterised by the body’s immune system reacting against the thyroid. The diagnosis is usually made on the basis of the clinical picture as well as blood tests for antibodies that the body can make that damage the thyroid. The two antibodies that are usually tested are known as anti-thyroid peroxidase and anti-thyroglobulin. Even if one or both of these is positive, treatment will not normally be initiated for low thyroid function unless there is the presence of a raised TSH levels and possibly a low T4 level too.

However, some (though not many) doctors argue that treatment should be tried in individuals with positive antibodies if symptoms suggest low thyroid even if TSH and T4 levels are ‘normal’.

In the study in question, individuals with Hashimotos were identified (defined by the researchers as individuals with anti-thyroid peroxidase levels of greater than 121.0 IU/mL. These individuals were quizzed for the presence of thyroid-related symptoms such as chronic (long-term) fatigue, dry hair, chronic irritability, chronic nervousness, and lower quality-of-life. Compared to individuals in whom there was no diagnosis of Hashimoto’s disease, those with positive antibodies had a significantly higher level of symptoms suggestive of thyroid dysfunction.

TSH levels, on the other hand, did not differ between the two groups.

One way of interpreting this is that individuals with Hashimoto’s thyroiditis have a fair chance of exhibiting hypothyroid symptoms even when their blood tests are ‘normal’.

In recent months I became aware of a book which is about Hasimoto’s thyroiditis, the different ways it can present, and how it might be treated. Those who feel they may have a particular problem in this area may get a lot out of reading this book. You can learn more about it, as well as the doctor who wrote it (Dr Datis Kharrazian) here.


1. Ott J, et al Hashimoto’s Thyroiditis Affects Symptom Load and Quality of Life Unrelated to Hypothyroidism: A Prospective Case–Control Study in Women Undergoing Thyroidectomy for Benign Goiter. Thyroid 2011;21(2):161

8 Responses to Individuals with ‘normal’ thyroid function may still have symptoms of low thyroid function

  1. julianne 2 March 2011 at 11:34 pm #

    I have Hashimotos with ‘strongly positive’ anti-bodies. I saw this study too. My Hashimotos was discovered entirely ‘by accident’. I do have not particular symptoms, and a medical checkup on turning 50 picked up a high TSH and consequently high anti-bodies.

    I wonder how many others out there have undiagnosed Hashimotos, who only end up getting treatment when their thyroid is so badly damaged they can no longer make sufficient hormones.

    I second Dr K’s thyroid book. I’ve been strict gluten free since reading it. I was already paleo, with a few cheats. No more gluten cheats now.

  2. Janet 4 March 2011 at 2:42 pm #

    Thank you for this link and the information it has to help. I had high antibodies some years ago but my doctor did nothing about them. Then I recently went back to my thyroid doctor who dispite the test he asked for showing high cortisol levels dismissed me telling me not to go back again complaining of my weight. The weight would have been only the beginning. I have since become very ill and I hope this book will be helpful albeit one has still to find a doctor in the UK to help.

  3. Denise 4 March 2011 at 7:41 pm #

    Hurrah Dr Briffa for bringing this to our attention! I suffered from all the symptoms listed, and more, for 3 years, with no successful diagnosis from two GPs (one UK, one USA) who took little interest. The fatigue (mental and physical), insomnia and anxiety/depression were chronic, and Candida completely upset my digestion, so in the end I had to stop working. A Nutritionist was really helpful and treated me throughout.
    It wasn’t until I found an Allergy and ENT surgeon who immediately tested for antibodies, that I was correctly diagnosed. He was angry at the entire profession of doctors that they do not routinely test for antibodies when presented with these symptoms. Even though my antibody count wasn’t that high I had ground to a halt, but 90mg of Armour Thyroid restored me within a matter of weeks. He prescribed Nystatin for the Candida, and I haven’t looked back.
    What does our GPs training comprise that is useful? They seem lazy and complacent in my experience.

  4. AndreaAndrea Nakayama 4 March 2011 at 8:37 pm #

    Right on Dr. Briffa! As the others explained, most docs seem to be unaware of these critical connections and end up treating symptoms unsuccessfully. I’ll be teaching an on-line nutrition course in the spring that not only walks patients through dietary change but also articulates the role of hormones in these symptoms. As hypothyroid and Hashimoto’s are so prevalent for women, especially after childbirth, we’ll ficus plenty of attention there. I’m always happy to see more doctors on board with this understanding. And thanks to Dr. K’s insights for us all!
    Andrea Nakayama
    Functional Nutritionist

  5. Jackie at 6 March 2011 at 5:49 pm #

    Janet, try Dr Peatfield, he is the thyroid specialist many of us hypothyroids go to now we have realised that although the NHS can’t/won’t help us, there are doctors out there who have a proper understanding of how the thyroid works. Find him at

    Good luck!

  6. Emily 27 April 2012 at 11:35 pm #

    Thank you for calling attention to this! I experienced exactly what you described. Around age 19, I started noticing I had gained weight I couldn’t seem to lose, and I was tired all the time. When I spoke to a doctor about this offhandedly at an appointment for something else, he asked if I was frequently cold, and upon me saying yes, he ordered a thyroid test. It came back “normal” (his words, I never saw the test results), he diagnosed me with Reynaud’s and offered no treatment. This happened with 3 additional doctors over the next 6 years. I would say something about weight gain and fatigue, they would test my thyroid, tell me it was normal, tell me they didn’t have an explanation for my illness, and send me away without treatment.

    Finally, a little over a year ago, as I got into natural medicine, I got my own full thyroid panel done and had an integrative physician look over my results. He immediately spotted the problem: my T4 was actually quite high, and my T3, while within the normal range, was fairly low. He asked me if I was a vegetarian. I had in fact gone vegetarian at age 18 (about a year before I began experiencing hypothyroid symptoms). He suggested that a protein deficiency was impairing my body’s ability to convert T4 into T3 and suggested that I either supplement with a master amino acid pattern or find a way to get more protein in my diet. He also instructed me to supplement with iodine and stop eating soy.

    I did as he said – stopped eating soy, started eating meat, and started adding a few drops of liquid iodine to my water bottle each day. I’ve now lost the weight I carried for six years, improved my energy levels, improved my mood, and I can actually sit outside on a crisp autumn day without having to soak my hands and feet in a warm bath to restore circulation when I get back inside!

    My heart breaks for everyone out there who is still in the position I used to be in–walking around sick, not so sick as to be completely debilitating, but sick enough to diminish their quality of life. Probably walking around sick for so many years they don’t remember what it’s like not to be sick. There needs to be more awareness of the various less common forms of hypothyroidism.


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