Let’s Talk About Hypothyroidism Diagnosis and Treatment
Symptoms can be debilitating, but early diagnosis and treatment can get you back to feeling your best.
Hypothyroidism is often a lifelong condition, but that doesn’t mean it has to take over your life. Highly effective treatments are available to help you get your thyroid levels back to where your body needs them to be. And once that happens, those frustrating hypo symptoms from severe fatigue to depression should dissipate, too. Of course, the sooner you get an accurate diagnosis, the sooner you can get started with your treatment and get to feeling better. We asked the top docs about the steps to diagnosing this disease, plus the latest on options for hypothyroidism management.
Our Pro Panel
We went to some of the nation’s top hypothyroidism experts to bring you the most scientific and up-to-date information possible. Look who’s on your side:
Jennifer Mammen, M.D.
Assistant Professor of Medicine in the Division of Endocrinology, Diabetes, and Metabolism
Johns Hopkins University School of Medicine
Debbie Chen, M.D.
Clinical Lecturer in Endocrinology
Ann Arbor, MI
Thayer Idrees, M.D.
Assistant Professor of Medicine in the Division of Endocrinology, Metabolism, and Lipids
Emory University School of Medicine
An endocrinologist is a doctor who specializes in hormone disorders, including thyroid disease. While your primary care doctor may diagnose you with hypothyroidism, you will likely be referred to an endocrinologist for more specialized care and monitoring.
The most common blood test used to test thyroid function is called the thyroid stimulating hormone (TSH) test. A TSH above normal levels (40-4.50 miU/mL) may indicate hypothyroidism.
Hypothyroidism is treated with medications that replace thyroid hormone that your body is lacking. The most common medication is levothyroxine, which is a synthetic replacement of the hormone T4.
Some people with hypothyroidism prefer to take a drug made from dehydrated pig thyroid, containing both T4 and T3, rather than synthetic thyroid hormone replacements, because they feel better on the drug and like that it is perceived as a “natural” alternative.
What Is Hypothyroidism Again?
Let’s recap: Hypothyroidism is a chronic condition in which your thyroid—the butterfly shaped gland on the front of your neck—doesn’t produce enough hormones for your body to function properly. Without the right level of thyroid hormones, your body’s processes slow down, which can cause a variety of symptoms, like fatigue, hair loss, weight gain, and difficulty tolerating cold.
About 20 million Americans are living with thyroid disease—and hypothyroidism is the most common form of thyroid disease, affecting around 5% of Americans over age 12. The majority of people with hypothyroidism have it due to an autoimmune disease called Hashimoto’s, which is when your immune system accidentally attacks your thyroid and prevents it from making the right amount of hormones. Other people may have hypo because their thyroid was removed in surgery or for other reasons.
Hypo can affect anyone, but it’s most common in women and people over age 60. In some cases, your hypothyroidism symptoms may be so mild you barely notice them—but for others, symptoms are serious and can make it hard to live the life you want, and in rare cases even becoming life-threatening.
And that’s why it’s so important to get diagnosed and treated as early as possible. Here’s how you can make that happen.
How Is Hypothyroidism Diagnosed?
Here’s the thing: You can’t diagnose hypothyroidism just based on your symptoms. That’s because the typical warning signs of hypothyroidism are what are called “non-specific,” which basically means they could have a ton of other potential causes. For example, if you Google “causes of fatigue,” you’re going to get a lot of potential results beyond just hypo. That said, the more potential hypothyroidism symptoms you have, the more likely you are to actually have hypothyroidism, per a recent study in the European Journal of Endocrinology. But to actually confirm that you have hypothyroidism, you have to see your doctor and get tested.
What to Expect at the Doctor’s Office
If you’re experiencing any of the symptoms of hypothyroidism, it’s a wise move to see your primary care doctor right away. As with most conditions, early diagnosis can make for earlier treatment, which means a better chance of getting your symptoms under control before they become severe. Your primary care doctor also may refer you to an endocrinologist. An endocrinologist is a doctor who specializes in hormone disorders, including thyroid disease.
At your appointment, your doctor will likely start by asking some questions about your health. Those may include:
What are your symptoms and when did they begin?
Does anyone in your family have a history of thyroid disease?
Have you had any medication changes recently?
Have you had surgery or any major health procedures recently or in the past?
Have you been pregnant or had a baby recently?
These questions will help your doctor start to get the big picture of your health and rule out other potential causes of your symptoms.
Next, your doctor will likely perform a physical exam. During this exam, they’ll be looking for any potential signs of hypothyroidism. This may involve:
Feeling your thyroid gland. Your doctor will likely feel the front of your neck where your thyroid gland is to detect any potential changes that could signal a problem, such as enlargement of the gland or nodules.
Measuring your heart rate. A slower heart rate can be a sign of hypothyroidism.
Checking your reflexes. One study in CMAJ, the journal of the Canadian Medical Association, found that about 75% of people with hypothyroidism had what’s called Woltman sign, or delayed reflexes.
Observing your skin. Dry skin is a common symptom of hypothyroidism.
Watching for swelling. Swelling around the eyes and legs may also be a sign of hypothyroidism.
Blood Tests for Hypothyroidism
Along with this physical exam, your doc will likely run some blood tests—this is the typical way a diagnosis of hypothyroidism is confirmed. Thyroid-related blood tests, like the ones below, can determine whether your thyroid hormone levels are where they should be.
Thyroid Stimulating Hormone (TSH) Test
A thyroid stimulating hormone (TSH) test is the most common and sensitive tool doctors use to diagnose hypothyroidism. TSH is a hormone made by your pituitary gland, the “master” gland in the brain, and it tells your thyroid exactly how much thyroid hormone (called T4 and T3) it should make.
So with a TSH blood test, your doctor can learn exactly how much TSH is circulating in your body. For an adult, a normal range for TSH is 0.40-4.50 miU/mL. A higher level usually means you have hypothyroidism. Basically, when thyroid hormone levels are too low (meaning you are hypothyroid), your pituitary gland kicks into overdrive to make more TSH to try to signal your body to make more thyroid hormone.
Total T4 Test and Free T4 Test
T4, a.k.a. thyroxine, makes up about 90% of the thyroid hormone that the human body usually makes (the other 10% is T3, a.k.a. triiodothyronine). If your TSH results come back normal but your doctor still thinks you may have hypothyroidism, they may decide to test your T4, too. Low T4 can sometimes indicate hypothyroidism.
There are two types of T4 tests: total T4 and free T4. A total T4 test looks at the amount of both “bound” and “free” T4 in your blood. “Bound” T4 refers to the hormone that is kept in storage until your body needs it, while “free” T4 is able to enter the body’s tissues for use. Usually, doctors prefer to test free T4 since it is more accurate in assessing how well your thyroid is working. The normal total T4 range for an adult is 5.0-11.0 ug/dL, and the normal free T4 range is 0.9-1.7 ng/dL.
Thyroid Antibody Test
In addition to the above tests, your doctor may also order a thyroid antibody test. Measuring levels of thyroid antibodies in your blood can help determine whether you have an autoimmune form of hypothyroidism. For example, if you test positive for anti-thyroid peroxidase and/or anti-thyroglobulin antibodies, it means you have Hashimoto’s disease.
How to Prepare for Thyroid Blood Tests
Don’t worry—no fasting required. There’s nothing you have to do to prepare for any of these blood tests. That said, some medications can interfere with the accuracy of thyroid blood test results. For example, medications containing estrogen (like some birth control pills) cause high levels of total T4. If you’re on one of these drugs, your doctor should use both a TSH and a free T4 test to confirm your diagnosis.
Additionally, some people take biotin supplements for healthy hair and nails—but this can lead to false positives for thyroid problems. Make sure you don’t take your biotin for two full days before your thyroid blood tests are drawn.
In addition to blood tests, your doctor also may use imaging tests to investigate what’s going on with your thyroid. These are some of the common tests you can expect:
For this procedure, an ultrasound technician will use a device called a transducer to send sound waves at your neck to create pictures of your thyroid gland (don’t worry—it’s painless). An ultrasound is typically used to detect thyroid nodules and determine whether they are potentially cancerous.
A thyroid scan uses a small amount of radioactive iodine to help find and examine thyroid nodules. You will either swallow the radioactive iodine in pill form or your doctor will inject it into your vein. Then, a special camera will take pictures of your thyroid gland, with the radioactive iodine making it easier to see potential problems.
Radioactive Iodine Uptake Test
For this test, your doctor will give you a small amount of radioactive iodine in a pill or liquid to swallow. Then, they will use a handheld device called a gamma probe on your neck to measure how much of the iodine your thyroid takes up. If the amount is low, it may indicate hypothyroidism.
Because there’s no way to prevent hypothyroidism, the best thing you can do is get treatment as soon as possible. Early treatment can help to reduce the impact of symptoms on your life—not to mention help you avoid some of the more severe complications of this condition.
The goal of hypothyroidism treatment is to get your thyroid hormone levels in check so that your body can function properly. In turn, this will reduce any hypo-related symptoms you may be having. And thankfully, available treatments for hypothyroidism are highly effective. While hypothyroidism can’t be cured, these treatments can make the condition extremely manageable.
Medications are a must with hypothyroidism treatment because they can replace the thyroid hormones your body is missing and get your levels back within a healthy range. This should resolve any thyroid-related symptoms you’ve been having, too!
T4 Replacement (Levothyroxine)
Levothyroxine is the gold standard of hypothyroidism treatment. It’s an identical lab-synthesized replacement for the thyroid hormone T4 that can be taken in pill form, although it’s also available as a liquid and soft gel capsule. Brand names of this drug include Levoxyl, Tirosint, Levo-T, Synthroid, and Unithyroid.
Because T4 is the hormone you’re most missing out on with hypothyroidism, and your body is typically able to convert T4 into T3 if it needs more of that form of thyroid hormone, taking this medication is usually all you need to get back to feeling better.
It’s important to note that there may be certain things you need to avoid eating around the same time you take your levothyroxine medication because they can interfere with your body’s ability to absorb the drug. These include:
Foods high in soy protein
Your doctor will likely suggest you take this drug at the same time every day on an empty stomach, waiting an hour before eating or taking other drugs afterward. Talk with your doctor or pharmacist to make sure you understand the best way to take your medication.
T3 Replacement (Liothyronine)
Most people only need to take T4 replacement, but in rare cases, due to genetic reasons, people with hypothyroidism can struggle to convert T4 into T3. For these folks, taking a T3 supplement called liothyronine (brand names: Triostat, Cytomel) may also be necessary. This is sometimes referred to as combination therapy, and research is still emerging about this approach.
Desiccated Thyroid Extract/Porcine Thyroid
We know it may sound weird, but some people with hypothyroidism prefer to take a drug made from dehydrated pig thyroid, containing both T4 and T3, rather than synthetic thyroid hormone replacements. It is important to note that this drug is not approved by the U.S. Food and Drug Administration (FDA) and is not often prescribed by doctors for treating hypothyroidism. Still, some people perceive this option as more “natural,” or they simply feel better on the drug compared with taking levothyroxine. In fact, one study in The Journal of Clinical Endocrinology and Metabolism found that nearly half of patients studied preferred desiccated thyroid extract treatment to levothyroxine treatment. But it’s important to understand that the proportions of the hormones in pigs are not the same as they are in humans, and it may be harder to monitor how much you are getting from a dose compared with taking levothyroxine. This means you may not be adequately treating your hypothyroidism.
Talk to your doctor about whether this is an appropriate treatment option for you. It’s not recommended for some people, such as pregnant women and those with pork allergies. This drug is sold under brand names Armour Thyroid, Bio-Throid, Nature Thyroid, and others.
Thyroid Medication Dosing
Finding the right dose of thyroid hormone replacement for your body can take some time. Typically, after starting a new thyroid hormone replacement drug, your doctor will want to re-check your TSH levels six to 10 weeks afterward. Six months later, they may want to check you again. Once your dose is established, you’ll need to get re-checked around once a year. Some people may need to be monitored more often, such as if you are pregnant or taking certain medications.
Determining the appropriate dose for your body is important because taking too little won’t resolve your hypothyroid symptoms and taking too much can actually tip you to the opposite end of the spectrum and cause symptoms of overactive thyroid (hyperthyroidism), including insomnia, heart palpitations, shakiness, and more. When you’re on the proper dose, you shouldn’t have any significant side effects.
Natural Treatment for Hypothyroidism
You’ve heard it before, and you’re about to hear it again: A healthy lifestyle is a must for overall well-being. Getting enough sleep, reducing stress where you can, eating well, and getting some exercise are always wise steps to take and they can also help you manage symptoms of your condition while you figure out the right dosage of thyroid hormone for you.
But unlike some other chronic illnesses, lifestyle changes like diet and exercise can’t do much to treat the root cause of your condition—thyroid hormone replacement really is the key for this. Getting on the right dose of thyroid hormone replacement medication should be enough to help you feel back-to-normal. If your thyroid hormone levels are looking good on blood tests but you’re still experiencing symptoms of fatigue and brain fogginess, it’s possible those symptoms aren’t being caused by your thyroid at all—it may be time to look into other causes.
Hypothyroidism and Diet
There’s no such thing as a “hypothyroidism diet,” but there may be certain things you want to avoid eating around the same time you take your thyroid medication because they can interfere with your body’s ability to absorb it—so make sure you talk with your doctor about the best way to take your medication and things to avoid.
If you have an autoimmune form of hypothyroidism like Hashimoto’s, you may also need to avoid iodine because it can cause harmful side effects.
But of course, eating a healthy diet is always a good idea, as this can help you feel your best and support a healthy thyroid. Focus on getting a variety of nutrients through fruits and veggies, whole grains, lean proteins, and healthy fats.
Hypothyroidism Treatment and Mental Health
Managing a chronic condition like hypothyroidism is no joke—especially if you’re in the phase of trying to get a diagnosis or adjusting your medication dose so that it works for you. Plus, hypothyroidism increases the risk of mental-health problems like depression and anxiety. That’s why it’s important to take care of your mental health when you’re living with hypothyroidism. That may mean upping your self-care game with things like meditation or relaxation techniques, or even seeing a mental-health professional for additional support.
Seeing a therapist is one proven way to help reduce symptoms of depression and anxiety, which can be common when you have thyroid disease. Therapists can help teach you strategies to better cope with these symptoms and feel validated in your emotions. In fact, a recent study in Thyroid Research found that emotional health, physical health, and spiritual health all significantly improved in hypothyroidism patients after receiving cognitive-behavioral therapy (CBT). There are even therapists who specialize in treating people who live with chronic illnesses like thyroid disease.
In some cases, a doctor or psychiatrist may also suggest antidepressant medications to help you manage your mental-health symptoms as well. Don’t be afraid to talk to your healthcare provider if you’re experiencing difficulty with your mood or feeling stressed—you don’t have to suffer in silence.
Most importantly, remember: Treatments for hypothyroidism do work. Be patient and keep working toward finding the optimal medication and dosage for you. Eventually, you will begin feeling like your old self again.
- Thyroid Disease Symptom Study: European Journal of Endocrinology. (2014.) “Hypothyroid symptoms and the likelihood of overt thyroid failure: a population-based case–control study.” https://eje.bioscientifica.com/view/journals/eje/171/5/593.xml
- Correlation of Hypothyroidism Symptoms Study: Journal of General Internal Medicine. (1997.) “Do Traditional Symptoms of Hypothyroidism Correlate with Biochemical Disease?” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497160/
- Hypothyroidism Information: National Institute of Diabetes and Digestive and Kidney Diseases. (2021.) “Hypothyroidism (Underactive thyroid).” https://www.niddk.nih.gov/health-information/endocrine-diseases/hypothyroidism
- Hypothyroidism FAQs: American Thyroid Association. (2021.) “Hypothyroidism FAQs.” http://www.thyroid.org/hypothyroidism/
- Thyroid Disease Diagnosis: National Institute of Diabetes and Digestive and Kidney Diseases. (2017.) “Thyroid Tests.” https://www.niddk.nih.gov/health-information/diagnostic-tests/thyroid
- Tests for Thyroid Function: American Thyroid Association. (2021.) “Thyroid Function Tests.” http://www.thyroid.org/thyroid-function-tests/
- Thyroid Blood Tests: Cleveland Clinic. (2019.) “Thyroid Blood Tests.” https://my.clevelandclinic.org/health/diagnostics/17556-thyroid-blood-tests
- TSH Test: MedlinePlus. (2020.) “TSH (Thyroid-stimulating hormone) Test.” https://medlineplus.gov/lab-tests/tsh-thyroid-stimulating-hormone-test/
- Thyroid Disease and Mood: The Mayo Clinic. (2020.) “Can thyroid disease affect my mood?” https://www.mayoclinic.org/diseases-conditions/hyperthyroidism/expert-answers/thyroid-disease/faq-20058228
- Hypothyroidism Medications: Mayo Clinic. (2020.) “Hypothyroidism (underactive thyroid).” https://www.mayoclinic.org/diseases-conditions/hypothyroidism/diagnosis-treatment/drc-20350289
- CBT for Hypothyroidism Study: Thyroid Research. (2020.) “The effectiveness of cognitive-behavioral therapy on quality of life in women with hypothyroidism in reproductive age: a randomized controlled trial.” https://thyroidresearchjournal.biomedcentral.com/articles/10.1186/s13044-020-00080-z
- Hypothyroidism and Diet: Mayo Clinic. (2019.) “Hypothyroidism diet: Can certain foods increase thyroid function?” https://www.mayoclinic.org/diseases-conditions/hypothyroidism/expert-answers/hypothyroidism-diet/faq-20058554
- Healthy Eating With Thyroid Disease: Harvard Health. (2017.) “Healthy eating for a healthy thyroid.” https://www.health.harvard.edu/staying-healthy/healthy-eating-for-a-healthy-thyroid
- Coffee and Thyroid Medication: American Thyroid Association. (2008.) “Altered Intestinal Absorption of L-Thyroxine Caused by Coffee.” http://www.thyroid.org/patient-thyroid-information/ct-for-patients/vol-1-issue-1/vol-1-issue-1-p-21/
- Delayed Reflexes in Hypothyroidism: CMAJ. (2013.) “A classic sign of hypothyroidism.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2492977/
- Desiccated Thyroid Extract Study: The Journal of Clinical Endocrinology and Metabolism. (2013.) “Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study.” https://pubmed.ncbi.nlm.nih.gov/23539727/