HELP! My TSH Is "Normal" But I Think I'm Hypothyroid

Hypothyroidism with Normal TSH Is Possible

laboratory tests, blood tests, blood work, thyroid tests

Many people write to me, asking if they could be hypothyroid, despite having had their TSH tested, and it comes back in the "normal" range. These people often describe a list of standard hypothyroid symptoms and have shown low basal body temperature tests, but standard TSH testing has shown them to be in the "normal range."

Here are some things to pursue in getting a diagnosis.

What is your lab's "normal" range, and how does your doctor define "normal?"

Different labs have different values for what is normal.

For example, at the lab my doctor uses, the normal range is .5 to 5.5. A TSH of less than .5 is considered hyPERthyroid, and a TSH of more than 5.5 is considered hyPOthyroid. Other labs might use .35 to 5, or .6 to 5.2, etc., but it's important for you to know the values at YOUR lab.

AND, it's important to know that in March 2003, the endocrinology community suggested that the normal range is narrowed and that a new "normal range" of .3 to 3.0 be adopted. (For more information, read: Endos Say Normal TSH Range Now .3 to 3: Millions More at Thyroid Risk.) 

The issue was not closed, however, and as of 2016, the endocrinology community is back to using the old reference range of a decade earlier.

So what a "normal" TSH is still up in the air, depending on the doctor you're consulting, and his or her ideas about thyroid disease. If you're on the higher end of the normal range, you could very well be borderline hypothyroid for YOU, but still in the "normal" range.

So, you need to know what TSH level your doctor is targeting for you. This is a very loaded, but VERY important question. Your doctor's answer will tell you her or his philosophy about "normal" TSH. Some doctors believe that being in, or getting you into the very top of the normal range is their sole objective, and then the job is done.

So, for example, using the 5.5 outer edge of the TSH level from my lab, that sort of doctor believes that getting me to somewhere around there constitutes full treatment.

Other doctors believe that certain TSH levels within the normal range are more appropriate targets. My doctor, for example, believes that women don't feel well (and can't lose weight or get rid of other hypothyroidism symptoms) unless TSH is down between 1 and 2, far below the higher end of "normal." (There are some suggestions in research that have shown that the average TSH of women without thyroid disease is 2, so that may be why some women don't feel well at 4 or 5.) My doctor wants me to feel as well as possible within the normal range but finds that on average, women don't feel well at the higher end, so she aims to take it lower.

In my own experience, I feel downright awful at anything above 4, and I feel great below 1, which my doctor keeps my TSH. But some doctors would have no problem keeping me between a TSH of 3 and 4, still in the laboratory "normal" range, despite the fact that I still have the full range of hypothyroid symptoms -- fatigue, weight gain, irregular menstrual periods, dry skin, hair falling out -- at those levels.

The best doctor is one who believes that managing your thyroid is a combination of TSH AND how you feel. These are doctors who treat you like a patient, not a lab value! These doctors might say "well, let's get you into the normal range, see how you feel, and adjust the dosage from there."

Have you been tested for thyroid antibodies?

Some doctors believe that a thyroid that is in the process of autoimmune failure -- as evidenced by elevated antibody levels -- can cause hypothyroid symptoms BEFORE the hypothyroidism shows up as TSH outside the normal range, and should be treated with small doses of thyroid hormone.

One doctor who explored this information is Elizabeth Lee Vliet, M.D., in her book Screaming to be Heard: Hormonal Connections Women Suspect...and Doctors Ignore. Dr. Vliet does not believe that TSH tests are the almighty indicator of a woman's thyroid health. She said that symptoms, along with elevated thyroid antibodies and normal TSH, may be a reason for treatment with thyroid hormone. Here's a quote from Dr. Vliet:

The problem I have found is that too often women are told their thyroid is normal without having the complete thyroid tests done. Of course, what most people, and many physicians, don't realize is that...a 'normal range' on a laboratory report is just that: a range. A given person may require higher or lower levels to feel well and to function optimally. I think we must look at the lab results along with the clinical picture described by the patient...I have a series of more than a hundred patients, all but two are women, who had a normal TSH and turned out to have significantly elevated thyroid antibodies that meant they needed thyroid medication in order to feel normal. This type of oversight is particularly common with a type of thyroid disease called thyroiditis, which is about 25 times more common in females than males...a woman may experience the symptoms of disease months to years before TSH goes up..."

Could You Have an Underlying Additional Problem that Requires More than Just Standard Thyroid Hormone Replacement?

Synthroid, Levoxyl, and Tirosint are all brand names for the thyroid drug levothyroxine sodium, which is a synthetic version of the thyroid hormone T4. These are most often the drugs prescribed for thyroid hormone replacement for most patients.

But if you have hypothyroidism and are taking one of these conventional thyroid replacement drugs, your blood tests show a "normal" TSH and yet you still don't feel well, there may be a need for the addition of T3, the other major thyroid hormone.

For example, the book "Myofascial Pain and Dysfunction: Trigger Point Manual," describes the condition of "hypometabolism," where an inability to adequately convert T4 to the T3 needed by the body leaves someone with a normal TSH level, but hypothyroid symptoms. Serum hormone studies typically show marginally low T3 and T4 levels, usually within the "normal" range, and TSH is rarely elevated out of the "normal range." At the same time, cholesterol is often elevated, and the basal temperature is likely to be 97 degrees F or less. Patients with hypometabolism problems often respond well to T3 or T4/T3 treatments.

Fibromyalgia can also be an underlying reason. Symptoms of fibromyalgia can be very similar to thyroid disease, and researchers have found a higher incidence of thyroid disease among fibromyalgia patients. And the researchers are also finding that these patients need the additional thyroid hormone T3 to resolve symptoms. For more information on fibromyalgia and its symptoms, diagnosis, and relationship to thyroid disease see my article Chronic Fatigue, Fibromyalgia, and Autoimmune Thyroid Disease.

T3 is available on its own, as a brand name drug known as Cytomel, or can be included with T4 in the naturally derived thyroid drugs Nature-Throid or Armour Thyroid

But My Doctor Thinks that TSH Testing is the Only Way to Diagnose Hypothyroidism, Antibody Tests are a Waste of Time, Synthroid is the Only Drug to Prescribe, and There's no Such Thing as Hypometabolism or Conversion Problems or Fibromyalgia, and Natural Thyroid is an Old-Fashioned, Dangerous Drug

Many endocrinologists are known for being "numbers" people. They manage by the numbers, and not by the symptoms, which can often create the "you're in the normal range, so you're fine" response many of us get to complaints that we still don't feel well. So keep in mind that even if you have easily diagnosed hypothyroidism, it may take some serious looking to find an endocrinologist who believes in finding an optimal TSH for you, and not just getting you into the high normal range and declaring you cured.

As for getting a diagnosis and treatment via the less conventional methods -- basal body temperature testing, TRH tests, antibody testing -- or drugs -- Nature-thyroid, Armour, Cytomel --you're probably going to need to look outside the standard endocrinology community and find a doctor who has a more holistic approach.

If you have a doctor like this, your best option is to explore how to find the right doctor for your thyroid care.

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