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Research Thyroid-Stimulating Hormone (TSH)
Thyroid Panel

Thyroid-Stimulating Hormone (TSH)

Serum
Optimal Result: 0.45 - 4.5 mIU/L, or 0.45 - 4.50 IU/L.

The table below provides estimates of TSH levels that are normal, low (indicating hyperthyroidism) and high (indicating hypothyroidism):

hyperthyroidism normal mild hypothyroidism hypothyroidism
0 - 0.4 0.4 - 4 4 - 10 10

Most labs use these reference values.

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TSH stands for thyroid stimulating hormone, though it is sometimes called thyrotropin or thyrotropic hormone. TSH stimulates the thyroid gland to produce thyroid hormone, which is is critical for the proper function of virtually every cell in the body. TSH is released by the pituitary gland after the gland has been stimulated by thyroid releasing hormone (TRH), which is secreted by the hypothalamus. Thyroid hormone provides negative feedback on the hypothalamus and/or the pituitary to reduce thyroid hormone production and release. TSH measurements are important for diagnosing hypothyroidism and hyperthyroidism. TSH may be measured in conjunction with total thyroxine (T4), total triiodothyronine (T3), free T4, free T3, and reverse T3 concentrations in the serum.

Normal Ranges for TSH:

Children:

- 1-2 Days --- 3.20-34.60 mIU/L

- 3-4 Days --- 0.70-15.40 mIU/L

- 5 Days-4 Weeks --- 1.70-9.10 mIU/L

- 1-11 Months --- 0.80-8.20 mIU/L

- 1-19 Years --- 0.50-4.30 mIU/L

Adult (non-pregnant):

0.40-4.50 mIU/L

Pregnancy  

- First Trimester --- 0.26-2.66 mIU/L

- Second Trimester --- 0.55-2.73 mIU/L

- Third Trimester --- 0.43-2.91 mIU/L

Factors That May Affect Your TSH Results:

There are a number of variations and factors that can affect TSH levels. It's important to be aware of these, as treatment that is dictated solely by lab values (as opposed to also considering an individual's symptoms) can result in an ineffective plan.

- Laboratory Error: If a TSH level is surprising, sometimes simply repeating the test is the best course. Errors can occur during the blood draw, in transcribing the results, or due to mix-ups in the lab. Statistically, there is always a risk of lab error, and results should always be interpreted along with clinical symptoms and findings.

- Antibodies: Antibodies are thought to interfere with accurate thyroid testing in roughly 1 percent of people. In a 2018 review, it was estimated that in people who have these antibodies, the interference with TSH testing caused either misdiagnosis or inappropriate treatment in more than 50 percent of cases:

Heterophile antibodies: Heterophile antibodies are antibodies that may occur when a person is exposed to animal-derived pharmaceuticals and antibody therapies. Their presence is more common in people who have had certain vaccinations, blood transfusions, or have been exposed to some animals (not household pets). The estimated incidence of these antibodies varies widely, but when present, they can interfere with TSH levels. There is no easy way to know if you have these antibodies, but a discrepancy between TSH levels and free T4 (the hallmark of heterophile antibodies), or between TSH levels and how you feel, should raise the question.

Thyroid antibodies: Thyroid autoantibodies, present in some people with or without a thyroid condition, may also affect TSH levels. Again, a discrepancy between lab values and how you feel should raise the question of whether or not the test is accurate.

Other antibodies: Other antibodies important in TSH testing interference include anti-ruthenium antibodies and anti-streptavidin antibodies.

- Other Factors: A number of other factors can affect TSH test results either through having an effect on actual levels of thyroid hormones or interacting with testing measures. 

Some of these include:

- The time of day that the test is done: TSH levels are higher if you're tested after fasting (for example, in the morning after not having eaten since the night before) as compared to after eating later in the day.

- Illness

- Pregnancy

- Some medications that are used for heart disease and in cancer treatment

- Foods or supplements rich in/derived from iodine or kelp

- Biotin supplements

- Non-steroidal anti-inflammatory medications such as Advil (ibuprofen)

- Changes in sleep habits

In order to get the most accurate results, it's important to be consistent. For example, always having your test done at the same time of day.

Sources:

http://www.uptodate.com/contents/thyroid-hormone-synthesis-and-physiology

http://www.ncbi.nlm.nih.gov/pubmed/2194786

http://www.uptodate.com/contents/laboratory-assessment-of-thyroid-function

http://www.questdiagnostics.com/testcenter/TestDetail.action?ntc=899

http://www.uptodate.com/contents/disorders-that-cause-hypothyroidism

http://www.uptodate.com/contents/disorders-that-cause-hyperthyroidism

http://www.ncbi.nlm.nih.gov/pubmed/21048053

http://www.nejm.org/doi/full/10.1056/NEJMcp0801880

http://www.uptodate.com/contents/disorders-that-cause-hyperthyroidism

What does it mean if your Thyroid-Stimulating Hormone (TSH) result is too high?

Elevated TSH Levels: Causes, Symptoms, Diagnosis, and Treatment Options

High levels of Thyroid Stimulating Hormone (TSH) typically indicate an underactive thyroid, a condition known as primary hypothyroidism or subclinical hypothyroidism. When thyroid hormone levels (T3 and T4) are low, the hypothalamus and pituitary gland respond by raising TSH levels to stimulate more hormone production by the thyroid. High TSH levels can signal a range of thyroid-related disorders, each with varying underlying causes, symptoms, and treatment options.

TSH Reference Ranges

It's important to note that TSH reference ranges can vary slightly between laboratories and age groups. Generally, for adults, the normal range is considered to be between 0.4 and 4.0 mIU/L (milliunits per liter). However, some experts suggest that the upper limit should be 2.5 mIU/L for optimal thyroid function. In pregnancy, TSH levels are typically lower, with a recommended range of 0.1-2.5 mIU/L in the first trimester and 0.2-3.0 mIU/L in the second and third trimesters.

Common Symptoms of Elevated TSH Levels

The symptoms of high TSH and the associated hypothyroidism can vary depending on the severity of the condition. Common symptoms include:

  • Fatigue and weakness: Feeling constantly tired and lacking energy.
  • Cold intolerance: Sensitivity to cold temperatures, feeling chilly even in warm environments.
  • Weight gain: Unexplained weight gain despite a normal diet and lifestyle.
  • Constipation: Difficulty passing stools, even with a high-fiber diet.
  • Cognitive problems: Difficulty concentrating, memory problems, and general cognitive "fog."
  • Dry skin and hair: Dry, flaky skin and brittle hair that falls out easily.
  • Hoarseness: A deep or raspy voice.
  • Swelling (edema): Puffiness in the face, around the eyes, and in the hands and feet.
  • Muscle pain or weakness: Unexplained muscle cramps or general weakness.
  • Depression or mood changes: Feeling low, irritable, or unusually anxious.

Possible Causes of High TSH Levels

  • Primary Hypothyroidism: The most common cause of elevated TSH, where the thyroid gland produces insufficient thyroid hormones.

  • Subclinical Hypothyroidism: A milder form of hypothyroidism where TSH levels are elevated but T3 and T4 levels are within the normal range, often without noticeable symptoms.

  • Transient Hypothyroidism: Temporary hypothyroidism that resolves on its own, often seen after thyroiditis or a viral illness.

  • Painless Thyroiditis: An inflammation of the thyroid gland that leads to temporary hypothyroidism.

  • Subacute Granulomatous Thyroiditis: A form of thyroiditis that often occurs after a viral infection, leading to swelling and pain in the thyroid gland.

  • Postpartum Thyroiditis: Inflammation of the thyroid that occurs after giving birth, leading to temporary hypothyroidism.

  • Thyroidectomy or Radioiodine Therapy: Surgical removal of the thyroid gland or treatment with radioactive iodine can lead to hypothyroidism due to insufficient thyroid tissue.

  • Chronic Autoimmune Thyroiditis (Hashimoto’s Thyroiditis): The immune system attacks the thyroid gland, causing gradual destruction and eventual hypothyroidism.

  • Iodine Imbalance: Both iodine deficiency and excess can lead to high TSH levels. Iodine is essential for thyroid hormone production, but too much or too little can disrupt function.

  • Drug-induced Hypothyroidism: Certain medications, like lithium (used to treat bipolar disorder) and amiodarone (used for heart arrhythmias), can interfere with thyroid function and lead to elevated TSH.

  • Congenital Thyroid Disorders: Conditions like congenital thyroid agenesis (absence of the thyroid gland), dysgenesis (malformation), or defects in hormone synthesis can cause hypothyroidism from birth.

  • Generalized Thyroid Hormone Resistance: A rare genetic condition in which the body’s cells are resistant to thyroid hormone, leading to high TSH levels despite normal thyroid hormone levels.

  • Other Conditions: Less common causes like fibrous thyroiditis, sarcoidosis, and hemochromatosis (iron overload) can also lead to thyroid dysfunction and elevated TSH.

Diagnosis of Elevated TSH Levels

If your doctor suspects thyroid dysfunction, they will typically order blood tests to measure TSH, T3, and T4 levels. A high TSH level, along with low T3 and T4, confirms hypothyroidism. Additional diagnostic tests may include:

  • Thyroid antibodies: To check for autoimmune thyroid diseases like Hashimoto’s thyroiditis.
  • Ultrasound: To examine the structure of the thyroid gland and check for nodules or inflammation.
  • Radioactive iodine uptake test: To assess how well the thyroid is functioning in producing hormones.

Treatment Options for Elevated TSH

The treatment for elevated TSH levels largely depends on the underlying cause and the severity of the symptoms. Common treatments include:

  1. Thyroid Hormone Replacement Therapy:
    • The most common treatment for hypothyroidism is levothyroxine, a synthetic form of the thyroid hormone T4. It helps restore normal hormone levels and bring down TSH levels.
    • Dosages are adjusted over time based on regular monitoring of TSH, T3, and T4 levels to ensure optimal thyroid function.
    • It's crucial to take levothyroxine consistently and as prescribed, typically on an empty stomach 30-60 minutes before breakfast or at bedtime, at least 4 hours after the last meal.
  2. Management of Underlying Conditions:
    • For conditions like thyroiditis or postpartum thyroiditis, treatment may be temporary or involve anti-inflammatory medications like corticosteroids in the case of subacute thyroiditis.
    • In cases of drug-induced hypothyroidism, adjusting or discontinuing the offending medication (like lithium or amiodarone) may help normalize TSH levels.
  3. Iodine Management: 
    • For iodine-related causes of hypothyroidism, balancing iodine intake through diet or supplements may resolve the condition.
  4. Surgery or Radioactive Iodine:
    • In severe cases, such as thyroid cancer or large goiters, surgery (thyroidectomy) or radioactive iodine treatment may be necessary, often followed by lifelong thyroid hormone replacement therapy.
  5. Monitoring in Subclinical Hypothyroidism:
    • If you have subclinical hypothyroidism (elevated TSH with normal T3 and T4) with few or no symptoms, your doctor may recommend regular monitoring without immediate treatment.
    • Treatment is more likely if TSH levels are very high (typically above 10 mIU/L) or if there is a risk of progression to overt hypothyroidism.
    • There is ongoing debate in the medical community about when to treat subclinical hypothyroidism, especially in older adults. Your doctor will consider factors such as your age, symptoms, and overall health when making treatment decisions.

Special Considerations

  1. Pregnancy:
    • Proper thyroid function is crucial during pregnancy for both maternal and fetal health.
    • Women with known thyroid disorders often require increased doses of levothyroxine during pregnancy.
    • Regular monitoring of thyroid function is essential throughout pregnancy, with TSH levels checked at least once each trimester.
  2. Medication Interactions:
    • Several medications and supplements can interfere with levothyroxine absorption or effectiveness. These include:
      • Calcium and iron supplements
      • Proton pump inhibitors and antacids
      • Certain cholesterol-lowering drugs
      • Estrogens and oral contraceptives
    • Always inform your healthcare provider about all medications and supplements you're taking.

Follow-up Care

Regular monitoring is crucial for managing elevated TSH levels effectively:

  • Initially, TSH levels should be checked every 6-8 weeks after starting treatment or changing dosage.
  • Once stable, annual check-ups are typically sufficient for most patients.
  • Dose adjustments may be necessary due to changes in weight, aging, or other health conditions.
  • Never adjust your medication dosage without consulting your healthcare provider.

Lifestyle Adjustments and Support

In addition to medical treatment, managing elevated TSH levels may also involve lifestyle changes:

  • Diet: A balanced diet rich in essential nutrients like iodine, selenium, and zinc can support thyroid health. Avoid excessive intake of goitrogenic foods (such as raw cruciferous vegetables) if iodine levels are low.
  • Exercise: Regular physical activity can help combat symptoms like weight gain, fatigue, and mood changes.
  • Mental Health Support: Coping with hypothyroidism-related depression or cognitive difficulties may benefit from counseling or support groups.

By following these guidelines and working closely with your healthcare provider, most people with elevated TSH levels can effectively manage their condition and maintain good overall health.

What does it mean if your Thyroid-Stimulating Hormone (TSH) result is too low?

- A low TSH often, but not always, means that a person has an elevated level of thyroid hormones.

- While often associated with hyperthyroidism, a low TSH could also be a sign of central hypothyroidism.

- If you have low levels of thyroid stimulating hormone (TSH), but normal levels of T3 and T4 it could mean that you have a condition that is called subclinical hyperthyroidism. Please refer to this article for more information on subclinical hyperthyroidism. 

Some specific causes of low TSH are:

- Graves' disease

- Thyroiditis (e.g. postpartum thyroiditis, de Quervain's thyroiditis)

- Euthyroid sick syndrome

- Excessive thyroid hormone replacement therapy

- Iodine-induced hyperthyroidism 

- Toxic nodular goiter

- Amiodarone

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