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THYROID FUNCTION
TESTS
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TFTs
• used to assess thyroid function

• Commonly estimates the levels of TSH, T4 and T3

• TSH is the best and most reliable test

• In fact, certain labs only estimate TSH levels

• The reference ranges vary from lab to lab

• Additional tests could be done for antibodies specific for

different auto immune diseases

•
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Hypothalamus-pituitary-thyroid axis
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Thyroid-stimulating hormone

• Glycoprotein hormone secreted by the anterior pituitary.

• TSH is firmly established as the first-line thyroid function
test to assess thyroid status
• Its diagnostic superiority arises principally from the
physiological inverse log-linear relationship between
circulating TSH and free T4 (FT4) concentrations
• An abnormal TSH is the first abnormality to appear in
thyroid disease, where other thyroid tests can be normal.
• Using TSH as a single criterion has been shown to
accurately classify the thyroid state of a patient in over
95% of cases
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• TSH alone can only be used to assess thyroid status

when the pituitary-thyroid axis is stable
• Non-thyroidal illness (NTI), pituitary disease and various
drugs can all affect the axis and cause discrepancies
between TSH levels, thyroid hormone levels and the
clinical state
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Thyroid hormones T4/T3

• T4 is the principal hormone secreted by the thyroid gland.
• It is a prohormone with minimal biological activity
• It gets de-iodinated in the peripheral tissues to the active
hormone tri-iodothyronine (T3)
• Thyroid-binding proteins (thyroxin-binding globulin,
transthyretin, and albumin) bind almost all of the available
thyroid hormones in serum
• It is the minute free fraction of hormone (0.02% for T4 and
0.2% for T3) that is responsible for the biological activity
of thyroid hormones.
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Normal ranges
• TSH
• 0.2 - 4.0 mu/L
• T4
• 10 - 20 pmol/L
• T3
• 0.9 - 2.5 nmol/L
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TFTS
• Six patterns commonly encountered in the clinical setting
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Low TSH and high T4 and T3

• This is the picture of primary hyperthyroidism

• In overt primary hyperthyroidism TSH is nearly always

below 0.10 mIU/l and the T4/T3 are above the reference
range
• Graves’ disease (GD) and toxic multinodular goitre (MNG)

are the two most common causes

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High TSH and low T4 and FT3

• This combination of TFTs suggests primary

hypothyroidism
• It is most usually the result of autoimmune thyroiditis

(Hashimoto’s disease or follows thyroidectomy.

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Low TSH and normal T4 and/or T3

• Subclinical hyperthyroidism
• (eg owing to a ‘low-grade’ toxic multinodular goitre or
adenoma)
• Characterised by apparently ‘normal’ TH levels, but low
TSH
• Non-thyroidal illness (NTI) is another common cause of
transiently low (but not fully suppressed) TSH
• resolves following recovery, and emphasises the
importance of not acting on a single TSH result.
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High TSH and normal T4 and T3)

• subclinical hypothyroidism

• Measurement of antithyroid peroxidase (TPO) antibody

titres is a useful adjunct to help guide decision-making

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low TSH with

Low T4 and/or T3
• This combination of TFTs is also seen in NTI and resolves
with recovery.
• However, in the absence of a clear alternative diagnosis,
central hypothyroidism must be considered
• full pituitary hormone profile, including assessment for
secondary hypoadrenalism, is mandatory
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High FT4 (±FT3) with inappropriately

normal or high TSH
• unusual pattern of TFTs
• most commonly accounted for by assay interference,
confounding effects of drugs (eg amiodarone or heparin)
or T4 replacement therapy (including non-compliance)
• Once these have been excluded, two rare but important
conditions must be distinguished: resistance to TH (RTH)
and a TSH-secreting pituitary adenoma
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