Hashimoto’s Lab Tests

Hashimoto’s is one of the most common autoimmune disease in the United States, yet is is also one of the most poorly managed. One of the most common questions I get is, what tests should I ask my doctor to order?

Because Hashimoto’s is a thyroid disorder and an autoimmune disease there are a number of additional lab tests that are important but are not, specifically, tests for the thyroid. In this post I will discuss them all and explain why it is important to order them, as well.

Should You Order Tests Yourself?

There are some people out there on the internet, who, out of frustration, believe that you should forget about asking a doctor to order tests for you and just order them for yourself.

In their defense, many doctors do not order the appropriate tests to do proper management of thyroid patients. There is too much emphasis put on some tests, and not enough on others that can give a great deal of information about how you are doing and how your medication is working.

However, here’s my take on that:

If you bought a luxury car, say a Tesla or a Lamborghini, you’d want to make sure it was kept in tip top shape. Would you do the diagnostics yourself? Think about how long it would take you to master the proper care of those vehicles.

It’s kind of the same thing with your body and lab testing. Hashimoto’s has so many moving parts. You are better off finding a doctor who you can have a partnership with who can give you his years of clinical expertise and help you to make sense of it all.

And if your doctor can’t or won’t do that? Well, find a doctor who will and work together to do a proper history, evaluation and diagnostic testing so that you can optimize your body and your health.

For myself, my health and my body are worth way more than a luxury car. I want to do everything I can to make sure it is kept in the best possible running order. And ordering your own lab tests can be very expensive, especially if you don’t have insurance. I give my patients lab tests at my cost. We can get them at a substantial discount and we are able to pass the savings onto them.

What Does the Lab Range Mean?

When interpreting Hashimoto’s lab tests you are always given 2 sets of numbers. Your test results and the laboratory range. The laboratory range is an average that is calculated based on the number of people who go to the lab in a given geographic area for a fixed amount of time.

These averages are influenced by many things: the health of that general population, the medication that is popular and prescribed during that period of time and by what general diseases those people have.

All of these factors skew the numbers. Have you been to a lab lately in your area? Spend a day there and ask yourself if those people represent the quality of life and general state of health that you want.

In many areas, in the US in particular, the general population has not gotten any healthier over the last 20 years. Look at the statistics. You probably don’t want to be among that average group. What I am getting at is, the laboratory range is not really a measure of good health. This is particularly true when it comes to the thyroid.

Millions and millions of Americans have thyroid disease and are on thyroid medication. This skews the numbers. Practitioners of functional medicine, like myself, use an additional set of numbers when we evaluate people’s health.

This is called the functional range and different specialists in various fields have identified these ranges as being where optimal health is.

So, when you are looking at laboratory results make sure you ask about functional ranges as well as laboratory ranges. Many doctors do not look at functional ranges, so be aware that asking about this may elicit a confused or dismissive response. (In this post we are focusing on lab tests alone, in a future post I will discuss how to interpret these tests.)

An Overview of What Should Be Tested

Hashimoto’s is an autoimmune disease and a thyroid disorder, so we must evaluate many things not just the thyroid. Here’s a list of what any good workup should include:

* Thyroid tests: TSH,  free T3 (fT3), free T4 (fT4), Reverse T3, (rT3)

* Blood Sugar Analysis: Fasting glucose, HgA1C, Triglycerides, Cholesterol, LDL, and HDL

* Iron: Serum iron, TIBC, Transferrin and Ferritin

* Vitamin D3

* Vitamin B12 and B6

* Red and White Blood Cell Count: Complete CBC

* Tests to determine Adrenal Gland Health: BUN, Creatinine, Sodium and Potassium, Special test(s)

* Electrolytes: Sodium, Potassium, Magnesium, CO2, Chloride, and Phosphorous

* Markers that Evaluate the Health of the Intestines: Protein and Globulin, Special tests

* Hormone Testing: Saliva tests

* Immune Cell Testing: Special tests

…and maybe more, depending on what is found in a good thorough history. Let’s take a look at each of these briefly to give you a good sense of what we are looking for.

Thyroid Testing

TSH – Thyroid stimulating hormone (TSH), also called thyrotropin is released by the pituitary gland after the hypothalamus releases TRH (thyrotropin releasing hormone). TSH is the most common and most sensitive marker used to assess thyroid function. But it is not the be all and end all in thyroid testing, the way that so many doctors and practitioners make it.

In addition, many laboratories have do what is called a “thyroid cascade” in order to save themselves and insurance companies money. Basically, if the TSH is deemed to be in the normal range they will not analyze for T3 or T4 or anything else. That doesn’t help you and there not much agreement on what the normal range should be.

TSH levels increase as T4 levels drop and TSH levels decrease as T4 levels rise. The reason this is the most popular test in today’s medical model is because the only treatment offered for thyroid dysfunction is thyroid hormone replacement and that’s what doctors are checking when they test your TSH.

A TSH test alone doesn’t give you information about thyroid-pituitary communication, about T3 to T4 conversion in other parts of the body or about whether or not your immune system is attacking your thyroid.

One important thing for Hashimoto’s people to understand is that some antibodies can inhibit thyroid function by turning off instead of stimulating TSH receptors on cells. In this case, you will see high TSH and high antibodies.

Free T3 – measures the free T3 hormone levels. This test is rarely ordered by traditional endocrinologists and is usually only used when a patient has hyperthyroid symptoms and the fT4 levels are normal.

Even so, this test can be really useful for finding out what amount of active thyroid hormones are available for the thyroid receptor sites. Free T3 is high in hyperthyroid conditions and low in hypothyroid conditions. May also be high in thyroid toxicosis.

Free T4 – used to measure the amount of free or active T4 in the blood. High with hyperthyroidism, low with hypothyroidism. The drug Heparin can also cause elevated free T4 as can some acute illness. Its also high in an overdose of thyroid hormone.

Reverse T3 – Reverse T3 is usually produced when there is an extreme amount of stress. For example, a serious car accident, or surgery or really bad chronic stress.

Its no surprise that this is elevated after a stress response or when the body produces high amounts of the stress hormone cortisol. Reverse T3 is low when you have severe tissue damage like a bad burn or laceration or when you have liver disease like cirrhosis.

This may also be high if your iron is low.

Thyroid Antibodies

When these antibodies are present, it means that your immune system is attacking your own tissue. When your body produces thyroid autoantibodies it could create a hypo- or hyper- thyroid state.

They may also be elevated if there is thyroid cancer. Some antibodies can attach to TSH receptors, but they don’t cause a response in the thyroid.

These people will complain of low thyroid symptoms, but the TSH might not change at all. In other cases, the antibodies bind to receptor sites and cause the thyroid to be over active. Here you will see high T4, low TSH and high antibodies.

There are 3 autoantibodies that are tested. The first 2 are the most common:

Thyroid Peroxidase Antibody (TPO Ab): This antibody is the one that is usually high in autoimmune thyroid conditions like Hashimoto’s. It is also known as microsomal antibody.

Thyroglobulin Antibodies (TgAb): These aren’t seen high as often as TPO Ab. They are usually ordered when thyroid lab results seem strange because these antibodies can interfere with thyroid hormone production.

TgAb is also used to monitor progress after surgery for removing the thyroid in thyroid cancer.

Thyroid-Stimulating Hormone Receptor Antibody (TRAb): This antibody is only ordered when a patient is hyperthyroid. Positive results usually mean Grave’s disease.

For a complete overview of all thyroid tests to order, you can read my previous post here.

Blood Sugar

Measuring blood sugar is critically important for Hashimoto’s patients because if you have issues with your blood sugar (too high or too low) it can undermine everything else you are trying to do.

Fasting Glucose: A snapshot of how your blood sugar is at the time of the test.

HbA1C (Hemaglobin A1C): This test is a long term sugar marker and commonly used to assess type II diabetes and metabolic syndrome. (It’s optional, but should be ordered if you are overweight and have a history of high triglycerides and fat around your waist.)

Triglycerides: These are sugars stored in the fat in the liver.

Cholesterol, LDL, HDL: Most people have been brainwashed into thinking cholesterol is about fat. Don’t be misled. Its about sugar and sugar consumption and statin drugs do nothing to fix this.


Iron is another “deal breaker”. If you have low iron it will undermine everything you are trying to do and make it unsuccessful. Hashimoto’s folks, especially women, often have issues with their iron levels. Most iron panels contain all of the following tests:

Serum Iron – Iron is necessary for making hemoglobin which carries oxygen on red blood cells. Decreased iron levels must be correlated with RBC, HGB, and HCT to rule out anemia (more on what those mean in a moment).

TIBC – Total iron binding capacity. this will be elevated in iron deficiency because this increases the cells’ potential to bind to iron. TIBC is high before anemia develops and, therefore, can be a good way to find iron deficiency early.

Transferrin – Regulates iron absorption. Increased with iron anemia.

Ferritin – A good marker for total body iron levels and reflects how much iron the body has stored. It also called an “acute phase reactant” and can be a good marker of inflammation.

Vitamin D:

Test for Vitamin D3  (25-hydroxyvitamin D). Vitamin D is hugely important for people with Hashimoto’s because it strengthens the regulatory part of the immune system and we often have difficulty absorbing it.

Vitamin B12, B6 and Folate

These tests can be expensive and B12 and B6 can be tested by reading a CBC (Complete Blood Count) properly, a test that is available for under $20. (I’ll explain how to do this in a future post.)


A complete blood count that includes: Red Blood Cell counts: Red Blood Cells (RBC), Hemoglobin (HGb), Hematcrit (HCT), MCV, MCH, MCHC

and White Blood cell counts: White Blood Cell Count (WBC), Lymphocytes, Neutrophils, Basophils, Monocytes, Eosinophils.

There is a ton of information that you can gather from this very inexpensive test, including information about various anemias, autoimmunity, and possible infections that may be affecting your progress. (More on how to interpret this in a future post).

Electrolytes: These tests are usually part of what is called a “metabolic panel” and can be helpful in finding mineral deficiencies and electrolyte imbalances. These include: Sodium, Potassium, Magnesium, CO2, Chloride, and Phosphorous. The metabolic panel will also include Serum Protein, Albumin and Globulin.

Adrenal Health:

On a simple blood test, you can test the adrenals by ordering a Renal panel (BUN, Uric Acid, Creatinine) and by evaluating electrolytes, Potassium and Sodium.

The gold standard for measuring adrenal health is a saliva test that tests cortisol levels throughout the day. This can tell you a lot about how adversely stress may be affecting your health and your thyroid.

Special Tests:

These are all tests that can be very important for Hashimoto’s patients, but they are complicated and should be ordered by someone who knows what to do with the information that they provide.

Intestinal Health:

Healing the intestines is job #1 for many Hashimoto’s patients because the gut is where the immune system lives and if you want to modulate and calm your immune system, you must go there it lives. In a common blood test, Serum protein, and globulin levels can give clues to intestinal issues.

There are test on the market for intestinal permeability (leaky gut), gluten sensitivity and intolerance, and cross reactive foods that may be causing immune flare ups. The best Lab for this is Cyrex labs.

Hormone Testing:

There are various hormones that can be tested including, estrogen, progesterone and testosterone. This is involved and deserves a blog post of its own (which I will, humbly provide, in due time).

Depending on what you want to accomplish, the best of these to determine fertility and possible defects throughout a woman’s cycle are saliva tests gathered at intervals throughout the entire month.

Immune System Testing:

There are various ways to test the different aspects of the immune system from Cytokine testing, to TH-1 and TH-2 challenges. This is also quite complicated and involved and must be done with someone who understands what to do with this data.

Bottom Line:

As you can see, this can get pretty complicated, pretty quick. The best thing to do is inform yourself and then work with someone who is experienced in reading and evaluating these kinds of tests and who knows what to do with the data that is gathered.

That is what I offer here at Hashimotoshealing.com and why I created my program, Healing Hashimoto’s: the 5 Elements of Thyroid Health. In this 6 week intensive you will learn how to interpret your blood tests and, more importantly, learn what to do with that information in order to create an effective strategy for Healing your Hashimoto’s.

Mastering Functional Blood Chemistry Analysis, Datis Kharrazian, DC. 2012
Laboratory Evaluations for Integrative and Functional Medicine, 2nd Edition, Richard  S. Lord, J. Alexander Bralley, 2008

About the Author Marc Ryan

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