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Well Women Guide to TestsTests for Thyroid and Adrenal Function I have been forwarded detailed information regarding tests from Thyroid UK. The first thing to be said about tests in general is that they should be used to help or clarify a diagnosis. They should not be an end in themselves, and should be secondary to a clinical diagnosis. In this present day, far too much reliance is placed on a multiplicity of tests, many expensive and not necessarily appropriate; and this done in place of a proper clinical appraisal as a sort of shortcut. This tendency in modern medicine, which pushes commonsense aside and replaces it with unbending establishment belief in medical technology so that doctors simply don’t think, is to be deeply deplored. Having said this, there is certainly a place for proper testing, but tests should not, and must not, take precedence over listening to the patient's symptoms and undertaking a proper examination. Cetainly there is a controversy within the world of endocrinolgy regarding the reliance on lab tests. For further reading on this matter please read Dr Jacob Teitelbaums article. Dr Teitelbaum is an expert in hypothyroidism, Chronic Fatigue Syndrome, Fibromyalgia and autoimmune disease. The appropriate tests fall into several categories: Blood Tests a. General Tests b. Thyroid Tests c. Why Tests Go Wrong d. Adrenal Tests
Urine Tests
a. General Tests b. Specific Tests
Salivary Tests
a. Thyroid Tests b. Adrenal Tests c. Other Hormone Tests
Other Tests a. X-Ray b. Fine Needle Aspiration (FNA) c. Scanning
d. ECG e. Live Blood Analysis
Blood Tests
General Tests
A complete “work up” should include:
A full blood count (FBC) which will include:
Haemoglobin (Hb) and Red Cell Count (RBC) to check for anaemia, commonly found in hypothyroidism. White Cell Count (WBC) and Differential (Diff) to check for general health. Erythrocyte Sedimentation Rate (ESR) also for general health. Ferritin for iron level. Low in anaemia, and necessary for proper thyroid metabolism.
Additionally should be carried out:
Blood Sugar a rise may indicate diabetes; a deficiency, hypoglycaemia. Urea and Electrolytes checking kidney function. Kidney efficiency declines in hypothyroidism.
Bilirubin and Liver Function Tests checking liver function, which also depends on thyroid health. Cholesterol usually raised in hypothyroidism and deficient liver function.
Parathyroid Hormone (PTH) to check on parathyroid and calcium status. (Deficiencies may occur due to the accidental removal of parathyroid glands during a total thyroidectomy).
Finally, sex hormones:
Oestrogen and Progesterone for ladies Testosterone for men
These tests are necessary, particularly for any patient in middle life or beyond, since they affect thyroid hormone transport and uptake.
Thyroid Tests
Thyroid Stimulating Hormone (TSH)
Widely considered the most useful of thyroid tests, it is nevertheless nothing like as sensitive as doctors like to think, especially for mild to moderate hypothyroidism. In low thyroid function, the TSH is expected to rise above its reference range. Unfortunately, this reference range varies from laboratory to laboratory and from doctor to doctor, but anything over 2.5mU/L should be considered highly suspicious. The reasons the TSH test fails to show the true picture are related to a general depression of the metabolism (as with hypothyroidism) making the pituitary gland unresponsive to low blood thyroid levels, so that the rise above 2.5 may not occur or only insignificantly. A very low level is likely to be due to primary hyperthyroidism. Also, the pituitary or hypothalamus may be damaged anyway (secondary or tertiary hypothyroidism), again making the tests unreliable. (See Interpretation of TSH Blood Test Results.)
Free T4 (FT4) and Total T4 (TT4)
Most of the circulating thyroxine is attached to transport proteins called binding globulins and the Total T4 indicates the total amount of thyroid circulating in the bloodstream, that is, both unusable bound thyroid and the usable free thyroid. The thyroxine free of the binding globulin (FT4) indicates the amount of thyroid hormone actually available for use in the bloodstream, prior to its conversion to the active thyroid hormone tri-iodothyronine (T3). The reference range for TT4 is 54-142 nmol/L. The range for FT4 is 9-23 pmol/L. Values significantly above the top end of both ranges would suggest hyperthyroidism. Free T3 (FT3) and Total T3 (TT3)
If T3 is measured, the free form is almost invariably used since it is attached to a transport protein in a very limited amount. The Free T3 therefore indicates for the amount of converted active thyroid hormone available. The reference range of FT3 is 0.8-2.5 nmol/L. The range for TT3 is 3-8 pmol/L. Values significantly above the top end of the ranges would suggest hyperthyroidism.
Reverse T3 (rT3)
Excess conversion of T4 into reverse T3 as suggested by Dr Wilson, is a possible cause of hypothyroidism. A measurement may therefore be made of the unusable rT3, whose range is between 0.2-6.7 nmol/L. Thyroxine Binding Globulin (TBG)
This test is not as used quite so much today as previously, although a raised level of globulin may be associated with a hypothyroid state due to thyroid being taken out of circulation and therefore bound and unusable. A low TBG may also be associated with thyroid transport failure and this makes the test difficult to interpret. Normal range is 6-17 mg/L.
Antithyroid Peroxidase Antibody (TPO Ab), Antithyroglobulin Antibody (TG Ab) and Thyroid Stimulating Immunoglobulin (TSI Ab)
In general there should be no antibodies present, or at least at very low levels. The presence of antibodies indicates an autoimmune situation and thyroid damage: Hashimoto’s disease is the most common example of this. Antibodies diminish with treatment or as the immune thyroiditis progresses. The reference range for TPO Ab is anything less than 150 mUI/ml or Ab Index less than 0.9; the TG Ab is 200 mUI/ml or Ab Index less than 0.9. If the TSI shows any antibodies at all, it is evidence of hyperthyroidism (Graves’ disease), though these antibodies may also appear in Hashimoto’s disease.
Why Tests Go Wrong The ranges given above are broadly those used by most laboratories. All these tests are subject to errors which have to be carefully borne in mind when interpreting them:
1. The blood tests themselves are not sensitive enough and each laboratory that undertakes them uses different methods and may have different reference ranges. 2. They represent a snapshot of levels of thyroid hormones in the bloodstream which are subject to daily, even hourly, variation, so that the time of day and circumstances of the test may cause inaccuracies. 3. In hypothyroidism the circulation is slowed to a variable degree, interfering with accurate estimation. 4. In hypothyroidism the blood is subject to a degree of concentration, also resulting from the slowed circulation, and this has the effect of raising blood levels above their true figure. 5. Most important is the slowed T4 to T3 conversion, together with the slowed uptake of T3 into tissues affected by low metabolism, so that the mechanisms within the cell to aid the passage of thyroid hormones into the cell are damaged. The action of the cellular power source, the mitochondrion, is similarly slowed. This means blood levels may be raised because thyroid hormone is not being used in the normal way. 6. Many doctors lack the basic training in thyroid medicine to interpret the results of the tests correctly. Frequently they hope that the laboratory results will do the interpretation for them; but without a full clinical history, and perhaps other tests available, the interpretation may be wrong.
Adrenal Tests 1. Serum Cortisol – while this would appear to be the most obvious check on adrenal function, as well as the most important from our point of view, in fact it is almost completely useless. The daily output varies widely from morning to evening, and almost from minute to minute. This variation is worsened by moment to moment challenges: for example, a white coated (but well meaning) physician, advancing on his patient syringe in hand, may double the cortisol in the bloodstream in moments. The morning range is 220-770 nmol/L and the evening range is 55-250 nmol/L.
2. DHEA (dehydroepiandrosterone) Sulphate - this is of more value than serum cortisol. The adrenals produce more of this hormone than any other, so that a low level may indicate poorly functioning adrenal glands. On the other hand, the levels may be raised, which indicates that the production of cortisol from the glucocorticoid path-way, is likely to be interrupted by an enzyme failure. Both situations will result in an insufficiency of cortisone. 3. Synacthen Test - this is an adrenal function test widely approved of by hospital consultants. Adrenocorticotrophic Hormone (ACTH) in the form of synacthen is given by injection. This stimulates adrenal production of cortisone, which is then measured 30 minutes or more later. It may be given in a weakened form, the Short Synacthen Test. A normal response, where the amount of cortisone is doubled, is considered to be proof of a normal adrenal response. Certainly, Addison’s disease will be demonstrated by this test since the adrenal response is absent or very weak. Low adrenal reserve, however, is likely to be swamped by the synacthen; the adrenals, under such a powerful stimulus, may produce - for a short while - an apparently normal response. There is no specific reference range for this, but the accepted response is for the base line level of cortisol (that is, before the test) to double.
Urine Tests General Tests The urine will be tested routinely for: 1. Protein – to check for infection or damaged kidneys, related to hypothyroidism. 2. Sugar – to check for diabetes mellitus, common in hypothyroidism. 3. Ketones – to check for malnutrition or loss of tissue in either Graves’ disease or adrenal insufficiency, or diabetes mellitus, common in hypothyroidism. 4. Bile Pigments – to check liver function, which is affected by hypothyroidism.
Specific Urine Tests 1. Thyroid Hormones - just at present, this is not routinely done in the UK, but is undertaken by one or two laboratories in Europe. The urine passed over 24 hours is collected, a sample of which is taken, and then delivered to the laboratory within 24 hours. Total T4 and T3 is measured showing the amount of thyroid hormone actually being used by the tissues, making this a valuable test.
2. 17 Hydroxy-ketosteroids – these can be measured by the same technique; since they are products of the metabolism of cortisone, an accurate estimation of adrenal cortisol output may be made. A simpler test for total cortisol is available.
Urine tests are useful but not widely available and therefore not usually asked for by the NHS. A positive result may, however, convince your doctor if he is unsure of the diagnosis. Salivary Tests
Thyroid Tests Unfortunately, it has not been found possible to reliably estimate thyroid status using the saliva.
Adrenal Tests Salivary sampling can provide useful estimations showing variation of output of both cortisol and DHEA levels during the day and may be graphically presented. The saliva samples are collected at intervals from 8am – Midnight. Other Hormone Tests A selection of male and female sex hormone profiles are offered and are an excellent alternative to blood testing. (See Resources). Menopausal levels in either sex have an important impact on thyroid metabolism.
Other Tests 1. X-ray A chest x-ray is likely to have been done if you are breathless or have other respiratory symptoms. Enlargement of the heart or fluid congestion in the bases of the lungs can be due to low thyroid, although there are of course many other possible causes.
2. Fine Needle Aspiration (FNA) This is a technique for sampling cells and fluid in nodules within the thyroid itself. It has particular diagnostic significance in the exclusion of cancer. It is not generally necessary unless the thyroid is obviously lumpy and nodular.
3. Scanning Ultrasound scan, CAT scan (Computerised Axial Tomography) and MRI scan (Magnetic Resonance Imaging) may be used as appropriate in hospital where structural changes or growths are suspected. These may not be routine tests in NHS hospitals, but can be undertaken privately. In general, they should not be necessary unless the thyroid is nodular, very much enlarged or causing swallowing or respiratory symptoms. Needless to say, both the heart and adrenals can also be scanned.
4. ECG An electrocardiogram, which is a commonly used test of the electrical function of the heart, may reveal abnormalities in either over-active or under-active thyroid disease. It is possible that an abnormally slow pulse may have suggested to the physician that there is a structural problem of the heart, when in fact the low pulse is simply due to hypothyroidism.
5. Live Blood Analysis This is an exciting recent development in the use of high powered microscopy on live blood cells, which promises to be a valuable screening tool in the diagnosis of thyroid disorders, nutritional deficiencies, reduced immunity, metal toxicity and the presence of oxidising radicals.
This valuable information regarding thyroid tests and provided by Thyroid UK should help you in requesting tests to help you be diagnosed correctly. It would be a good idea to print it out and take it to your GP in the hope that they will act upon it. Here is a useful link to interpreting thyroid function tests from Endocrine Web Also, if you have ever wondered why your doctor has ticked certain boxes on the blood tests request form and wonder what they mean and why, such as U&E, Gamma GT, Fasting Trigs etc then visit Lab tests online An excellent site providing information on a range of tests that your GP may be requesting. There is also a facility to click on the flag of your country (Australia, Germany, Hungary, Italy, Poland, Spain, Uk and U.S.)to read about the test interpretations in your own country. Great site.
Private Tests The good news is that you can now order tests yourself from Genova Diagnostics. You must mention Thyroid UK when ordering these tests or you simply won't be able to order them. Genova Diagnostics offer the most comprehensive range of diagnostic procedures and some of the most advanced diagnostic services currently available in the UK. They are a fully recognised laboratory that has been established since 1994.
Below is a comprehensive list of tests you can order to bring along to one of the Private doctors when you go. (Will save you extra money in the long run as the private docs may want to do their own tests and if you bring the results with you already, it will probably save you money on the docs tests,) Please contact me for the list of doctors specialising in thyroid disease and adrenal exhaustion in the UK and Republic of Ireland. Presently, my favourite Thyroid Doctor is Doctor Barry Durrant- Peatfield. He came to My friends house to give us a talk (friday 19th Sept 2008) and he has given hope to us all. He has made many hundrends of women well with his treatment protocol. His clinic is in Crawley, Sussex and to arrange a consultation, please contact: 01883 623125. Dr Peatfield also has outreach clinics in Aberdeen, Castle Donnington, Great Yarmouth, Leeds, Lytham St Annes, Malvern(Gloucestershire), Morpeth (Northumberland) Stockport (Manchester) Totnes (Devon) and Birtley (County Durham). These are held every 2 to 3 months. For more details, contact the number above. Special Tests: Thyroid UK can offer a wide range of diagnostic tests and receive a small commission for the service from Genova Diagnostics which they use for their campaigns.
Thyroid Blood Profile: TSH/TT4/FT4/FT3/Antithyroid Peroxidase Antibody (TPOAb)/Antithyroglobulin Antibody(TgAb) £50.00(Order Code: TUK1) (Discounted price for TUK only) T3/T4 24hr Urine Test £85.00 (Order Code: TUK2) Reverse T3 test £60.00 (Order Code: TUK 3) Adrenal Stress Index (ASI) £70 - (Code: HOR01) Comprehensive Adrenal Stress Index £90 (Code: HOR02) The Menopause Profile £120.00 (Code: TUK7) Testosterone Saliva Test £65.00(Order Code: HOR07) Testosterone is found in both men and women and raised levels in women are usually seen in Polycystic Ovarian Syndrome (PCOS) and stress can often put this hormone out of balance in both men and women. Female Hormone Panel £144 (Code: TUK4) 1 Day Progesterone/Oestrogen £65.00 (Code: TUK5) Comprehensive Menopause Panel £170.00 (Code: TUK8) Comprehensive Female Hormone Panel £180.00 (Code:TUK6) Candida Antibody Profile £70.00 (Order Code: ANT01) Hair Mineral Analysis £65.00(Order Code: ELE01) to check for toxic levels in the body and also essential mineral deficiencies and includes the following: Toxic Elements: Aluminium, Antimony, Arsenic, Beryllium, Bismouth, Cadmium, Lead, Mercury, Platinum, Thallium, Thorium, Uranium, Nickel, Silver, Tin, Titanium Essential Elements: Calcium, Magnesium, Sodium, Potassium, Copper, Zinc, Manganese, Chromium, Vanadium, Molybdenum, Boron, Iodine, Lithium, Phosphorus, Selenium, Strontium, Sulphur, Barium, Cobalt, Iron, Germanium, Rubidium, Zirconium. How to Order To order a test all you need to do is: Telephone Genova Diagnostics (020 8336 7750) or email them (kitorders@gdx.net) Give them your name, address, date of birth and the code for the test/s you require and mention Thyroid UK when ordering. These private tests will be a marvellous diagnostic tool and since adrenal fatigue, thyroid dysfunction and systemic candida go hand in glove, as well as sex hormone imbalance, the tests may well be your way to overcoming all your chronic illness and be on the road to recovery once and for all.
Please click here to go to the thyroid treatment page
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