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Thyroid/ hashimoto's testing and diagnosis

Thyroid 101 – Part 2 Diagnosis and Testing

Today we are going to jump right into the examination and testing of the thyroid. This is the second part of a series of articles covering the basics of the thyroid gland. For part one, covering how the thyroid works, click HERE!

How to diagnose Hashimoto’s?

Physical examination

The physical examination of the thyroid gland includes palpation of the tissues. Additionally, some clinicians may inspect the thyroid gland visually. In the sitting position your clinician will place your head in a slight hyperextended position and will shine a light across the front of your neck. Then you will be instructed to swallow. The clinician will monitor for any abnormal enlargement, masses, contour and asymmetry when you swallow. The physical examination of the neck is done to check for any abnormal masses and presence of any prominent pulsation[11]. The following are some findings observed in the physical examination of a patient with Hashimoto’s disease:

  • Enlargement of the thyroid gland, which is present in the neck, is a common finding of Hashimoto’s disease[11]. As TSH secretion is increased in hypothyroidism the gland will work harder and harder to produce hormones and therefore grow [7].
  • Hashimoto’s disease is the result of an autoimmune disorder of thyroid gland and therefore, it has a fine nodular texture. Furthermore, uninodular or multinodular lesions can also be present in Hashimoto’s disease [11].
  • This autoimmune goiter is usually painless, swelling and tenderness may be present with acute inflammation or attack[11].

Apart from the above mentioned signs, the following hypothyroidism related symptoms may also be observed during physical examination of Hashimoto’s disease [11]:

  • Delayed response of deep tendon reflexes
  • Parathesias
  • Low resting/basal body temperature
  • Dry skin
  • Puffy face
  • Hertog’s Sign (lateral thinning of the eye brow)
  • Hoarseness
  • Confusion
  • Depression

“Hashimoto’s disease associated with hypothyroidism and if left untreated it can cause hyperlipidemia, which is detected by increased levels of low-density lipid (LDL)”

Blood tests

The diagnosis of Hashimoto’s disease depends on the findings of circulating antibodies to thyroid antigens (mainly, thyroperoxidase (anti-TPO) and thyroglobulin (anti-TG)) along with proper clinical features demonstrated on physical examination [12]. The following blood tests are conducted to detect Hashimoto’s disease.

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TSH test

The initial procedure followed to diagnose Hashimoto’s disease is to check the TSH level. The measurement of the TSH level in blood is important, as it indicates the communication between the brain and the thyroid. In theory, this marker also represents thyroid gland activity. An elevated level of TSH has been considered as a hallmark of hypothyroidism [10]. Despite this, my clinical experience suggests that you can have a normal TSH, and still have both the symptoms of hypothyroidism, and circulating anti-bodies. That is why a simple TSH test is not enough, and a full thyroid panel should be completed.

T4 test

The amount of T4 in the blood helps to determine the T3 potential, and also offers suggestions about issues with hormone conversion. The usual findings of hypothyroidism include a decreased level of T4 in the blood [10]. The ratio between T3 and T4 is especially important if you are on synthroid, as many people do not properly convert this T4 containing medication into the active T3.

T3 test

The amount of T3 in the blood is often proportional to symptoms. It should be measured regularly.

Antithyroid antibody test

The anti-thyroid antibody test is performed to determine the presence of thyroid autoantibodies. Thyroid autoantibodies are mainly of two types: anti-TG antibodies and anti-thyroperoxidase (TPO) antibodies. These erroneously attack the thyroid tissues and destroy thyroid follicular cells [7].

  • Anti-TG antibodies attack thyroglobulin (a protein in the thyroid)
  • Anti-thyroperoxidase antibodies (anti-TPO) are the biomarker of autoimmune thyroid diseaseand are present in almost all patients with Hashimoto’s thyroiditis [13]. TPO antibodies attack thyroperoxidase, an enzyme present in thyroid cells that assist in the conversion of T4 to T3. The presence of TPO autoantibodies in the blood provides the evidence of the previous attack on the thyroid tissue by the body’s immune system [10].


Complications of Untreated Hashimoto’s Disease

Untreated Hashimoto’s can cause a number of chronic complications, which include:


Untreated Hashimoto’s leads to chronic hypothyroidism and the enlargement of the thyroid, AKA a goiter. Large sized goiters affect the appearance of the individual, along with possible breathing and swallowing difficulty[14].

Cardiac Problems

Hashimoto’s disease associated with hypothyroidism causes hyperlipidemia, which is detected by increased levels of low-density lipid (LDL). LDL, which is considered as ‘bad cholesterol’ is one of the primary causes of plaque formation. This is especially true of the small sized LDL particles. Consequences of this lead to atherosclerosis and other related cardiac problems [14].

Mental Health Issues

Depression is another common symptom of Hashimoto’s disease which can be worsened in untreated patients. Another concern that can be noted is a decreased libido in both men and women, which also reduces mental functioning (who knew!) [14].


Chronic hypothyroidism due to untreated Hashimoto’s disease can cause dermatological complications i.e. Myxedema. Myxedema refers to the deposition of mucopolysaccharides in the skin, resulting in swelling of the affected area. Other clinical symptoms of Myxedema include drowsiness, lethargy, and in severe cases, unconsciousness. Some triggering factors such as exposure to cold, infection, stress or administration of sedative drugs may cause myxedema coma, which is an emergent condition that requires immediate medical attention [14].

Complications in Pregnancy

Untreated Hashimoto’s disease during pregnancy can damage the neurological growth of the fetus due to a decreased availability of maternal thyroxine hormone during early gestation [15]. Thyroid hormones and anti-bodies should be monitored closely in early pregnancy to prevent complications.


Now that you have a thorough grasp on the diagnosis of Hashimoto’s and hypothyroidism it is time to understand how to begin to feel better! The first step in this is to pick up my guide on Reading your Thyroid Labs – the Optimal Reference ranges. This will help you to better understand how well  your condition is managed. Additionally, don’t forget to stay tuned next week for part 3, the treatment section.


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