THYROID FUNCTION TEST

Patricia A. Jacinto
QMMC Department of Surgery, Pre-resident
• (THYROID ANA)
Thyroid Hormone Physiology
Hypothalamic-Pituitary-Thyroid hormone axis
Tests of Thyroid Function
• Thyroid Stimulating Hormone (TSH)
• T4 (Total or Free)
• T3 (Total or Free)
• Thyrotropin-Releasing Hormone (TRH)
• Thyroid Antibodies
• Thyroglobulin
Thyroid Stimulating Hormone (TSH)
• Reference range: 0.5 – 5 U/mL
• Only test necessary in most patients with thyroid nodules that
clinically appear to be euthyroid
• Serum TSH levels reflect the ability of the anterior pituitary to detect
free T4 levels
• Ultrasensitive TSH assay: most sensitive and most specific test for the
diagnosis of hyperthyroidism and hypothyroidism
Total T4
• Reference range: 55 – 150 nmol/L
• Total T4 levels reflect the output from the thyroid gland itself
• Not suitable as a general screening test
• Increased levels seen in:
• Hyperthyroid patients
• Elevated Tg levels secondary to pregnancy, estrogen/progesterone use or
congenital diseases
• Decreased levels seen in:
• Hypothyroid patients
• Decreased Tg levels secondary to anabolic steroid use and protein losing
disorders (i.e. nephrotic syndrome)
Total T3
• Reference range: 1.5 – 3.5 nmol/L
• Total T3 levels reflect peripheral thyroid hormone metabolism
• Not suitable as a general screening test
• Measurement of total T3 levels is important for clinically hyperthyroid
patients with normal T4 levels
• May have T3 thyrotoxicosis (Early hypothyroidism)
Free T4 (FT4)
• Reference range: 12 – 28 pmol/L
• Free thyroid hormones are a sensitive and accurate measurement of
the biologically active thyroid hormone
• Its utility is confined in detecting early hyperthyroidism in which total
T4 levels maybe normal but free T4 levels are raised
• Not performed as a routine screening test in thyroid disease
• Refetoff syndrome
• End-organ resistance to T4
• ↑ FT4 are and TSH levels are normal
•
Free T3 (FT3)
• Reference range: 3 – 9 pmol/L
• Most useful in confirming the diagnosis of early hyperthyroidism in
which levels of free T3 and T4 rise before total T3 and T4
Thyrotropin-Releasing Hormone (TRH)
• Used in the evaluation of pituitary TSH secretory function
• Previously used to assess borderline hyperthyroidism, but has largely
been replaced by TSH assays
Thyroid Antibodies
• Include Anti-Tg, Antimicrosomal, or Anti-TPO and Thyroid-stimulating
immunoglobulin (TSI)
• Anti-Tg & Anti-TPO antibody levels: usually elevated in autoimmune
thyroiditis
• Do not determine thyroid function
• Elevated in:
• Hashimoto’s thyroiditis, ~80%
• Graves’ disease
• Multinodular goiter
• Thyroid neoplasms, occasionally
Thyroglobulin
• Only made by normal or abnormal thyroid tissue
• Increased levels in:
• Destructive processes of the thyroid gland – Thyroiditis
• Overactive states – Graves’ disease and Toxic multinodular goiter)
• Most important use is for the monitoring of differentiated thyroid
cancer recurrence, after total thyroidectomy and RAI ablation.
• Elevated anti-Tg antibodies can interfere with the accuracy of Tg levels, hence,
should always be measured when interpreting Tg levels.
Calcitonin
• Reference range: 0-4 pg/mL basal
• secreted by C cells
• Functions to lower serum calcium
• sensitive marker for Medullary Thyroid cancer
 TSH Free T4 Free T3 Condition
Normal Normal Normal Euthyroid
Decreased Increased Increased Primary Hyperthyroidism
• Graves’ disease
• Multinodular goiter or toxic adenoma
Decreased Normal Normal Subclinical Hyperthyroidism
Decreased Normal Increased T3 thyrotoxicosis
Decreased Increased Normal Thyroiditis
T4 ingestion
Hyperthyroidism in the elderly or with comorbid illness
Decreased Decreased Decreased Central Hypothyroidism
Decreased or Decreased Decreased Euthyroid sick syndrome
Normal
Increased Normal Normal Subclinical Hypothyroidism
Recovery from euthyroid sick syndrome
Increased Decreased Decreased Primary Hypothyroidism
• Hashimoto’s thyroiditis – (+) anti-TPO, anti-Tg
• Post-thyroidectomy
Increased or Increased Increased (-) TRH test: TSH secreting Pituitary adenoma (Secondary
Normal Hyperthyroidism)
(+) TRH test: Thyroid hormone resistance syndrome
Hypothyroidism: Etiology
↓ T4, T3
PRIMARY (↑ TSH) SECONDARY (↓ TSH) TERTIARY
Hashimoto’s thyroiditis Pituitary tumor Hypothalamic insufficiency
RAI therapy for Graves’ disease Pituitary resection or ablation Resistance to thyroid hormone
Postthyroidectomy
Excessive iodine intake
Subacute thyroiditis
Medications: antithyroid drugs,
lithium
Rare: iodine deficiency,
dyshormogenesis
Hypothyroidism
• Deficiency in circulating thyroid hormone
• Associated conditions:
• Cretinism – in neonates; neurologic impairment and mental retardation
• Pendred’s syndrome – deafness
• Turner’s syndrome
Hypothyroidism
• Neonates: failure to thrive, severe mental retardation
• Childhood or adolescence: delayed development and may also lead to
abdominal distention, umbilical hernia, and rectal prolapse
• Adults: nonspecific, including tiredness, weight gain, cold intolerance,
constipation, and menorrhagia
Hypothyroidism: Clinical Features
• Facial and periorbital puffiness
• Rough, dry skin with yellowish hue
• Dry and brittle hair, with severe hair loss, characteristic loss of the
outer two thirds of the eyebrows
• Enlarged tongue
• Cardiovascular changes include bradycardia, cardiomegaly, pericardial
effusion, reduced cardiac output, and pulmonary effusions. When
hypothyroidism occurs as a result of pituitary failure, other features of
hypopituitarism, such as pale, waxy skin; loss of body hair; and
atrophic genitalia, may be present.
• Nonspecific abdominal pain accompanied by distention and
constipation.
• Libido and fertility are impaired in both sexes.
• Hypothyroidism secondary to pituitary failure: pale, waxy skin, loss of
body hair, and atrophic genitalia.
Hypothyroidism: Laboratory findings
• Low T4 and T3
• Primary hypothyroidism: ↑ TSH
• Secondary hypothyroidism: ↓ TSH despite TRH stimulation