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==Overview==
==Overview==
'''Thyroid function tests''' ('''TFTs''') is a collective term for [[blood test]]s used to check the function of the [[thyroid]].
'''Thyroid function tests''' ('''TFTs''') is a collective term for [[blood test]]s used to check the function of the [[thyroid]]. A TFT panel typically includes [[thyroid-stimulating hormone]] ([[TSH]], [[thyrotropin]]) and [[thyroxine]] ([[T4]]), and [[triiodothyronine]] ([[T3]]) depending on local laboratory policy.TFTs may be requested if a patient is thought to suffer from [[hyperthyroidism]] (overactive thyroid) or [[hypothyroidism]] (underactive thyroid) or to monitor the effectiveness of either thyroid-suppression or hormone replacement therapy. It is also requested routinely in conditions linked to thyroid disease, such as [[atrial fibrillation]]. The normal adult reference range for serum [[TSH]] is 0.4-4.5 mIU/L. The adult reference range of [[FT4]] using comparative direct methods is 0.7-1.8 ng/dL (9-23 pmol/L) and that for FT3 is 2.3-5.0 pg/mL (35-77 pmol/L). A high [[TSH]] level may indicate [[hypothyroidism]]. If the results indicate high [[TSH]] levels, a second confirmatory sample including [[TSH]] and free [[Thyroxine|T4]] levels should be tested prior to starting treatment. [[TSH]] should not be measured in isolation in patients with suspected hypothalamic-pituitary disease; the measurement of free [[T4]] is essential. Free [[T4]] testing, combined with TSH testing, is recommended for the routine assessment and diagnosis of thyroid function and following [[hyperthyroidism]] treatment and may or may not be used in cases of [[hypothyroidism]].
 
A TFT panel typically includes [[thyroid-stimulating hormone]] ([[TSH]], [[thyrotropin]]) and [[thyroxine]] ([[T4]]), and [[triiodothyronine]] ([[T3]]) depending on local laboratory policy.TFTs may be requested if a patient is thought to suffer from [[hyperthyroidism]] (overactive thyroid) or [[hypothyroidism]] (underactive thyroid), or to monitor the effectiveness of either thyroid-suppression or hormone replacement therapy. It is also requested routinely in conditions linked to thyroid disease, such as [[atrial fibrillation]]. The normal adult reference range for serum TSH is 0.4-4.5 mIU/L. The adult reference range of FT4 using comparative direct methods is 0.7-1.8 ng/dL (9-23 pmol/L) and that for FT3 is 2.3-5.0 pg/mL (35-77 pmol/L). A high TSH level may indicate hypothyroidism. If the results indicate high TSH levels, a second confirmatory sample including TSH and free T4 levels should be tested prior to starting treatment. TSH should not be measured in isolation in patients with suspected hypothalamic-pituitary disease; the measurement of free T4 is essential. Free T4 testing, combined with TSH testing, is recommended for the routine assessment and diagnosis of thyroid function and following hyperthyroidism treatment and may or may not be used in cases of hypothyroidism.


==Thyroid function tests==
==Thyroid function tests==
Thyroid function tests serve as an important diagnostic tool in the diagnosis and follow-up of various hyper and hypothyroid states:<ref name="urlUtilização dos testes de função tireoidiana na prática clínica">{{cite web |url=http://dx.doi.org/10.1590/S0004-27302013000300005+ |title=Utilização dos testes de função tireoidiana na prática clínica |format= |work= |accessdate=}}</ref>
Thyroid function tests serve as an important diagnostic tool in the diagnosis and follow-up of various [[Hyperthyroidism|hyper]] and [[Hypothyroidism|hypothyroid]] states:<ref name="urlUtilização dos testes de função tireoidiana na prática clínica">{{cite web |url=http://dx.doi.org/10.1590/S0004-27302013000300005+ |title=Utilização dos testes de função tireoidiana na prática clínica |format= |work= |accessdate=}}</ref>
*The normal adult reference range for serum TSH is 0.4-4.5 mIU/L. A high TSH level may indicate hypothyroidism. If the results indicate high TSH levels, a second confirmatory sample including TSH and free T4 levels should be tested prior to starting treatment.
*The normal adult reference range for serum [[TSH]] is 0.4-4.5 mIU/L. A high [[TSH]] level may indicate [[hypothyroidism]]. If the results indicate high [[TSH]] levels, a second confirmatory sample including [[TSH]] and free T4 levels should be tested prior to starting treatment.
*The adult reference range of FT4 using comparative direct methods is 0.7-1.8 ng/dL (9-23 pmol/L) and that for FT3 is 2.3-5.0 pg/mL (35-77 pmol/L).  
*The adult reference range of FT4 using comparative direct methods is 0.7-1.8 ng/dL (9-23 pmol/L) and that for FT3 is 2.3-5.0 pg/mL (35-77 pmol/L).  
*TSH should not be measured in isolation in patients with suspected hypothalamic-pituitary disease; the measurement of free T4 is essential. Free T4 testing, combined with TSH testing, is recommended for the routine assessment and diagnosis of thyroid function and following hyperthyroidism treatment and may or may not be used in cases of hypothyroidism.
*[[TSH]] should not be measured in isolation in patients with suspected hypothalamic-pituitary disease; the measurement of free [[T4]] is essential. Free [[T4]] testing, combined with [[TSH]] testing, is recommended for the routine assessment and diagnosis of thyroid function and following [[hyperthyroidism]] treatment and may or may not be used in cases of [[hypothyroidism]].
*Serum T3 testing has a low sensitivity and specificity for diagnosing hypothyroidism.
*Serum [[T3]] testing has a low sensitivity and specificity for diagnosing [[hypothyroidism]].
*Abnormal levels of total T4 and T3 often result from changes in transport proteins, not thyroid function. Total hormone testing should only be performed when there are discrepancies in the free hormone levels.  
*Abnormal levels of total [[T4]] and [[T3]] often result from changes in transport proteins, not thyroid function. Total hormone testing should only be performed when there are discrepancies in the free hormone levels.  
*Conditions other than thyroid disease should be considered when TSH levels are abnormal such as physiological changes associated with pregnancy, severe nonthyroidal illness, and medication use (including amiodarone, lithium, dopamine and glucocorticoids).
*Conditions other than thyroid disease should be considered when [[TSH]] levels are abnormal such as physiological changes associated with pregnancy, severe nonthyroidal illness, and medication use (including [[amiodarone]], [[lithium]], [[dopamine]], and [[glucocorticoids]]).


==Differential Diagnosis==
==Differential Diagnosis==


===TSH levels increased===
===Increased TSH levels ===
*Hashimoto's thyroiditis
*[[Hashimoto's thyroiditis]]
*Riedel's thyroiditis
*[[Riedel's thyroiditis]]
*De Quervain's thyroiditis
*[[De Quervain's thyroiditis]]
 
===Decreased TSH levels ===
*[[Graves' disease|Graves disease]]
*[[Thyrotoxicosis]]
**[[De Quervain's thyroiditis]]
**[[Hashimoto's thyroiditis]]
*[[Amiodarone]]
===Thyroid function tests in hypothyroidism===
*Thyroid function tests may differentiate various causes of [[hypothyroidism]]:<ref name="pmid16734054">{{cite journal |vauthors=Bindra A, Braunstein GD |title=Thyroiditis |journal=Am Fam Physician |volume=73 |issue=10 |pages=1769–76 |year=2006 |pmid=16734054 |doi= |url=}}</ref><ref name="pmid19949140">{{cite journal |vauthors=McDermott MT |title=In the clinic. Hypothyroidism |journal=Ann. Intern. Med. |volume=151 |issue=11 |pages=ITC61 |year=2009 |pmid=19949140 |doi=10.7326/0003-4819-151-11-200912010-01006 |url=}}</ref><ref name="urlThyroiditis — NEJM">{{cite web |url=http://www.nejm.org/doi/full/10.1056/NEJMra021194 |title=Thyroiditis — NEJM |format= |work= |accessdate=}}</ref><ref name="pmid18177256">{{cite journal |vauthors=Aoki Y, Belin RM, Clickner R, Jeffries R, Phillips L, Mahaffey KR |title=Serum TSH and total T4 in the United States population and their association with participant characteristics: National Health and Nutrition Examination Survey (NHANES 1999-2002) |journal=Thyroid |volume=17 |issue=12 |pages=1211–23 |year=2007 |pmid=18177256 |doi=10.1089/thy.2006.0235 |url=}}</ref><ref name="pmid18415684">{{cite journal |vauthors=Lania A, Persani L, Beck-Peccoz P |title=Central hypothyroidism |journal=Pituitary |volume=11 |issue=2 |pages=181–6 |year=2008 |pmid=18415684 |doi=10.1007/s11102-008-0122-6 |url=}}</ref><ref name="pmid25905413">{{cite journal |vauthors=De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Stockigt J |title=Clinical Strategies in the Testing of Thyroid Function |journal= |volume= |issue= |pages= |year= |pmid=25905413 |doi= |url=}}</ref>
 
{| class="wikitable" align="center" style="border: 0px; margin: 3px;"
! colspan="2" rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Disease
! colspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |History and symptoms
! colspan="7" align="center" style="background: #4479BA; color: #FFFFFF; " |Laboratory findings
! rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Additional findings
|-
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Fever 
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Pain
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TSH
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Free T4
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3RU<small>†
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Thyroglobin
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TRH
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TPOAb^
|-
| rowspan="3" style="background:#DCDCDC;" |[[Primary hypothyroidism]]
| align="center" style="background:#DCDCDC;" |[[Hashimoto's thyroiditis|Autoimmune]] ([[Hashimoto's thyroiditis]])
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''<small>*
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''''↓'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''''↓'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Present (high titer)
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* May be accompanied by other [[autoimmune diseases]]
|-
| align="center" style="background:#DCDCDC;" |[[Riedel's thyroiditis]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Usually present
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*[[Riedel's thyroiditis]] usually presents with hard and fixed thyroid mass.
|-
| align="center" style="background:#DCDCDC;" |[[Infectious thyroiditis]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*[[Thyroiditis|Infectious thyroiditis]] associated with [[neck pain]]
|-
| rowspan="3" style="background:#DCDCDC;" |[[Hypothyroidism|Transient hypothyroidism]]
| align="center" style="background:#DCDCDC;" |[[De Quervain's thyroiditis|Subacute (de Quervain's) thyroiditis]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑/'''↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Low/absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*May present primarily with [[hyperthyroidism]]
|-
| align="center" style="background:#DCDCDC;" |[[Postpartum thyroiditis]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑/'''↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Present (high titer)
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*May present primarily with [[hyperthyroidism]]
|-
| align="center" style="background:#DCDCDC;" |[[Silent thyroiditis]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑/'''↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Present (high titer)
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*May present primarily with [[hyperthyroidism]]
|-
| rowspan="8" style="background:#DCDCDC;" |Others
| align="center" style="background:#DCDCDC;" |Drug-induced
| rowspan="5" align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| rowspan="5" align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| rowspan="5" align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''/↓
| rowspan="5" align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''''↓'''''/↑
| rowspan="5" align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| rowspan="5" align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| rowspan="5" align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| rowspan="5" align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| rowspan="5" align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent**
| rowspan="5" align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* History of [[hyperthyroidism]]
* History of trauma
*History of drug use, surgery, or radiation
|-
| align="center" style="background:#DCDCDC;" |Radiation-induced
|-
| align="center" style="background:#DCDCDC;" |Trauma induced
|-
| align="center" style="background:#DCDCDC;" |Radioiodine induced
|-
| align="center" style="background:#DCDCDC;" |Thyroidectomy
|-
| align="center" style="background:#DCDCDC;" |Subclinical hypothyroidism
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* Asymptomatic
|-
|}
<br style="clear:left" />
<small>''(†)T3RU; Triiodothyronine Resin uptake. (^)TPOAb; [[Thyroid peroxidase]] antibodies. (*)[[TSH]] may be decreased transiently in the [[thyrotoxicosis]]. (**)TPOAb may be present in drug-induced [[Hypothyroidism|hypo]]/[[hyperthyroidism]] such as [[Interferon-alpha]], [[Interleukin 2|interleukin-2]], and [[lithium]].''</small>


===TSH leves decreased===
===Thyroid function tests in hyperthyroidism===
*Graves disease
*Thyroid function tests may differentiate various causes of [[hyperthyroidism]]:<ref name="pmid16734054">{{cite journal |vauthors=Bindra A, Braunstein GD |title=Thyroiditis |journal=Am Fam Physician |volume=73 |issue=10 |pages=1769–76 |year=2006 |pmid=16734054 |doi= |url=}}</ref><ref name="pmid19949140">{{cite journal |vauthors=McDermott MT |title=In the clinic. Hypothyroidism |journal=Ann. Intern. Med. |volume=151 |issue=11 |pages=ITC61 |year=2009 |pmid=19949140 |doi=10.7326/0003-4819-151-11-200912010-01006 |url=}}</ref><ref name="urlThyroiditis — NEJM">{{cite web |url=http://www.nejm.org/doi/full/10.1056/NEJMra021194 |title=Thyroiditis — NEJM |format= |work= |accessdate=}}</ref><ref name="pmid18177256">{{cite journal |vauthors=Aoki Y, Belin RM, Clickner R, Jeffries R, Phillips L, Mahaffey KR |title=Serum TSH and total T4 in the United States population and their association with participant characteristics: National Health and Nutrition Examination Survey (NHANES 1999-2002) |journal=Thyroid |volume=17 |issue=12 |pages=1211–23 |year=2007 |pmid=18177256 |doi=10.1089/thy.2006.0235 |url=}}</ref><ref name="pmid18415684">{{cite journal |vauthors=Lania A, Persani L, Beck-Peccoz P |title=Central hypothyroidism |journal=Pituitary |volume=11 |issue=2 |pages=181–6 |year=2008 |pmid=18415684 |doi=10.1007/s11102-008-0122-6 |url=}}</ref><ref name="pmid25905413">{{cite journal |vauthors=De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Stockigt J |title=Clinical Strategies in the Testing of Thyroid Function |journal= |volume= |issue= |pages= |year= |pmid=25905413 |doi= |url=}}</ref><ref name="urlClinical Finding and Thyroid Function in Women with Struma Ovarii">{{cite web |url=https://www.hindawi.com/archive/2013/717584/ |title=Clinical Finding and Thyroid Function in Women with Struma Ovarii |format= |work= |accessdate=}}</ref><ref name="pmid25146390">{{cite journal |vauthors=Vaidya B, Pearce SH |title=Diagnosis and management of thyrotoxicosis |journal=BMJ |volume=349 |issue= |pages=g5128 |year=2014 |pmid=25146390 |doi= |url=}}</ref><ref name="urlThink thyrotoxicosis factitia - measure thyroglobulin | The BMJ">{{cite web |url=http://www.bmj.com/content/349/bmj.g5128/rr/763450 |title=Think thyrotoxicosis factitia - measure thyroglobulin &#124; The BMJ |format= |work= |accessdate=}}</ref>
*Thyrotoxicosis
{| class="wikitable" align="center" style="border: 0px; margin: 3px;"
*Amiodarone
! colspan="2" rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Disease
! colspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |History and symptoms
! colspan="8" align="center" style="background: #4479BA; color: #FFFFFF; " |Laboratory findings
! rowspan="2" align="center" style="background: #4479BA; color: #FFFFFF; " |Additional findings
|-
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Fever 
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Pain
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TSH
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Free T4
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> T3RU<small>†
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> Thyroglobin
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TRH
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TSH Receptor Antibody
! align="center" style="background: #4479BA; color: #FFFFFF; " |<small> TPOAb^
|-
| rowspan="4" style="background:#DCDCDC;" |[[Thyroiditis]]
| align="center" style="background:#DCDCDC;" |[[Hashimoto's thyroiditis]] (Hashitoxicosis)
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑'''<small>*
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''''↓'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''''↓'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Present (high titer)
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* May be accompanied by other [[autoimmune diseases]]
|-
| align="center" style="background:#DCDCDC;" |[[De Quervain's thyroiditis|Subacute (de Quervain's) thyroiditis]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑/'''↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Low/absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*May present with [[hypothyroidism]]
|-
| align="center" style="background:#DCDCDC;" |[[Postpartum thyroiditis]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | +/-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑/'''↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Present (high titer)
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*May present with [[hypothyroidism]]
|-
| align="center" style="background:#DCDCDC;" |[[Silent thyroiditis]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |'''↑/'''↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Present (high titer)
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*May present with [[hypothyroidism]]
|-
| rowspan="2" style="background:#DCDCDC;" |[[hyperthyroidism|Primary hyperthyroidism]]
| align="center" style="background:#DCDCDC;" |[[Grave's disease]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''''↑'''''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Present
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
* Patient may have opthalmopathy and dermopathy
|-
| align="center" style="background:#DCDCDC;" |[[Toxic thyroid nodule]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑(hot nodule)
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
-
|-
| rowspan="1" style="background:#DCDCDC;" |[[Hyperthyroidism|Secondary hyperthyroidism]]
| align="center" style="background:#DCDCDC;" |[[Pituitary adenoma]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*Inappropriately normal or increased TSH
|-
| rowspan="1" style="background:#DCDCDC;" |[[Tertiary hyperthyroidism]]
| align="center" style="background:#DCDCDC;" |[[Hyperthyroidism|Tertiary hyperthyroidism]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*Inappropriately normal or increased TSH
|-
| rowspan="2" style="background:#DCDCDC;" |Drug induced
| align="center" style="background:#DCDCDC;" |[[Amiodarone| Amiodarone type 1]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*High urinary iodine
|-
| align="center" style="background:#DCDCDC;" |[[Amiodarone|Amiodarone type 2]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent/↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/'''↑'''
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*High urinary iodine
|-
| rowspan="3" style="background:#DCDCDC;" |Others
| align="center" style="background:#DCDCDC;" |[[Factitious thyrotoxicosis]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
*Decreased thyroglobulin
|-
| align="center" style="background:#DCDCDC;" |[[Trophoblastic disease]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
-
|-
| align="center" style="background:#DCDCDC;" |[[Struma ovarii]]
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" | -
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal/↑
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |↓
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |-
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Normal
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="center" style="padding: 5px 5px; background: #F5F5F5;" |Absent
| align="left" style="padding: 5px 5px; background: #F5F5F5;" |
-
|-
|}
<small>''(†)T3RU; Triiodothyronine Resin uptake. (^)TPOAb; [[Thyroid peroxidase]] antibodies.''</small>


==References==
{{Reflist|2}}


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Furqan M M. M.B.B.S[2]

Synonyms and keywords: TFTs

Overview

Thyroid function tests (TFTs) is a collective term for blood tests used to check the function of the thyroid. A TFT panel typically includes thyroid-stimulating hormone (TSH, thyrotropin) and thyroxine (T4), and triiodothyronine (T3) depending on local laboratory policy.TFTs may be requested if a patient is thought to suffer from hyperthyroidism (overactive thyroid) or hypothyroidism (underactive thyroid) or to monitor the effectiveness of either thyroid-suppression or hormone replacement therapy. It is also requested routinely in conditions linked to thyroid disease, such as atrial fibrillation. The normal adult reference range for serum TSH is 0.4-4.5 mIU/L. The adult reference range of FT4 using comparative direct methods is 0.7-1.8 ng/dL (9-23 pmol/L) and that for FT3 is 2.3-5.0 pg/mL (35-77 pmol/L). A high TSH level may indicate hypothyroidism. If the results indicate high TSH levels, a second confirmatory sample including TSH and free T4 levels should be tested prior to starting treatment. TSH should not be measured in isolation in patients with suspected hypothalamic-pituitary disease; the measurement of free T4 is essential. Free T4 testing, combined with TSH testing, is recommended for the routine assessment and diagnosis of thyroid function and following hyperthyroidism treatment and may or may not be used in cases of hypothyroidism.

Thyroid function tests

Thyroid function tests serve as an important diagnostic tool in the diagnosis and follow-up of various hyper and hypothyroid states:[1]

  • The normal adult reference range for serum TSH is 0.4-4.5 mIU/L. A high TSH level may indicate hypothyroidism. If the results indicate high TSH levels, a second confirmatory sample including TSH and free T4 levels should be tested prior to starting treatment.
  • The adult reference range of FT4 using comparative direct methods is 0.7-1.8 ng/dL (9-23 pmol/L) and that for FT3 is 2.3-5.0 pg/mL (35-77 pmol/L).
  • TSH should not be measured in isolation in patients with suspected hypothalamic-pituitary disease; the measurement of free T4 is essential. Free T4 testing, combined with TSH testing, is recommended for the routine assessment and diagnosis of thyroid function and following hyperthyroidism treatment and may or may not be used in cases of hypothyroidism.
  • Serum T3 testing has a low sensitivity and specificity for diagnosing hypothyroidism.
  • Abnormal levels of total T4 and T3 often result from changes in transport proteins, not thyroid function. Total hormone testing should only be performed when there are discrepancies in the free hormone levels.
  • Conditions other than thyroid disease should be considered when TSH levels are abnormal such as physiological changes associated with pregnancy, severe nonthyroidal illness, and medication use (including amiodarone, lithium, dopamine, and glucocorticoids).

Differential Diagnosis

Increased TSH levels

Decreased TSH levels

Thyroid function tests in hypothyroidism

Disease History and symptoms Laboratory findings Additional findings
Fever Pain TSH Free T4 T3 T3RU† Thyroglobin TRH TPOAb^
Primary hypothyroidism Autoimmune (Hashimoto's thyroiditis) - - ↑* ↓ Normal/↓ Normal/↓ Normal/↑ Normal Present (high titer)
Riedel's thyroiditis - - Normal/↑ Normal/↓ Normal/↓ Normal/↓ Normal Normal Usually present
Infectious thyroiditis + + Normal Normal Normal Normal Normal Normal Absent
Transient hypothyroidism Subacute (de Quervain's) thyroiditis +/- +/- ↑/↓ ↓/↑ Normal ↓ ↑ Normal Low/absent
Postpartum thyroiditis +/- +/- ↑/↓ ↓/↑ Normal ↓ ↑ Normal/↑ Present (high titer)
Silent thyroiditis - - ↑/↓ ↓/↑ Normal ↓ ↑ Normal Present (high titer)
Others Drug-induced - - ↑/↓ ↓/↑ Normal ↓ Normal/↑ Normal Absent**
  • History of hyperthyroidism
  • History of trauma
  • History of drug use, surgery, or radiation
Radiation-induced
Trauma induced
Radioiodine induced
Thyroidectomy
Subclinical hypothyroidism - - ↑ Normal Normal Normal Normal Normal Normal/↑
  • Asymptomatic


(†)T3RU; Triiodothyronine Resin uptake. (^)TPOAb; Thyroid peroxidase antibodies. (*)TSH may be decreased transiently in the thyrotoxicosis. (**)TPOAb may be present in drug-induced hypo/hyperthyroidism such as Interferon-alpha, interleukin-2, and lithium.

Thyroid function tests in hyperthyroidism

Disease History and symptoms Laboratory findings Additional findings
Fever Pain TSH Free T4 T3 T3RU† Thyroglobin TRH TSH Receptor Antibody TPOAb^
Thyroiditis Hashimoto's thyroiditis (Hashitoxicosis) - - ↑* ↓ Normal/↓ Normal/↓ Normal/↑ Normal Absent Present (high titer)
Subacute (de Quervain's) thyroiditis +/- +/- ↑/↓ ↓/↑ Normal ↓ ↑ Normal Absent Low/absent
Postpartum thyroiditis +/- +/- ↑/↓ ↓/↑ Normal ↓ ↑ Normal/↑ Absent Present (high titer)
Silent thyroiditis - - ↑/↓ ↓/↑ Normal ↓ ↑ Normal Absent Present (high titer)
Primary hyperthyroidism Grave's disease - - ↓ ↑ Normal/↑ ↑ ↑ Normal Present Absent
  • Patient may have opthalmopathy and dermopathy
Toxic thyroid nodule - - ↓ ↑ Normal/↑ ↑(hot nodule) Normal/↑ Normal Absent Absent

-

Secondary hyperthyroidism Pituitary adenoma - - ↑ ↑ Normal/↑ ↑ Normal/↑ Normal Absent Absent
  • Inappropriately normal or increased TSH
Tertiary hyperthyroidism Tertiary hyperthyroidism - - ↑ ↑ ↑ ↑ Normal/↑ ↑ Absent Absent
  • Inappropriately normal or increased TSH
Drug induced Amiodarone type 1 - - ↓ ↑ Normal/↑ ↓ Normal/↑ Normal Absent Absent
  • High urinary iodine
Amiodarone type 2 - - ↓ ↑ Normal/↑ Absent/↓ Normal/↑ Normal Absent Absent
  • High urinary iodine
Others Factitious thyrotoxicosis - - ↓ ↑ Normal/↑ ↓ ↓ Normal Absent Absent
  • Decreased thyroglobulin
Trophoblastic disease - - ↓ ↑ Normal/↑ ↑ - Normal Absent Absent

-

Struma ovarii - - ↓ ↑ Normal/↑ ↓ - Normal Absent Absent

-

(†)T3RU; Triiodothyronine Resin uptake. (^)TPOAb; Thyroid peroxidase antibodies.

References

  1. ↑ "Utilização dos testes de função tireoidiana na prática clínica".
  2. ↑ 2.0 2.1 Bindra A, Braunstein GD (2006). "Thyroiditis". Am Fam Physician. 73 (10): 1769–76. PMID 16734054.
  3. ↑ 3.0 3.1 McDermott MT (2009). "In the clinic. Hypothyroidism". Ann. Intern. Med. 151 (11): ITC61. doi:10.7326/0003-4819-151-11-200912010-01006. PMID 19949140.
  4. ↑ 4.0 4.1 "Thyroiditis — NEJM".
  5. ↑ 5.0 5.1 Aoki Y, Belin RM, Clickner R, Jeffries R, Phillips L, Mahaffey KR (2007). "Serum TSH and total T4 in the United States population and their association with participant characteristics: National Health and Nutrition Examination Survey (NHANES 1999-2002)". Thyroid. 17 (12): 1211–23. doi:10.1089/thy.2006.0235. PMID 18177256.
  6. ↑ 6.0 6.1 Lania A, Persani L, Beck-Peccoz P (2008). "Central hypothyroidism". Pituitary. 11 (2): 181–6. doi:10.1007/s11102-008-0122-6. PMID 18415684.
  7. ↑ 7.0 7.1 De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, Koch C, Korbonits M, McLachlan R, New M, Purnell J, Rebar R, Singer F, Vinik A, Stockigt J. "Clinical Strategies in the Testing of Thyroid Function". PMID 25905413.
  8. ↑ "Clinical Finding and Thyroid Function in Women with Struma Ovarii".
  9. ↑ Vaidya B, Pearce SH (2014). "Diagnosis and management of thyrotoxicosis". BMJ. 349: g5128. PMID 25146390.
  10. ↑ "Think thyrotoxicosis factitia - measure thyroglobulin | The BMJ".

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