Five Tests to Tell If You Have Hashimoto’s

If you have hypothyroidism, you might also have Hashimoto's autoimmune thyroiditis. What is the difference?

By Dr. J.E. Williams |

Woman in business clothes exhausted on couch

Carol looked tired. Her complexion was ashen and purplish crescents framed the lower rim of her eyes. She was overweight even though she ate a mostly vegetarian diet, avoided refined sugar and dairy products; had stopped eating wheat, didn’t eat fatty or fried foods, and never snacked. She felt cold all the time even in summer. She couldn’t get her cholesterol and LDL levels down. Carol’s general practitioner diagnosed her with hypothyroidism and high LDL. She refused to take the statin drug he prescribed but took the levothyroxine. After several months of thyroid hormone replacement, she still didn’t feel better even though her thyroid hormone levels improved on her follow-up blood tests. Something wasn’t right, and she felt it. That’s when she came to see me.

When I examined her, I found that her blood pressure was low, her extremities felt cold, her lower eyelids were puffy, and the lymph glands under her chin we slightly enlarged and tender. I told her she might have an autoimmune thyroid condition. I retested her thyroid hormones and added tests for autoimmune activity. Although her thyroid hormone results were not in the optimal ranges according to my clinical view, all were within the normal reference ranges. But, her Thyroid Peroxidase Antibodies (TPO Ab), the telltale marker for Hashimoto’s disease. Carol’s TPO Ab was extremely high at over 500 IU/mL. She had chronic autoimmune lymphocytic thyroiditis, the medical name for Hashimoto’s disease.

What Is Hashimoto’s Disease?

Hashimoto’s is the most common autoimmune thyroid disorder. For a variety of reasons, your immune system sets out to attack your thyroid gland. Over time, the thyroid gland is destroyed by your body’s lymphocytes, a type of white blood cell. Lymphocytes also produce inflammatory cytokines that further activates autoimmune activing in the thyroid gland. A tipping point occurs when thyroid cells can no longer produce thyroid hormones.
Well before that stage, your thyroid stimulating hormone (TSH) level goes up, and your thyroid hormones become deficient. The pituitary, the “master” gland that regulates hormone production in the body, makes TSH. When the levels of thyroid hormones, thyroxin (T4) and triiodothyronine (T3), decline your anterior pituitary produces more TSH to stimulate thyroid cells to produce more T4 and T3.

TSH Levels from The Complete Blood Test Blue Print Program by Dr. J. E. Williams

When TSH pushes over 4.500, it means that the pituitary signaled your thyroid gland to produce more thyroid hormones. Elevated TSH is a hallmark sign of hypothyroidism. But, damaged thyroid tissue caused by autoimmune activity that’s associated with chronic inflammation cannot produce enough hormones. The pituitary responds; so TSH continues to rise. I’ve had patients with TSH levels more than 200 mU/L.

Eventually, the anterior pituitary tires and can no long produce TSH. In this scenario, TSH is low and so are T4 and T3 levels. This is an advanced stage of Hashimoto’s associated with failure of the anterior pituitary function and the thyroid cells.

Long before the advanced stages of Hashimoto’s disease, you may have no symptoms at all. It’s at this stage that many get misdiagnosed with depression. Alternative practitioners blame it on adrenal burnout. Both views are inaccurate. Though it’s physiologically true that fatigue and depression, as well as adrenal gland imbalances often accompany Hashimoto’s, only accurate diagnosis leads to effective treatment. That’s why it’s important to test for Hashimoto’s early in their diagnosis of hypothyroidism.

“Long before the advanced stages of Hashimoto’s disease, you may have no symptoms at all. It’s at this stage that many get misdiagnosed with depression.”

What Is the Difference Between Hashimoto’s and Hypothyroidism?

As your thyroid gland weakens, symptoms gradually appear. At first, you may feel tired without reason. You might even wake up tired. Your skin and hair become dryer. You feel cold, even in warm weather. Over time, other symptoms occur including: poor digestion, constipation, and carotenemia, a yellowish-orange color of the palms.

Woman massaging Thyroid

Common Symptoms of Hashimoto’s:

  • Severe fatigue
  • Weakness
  • Pale, puffy face
  • Anxiety and panic attacks
  • Depression
  • Dry skin
  • Water retention
  • Forgetfulness
  • Trouble finding words
  • Sensitivity to cold
  • Hair loss
  • Heavy menstruation
  • Unexplained weight gain
  • Constipation

If you complain to your doctor about fatigue – one of the cardinal symptoms of hypothyroidism – you will likely get clinical screening tests for infections, anemia, and hypothyroidism. The standard thyroid profile includes free thyroxine index; T3 uptake, thyroid-stimulating hormone, and thyroxine (T4). If your TSH is elevated, your medical doctor will diagnose hypothyroidism and prescribe synthetic thyroid hormone replacement therapy. Synthroid or generic levothyroxine are the most common thyroid hormones prescribed in conventional medicine. If you see a naturopathic doctor or a traditional physician practicing functional medicine, you will get desiccated thyroid hormones like Armour Thyroid or Nature-Throid that contain both T4 and T3.

If your doctor takes an integrative approach, your plan may include supplements like vitamin D3, vitamin A, selenium, and the amino acid L-tyrosine to support thyroid function. Sometimes, practitioners prescribe iodine. But, many doctors consider iodine contraindicated in Hashimoto’s because it can over stimulate TPO Ab.

What if you have a more complicated form of hypothyroidism that routine tests cannot pick up? It is surprising to me that even though autoimmune thyroid conditions are more common than a few decades ago, conventional doctors do not routinely screen patients for Hashimoto’s. Sometimes T4 and T3 are within normal ranges, leading doctors not to consider hypothyroidism. A diagnosis of Hashimoto’s can get overlooked without testing autoimmune markers like TPO Ab.

The Gender and Gene Connection

Women are three times more likely than men to develop Hashimoto’s. (Staii, Mirocha, Todorova-Koteva, Glinberg, & Jaume, 2010) Some studies state that Hashimoto’s is 5 to 10 times more common in women than men. Other gender-specific associations cluster with Hashimoto’s For example, researchers found that increased breast density occurs more often in women with Hashimoto’s. (Pedraza-Flechas et al., 2017)

There is also a genetic connection. Hashimoto’s tends to run in families. (Davies, Latif, & Yin, 2012) At least three genetic mutations are thought to be responsible for triggering thyroid autoimmunity. Scientists are confident that the HLA-DR5, CTLA-4, and PTPN22 genes play a major part in the autoimmune cascade that leads to Hashimoto’s. (Stock, 2002)
“ Even those with milder forms of Hashimoto’s have problems with cognition.”
In severe cases, Hashimoto’s can lead to inflammation of the brain. Hashimoto’s encephalopathy is a rare and serious form of autoimmune thyroiditis.(Wang et al., 2013) The most frequent symptoms involve confusion, occasionally coma and stroke-like episodes, cognitive decline, seizures, depression, mania or hallucinations, and movement disorders. Even those with milder forms of Hashimoto’s have problems with cognition, but the exact nature of brain impairment remains unclear.

Idea bulb iconHashimoto’s disease was named in 1957 after the Japanese physician, Hakaru Hashimoto of Kyushu University. It was the first identified organ-specific autoimmune disorder.

Hashimoto’s autoimmune thyroiditis is often the pivotal dysfunction in other autoimmune diseases. Lupus and autoimmune gastritis, or thyrogastric syndrome, occur in up to 40% of Hashimoto’s cases. (Cellini et al., 2017)

Determining Hashimoto’s

The first step in diagnosing Hashimoto’s is assessing symptoms. However, the list of symptoms is long and overlaps with other conditions, which is one reason why Hashimoto’s gets misdiagnosed as chronic fatigue syndrome, adrenal fatigue, depression, or fibromyalgia.

The second step is an examination. Your doctor is trained to find and asses the size of your thyroid. An enlarged thyroid gland is called a goiter. But even a slightly enlarged thyroid signals trouble. With Hashimoto’s the lymph nodes at the front of your neck and just under the chin line get swollen. You can feel these for yourself.

Distinguishing hypothyroidism from Hashimoto’s by symptoms is not easy because both conditions share similar indications. However, one of the hallmarks for Hashimoto’s is swollen lymph nodes under the chin in the front of both sides of the neck. A profile of blood tests and an ultrasound scan of your thyroid gland in the only sure way to know if you have Hashimoto’s.

5 Tests for Hashimoto’s:

1. Thyroid stimulating hormone (TSH)
2. Free liothyronine (T3)
3. Free thyroxine (T4)
4. Thyroid peroxidase antibodies (TPOAb)
5. Thyroglobulin antibodies (TGAb)

You very likely have Hashimoto’s disease if your TSH is high, your free T3 and T4 are low, and your TPO Ab is elevated. High TPO Ab is the key marker because it is present in over 90% of those with Hashimoto’s. TG Ab is present in about 80% of cases. (Zaletel & Gaberr, 2011)

Primary lab markers used to diagnose Hashimoto's.

Primary lab markers used to diagnose Hashimoto’s.


Hashimoto’s disease is more common than previously thought. Despite the high incidence of Hashimoto’s, this debilitating condition remains poorly understood and often goes undertreated. There is a low risk of papillary thyroid cancer in those with Hashimoto’s, but no association with other forms of thyroid cancer. (Resende de Paiva, Grønhøj, Feldt-Rasmussen, & von Buchwald, 2017)

If you are female, already have hypothyroidism, or have Hashimoto’s disease in your family, get screening tests for Hashimoto’s. Your doctor, nurse practitioner, or physician’s assistant can order thyroid tests. You can also order them on your own from independent lab testing services like PersonaLabs or membership services like Life Extension. These kinds of services use the same national labs like LabCorp and Quest Diagnostics that doctors use. You’ll be surprised at how much lab costs vary. Remember, your health insurance will not pay for self-ordered blood tests. So, shop around for the best price.