How to Diagnose Hashimoto’s Thyroiditis with Lab Tests & Symptoms

If you have or suspect that you have thyroid problems then this article is very important to you. 

It turns out that the majority of people who have a thyroid problem have it because of an autoimmune condition. 

This condition is often referred to as Hashimoto's thyroiditis and it is something that EVERY thyroid patient should be aware of (and should be tested for). 

This article will walk you through the importance of thyroid antibody testing, how to test for Hashimoto's, and some basic treatment guidelines

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Why Diagnosing Hashimoto's Thyroiditis is Important

If you are reading this then you are probably already at least somewhat aware of the disease known as Hashimoto's thyroiditis. 

But for those of you who may not be familiar with it, let's discuss some of the basics. 

Hashimoto's thyroiditis is an autoimmune disease of the thyroid gland. 

As an autoimmune disease, Hashimoto's results in inflammation and destruction of the thyroid gland which sits at the base of your neck. 

It is felt that this inflammation will eventually lead to some permanent destruction of the thyroid gland. 

And, because you need your thyroid gland to function, this is a big deal!

As your own body attacks and kills your thyroid gland (this is the hallmark of autoimmune disease) you will start to experience certain symptoms

These symptoms stem from the fact that your body is not able to keep up with the production of thyroid hormone from your thyroid gland as it is destroyed. 

The good news is that diagnosing this problem isn't all that difficult...

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How Hashimoto's Thyroiditis is Diagnosed

Diagnosing Hashimoto's is VERY important because knowing that you have this disease changes how you should approach treatment. 

Run of the mill hypothyroidism is often treated with thyroid hormone replacement. 

And while many patients with Hashimoto's thyroiditis may need thyroid medication at some point, you may be able to catch your disease early and either reverse or halt the progression of your disease. 

This means that, for some people, it's possible to avoid long-term destruction and the need to use thyroid medication for the rest of their life. 

The first step to doing this is to find out that you HAVE the disease! 

And while this logic may sound obvious to you, it may not be obvious to your physician (the one who typically diagnoses you). 

Why?

Because most doctors are conditioned to look only at thyroid gland FUNCTION. 

They are trained to treat only when the thyroid gland has been compromised enough to result in certain symptoms in the body (such as hair loss, fatigue, weight gain, and cold intolerance). 

Furthermore, most doctors do not feel that the diagnosis of Hashimoto's is even necessary or helpful because it doesn't change how they plan to treat you. 

The conventional thought process is to "wait and see" (1) while your own body attacks and destroys your thyroid gland and until you eventually need thyroid hormone medication. 

If this doesn't sit well with you, you are not alone!

The entire goal of this article is to help you understand how you can easily and quickly diagnose this disease so that you can take ACTION. 

There are 3-4 main ways that Hashimoto's thyroiditis is diagnosed (2), but you don't necessarily have to go through all of them to get your diagnosis. 

Some of the tests we are about to talk about are easy to get and others may require more invasive procedures. 

Don't let any of this scare you, however, because most doctors feel comfortable making the diagnosis if you have a positive test in any of the three areas. 

This means that you do NOT necessarily have to get ALL of the tests done!

In many cases, it's possible to make the diagnosis if you have the symptoms of hypothyroidism, abnormal thyroid lab tests, and positive antibodies. 

#1. Lab Testing for Antibodies

No test in medicine is ever perfect. 

It's possible that you can test positive for some test but not actually have the disease that it purports to test for. 

I know this may seem confusing, but it isn't if you consider that all tests have false positives and false negatives. 

False positives are tests which test for a specific condition or disease and in which the test is positive but the patient doesn't actually have the disease. 

False negatives are tests which test for a specific condition or disease and in which the person tests negative but actually has the disease. 

The reason I am bringing this up here is that you must realize that even though we are talking about testing for a specific condition, not all of these tests are 100% accurate. 

With that out of the way, the easiest way to test for Hashimoto's thyroiditis is by looking specifically for antibody levels in the bloodstream. 

We already know that Hashimoto's stems from an autoimmune attack on the body. 

And it turns out that you can test directly for these antibodies to see if they exist in your bloodstream (3). 

If you have a positive antibody level, there is a very high chance that you are suffering from Hashimoto's thyroiditis. 

But, as I said earlier, just because you have positive antibodies does not 100% mean that you have Hashimoto's. 

However, I feel, and a great many other people feel as well, that if you have the symptoms of hypothyroidism AND elevated thyroid antibodies AND abnormal thyroid lab tests, then you can safely diagnose that person with Hashimoto's. 

But the real world isn't that clear cut. 

Sometimes people have the symptoms of hypothyroidism with elevated antibodies but normal thyroid lab tests (4).

Does this mean these people don't have Hashimoto's? Not at all. 

In fact, a great many people with early Hashimoto's present with this exact combination. 

Other people have absolutely zero symptoms of hypothyroidism but elevated antibodies. 

Does this mean these people doesn't have Hashimoto's? Not necessarily, it's possible that this person may progress to Hashimoto's and hypothyroidism at some point in their life. 

In either event, it's absolutely critical that you TEST for these antibodies AND put them into context with your personal history, other lab tests, and how you are feeling. 

I believe that you can diagnose Hashimoto's, with a high degree of certainty, in individuals who have BOTH the symptoms of hypothyroidism and slightly elevated antibodies. 

The antibodies that you want to look for include:

#2. Lab Testing for Thyroid Function

In addition to testing directly for thyroid antibodies, you can also test how well your thyroid gland is actually functioning. 

This can be done with blood tests so this is a non-invasive test which is quick and easy to get. 

Thyroid lab testing, while important, is not the MOST important test if you have Hashimoto's. 

The reason for this is simple:

It appears that thyroid function lab tests lag behind the development and progression of Hashimoto's in a large percentage of patients. 

What does this mean?

It means that many people with Hashimoto's thyroiditis are walking around with normal thyroid lab tests even though they technically have Hashimoto's. 

diagnosis of hashimoto's thyroiditis with biopsy

Newer studies have shown that there appears to be a pre-clinical stage of Hashimoto's thyroiditis (5) which can be seen only with a biopsy. And this state is not uncommon either. 

People at this stage of their disease often have normal thyroid lab tests but will eventually progress to develop full-blown hypothyroidism from their Hashimoto's at some point in the future. 

So while some patients with Hashimoto's may have relatively normal thyroid lab tests, some patients have overtly hypothyroid lab tests as well. 

Those people who have overtly hypothyroid lab tests are rarely ever missed by the doctor because the connection between your symptoms and your lab tests are often quite clear. 

If you have the symptoms of weight gain, fatigue, and hair loss AND your TSH is greater than 5.0 then the diagnosis is a no brainer. 

But the diagnosis can become more difficult to make if your TSH (and other thyroid hormone levels) are in the "normal" range. 

Despite the potential drawbacks of thyroid function testing, it should still be done in ALL thyroid patients, including those with Hashimoto's thyroiditis. 

And I typically recommend you test for both your antibodies and your thyroid function at the same time. 

#3. Ultrasound Testing

Another non-invasive way to test for Hashimoto's is with the use of ultrasound imaging. 

Ultrasound only requires the use of an ultrasound wand which is placed over the skin. 

From there, sound waves can provide an image of the thyroid gland which is projected onto a screen. 

ultrasound imaging of a thyroid gland with Hashimoto's thyroiditis

A radiologist can look at the features of your thyroid gland and determine a lot about it including is inflammation present? How big is your gland? Are there any nodules or lesions which look cancerous? Are there any irregularities or does it appear bumpy? 

The presence, or absence, of these features, can help shed light on what is happening to your thyroid gland and can be very helpful in certain cases. 

The only downside to ultrasound testing is that it isn't very specific. 

Ultrasound can tell you if there is inflammation present, but it can't tell you where that inflammation is coming from. 

So using ultrasound testing is often best when it is in combination with other tests such as your thyroid lab tests. 

Reading an ultrasound report can be confusing as a patient, but there are some basics that you can take away from your report. 

If you read in your report that your thyroid looks 'homogenously hypoechoic' or 'peripherally hypoechoic' then there is a relatively high chance that you have Hashimoto's. 

Studies show that people with these patterns are found in 45.2% and 40.3% (6) (respectively) of patients with Hashimoto's thyroiditis. 

#4. Biopsy

Finally, the last way to test for Hashimoto's is with a direct biopsy of the thyroid gland. 

A biopsy is the most invasive of all of the tests that I've listed so far but it also happens to be the most accurate. 

But just because it's the most accurate does not mean that you need to run around poking a needle into everyone's thyroid gland to diagnose them. 

Instead, it's far better to use the other tests listed above, in concert with each other and with your symptoms, to get to the diagnosis. 

In some instances, however, you may actually need a biopsy (such as when you have a large thyroid nodule or if your doctor suspects thyroid cancer). 

A biopsy allows doctors to stain your thyroid gland tissue and evaluate it under a microscope. 

When they do this, they are looking at something like this image: 

diagnosis of Hashimoto's with biopsy

Your doctor will be looking for certain signs of Hashimoto's including the infiltration of certain white blood cells into your thyroid gland (7) which indicate inflammation and damage. 

Antibodies During Pregnancy

We've spent this whole time talking about diagnosing Hashimoto's and I want to just spend one minute talking specifically about pregnancy. 

I told you earlier that there are some conditions where your thyroid antibodies could be elevated but that doesn't mean that you have Hashimoto's. 

Well, pregnancy is one of those conditions. 

It turns out that some pregnant women will experience elevated thyroid antibodies during pregnancy (8) and it doesn't mean that these women necessarily have thyroid disease. 

thyroid antibodies during pregnancy

Now some of them may very well have it, but there plenty of women who experience only a transient (short-term) elevation in thyroid antibodies which do go away after delivery. 

Some women, however, may experience a further increase in antibodies in the post-partum period and they may go on to develop post-partum thyroiditis which is a Hashimoto's like condition which is usually temporary. 

We do know, however, that these antibodies are NOT healthy for either the mother or the fetus, even in the absence of thyroid disease. 

These antibodies can cross the placenta and may cause issues for your child. In addition, the mere presence of thyroid antibodies does increase your lifetime risk of developing thyroid disease at some point in the future and may also increase your risk for certain cancers (9). 

If you have Hashimoto's it may be helpful to test your antibodies at various stages during pregnancy to track them. 

Many women, who have Hashimoto's prior to pregnancy, may see a decline in their antibodies during the actual pregnancy only to find an increase in the post-partum period. 

This information can be very helpful and can guide your treatment! 

Treatment

If you have elevated antibodies in your body you may be wondering if it's possible to lower them. 

And the answer is yes

I've written about how to do this in other articles, but I will also provide a quick recap of some of the therapies that may help you reduce your antibodies below: 

Many of these therapies are things that YOU can do by yourself starting today. 

If you have Hashimoto's, or even if you suspect it, you should do all that you can to learn more about those therapies.

Conclusion

Testing for Hashimoto's does not have to be difficult and it is something that every patient with known thyroid disease should undergo. 

Simple tests such as looking at your thyroid function and checking to see if you have elevated thyroid antibodies should be your first step. 

This information is usually enough to diagnose the presence of Hashimoto's in the vast majority of individuals. 

If there is any question after you get these tests then you can look at the more advanced tests such as ultrasound and biopsy. 

Once you have the diagnosis nailed down your next step is to undergo treatment!

Don't just stop at diagnosis, because you can potentially make an impact on your disease and slow down the eventual progression to hypothyroidism or thyroid gland atrophy. 

Now I want to hear from you:

Do you have Hashimoto's?

Do you suspect you have Hashimoto's?

Which tests have been helpful in your diagnosis?

Are you struggling to get your doctor to order the right tests?

Leave your questions or comments below! 

References (Click to Expand)

This post was most recently updated on August 23rd, 2019

Dr. Westin Childs

Dr. Westin Childs is a Doctor of Osteopathic Medicine. He provides well-researched actionable information about hormone-related disorders and formulates supplements to treat these disorders.He is trained in Internal Medicine, Functional Medicine, and Integrative Medicine. His focus is on managing thyroid disorders, weight loss resistance, and other sex hormone imbalances.You can read more about his own personal journey here.

20 thoughts on “How to Diagnose Hashimoto’s Thyroiditis with Lab Tests & Symptoms”

  1. Hello Dr. Childs.

    Could you confirm that you are still in practice? Arizona shows your license is not active and I read you closed your practice as well from multiple other forums. Could you elaborate for those of us that rely on this board for help, please? Also, I can’t find a board certification anywhere. Just where you went to medical school. Anyway…I have your new program for weight loss and took the studies to my dr as you recommended and when he asked where I got them he went to look you up and could not find you either. Sorry to ask but as I said, many of us rely on this site and having a dr. that helps with resources to get our own Drs to work with us makes a difference when ‘backing up’ validity of why we would like to try treatments you recommend when others fail. If your license is not active and you closed your practice…well then that leaves many of us out gas with our doctors. Thank you.

    • Hi Angie,

      That is correct, I am no longer personally practicing. I am planning on opening up a clinic sometime this year to accept new patients but it will be through another provider that I am training and I hope to train multiple providers to practice in the way that I describe on my site. In the meantime, all of my articles have references at the bottom that support the claims in the articles as well which you can use.

  2. Hi Dr. Childs,
    As always, thank you for the practical and user-friendly information. In my early 40s, I developed a rapidly growing, and very noticeable nodule in a relatively short period of time. Prior to that no thyroid history. With a TSH of 43, I, of course, had multiple ultrasounds as well as a couple of biopsies. Everything was benign, and all antibodies were negative. I was however diagnosed with Hashimoto’s through ultrasound. Eventually, I had a partial thyroidectomy because even on meds the nodule didn’t shrink very much. The question I have relates to the surgical pathology, which was reviewed by a tumor board and came back with consensus finding, that was consistent with Graves. Given the preoperative ultrasound diagnosis (at least three or four of them if I recall), is this possible? Are there similarities between Graves and Hashimotos Thyroiditis on ultrasound, and can they coexist?
    I provided my own info simply as context. Mostly I’m curious about how distinct the two conditions are on ultrasound, and when reviewed under a microscope.
    Thank you.

    • Hi Melissa,

      Yes, both Graves’ and Hashimoto’s can present with similar findings on ultrasound. The findings that typically exist with Hashimoto’s tend to occur in those with Graves’ (and vice versa) but just with much less frequency.

  3. If a patient has both Hashimoto’s and hypothyroidism, will reducing antibodies be enough to optimize levels of TSH, T4, T3, etc? Or is treatment with levothyroxine (or Synthroid, Armor, etc) and liothyronine/Cytomel still necessary?

  4. Good afternoon! I have been reading your blogs and ask my endocrinologist to add they cytomel to take a long with my synthroid. I was taking 137mcg of synthroid. She reduced my synthroid to 100mcg and gave me cytomel 5mg. Since then, I’ve been fatiued and have major, MAJOR hair loss every single day. I’ve gone from a thick head of hair to very thin, with balding on the top. I’m majorly constipated despite what I eat and have dry skin. My temps first thing in the morning run about 94-95. I spoke with my dr in January and told her my symptoms. I’ve been on Cytomel with synthroid since last February, so a year now. She ran test in January and only ran Free T4 and and TSh (that’s all she’s ran the past year). My results were as follows: TSH-0.670 and Free T4- 0.980. She says they are normal. I’ve ask if we could adjust my meds to treat my symptoms. Her response was no and that I could still have symptoms even though my labs are normal. My question is, are my med dosages accurate to what my labs say or should I find another dr? I don’t want to go bald before they decide to do something. Thanks so much for any input you can give.
    Andrea

  5. Hi, I had Graves’s disease (hyperthyroid) when I was 26 y/o. I took the Radioactive Iodine pill, and I became hypothyroid. Now, I’m in my 50’s and still taking Synthroid. I still struggle with symptoms because of hypo (anxiety, tiredness, brain fog, depression, aches, etc.)
    I’m not sure if I also have Hashimoto. What is the difference?
    Thanks!

  6. First of all thank you so much for providing a place where people like me can access such helpful, concise, and pertinent information on our conditions.
    I have been to so many doctors, both traditional and holistic, and still I find I have to do so much diagnostics, research, and treatment on my own.
    I have been diagnosed once with hashimotos, and once with autoimmune hypothyroidism, and other times (as well as initially at age 16) as simply hypothyroid.
    One doctor told me my hashimotos diagnosis was wrong as I only have TPO antibodies and do not have any TgAB present. It is my understanding that at any point I can develop the TgAb, but according to him, until I do I am not considered a hashimotos patient. Would you be able to tell me if the presence of both antibodies is required for this diagnosis.
    I feel it is an important diagnosis to figure out so I can properly move forward with doing the best I can for my health.
    Thank you so much!

    • Hi Meagan,

      Both antibodies are not required for a diagnosis of Hashimoto’s. The diagnosis of Hashimoto’s is suspected with elevated antibodies and abnormal thyroid lab studies but not confirmed unless a thyroid ultrasound or biopsy is done. Most people safely make the diagnosis if one antibody is elevated and the thyroid is abnormal, however, and don’t necessarily require an ultrasound/biopsy.

      • Ah, I understand. I have had ultrasounds done before that would then fully confirm the hashimotos even with the absence of TgAB. That one doctor had confused me and made me unsure of the diagnosis. Thank you so much for helping me better understand everything and providing such a good blog!

  7. Hi Dr Westin. Thank you so much for this article!
    I’ve recieved results of my own thyroid panel test.
    TSH 2.1 MIU/L
    FT4 13pmol/L
    FT3 4.7 pmol/L
    Anti Thyroglobulin <10 IU/ml
    Anti-Thyroid Peroxidase <15/ml
    Thyroglobulin 27.1 ug/L

    These all fall within the normal range. However I’m still experiencing symptoms of hypothyroidism. Is it possible that the presence of these antibodies, could indicate this. I have been following a strict thyroid diet for a few weeks before taking bloods.
    If you have any feedback or advice I would be so greatful
    -Erin

  8. Thank you so much Dr. Childs for all the great work and the free access you’ve provided for us to study and not just depend on doctors!!

    I have more symptoms of Hyperthyroidism- loss of muscle mass, fatigue, dryness in eyes, unable to sleep straight through the night.
    From my understanding of the optimal results that you provided I seem to have a Low T3 syndrome or hyperthyroidism.
    My ATg and ATP have reduced from 150 and 16 to 50 and 10 by small changes like avoiding wheat and milk since I been tested for positive food sensitivities a year ago. My estrogen levels were high and are in lab reference ranges now. My SHBG is still high (222).
    Can a person be hyperthyroid and still have Hashimoto’s?

  9. Hello.
    I just got diagnosed with Hashimotos. Confirmed with a positive TPO antibody test and put on NP3 Thyroid, iodine supplements (with zinc and selenium), testosterone pills, vitamin ADK, and omegas. I am also 48 yrs old and told I was pre- menopausal. I’m experiencing severe anxiety which mostly wakes me up at night so I stopped the thyroid medication, and afraid to take hormone pills or birth control which another OB/Gyn put me on – die idue to very heavy menstruation. My initial problem for going was severe menstrual bleeding , however after blood tests confirmed a TPO of 13, my doctor said I had Hashimotos . I have sensitivities to medications and feel like need to manage my symptoms of : major weight gain, heavy menstrual flow, low energy and occasional pedal swelling . My concern is that I don’t know if this is a female hormone issue (estrogen/progesterone), or my thyroid and if I do have Hashimotos, can the iodine supplements with zinc and selenium, and vitamin D alone help destroy these antibodies and heal my thyroid without thyroid meds and what are your thoughts on which I need to treat first. Thank you.

  10. Hi Dr. Childs,
    I’m wondering if results from anti-thyroglobulin AB, Anti-microsomal AB, SED rate, C reactive protein, and vitamin D 25 EDCC is enough to find out about having the autoimmune component and if any of these are the same as being tested for TPO and TgAb?
    Thanks so much,
    Cookie

    • Hi Cookie,

      Anti-thyroglobulin antibody is another name for TgAb. The other tests you mentioned test for other things but yes, the TgAb can give you insight as to whether or not you have Hashimoto’s thyroiditis (but you should also get the TPO antibody test as well (thyroid peroxidase).

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