High TSH Normal T4: What Does it Mean? + Other Thyroid Lab Patterns Explained

Are you experiencing a high TSH but normal T4?

Are you confused about interpreting these values?

Is your Doctor telling you that your tests are normal even though you are experiencing abnormal symptoms?

This article will help shed light on this thyroid lab pattern and help you understand what it means. 

You'll learn more about the symptoms associated with this pattern (and other patterns) and how to treat them below


Is This Thyroid Lab Testing Pattern Bad?

The first thing you should know is that having a high TSH, even if accompanied by a normal T4, is never a normal sign. 

A high TSH is a marker that the connection between your brain and your thyroid may not be functioning at 100%. 

What do I mean?

In order to understand this concept, you have to understand how TSH functions in your body. 

TSH (also known as thyroid stimulating hormone) is a hormone that is produced by the pituitary gland. 

Its job is to act on your thyroid gland (in your neck) to tell your thyroid to produce more thyroid hormone. 

If your TSH is elevated this means your brain is trying to increase the "stimulus" to your thyroid gland in an attempt to compensate for decreased thyroid hormone (1).

This process is how your brain and your thyroid gland regulate thyroid hormones in your blood. 

As thyroid hormones drop your TSH will rise to compensate to tell your gland to produce more. 

This rise in TSH is almost always seen as an early and sensitive marker for thyroid dysfunction! 

So, while TSH tells you how responsive your thyroid gland is to thyroid hormone it doesn't give information on your free thyroid hormone levels. 

Download my Free Resources:

Foods to Avoid if you have Thyroid Problems: 

I've found that these 10 foods cause the most problems for thyroid patients. Learn which foods you should absolutely be avoiding if you have thyroid disease of any type. 

How to Calculate "Optimal" Free T4, Free T3, & Reverse T3 Ratio: 

Calculating these ratios is important because it can help you determine if your efforts are on the right track and whether or not your medications are working. 

Download more free resources on this page

What your Free Thyroid Hormones Mean for You (Free T3 & Free T4)

Most physicians (Doctors) tend to order what is known as a TSH with reflex to free T4

This lab test is supposed to only order the free T4 IF the TSH is abnormal (2).

The idea is that it saves on the cost of unnecessary lab tests because why would you need to see the free T4 if the TSH is normal? 

So, what ends up happening, is many patients get their thyroid "checked" which results in this TSH with reflex to free T4. 

When they find that their TSH is abnormal the lab company will automatically order free T4. 

But they might get confused when the free T4 comes back as "normal" or within the normal range. 

How can this be if your TSH is high?

Several things may account for this phenomenon. 

#1. Your thyroid gland is struggling but still able to keep up... for now

The rise in your TSH is a normal physiologic response for lower than normal free thyroid hormones and it indicates that everything is working properly. 

But as TSH rises it means that your thyroid gland is no longer responsive to the lower doses of TSH that it once was. 

This usually indicates an early problem with the thyroid gland itself. 


Because your thyroid gland is getting the stimulus from the brain to produce more thyroid hormone (hence the high TSH) but it's only capable of producing a "normal" amount of T4. 

We know this because we know what a HEALTHY TSH level is supposed to be (3).

We also know that a high TSH is not necessary to produce adequate thyroid hormones. 

So this early rise in TSH can be used as a sensitive marker for early thyroid GLAND dysfunction. 

By the way, you may find that both your free T3 and free T4 stay "normal" despite having a very high TSH. 

This is seen as your body is attempting to compensate for the early problems described above but it does NOT mean that this is "normal". 

Eventually, your thyroid will be unable to meet the demand and you will experience severe symptoms (if you aren't already)

#2. The lab tests may not be accurate

This one is rare but it certainly does happen. 

It is estimated that up to 5% of all lab tests may be inaccurate or spurious. 

This is as high as 1 in 20 lab tests and if you get a full panel of lab tests you can count that at least a few of those results are not 100% accurate. 

This inaccuracy stems from the fact that lab testing machines must be calibrated to normal each and every day. 

If there is something wrong with the machine for one test or the calibration is not done accurately, then some of the lab tests may not be accurate. 

So what should you do if you feel that your results are not accurate?

The best thing to do is to simply re-test your TSH and free T4 within 1-2 weeks. 

The chances of your lab tests being inaccurate are very low, but it's worth going through this song and dance if you don't have any symptoms and feel great. 

#3. You may have Hashimoto's Thyroiditis

Another possibility is that you have an autoimmune disease known as Hashimoto's thyroiditis

It is well known that this thyroid condition can cause changes to thyroid lab tests which are not considered to be "normal" (4).

In fact, many patients with Hashimoto's are not treated sufficiently because their symptoms do not always correlate with their lab results. 

When in doubt, make sure that you always look at your body and your symptoms and don't focus solely on your lab tests. 

If you suspect that you may have Hashimoto's you can easily check for this condition with a blood test which checks for thyroid antibodies. 

#4. You may not be converting T4 to T3

Lastly, it's possible that you may not be seeing the "whole picture" when it comes to your thyroid. 

While your TSH and free T4 are important measures of thyroid function they do not test every facet of thyroid function in your body. 

One of the most important (if not the most important) lab test to look at when it comes to your thyroid is known as free T3

Free T3 is the ACTIVE thyroid hormone and it is created through a process known as thyroid conversion

In this process, your body takes free T4 and turns it into free T3. 

So, why does free T3 matter? 

Consider this scenario:

Imagine that your TSH is high and your free T4 is normal but you decide to check your free T3 as well. 

You may find that your free T3 is actually quite low which indicates that your body can produce some amount of T4 but it's not able to convert that T4 into T3. 

This is known as a problem with thyroid conversion and can be entirely missed unless you also check for your free T3.

For this reason, I always recommend that you look at a complete thyroid panel (if you suspect you have thyroid disease). 

If you didn't get a full thyroid panel to start with you can always go back and get everything retested. 

Symptoms Associated with a High TSH

Will you have symptoms if you have a high TSH and a normal T4?

You might expect that you would be without symptoms if your free thyroid level is "normal" but that isn't always the case. 

In fact, most patients with a high TSH (regardless of their free thyroid hormone levels) may be symptomatic. 

A handful of patients may be asymptomatic (meaning they won't experience symptoms) most likely due to their body being having a "reserve" level which can keep them going for some time. 

But, if you are like most people, you may start to experience certain symptoms. 

In fact, these symptoms may be the reason you went to your Doctor in the first place and had your blood work checked. 

The symptoms associated with a high TSH are easy to identify because they are the symptoms of low thyroid function or hypothyroidism. 

Symptoms of a high TSH and normal T4 include:

  • Mild weight gain (usually no more than 2-5 pounds)
  • Cold intolerance or feeling like you are cold all the time
  • Mild constipation
  • Dry skin
  • Feeling "down" or "depressed"
  • Mild brain fog or clouded thinking/judgment

The degree of symptoms that you will experience will depend on the degree of elevation of your TSH (5).

Put simply:

The higher your TSH, the more your thyroid gland is compromised and the more severe your symptoms will be.

So, you may experience only mild weight gain if your TSH is in the 3-5 range, but that weight gain will be more severe if your TSH is 5-10 and so on. 

These symptoms are an indication that your thyroid is NOT functioning properly and are a sign that you should seek out therapies to try and fix the problem. 

Treatment Options + What to do next

So what should you do if you have a high TSH? What therapies are available to you?

The first thing you should do is to make sure that your test results are indeed legitimate. 

That means that your lab results should match your clinical appearance. 

If you are completely asymptomatic, meaning you are not experiencing any of the symptoms listed above, then it may be reasonable to simply recheck your blood work in 6-8 weeks to see if your test was accurate. 

If you are symptomatic, however, then you can safely assume that your thyroid is not functioning appropriately. 

This would be an indication that some sort of intervention is warranted. 

In terms of the type of treatment available you really have a couple options: 

#1. Treatment with thyroid medication

The most common treatment for a high TSH is to take thyroid hormone replacement medication. 

This medication, usually in the form of T4 such as Levothyroxine, will help supplement your body with extra T4 which will, in turn, drive down your TSH to normal levels

This is the theory behind using thyroid medication to help if you have thyroid dysfunction. 

The problem is that not everyone will do well on T4 only thyroid medications (even though they are the most commonly prescribed). 

Previously, I mentioned that you may have an issue with thyroid conversion which leads to low free T3. 

If you fit this category then you may need to use a thyroid medication which contains both T4 and T3. 

These therapies should always be combined with #2...

#2. Treatment with Alternative Therapies Including Diet and supplements. 

These therapies shouldn't be considered "alternative" at all because they are really the single best way to improve your thyroid and other hormones. 

Using basic therapies which include eating a more healthy diet, taking vitamins and nutrients which you may be deficient in and exercising regularly should never be ignored if you have a thyroid issue!

Study after study has shown that these therapies do indeed help to reduce inflammation (6) and promote hormone balance (7).

The problem is that many patients forgo these therapies in favor of taking medications!

This behavior only reinforces future problems and never actually allows your body time to improve. 

Thyroid adrenal reset complex 400 x 350

In terms of your diet, you can read more about the type of healthy foods you should be eating in this article

For supplements, you'll want to focus on nutrients and vitamins which have been shown in scientific studies to improve your thyroid. 

I recommend a supplement such as this one which contains all of these nutrients

In addition to these therapies, you'll also want to ensure that you are sleeping 8 hours each night and managing your stress appropriately!

Doing these things, in conjunction with thyroid medication (if necessary) will go a long way toward helping you feel better. 

What if you have a High TSH and a Low T4?

Does anything change if you have a high TSH and a low T4 or low T3? 

The answer is no. 

The difference between those who have a high TSH and a low or normal T4 likely has to do with their "reserve capacity" for thyroid function. 

In other words, some people are probably able to tolerate different levels of T4 without becoming symptomatic due to either the number of thyroid receptors they have on their cells or due to receptor sensitivity (they may be more or less sensitive to thyroid hormone than you). 

So, don't be too concerned with your absolute T4 or T3 level, instead, try to focus on whether or not you have both a lab abnormality combined with symptoms. 

The combination of these two factors will give you the most information and help you zone in on a diagnosis. 

If you have low T4 you can read more about that condition here

Other Thyroid Lab Patterns which May Result in Hypothyroid Symptoms

Are your lab tests slightly different than what we discussed here?

Don't worry!

I've included a list of various other lab tests below and how they may present in terms of your symptoms:

  • High TSH, normal T4, normal T3 = This is the pattern we've been discussing in this post and will usually present with hypothyroid symptoms. 
  • High TSH, normal T4, low T3 = This pattern may be an indication that you are having issues with thyroid conversion and most often presents with hypothyroid symptoms. 
  • Normal TSH, low T4, low T3 = This pattern is usually what is seen in those with chronic illness and in those who are taking multiple medications. If you have this pattern you will most likely be symptomatic. 
  • Normal TSH, normal T4, low T3 = This pattern may be consistent with low T3 syndrome or euthyroid sick syndrome and may present with hypothyroid symptoms but not always. 
  • Normal TSH, normal T4, normal T3, positive thyroid antibodies = This is a classic presentation for early Hashimoto's and most patients with this pattern will be symptomatic. If you are symptomatic this is a valid reason to consider a trial of thyroid medication even though your lab tests are "normal". 
  • Normal TSH, normal T4, normal T3, high reverse T3 = This pattern is most often seen immediately after calorie restriction or after dieting and weight loss. This pattern usually indicates an adaptive response from your body and one that shows your metabolism will be slowing over the next few months (not ideal for weight loss). 

This isn't a comprehensive list of all of the thyroid patterns available, but it should really give you a good starting point if you aren't sure where you "fit in". 

Lastly, if you have any questions about your labs feel free to leave a question or a comment below and I can try to direct you further! 


The bottom line?

Your TSH and your free T4 are connected and changes in one will often time result in a change in the other. 

Don't let a single "normal" lab result in a sea of abnormal results alter how you look at your thyroid lab tests. 

It's not abnormal for one result to be "normal" even though many others are obviously abnormal. 

Lastly, make sure that you listen to your body and your symptoms. 

You are more than just your lab results!

Now I want to hear from you:

Do you have a high TSH with a normal T4? 

What about your free T3 levels?

Have you had a complete thyroid lab panel?

Leave your questions, comments or answers 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.

14 thoughts on “High TSH Normal T4: What Does it Mean? + Other Thyroid Lab Patterns Explained”

  1. Dr. Childs,
    I have been having issues with a low TSH and a Low FT4 on every lab test I have and my Endo keeps lowering my synthyroid no matter what I say she comes back with “your bones are going to crumble and you could get heart disease”,not caring that my cholesterol level have sky rocketed after thyroidectomy for cancer.

    I was taking 100mcg synthyroid and 15mcg Cytomel and now Im on 88mcg synthyroid and still the same 15mcg Cytomel. I feel under medicated and still have body pains that just won’t quit, emotional issues and the dreaded weight gain.

    I’m feeling this Endo is going to cause more health issues if I continue with her, I feel doomed.

    Any thought on why TSH and FT4 would keep dropping?

    • Hi Grace,

      The higher your dose of T3 the more your TSH will drop and the more your free T4 will drop as the stimulus to produce thyroid hormone decreases.

  2. My fT3 is consistently at the bottom of the normal range, sometimes lower. My doctor(s) say it’s okay. My endo says that it doesn’t matter because the fT3 does not really tell us how much T3 is in the cells and that the test is not reliable in any way. But I really don’t feel so fabulous. I also have Hashi.

    • Hi Eirene,

      It is certainly true that free T3 doesn’t tell you how much thyroid hormone is in your cells, but neither does free T4 or TSH, so using that same logic why would you look at any of the tests? The best solution is to look at all of them in tandem to get a better picture. The “best” marker for looking at cellular thyroid levels would be the free T3:reverse T3 ratio.

  3. What would cause normal T4, HIGH T3, and also slightly higher TSH (3)? It’s been this way for about a year. I can’t seem to figure out why my TSH would still be on the higher side when the T3 is high (just above normal range).

  4. Hi, I have been on levothyroxine for more than twenty years and have never been optimal. I also have Lupus and have always blamed not feeling well on Lupus. I now realize that it has been more Hashimoto’s than Lupus. I started on NDT four months ago stating with one grain alternating levo and NDT every other day for one month and I also started a gluten-free diet. The first month I felt great. It was emotional and I was encouraged as I haven’t felt well for years. After one month I declined and my dose was raised to one and a half grains. Still no improvement and no weight loss as I was dieting. Again the Doctor raised my dose to two grains which I have been on for the last six weeks. My TSH is now high, my free T3 is borderline low and my total T4 is midrange. I am having symptoms and I see my Doctor in a couple of days. I would love some direction as to what to discuss with her. Thank you

  5. Thank you for the information.
    My T S H IS at 17.48 and my free t4 is 1.1.
    Not sure as of what to do first but I do have all of the symptoms as you mentioned earlier.
    I am without insurance.

  6. My current Tsh 3.333 t4 is 1.53 t3 .74. 6 months ago my doc lowered my Synthroid from 100 to 75 to 50 mg. My thyroid was removed 35 years ago, they removed most of it and radiated the rest. He said it was because I was exercising (?) however all my numbers were within the lab’s parameters. The Tsh has gone from .693 to 3.333. My symptoms are extreme tiredness, dry skin which really itches and my hair is super dry. When I asked about these issues he said they weren’t his concern. My numbers were good. I told him I wouldn’t be back. I’m 69.

  7. Doctor, my mother is 65. Her T3 is 88 ng/dl, T4 is 5.7microgm/dl, TSH is 30.75 microIU/ml. As per the report, the T3 and T4 are in the normal range, whereas TSH is almost six times normal. What does this mean? My mother is on Thyroxine tablet(levothyroxine) 200mcg. 4-5 years back, she started with 50mcg and now has gone to 200mcg and still TSH is not normal. She has some weight gain. But she feels hot, not cold. Is this something we need to be concerned about? Anything else we can try? Thank you!

  8. What’s “optimal,” on ranges for TSH and Free T4? My TSH has been above 4 (average 4.375) for about the last 7 years, according to LabCorp, so my PCP has ignored it. I have NO symptoms, save for a benign nodule, and an average 1.1575 FT4. Antibody tests are “normal.”

    What can I do to protect my thyroid function?

  9. Sixty-two-year-old male with steadily rising TSH over a three year period. Results for each:
    Thyroid AB-1/2/2

    The only symptom of hyperthyroidism is cold sensitivity, but I’ve always been “cold natured.”

    How should I proceed?

    Thank you!!

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