6 Stages of Hashimoto's Thyroiditis That ALL Patients Progress Through

6 Stages of Hashimoto’s Thyroiditis That ALL Patients Progress Through

Hashimoto's Progresses Through Certain Stages Over Time

Every single patient with Hashimoto's will go through the same stages over the course of their disease. 

These stages outline are important because they outline exactly what will happen to you, provided you let your disease smolder and damage your thyroid. 

It's not all bad news though. 

By understanding these stages, and finding out where you fit within them, you can roughly identify how long you've had your disease and you can gain insight into what treatment options are best for you. 

Hashimoto's thyroiditis is what is referred to as a progressive disease. 

Meaning that it progresses and worsens over time. 

Doctors know this which is why they typically tend to avoid treating the autoimmune component of Hashimoto's. 

Instead of focusing on the autoimmune aspect, they tend to focus more on the thyroid aspect. 

But by ignoring the autoimmune aspect you will miss out on all of the treatment options available to you along the way! 

Today you will learn:

  • The 6 stages of Hashimoto's thyroiditis
  • How each of these stages presents in terms of lab tests and symptoms
  • At what stages Hashimoto's tends to be diagnosed
  • The best stage to start treatment if you have Hashimoto's (*hint: the earlier the better!)
  • And how to know if you've reached the "end-stage" of Hashimoto's
  • Why this information is important to ALL thyroid patients regardless of whether or not they have been diagnosed with Hashimoto's

Let's jump in:

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6 Stages of Hashimoto's Thyroiditis

I've mentioned it before but it's worth repeating here:

Hashimoto's thyroiditis is the #1 cause of low thyroid in the United States (1). 

It is estimated that as many as 90% of all cases of low thyroid are caused by autoimmune disease of the thyroid gland (AKA Hashimoto's). 

This number is probably not accurate when you consider the cases of seronegative Hashimoto's (yes, you can have Hashimoto's even with negative antibodies) and the fact that many doctors aren't ordering antibodies on every thyroid patient. 

This information is important because it means that if you have low thyroid function there's a HIGH probability that it's from Hashimoto's, whether you realize it or not. 

The takeaway here is to check your thyroid antibodies at least once a year if you have Hashimoto's or not. 

By checking your antibodies you can keep an eye on your disease state to see if your treatments are working and it will also help you diagnose Hashimoto's if you aren't already diagnosed. 

With that in mind, let's get into the 6 stages of Hashimoto's...

Remember, each person will progress through every stage over a period of time. 

From stage 0 to stage 5, it takes about 20-30 years (depending on the person). 

And unlike a video game, the goal here is to NOT go through every single stage. 

The goal is to identify where fit into these stages and then implement the right treatments so you can avoid further progression. 

And, yes, if you weren't already aware, it is possible to halt the progression of Hashimoto's!

Stage 0. - Genetic Predisposition

The first stage is what I refer to as stage 0. 

It's called stage 0 because there are many people who don't even know that they are in this stage. 

Stage 0 simply refers to a genetic predisposition that you have in your body. 

When it comes to autoimmune disease, genetics play an important role in determining whether or not you will get a specific disease. 

But just because you have the genetics does NOT guarantee that you will get a disease. 

More important than your genetics (2) are the triggers that you come into contact with on a daily basis. 

It is only when you combine a genetic predisposition with triggers (3) that you are primed to get Hashimoto's. 

How do you know if you have a genetic predisposition to developing Hashimoto's? 

You can get a good idea by looking at your family history. 

Do other members of your family have thyroid disease?

Do other members of your family have Hashimoto's disease?

Do other members of your family have autoimmune diseases like Celiac disease or Vitiligo?

If you answered yes to any of these questions then there's a good chance that you are positive for a genetic predisposition! 

A family history is not enough to guarantee that you will get Hashimoto's, though. 

It's not until you combine your family history with other triggers such as EBV infection (4), other viral infections, major stressors in your life (5), exposure to chemicals or heavy metals, eating an unhealthy diet (6), not exercising enough, and so on, that you will then develop Hashimoto's. 

It's not worth spending too much time on this area, though, because most people aren't even aware of their own family history and because it's often too late. 

For most people, they don't realize they have a family history of Hashimoto's until they've already been diagnosed. 

For this reason, we are labeling this as stage 0. 

If the conditions are met above, meaning that you have both the genetics and the triggers, you will progress to stage 1. 

Stage 1. - Immune Cell Infiltration (+ Antibodies)

Stage 1 is when we really get into what defines Hashimoto's thyroiditis and that is immune cell infiltration of the thyroid gland. 

This means that if you were to take a biopsy of the thyroid gland in this stage, you would find immune cells inside of the gland causing problems such as inflammation and stirring up other problems. 

This is the hallmark of Hashimoto's thyroiditis. Autoimmune attack of the thyroid gland and it starts in stage 1. 

Under normal circumstances, you should never find immune cells inside of thyroid gland tissue. 

The thyroid gland remains relatively tucked away from the rest of the body and immune cells shouldn't come into contact with glandular tissue unless something is awry. 

Because there is immune cell infiltration in this stage, you will also see positive antibodies when you look in the blood. 

Despite the fact that antibodies are present in this stage, most people are NOT diagnosed here. 

The reason is simple:

Even though you have positive antibodies, the symptoms associated with this stage tend to be VERY mild and they are often not related to your thyroid. 

While the antibodies are causing some damage to your thyroid, your body is still able to compensate by simply using more effort and energy to pump out extra thyroid hormone. 

supplements designed for hashimoto's

This effort and energy take a small toll on the body, though, so you may start to feel symptoms such as slightly low energy, feeling a little "blah", or feeling run-down. 

These symptoms are easy to miss and may accidentally be associated with extra stress from work or lack of sleep. 

Stage 1 is considered EARLY stage Hashimoto's and is, therefore, the BEST time to start treatment. 

Unfortunately, most cases of Hashimoto's are missed here but if you can somehow identify that you have Hashimoto's then treating here is the most effective. 

Natural treatments such as changing up your diet, using the right supplements, exercising regularly, detoxing (if necessary), avoiding exposure to your triggers, and reducing your exposure to stress, are all highly effective natural treatments. 

Stage 2. - Subclinical Hypothyroidism (+ Antibodies, Normal TSH)

If stage 1 is not halted it will eventually lead to stage 2. 

Stage 2 is defined as subclinical hypothyroidism which I will explain in more detail below. 

You can imagine that the longer you have thyroid antibodies floating around in your bloodstream and interfering with your thyroid gland, the more damage that will occur. 

And this is exactly what we see in stage 2. 

Stage 2 happens when your body is no longer able to compensate for the damage done to your thyroid (unlike stage 1). 

As damage to your thyroid gland mounts, eventually, your thyroid will not be able to pump out enough thyroid hormone. 

When this happens thyroid hormone levels begin to fall and you start to experience low thyroid symptoms. 

As your thyroid can no longer keep up, your body increases levels of TSH which is how it tries to force more thyroid hormone out of the thyroid gland. 

But because the thyroid gland is damaged, it can't respond to the increased TSH levels. 

So in subclinical hypothyroidism, we see 2 very important markers on your thyroid lab tests. 

The first is a RISE in your TSH levels (this is never normal and means that something is wrong with your thyroid gland). 

And a RISE in your thyroid antibodies (antibodies were raised in stage 1 but they may rise even higher in stage 2). 

These two markers will also now be associated with the start of low-grade low thyroid symptoms

Symptoms such as mild weight gain, mild fatigue, mild constipation, and even some mild hair fall

Unlike stage 1, these symptoms are enough to get people into their doctor's office but they are usually not enough to get the right diagnosis. 

This is usually the time that your doctor will order your TSH and tell you that it is "normal" even though it is a high-normal and not optimal

Your doctor may also identify that you have positive thyroid antibodies but will tell you that you aren't "bad enough" to get on thyroid medication

This stage is where many a thyroid patient gets frustrated. 

They will feel frustrated because they know something is obviously wrong, but most doctors aren't willing to treat them at this point. 

This is very unfortunate because starting thyroid medication at this stage is ideal! 

The early use of thyroid medication may help drive down thyroid antibodies and stop (or slow) the progression of thyroid gland damage. 

If you know that you are in this stage it's worth spending some time to find a doctor who is willing to prescribe thyroid medication in early Hashimoto's. 

Of course, you will also want to use the other natural treatments outlined in stage 1 as well, even if you are not able to get thyroid medication. 

These therapies are always more effective if started early!

(Stage 2.5) Thyroid Hormone Fluctuation

Before moving onto stage 3, we need to talk about what I call stage 2.5. 

This is a stage that is highlighted by thyroid hormone fluctuation. 

It isn't technically stage 3 because not every single patient with Hashimoto's will go through this problem. 

Thyroid hormone fluctuation refers to changes in your thyroid hormone levels over time

If you know anything about Hashimoto's then you probably already know that it usually results in LOW thyroid function or hypothyroidism. 

But this isn't true for everyone!

10-20% of people can also experience episodes of HYPERthyroidism or HIGH thyroid hormone. 

During this stage, your thyroid may swing from hypothyroidism to hyperthyroidism which can make diagnosis difficult. 

One month you may experience weight gain and constipation and the other you may experience hot flashes, weight loss, and diarrhea. 

What happens is that as your thyroid gland is damaged, it can sometimes release MORE thyroid hormone instead of less. 

During times that more thyroid hormone is released, you will experience hyperthyroid symptoms and during times when less thyroid hormone is released, you will go back to hypothyroidism. 

You should know that even if you do have periods of hyperthyroidism, you will always end up hypothyroidism over time. 

Hashimoto's does NOT result in long-term hyperthyroidism so your symptoms will always eventually go back to hypothyroidism. 

But diagnosis during this time can be confusing which is why it is included in this section. 

Stage 3. - Overt Hypothyroidism (+ Antibodies, Increased TSH, Decreased Free T3/Free T4)

All stages, regardless of whether you went through stage 2.5 or not, will end up with hypothyroidism. 

This stage is called overt hypothyroidism because, by this point, you obviously have hypothyroidism

Even if your doctor wanted to, they couldn't deny that you are now in a stage of low thyroid by stage 3. 

Stage 3 is associated with HIGH antibodies, an INCREASED TSH (higher than stage 2), and now decreased free T3 and free T4

The decreased free thyroid hormone levels are a dead giveaway that you are now in a hypothyroid state. 

It is never normal for your thyroid hormone levels to be low, and if you find that your free thyroid hormone levels are low you WILL feel it. 

Unfortunately, this is the stage that MOST patients with Hashimoto's thyroiditis are diagnosed. 

By this time, they've been kicked around from doctor to doctor for a few years until their thyroid function finally has fallen to a level that even the most basic doctor can't miss. 

The good news is that most people are finally diagnosed here, the bad news is that it's very late in the disease. 

Around 10+ years or so have passed from stage 1 to stage 3, which means that it takes years and years for the average Hashimoto's patient to be diagnosed. 

It's also around this time that you will NEED thyroid medication. 

Thyroid medication may have been optimal at stage 2 but by the time you get to stage 3, you will need it. 

If you remain untreated, you will experience significant weight gain, significant constipation, significant fatigue, significant hair loss, significant constipation, and so on. 

The use of thyroid medication here is required to help you feel better but it may also have a positive effect on your thyroid antibodies (in driving them downward). 

Natural therapies are still effective by the time you get to stage 3, but you will have to be more aggressive with them. 

If you catch Hashimoto's in stage 1, you may be able to get by with just going gluten-free or dairy-free. 

By the time you get to stage 3, those types of diets probably won't cut it. 

Instead, you will need to do more comprehensive diets such as the elimination diet, going gluten, dairy, and soy-free, or even diets such as the low FODMAPS diet. 

Stage 4. - Additional Autoimmune Diseases

After being at stage 3 for a while you may start to progress to stage 4. 

Stage 4 is characterized by the addition of other autoimmune diseases. 

Hashimoto's is an autoimmune disease and when you have one autoimmune disease you are much more likely to develop another. 

Some people get confused here and believe that once your thyroid antibodies run out of thyroid gland tissue to kill they will then move on to other tissues. 

That's not really what is happening. 

The thyroid antibodies in your body are highly specific to certain tissues in the thyroid gland so there is very little cross-reactivity with non-thyroid gland tissues. 

Having said that, if you fail to fix whatever was causing the immune dysfunction which started your disease in the beginning, your body may eventually start to develop antibodies to OTHER tissues. 

If your body creates antibodies to gluten then that is called Celiac disease (7).

If your body creates antibodies to destroy your joints then that is called rheumatoid arthritis (8). 

If your body creates antibodies to destroy your salivary glands then that is called Sjogren's

If your body creates antibodies to destroy melanin in your skin then that is called Vitiligo (9). 

And so on. 

What you need to understand here is that simply treating your thyroid with thyroid medication will NOT stop the progression of your autoimmune disease. 

It may help you feel better as you provide your body with the thyroid hormone it is lacking, but it's not enough to fix the underlying autoimmune disease which damaged your thyroid, to begin with. 

And this underlying immune problem, if left untreated, may ultimately lead to additional autoimmune diseases as mentioned above. 

It's also worth pointing out here that you may start to develop other autoimmune diseases earlier as well. 

These autoimmune diseases do not always come at this stage and can come at any point.

Stage 5. - End-Stage Hashimoto's Thyroiditis (Decreased or Negative Thyroid Antibodies)

The final stage of Hashimoto's is what is referred to as end-stage Hashimoto's. 

End-stage Hashimoto's is what happens when the autoimmune attack on your thyroid gland persists for years and years. 

When you get to this stage, your thyroid gland has atrophied and shrunk due to this damage. 

It's become so damaged that it can no longer produce thyroid hormone and is essentially non-functional. 

By this point, those with an atrophied thyroid gland are in the same position as those who have had thyroid gland removed or irradiated from RAI

Patients in end-stage Hashimoto's are REQUIRED to be on thyroid hormone for the rest of their life because their own thyroid gland no longer functions to produce it. 

In addition, by the time you get to this stage, you may find that your thyroid antibodies begin to decline and eventually fade away. 

And while this is something that you want in stages 1-4, it's not a good thing when it happens here. 

The decline in antibody levels in end-stage Hashimoto's occurs because your body has run out of tissue for your antibodies to attack. 

When your body runs out of tissue to attack it believes that the "treat" is gone so there is no need to produce more antibodies. 

Unfortunately, by the time you get to this stage, the damage is irreversible and it usually indicates that you've had Hashimoto's for 20-30+ years. 

At this stage, the natural therapies that I discussed back in stage 1 and stage 0 are still important, but they will not be enough to restore thyroid function. 

It doesn't mean you should avoid them but it does mean you should be aware of what they can and can't do. 

The entire goal of talking about these stages is to PREVENT you from progressing to stage 5. 

This is why it's so important for you to understand these stages so that you can get a start on treatments and therapies EARLY. 

If you are reading this and you suspect you are already here (there will be plenty of people in that situation), that's okay because you can still optimize thyroid function through thyroid medication, thyroid supplements, and lifestyle interventions. 

It's much harder to optimize thyroid hormone at this stage but it's definitely still possible. 

Wrapping it up

When you think about the stages of Hashimoto's, I want to leave you with this idea:

The earlier you start treatment the better!

The earlier you can catch your disease process the more likely you are to stop the progression of your disease to the later stages. 

Also, the farther down the stages that you progress the more aggressive you will have to be with treatment. 

Easy treatments such as going gluten-free may work when you are in stage 0 and stage 1, but will most likely not be sufficient by themselves when you get to stage 3 and stage 4. 

More aggressive diets, supplements, therapies, and thyroid medications will be necessary to feel optimal in the later stages. 

Lastly, remember that Hashimoto's does NOT have to be a progressive disease. 

It is possible to both stop and even reverse (sometimes) the damage to your thyroid gland. 

This should always be your goal when treating Hashimoto's. 

And, in order to do this, you have to focus on more than just thyroid function. You will need to also focus on your immune system. 

Now I want to hear from you:

What stage of Hashimoto's do you think you are currently at?

Have you had any success in stopping the progression of your disease or in reversing your Hashimoto's?

If so, what stage did you find the most success?

Are you someone who is just reading this and who is already in the later stages?

Leave a comment or share your experience below! 

References (Click to Expand)

the stages of hashimoto's thyroiditis explained

Dr. Westin Childs

About Dr. Westin Childs

Hey! I'm Westin Childs D.O. (former Osteopathic Physician). I don't practice medicine anymore and instead specialize in helping people like YOU who have thyroid problems, hormone imbalances, and weight loss resistance. I love to write and share what I've learned over the years. I also happen to formulate the best supplements on the market (well, at least in my opinion!) and I'm proud to say that over 45,000+ people have used them over the last 4.5 years. You can read more about my own personal health journey and why I am so passionate about what I do here.

11 thoughts on “6 Stages of Hashimoto’s Thyroiditis That ALL Patients Progress Through”

  1. I believe I am in stage 3. No other autoimmune that I am presently aware of. I am almost through one year of treatment and did better in part of spring and summer and early fall. I have been struggling pretty bad since sometime in November . I have also done some med switches with has been challenging. I am eating a strict diet and have been trying the hypothyroidism revolution diet laid out by Tom Brimeyer. He definitely believes in dairy and a significant amount of OJ. What are your thoughts on his program? I recently started synthroid and cytomel . I do work with a functional doc. Thanks Craig

    Reply
  2. Hi Craig, I have been recently diagnosed with Hashimoto’s. I had my first blood test 13 months ago and my second recently. I have refused current medication and am seeking a specialist in two weeks. I am uncertain as to what stage I am at but have my blood report. If I may I shall relate them to you for your opinion. Recent Autoantibodies, Thyroglobulin 149, Peroxidase 1300.
    The first Lipid Study 7.0, the second 8.3
    LDL Chol. 4.7, then 5.9
    Non-HDL Chol 5.2 then 5.9
    Thyroid function test, 7.7 then 11.32
    TSH 9.90 then 11.32
    I found your article informative but was confused by the suggested diet as some of the ingredience would seem not good for high cholesterol, e.g. bacon, another query is that you suggest that weight gain is typical, however I have lost weight, mind you I have given up drinking, white wine. I have problems sleeping and have not had a good sleep since mid December when I stopped drinking. If you have any insight I would welcome your advise, should I be taking supplements for example. Hope I have not overburdened you, but as you well know this is a worry and I could use some insight, also I have avoided salt for most of my adult life and though I don’t eat junk food I have always been very irregular with my eating. Many thanks in advance, Chris

    Reply
  3. I’m definitely in stage 5. I’m taking thyroid meds but dealing with vitiligo, early stages of arthritis in my fingers, eye issues, and I’ve been told my adrenals are “pooling”. I also had to undergo parathyroid surgery, and was told after surgery that my thyroid had atrophied and was “hard as a rock”. I’m taking supplements and have removed almost all gluten and most dairy from my diet, but Hashimoto’s is still thriving in me.

    Reply
    • Hi Lori,

      Even though it’s a bit more difficult to treat end-stage Hashimoto’s, it’s still not impossible and it sounds like you are on the right track!

      Reply
  4. I have been struggling with severe depression and anxiety, inability to lose weight despite being in ketosis, extreme fatigue, decrease in libido, and cold hands and feet most of the time. I am working with a nutritional therapist and recently got a full thyroid panel done. It showed that I am hyPERthyroid and my antibodies were very low, such that she ruled out Hashimoto’s. I have been SO confused, because my symptoms do not seem at all consistent with a typical diagnosis of hyperthyroidism. I keep wondering what I should do. I’m not sure who to go to for a further diagnosis and I’m nervous that I’m in what you described as stage 2.5. I don’t want to wait until stage 3 to get a plan in place.

    Reply
    • Hi April,

      Regardless of diagnosis, it’s never a bad idea to start with cleaning up your diet, taking some supplements, exercising, getting more sleep, etc. These therapies work regardless of what thyroid condition you have and should always be done 🙂

      Reply
  5. How can we know for sure what stage we are in? I thought I was around level 2.5 but in level 5 you mention antibodies going back to normal range. My levels have been in remission for about 5 years now but I still had symptoms up until about a year ago. I started LDN a year ago and feel great (I take your Hashimoto supplements). I am NOT medicated w medication. I have no other “known” autoimmune issues. So would this mean I am around level 2.5 or 3 or am I in level 5?

    Reply
    • Hi Nicole,

      It’s hard to know for sure what stage you are in without a lot of history and tests/imaging. It’s relatively easy to diagnose end stage Hashimoto’s with something like an ultrasound, though.

      Reply
  6. I know I’m in stage 5. I was diagnosed Hashimotos in 1996 and last couple of ultrasounds show atrophied thyroid. First ultrasound in 1999 showed thyroid 4.1 x 2.0 x 2.0 cm and 4.3 x 1.7 x 2.5 cm. Last ultrasound showed 2.8 x 0.9 x 1.0 cm and 3.2 x 0.9 x 1.1 cm. My antibodies have now come down to 12. I am currently on Tirosint and T3 as I always end up with high/over range RT3 if one T4 only. At this time I don’t have any other known autoimmune issues. It’s interesting when you talked about the Synthroid fillers in another blog post because when I was on Synthroid (20+ years) I had allergic type reactions. I don’t do well on dairy and have seasonal allergies. So when someone is at stage 5 what are your suggestions?

    Reply

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