Hashimoto's/hypothyroidism without clinically elevated TSH?

Medical Q&A [Moderated]
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Hey Docs,

I’ve struggled with a lot of comorbidites for most of my life (major depression, generalized anxiety, insomnia, fatigue, obesity, Msk pain). The mental health, sleep, and weight stuff has always been pretty treatment resistant. Zepbound has helped the weight significantly, but I’ve recently gained back some of what I lost (20lb of 48lb), from inactivity due to a more acute and extended period of depression, anxiety, insomnia, fatigue, and pain. I am working with both a psychiatrist and a therapist on these.

While I’ve always felt these symptoms to be just the unlucky genetic hand of comorbidites that I was dealt, I’ve recently wondered if it might help to rule out something like Hashimoto’s/hypothyroidism. Especially since my energy levels were nearly boundless a decade or so ago (I did half-marathon running and a high volume of lifting), but since then, they’ve only seemed to exponentially decrease, in a way that hasn’t let up. I’ve been working with Derek remotely for a couple/few years now, but rebuilding my lifts, returning to running, and just trying to re-increase my overall activity levels has been extremely slow-going, due to the stress of managing all my symptoms.

I see that my TSH levels were checked in 2023, and came in at 3.45 mIU/L, which was flagged as clinically normal, with no further testing indicated.

I just got a new doc, and I asked him about all this, and he suggested checking TSH. When I asked if Hashimoto’s/hypothyroidism is possible even with clinically “normal” TSH (and my accompanying symptoms), he said it’s rare, and that Kaiser’s lab will really only trigger a FT4 test if TSH is clinically elevated.

I’m not diagnosis-fishing here, or wanting to push for non-indicated testing. I’ve already gone most of my 37 years just accepting that this is hand I was dealt, and trying to get the appropriate treatment best I can for all these things. But, if there is some underlying pathology that’s warranted in ruling out, I figure, why not?

Thoughts?

Thanks So Much,

Josh

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Hi Josh,

I’m sorry to hear about these symptoms and challenges you’ve dealt with, and can understand the desire to search for explanations and potentially treatable issues.

The biggest challenge with these types of situations is the fact that the symptoms are often not specific enough to a particular organ, or “source” of pathology that helps us narrow things down with confidence. This leads to a need to think about and test a much wider variety of things, which necessarily involves a risk of finding things … some of which may be relevant, while others may be red herrings, false positives, or unrelated issues altogether. All of this is to say that if the symptoms and concerns you’re experiencing would require a pretty broad evaluation, and I’d need to see the entirety of the lab evaluation so far in order to be able to comment further.

Regarding your question here - it is certainly possible to have Hashimoto’s with a normal TSH, which can be suggested by the presence of Hashimoto’s antibodies (which I did not see you mention).

However, this would be distinct from having actual hypothyroidism, which would be more defined by low levels of thyroid hormone (and, as a result, elevated TSH levels). The added wrinkles here are that TSH levels, like all hormones, can fluctuate, so a single lab snapshot may be insufficient – and anecdotally, we see patients who report feeling better at certain TSH levels than others, although this is not a currently based on strong evidence.

So ultimately, I think if it’s been a few years, it would be very reasonable to re-assess the thyroid question, but this should be done together with casting a wider net, including blood counts, basic chemistries, ruling out sleep apnea or other sleep disorders, anemia, iron deficiency, testosterone deficiency, assessment for other autoimmune/inflammatory conditions, as well as substance-induced issues (medication side effects, alcohol use, etc., if relevant).

Unfortunately this world of chronic, non-specific, “medically unexplained symptoms” is a tricky one, where there’s a lot of with poor care in the “traditional” medical system, leaving a lot of patients prone to quacks and wasting lots of time and money in other ways. Tough situation to deal with for sure.

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Austin,

Thanks very much for the thoughtful reply.

I get everything that you’re saying, and I agree.

Kaiser SoCal can difficult when it comes to more complex care. I’ll see where I end up with this new GP. If I hit a wall in terms of Kaiser’s capacity, I will schedule a consult with you. Even if the end result is simply continuing the treatments I’m already doing, but getting a better sense of how to integrate everything, and figuring out how to progress back to the highly active lifestyle that I was accustomed to (and was so passionate about).

I think it’s a probably good time for a more formal zoom check-in with Derek, as well.

Best,

Josh

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