Thyroid function tests (TFTs) is a collective term for blood tests used to check the function of the thyroid. TFTs may be requested if a patient is thought to suffer from hyperthyroidism (overactive thyroid) or hypothyroidism (underactive thyroid), or to monitor the effectiveness of either thyroid-suppression or hormone replacement therapy. It is also requested routinely in conditions linked to thyroid disease, such as atrial fibrillation and anxiety disorder. A TFT panel typically includes thyroid hormones such as thyroid-stimulating hormone (TSH, thyrotropin) and thyroxine (T4), and triiodothyronine (T3) depending on local laboratory policy.
Thyroid-stimulating hormone Thyroid-stimulating hormone (TSH, thyrotropin) is generally increased in hypothyroidism and decreased in hyperthyroidism, making it the most important test for early detection of both of these conditions. The result of this assay is suggestive of the presence and cause of thyroid disease, since a measurement of elevated TSH generally indicates hypothyroidism, while a measurement of low TSH generally indicates hyperthyroidism. However, when TSH is measured by itself, it can yield misleading results, so additional thyroid function tests must be compared with the result of this test for accurate diagnosis. TSH is produced in the pituitary gland. The production of TSH is controlled by thyrotropin-releasing hormone (TRH), which is produced in the hypothalamus. TSH levels may be suppressed by excess free T3 (fT3) or free T4 (fT4) in the blood.
History First-generation TSH assays were done by radioimmunoassay and were introduced in 1965. There were variations and improvements upon TSH radioimmunoassay, but their use declined as a new immunometric assay technique became available in the middle of the 1980s. The new techniques were more accurate, leading to the second, third, and even fourth generations of TSH assay, with each generation possessing ten times greater functional sensitivity than the last. Third generation immunometric assay methods are typically automated. Fourth generation TSH immunometric assay has been developed for use in research.
Modern standard Third generation TSH assay is the requirement for modern standards of care. TSH testing in the United States is typically carried out with automated platforms using advanced forms of immunometric assay. Nonetheless, there is no international standard for measurement of thyroid-stimulating hormone.
Interpretation Accurate interpretation takes a variety of factors into account, such as the thyroid hormones i.e. thyroxine (T4) and triiodothyronine (T3), current medical status (such as pregnancy), certain medications like propylthiouracil, temporal effects including circadian rhythm and hysteresis, and other past medical history.
Thyroid hormones
Total thyroxine Total thyroxine is rarely measured, having been largely superseded by free thyroxine tests. Total thyroxine (Total T4) is generally elevated in hyperthyroidism and decreased in hypothyroidism. It is usually slightly elevated in pregnancy secondary to increased levels of thyroid binding globulin (TBG). Total T4 is measured to see the bound and unbound levels of T4. The total T4 is less useful in cases where there could be protein abnormalities. The total T4 is less accurate due to the large amount of T4 that is bound. The total T3 is measured in clinical practice since the T3 has decreased amount that is bound as compared to T4. Reference ranges depend on the method of analysis. Results should always be interpreted using the range from the laboratory that performed the test. Example values are:
Free thyroxine Free thyroxine (fT4 or free T4) is generally elevated in hyperthyroidism and decreased in hypothyroidism. Reference ranges depend on the method of analysis. Results should always be interpreted using the range from the laboratory that performed the test. Example values are:
Total triiodothyronine Total triiodothyronine (Total T3) is rarely measured, having been largely superseded by free T3 tests. Total T3 is generally elevated in hyperthyroidism and decreased in hypothyroidism. Reference ranges depend on the method of analysis. Results should always be interpreted using the range from the laboratory that performed the test. Example values are:
Free triiodothyronine Free triiodothyronine (fT3 or free T3) is generally elevated in hyperthyroidism and decreased in hypothyroidism. Reference ranges depend on the method of analysis. Results should always be interpreted using the range from the laboratory that performed the test. Example values are:
Carrier proteins
Thyroxine-binding globulin
An increased thyroxine-binding globulin results in an increased total thyroxine and total triiodothyronine without an actual increase in hormonal activity of thyroid hormones. Reference ranges:
Thyroglobulin Reference ranges:
Other binding hormones Transthyretin (prealbumin) Albumin
Protein binding function
Thyroid hormone uptake Thyroid hormone uptake (Tuptake or T3 uptake) is a measure of the unbound thyroxine binding globulins in the blood, that is, the TBG that is unsaturated with thyroid hormone. Unsaturated TBG increases with decreased levels of thyroid hormones. It is not directly related to triiodothyronine, despite the name T3 uptake. Reference ranges:
Other protein binding tests Thyroid Hormone Binding Ratio (THBR) Thyroxine-binding index (TBI)
Mixed parameters
Free thyroxine index The Free Thyroxine Index (FTI or T7) is obtained by multiplying the total T4 with T3 uptake. FTI is considered to be a more reliable indicator of thyroid status in the presence of abnormalities in plasma protein binding. This test is rarely used now that reliable free thyroxine and free triiodothyronine assays are routinely available. FTI is elevated in hyperthyroidism and decreased in hypothyroidism.
Calculated and structure parameters
Derived structure parameters that describe constant properties of the overall feedback control system may add useful information for special purposes, e.g. in diagnosis of nonthyroidal illness syndrome or central hypothyroidism.
Secretory capacity (GT)
Thyroid's secretory capacity (GT, also referred to as SPINA-GT) is the maximum stimulated amount of thyroxine the thyroid can produce in one second. GT is elevated in hyperthyroidism and reduced in hypothyroidism. GT is calculated with
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