The first thing you should know about thyroid disease is that most cases aren’t complicated. They only become complicated when doctors don’t follow the standards of care already laid out for them.
At times, I receive calls from patients who call themselves terms like a “hopeless case.” Doctors keep refusing to take their case and tell them they are "too complex." Nevertheless, whenever I examine the case history or review the thyroid blood test results more closely, any apparent mystery quickly disappears.
I have seen cases where patients had abnormal T4 and TSH levels, and the patient also suspected a spinal leak after an epidural steroid injection and was questioning whether her POTS was secondary to a spinal leak. When the patient sent over her brain MRI, she had the largest pituitary I had ever seen, which can be one sign of intracranial hypovolemia due to a leak but also can disrupt the pituitary-thyroid axis.
I quickly asked her about any hormonal symptoms, and she explained to me that she had been on Accutane for hormonal acne. Other symptoms that women have reported to me have been galactorrhea (the spontaneous production or leakage of a milky nipple discharge that is not related to normal pregnancy or breastfeeding), even in women who had never been pregnant. And yet, no physician had helped these women assemble these pieces of their clinical history in an integrative approach to care. Many times, I find that physicians don’t even ask patients if they’ve ever had a physically traumatic event like being in a car crash, and when patients eventually tell me this, when I ask if they volunteered this information, they said they were made to feel that it was unimportant information to tell.
Often, I have seen through patient reports and my own experience that physicians are over-relying on TSH levels and not considering the role of the pituitary in thyroid cases even where neurological injury was involved. The American Thyroid Association is very clear about next steps for certain abnormal results and to look further at the pituitary. Unfortunately, this critical step is frequently overlooked, leading to errors where the patient is blamed for being "complex." As a result, carrying this label causes the patient to struggle with accessing care in the future.
Let’s explore what your thyroid disease blood test actually means, how to read it, and the questions you should ask doctors when they try to label you as “complicated.”
Your thyroid is the butterfly-shaped gland in your neck that produces essential hormones that regulate metabolism, heart rate, body temperature, and pretty much every important bodily function. You can feel fine when your thyroid gland is healthy and working properly, but terrible when something is wrong.
There are two main types of thyroid disease you should know about: hypothyroidism and hyperthyroidism. The former refers to an underactive thyroid that doesn’t produce enough hormones, while the latter refers to an overactive thyroid that overproduces hormones. These often stem from autoimmune conditions like Hashimoto’s or Graves’ disease, but other issues like nodules, thyroiditis, iodine imbalance, cancers, or even certain medications can play a role.
Primary hypothyroidism is the most common form of thyroid disease. It occurs when the thyroid gland itself cannot produce enough thyroid hormones. Common causes include autoimmune conditions like Hashimoto’s thyroiditis, surgical removal or radioactive iodine treatment of the thyroid, certain medications, and (in some cases) iodine imbalance.
As a quick note on iodine excess, in research and clinical discussions, iodine-induced hypothyroidism is often grouped under primary hypothyroidism because the functional result is low thyroid hormone output. However, the mechanism can be a bit different than straightforward thyroid gland failure. The thyroid is often doing exactly what it’s designed to do, temporarily suppressing hormone production via the Wolff-Chaikoff effect to protect against excess iodine. In susceptible people (including those with underlying autoimmune issues or prior thyroid problems), the gland may fail to “escape” this protective state, leading to hypothyroidism. This highlights why root-cause investigation and careful nutrient titration matter so much in complex cases.
Central hypothyroidism (also called secondary or tertiary hypothyroidism) is much rarer. It happens when the pituitary gland or hypothalamus fails to send the proper signals (TSH and/or TRH) to a healthy thyroid gland. Causes can include pituitary tumors, trauma, radiation, surgery, certain medications, or congenital issues.
What you should know about thyroid disease blood test results is that these can give insight into the next step needed for investigation to determine what type of disorder you have. However, this requires your doctor to read it correctly and consider your clinical history. Unfortunately, here’s where many doctors fail regarding providing further investigation and proper treatment for thyroid disease.
The American Thyroid Association (ATA) recommends using TSH and free T4 together as the most efficient combination of blood tests for diagnosis and follow-up. Testing starts with TSH because it's said to be the most sensitive indicator by the ATA, and then only testing free T4 if the TSH is abnormal. TSH shifts out of its normal range sooner than T4 does when thyroid dysfunction is present.
However, problems occur when physicians over-focus on TSH. In my case of iodine-induced hyperthyroidism, my free T4 jumped to an extremely high level, which would have been overlooked if I had not requested a free T4 with each TSH evaluation. Because my TSH was still detectable, despite extremely high free T4 levels, my primary care provider told me that my hyperthyroidism should not be as extreme as I was experiencing and downplayed a life-threatening situation.
A few weeks later, my TSH became non-detectable as the high free T4 levels suppressed it. At other times, I have had high levels of TSH along with high-normal levels of free T4 after a sudden increase in iodine in my diet that dropped TSH some, although it still was in the subclinical hypothyroidism range if TSH levels were read in isolation. However, adding synthetic T4 in the form of levothyroxine to the mix would likely have been disastrous and pushed me over the edge into hyperthyroidism.
The normal TSH reference range is roughly 0.45–4.5 mIU/L, while the reference range for free T4 is 0.8 to 1.8 ng/dL. Other things to keep in mind when going over thyroid blood test results include:
And then there are the thyroid blood test results that trip many doctors up:
These types of cases are what make doctors scratch their heads and call patients "enigmas" when they fail to follow established investigation pathways to look at cause-and-effect processes.
Let me be blunt about this. The American Thyroid Association says to look at the pituitary when a patient has a low free T4 and a low TSH. The Endocrine Society says to evaluate for pituitary or hypothalamic dysfunction.
This isn't complicated. This isn't exotic. This isn't a mystery. The path doctors should follow is well-documented.
According to the American Thyroid Association, central hypothyroidism presents with low or inappropriately normal TSH with low free T4, and that distinguishes it from primary hypothyroidism.
So when a doctor looks at those labs and says “this matches with the standard for primary hypothyroidism,” they're not telling you the truth. They're telling you they don't know the standard of care. Those are two very different things.
And frankly? Patients need to stop giving U.S. doctors, who are not exactly known for their persistence in problem-solving, an out. An out can be framing your story as a “mystery that is impossible to solve” while your presentation matches nearly every textbook out there. That gives the doctor a very easy option to simply agree with you that you are an unsolvable mystery. Furthermore, this kind of framing of your story makes it easier for the healthcare system to leave many patients like you underserved.
First: don't panic. An abnormal thyroid blood test doesn't always mean something is seriously wrong. Sometimes it means nothing at all. For example, one study found that 10% of adults hospitalized for nonthyroidal illness (NTI) had abnormal TSH levels.
Here's what the guidelines actually say if your abnormal thyroid blood test shows low TSH and low T4:
These aren't my opinions or clinical advice. These are summarized from the standards of care from the American Thyroid Association, the Endocrine Society, and the American College of Endocrinology.
Here's the thing about thyroid disease and thyroid disease blood test results. The standards are written down. They're in black and white. The American Thyroid Association has published them. The Endocrine Society has published them. They're not a secret.
So when your doctor says you're "complicated" or "an enigma" or "too difficult," you can ask these questions:
"I understand you're saying this is complex. But the American Thyroid Association guidelines say the next step is to evaluate the pituitary. Are you going to follow that standard of care? And if not, could you please note in my medical records that you're choosing not to follow the ATA's recommendation?"
You’re not being confrontational by asking these questions; you’re holding your doctor accountable. Incompetent people make simple things seem complicated, and then patients think they're complex. We need to stop giving doctors an out.
Here is the real kicker—we even have U.S. doctors reading this site and asking me for advice on specific patient cases because they are completely clueless themselves, with one doctor telling me he knew it was probably illegal for me to review private patient data and give my feedback. That is just how bad the situation has become. And no, I do not participate in clinical decision-making nor review patients’ charts sent to me by physicians. Based on my consultations with lawyers, I am allowed to talk with clinicians on general trends I’ve seen in patient experiences and relevant literature in response to the clinicians providing me summaries of cases or key issues in a way that is not identifiable for the patient.
Let's say your TSH is between 4.5 and 10 mIU/L and your free T4 is normal. That's subclinical hypothyroidism. The American Thyroid Association recommends confirmatory testing in 3 to 6 weeks because 30 to 60% of these cases normalize spontaneously.
If it persists? The American Association of Clinical Endocrinologists recommends individualized treatment based on symptoms, antibody status, and patient factors. Treatment is recommended regardless of symptoms for TSH levels above 10 mIU/L.
Again, these are the standards. They're not opinions. They're not suggestions. They're the medical standard of care in the U.S.
These are all key insights and provide a way forward. And yet, many US clinicians use a one-size-fits-all approach and stigmatize the people who don’t fall inside this box. They might insinuate that patients will die a slow death of subclinical hypothyroidism. Then I receive messages on our business Facebook page at midnight from patients frantically searching and terrified they will die, asking if there is hope. Unfortunately, they often struggle to find mental health support in the US as well, with non-integrated care, as US therapists often echo whatever the authority (the physician) says, pathologize a failure on the patient’s part to accept this as reality, and say thyroid issues don’t fall within their wheelhouse even though thyroid issues can drastically affect mood.
I still remember telling my Colombian psychologist about the frantic behavior of patients who had been told there was no hope, only for her to start talking about terminal illnesses. I had to clarify that what I meant was doctors acting as if medication in cases such as subclinical hypothyroidism was the only way to avoid death and saying there was no hope if the patients could not tolerate the medication rather than investigate further.
When I shared with my therapist that my former doctors insisted diet exerted no effect on disorders or symptoms, her response left me completely stunned: "Well, that's false information." Thanks to a Colombian medical education system that emphasizes integrated mind-body care, mental health professionals there are equipped with the knowledge to publicly confront misinformation regarding physical health. It is difficult to envision a similar situation in the US, where clinicians rarely call out their peers so directly for spreading false information.
Here's what you need to remember about thyroid disease treatment: most cases follow clear patterns. Clear guidelines and published standards of care already exist. When physicians fail to follow them and brand you as a "complicated" patient, it isn't a reflection of your medical condition—it is a reflection of their own knowledge gap.
The results of a thyroid disease blood test should serve as a roadmap for treatment. If your doctor doesn't know how to interpret them, find one who does. And if your doctor refuses to follow the established standard of care, ask them to document that refusal in your chart.
Because here's the thing about "enigmatic" patients: they're usually just patients whose doctors didn't bother to read the manual regarding their conditions.
Have you been told your thyroid lab results are "too complicated" or called an "enigma"? That's a massive red flag. Sign up for our Newsletter to get the latest on thyroid testing standards, patient advocacy tips, and how to navigate a healthcare system that too often confuses incompetence with complexity, or book a one-on-one coaching session to learn how to better advocate for yourself.