Sorting Hashimoto’s labs starts with two buckets. TSH, free T4, free T3, and reverse T3 report on thyroid function. TPO antibodies, thyroglobulin antibodies, C-reactive protein, and vitamin D report on immune function. Most women leave the first appointment with only a TSH, which measures one bucket and never touches the other.
You have the lab printout. You have circled the flagged numbers, looked them up, and maybe compared them to somebody else’s results in a group. Nobody told you that some of those numbers measure your thyroid gland and the rest measure the immune system attacking it.
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Hashimoto’s is two systems, so your labs are two lists
Hashimoto’s is an autoimmune condition. Your immune system is attacking your thyroid. Knowing that is only the beginning.
Two things are happening at the same time. Your thyroid gland is trying to do its job. Your immune system is making that harder.
That is why one number cannot tell you enough. TSH says something about the gland. It says nothing about the attack.
So you have two buckets. What is thyroid, what is immune, and what can you do about each one.
The seven labs on a full Hashimoto’s panel
When I say full panel, I mean the list I gave you in episode 103, the thyroid labs to ask for.
Here is the list:
- TSH
- Free T4
- Free T3
- Reverse T3
- TPO antibodies
- Thyroglobulin antibodies (TG)
- Vitamin D
That is seven. Eight if you count C-reactive protein, which I recommend if you’re wondering about overall inflammation.
Most women come out of that first visit with one. Just the TSH. I want you to have the full panel, because I want you to be able to know what is going on.
Which labs go in the thyroid bucket
TSH goes in the thyroid bucket. It is not actually checking your thyroid. It is checking how much your brain is asking for more thyroid hormone.
Think of a light switch. When the lights are out, you flip the switch. TSH is your brain flipping that switch over and over saying I want more, I want more, please give me more.
The higher the number, the more your brain is asking. Which means you are producing less. That teeter-totter is the part that really confused me when I was first sorting out my own labs, and I talk about that in my own diagnosis story.
When you are sorting your Hashimoto’s labs, free T4 and free T3 are also thyroid. They tell you how much your thyroid is producing, and they tell you about conversion.
T4 is the hormone your thyroid makes. It is like a blank key, the kind you get at the hardware store. It is the exact same for everybody until you take it to the counter and they cut it.
Free T3 is the cut key. That is the one that works in the lock. That is the active hormone.
Your free T4 converts to free T3. Both of those numbers sit in the thyroid bucket.
Which labs go in the immune bucket
The antibodies are immune. Antibodies are created by your immune system.
TPO antibodies and thyroglobulin antibodies are the two that get run for thyroid when you get a full panel. There are other antibodies you can check if you are worried about Graves’ disease or something else. Those would sit in immune function too.
Sometimes I also request a C-reactive protein. That is a measure of how much inflammation is in the body.
I want that one checked on myself about once a year, maybe once every other year, to make sure I am keeping my inflammation in check. Inflammation is a huge root cause. The more inflamed you are, the more your immune system acts up, because it is reacting to all of that inflammation and to the stress happening in your body.
Vitamin D is not strictly on the thyroid lab panel, but I always want it. Vitamin D has a lot to do with your thyroid working optimally, and it has a ton to do with your immune system. I put it in the immune bucket.
What reverse T3 tells you that the other labs do not
Reverse T3 is a thyroid hormone, so it goes in the thyroid bucket. This one is trickier than the rest.
Reverse T3 also has to do with your immune system, inflammation, and how your liver is doing. A lot of different things can slow down conversion.
So it sits in the thyroid bucket and we still use it as an indicator to look at other things.
Here is where that matters. If you are feeling miserable, your free T4 is great, and your reverse T3 is really high, we need to look at your stress. We need to look at your root causes and what else is going on.
Your body is saying no. It is saying we are not going to convert T4 into T3 right now, because you need to prioritize rest.
This is also the lab that goes missing most often. Even when somebody gets a lot of thyroid labs, sometimes the reverse T3 is not there and the doctor says we do not order that here.
I had one client who thought it was her entire state. I knew that was wrong, because I have worked with other people in her state and they do run it. It might just be her clinic or her specific doctor who does not know how to ask or why to ask for it.
When I am working with somebody, I want that reverse T3. It tells us so much about what is happening at the conversion level between T4 and T3.
Sorting Hashimoto’s labs on your own report
Pull out your most recent results. Go line by line.
TSH, free T4, free T3, reverse T3 go in the thyroid column. TPO antibodies, thyroglobulin antibodies, C-reactive protein, and vitamin D go in the immune column.
Then look at what is not there. If the whole immune column is blank, the immune side of your condition has never been measured.
That is not your fault and it is not unusual. It is just incomplete.
If your TSH looks fine and you still feel terrible, that is a second bucket question, not a sign that you are imagining things.
Which lab episode to go to next
I have done several episodes about labs. Here they are, so you can pick the one that matches where you are right now.
- If you want the full list of labs to ask for, go to episode 103, Thyroid Labs to Check
- If you want to know what each value on your report means, go to episode 3, What Do My Thyroid Labs Mean
- If your TSH looks normal and you are still exhausted, go to episode 190, Why Your TSH Looks Normal but You Still Feel Tired with Hashimoto’s
- If your free T4 looks fine and your free T3 does not, go to episode 80, Labs: T4 vs Free T4
- If you want the difference between free T3 and reverse T3, go to episode 94, Labs: T3, Free T3, Reverse T3
- If your clinic will not order what you asked for, go to episode 39, Beyond TSH: How to Get the Thyroid Labs You Actually Need Using an Independent Lab
- If you want help preparing for the appointment itself, go to episode 78, Success at the Doctor’s Office
This whole post has been about sorting your labs once you have the results. Sometimes it is simple to get these labs as your provider will order them for you. Other times, you may want to go to an independent lab to either exercise your medical autonomy or save money. I greatly value medical autonomy and I am grateful to live in a state that allows for it. There are about three states in the US that do not allow you to use an independent lab.
Asking for the labs is one piece. Knowing what else to ask is the other.
My free guide, 10 Thyroid Questions to Ask Your Doctor, has a printable last page you can take with you, with space to write your notes.
Common questions about sorting Hashimoto’s labs
What to do before your next appointment
You now know which of your labs report on your thyroid gland and which report on your immune system. That is the sort. It takes about five minutes with your own results and a pen.
Do that first. Then look at the blank spaces and decide what you are going to ask for.
If you want the framework underneath all of this, that is what Hashimoto’s Decoded: Thyroid or Immune is for. In less than an hour, for $27, I walk you through the two systems so the rest of what you are reading finally has somewhere to go.