The diagnosis of Hashimoto’s thyroiditis – what should be considered?

The autoimmune disease Hashimoto’s thyroiditis is becoming more and more of a widespread disease and the number of those affected continues to skyrocket. There is hardly a disease that has spread so quickly and across the board in recent years.

In Germany alone, the number of sufferers is estimated at around 8 million people. In the US, the number of people affected is at least 10%. That’s 33 million people – and counting. However, the figures given are only for the cases that have actually been diagnosed.

However, the number of unreported cases is many times higher, since most Hashimoto cases were not even diagnosed and those affected usually have no idea of ​​their illness.

Due to this fact, many of those affected are alone with their symptoms and complaints and, if they are lucky, are usually “only” diagnosed with hypothyroidism, which is usually only treated with hormones.

For a Hashimoto diagnosis, on the other hand, it is extremely important to know the overall picture or the ratio between TSH, fT3 and fT4, as well as the level of the antibodies anti-thyroid peroxidase antibodies (TPO-AK), thyroglobulin antibodies (TAK) and microsomal antibodies ( MAK) to consider.

In addition, the thyroid should be scanned by the doctor treating you in order to detect any enlargement in advance. The thyroid should also be examined with ultrasound for the size, shape, and condition of the tissue.

A diagnosis with regard to Hashimoto’s thyroiditis is only possible if at least these factors are examined. But let’s go into a little more detail and see step by step how to diagnose Hashimoto’s thyroiditis with certainty:

Finding a Good Doctor: Which Doctor Diagnoses Hashimoto?

The most important task that one has to do first as a Hashimoto sufferer is to find a doctor . There is practically no point in relying on what your GP says unless they are actually a specialist in thyroid issues and accordingly claim that your symptoms are psychological in nature.

A clever diagnosis stands and falls with the treating doctor, which is why it is worth looking twice when looking for a doctor. Internists, nuclear medicine specialists and endocrinologists would be preferred here. These specialists should have the appropriate knowledge in relation to the endocrine system and also be able to initiate appropriate examinations and tests.

It may well be that the appointments with the above-mentioned specialists can be a little longer, but the longer waiting times are usually worth it and you save a lot of time, nerves and money afterwards.

However, experience has shown that looking for a good specialist can be like looking for a needle in a haystack. And if you should find him/her, they usually work on private accounts and many people with statutory health insurance cannot afford permanent treatment.

For this reason, I can always only recommend two things: read carefully, try to understand why you became ill and find the cause of your problems , because it is unlikely that a doctor will be able to help you with this.

An exchange with like-minded people in forums and Facebook groups is also useful. In this way, you can already make a “pre-selection” for the various doctors and do not run the risk of wasting time and money unnecessarily.

Anamnesis: The doctor-patient conversation

The anamnesis is the first conversation between the doctor and the patient. Most doctors don’t have much time to take a medical history, which is why it’s really important that you describe your problems and symptoms in detail, which you ideally wrote down at home and brought with you to the doctor’s appointment.

State your suspicions, but always remain matter-of-fact and calm. Only in this way can the limited time be used sensibly.

But the doctor will also ask you about various complaints and symptoms if he suspects Hashimoto’s thyroiditis. If the symptoms match the clinical picture, the doctor will arrange for further examinations. Important tips for visiting a doctor can be found below .

Physical exam: palpation of the thyroid gland

After a detailed medical history, a physical examination should follow. The experienced doctor can easily feel an enlarged or reduced thyroid gland with his hands.

But the condition of the thyroid gland can also provide initial indications of various clinical pictures:

  1. If the thyroid cannot be moved when swallowing or if it is particularly hard, this can be an indication of a malignant change in the thyroid or a so-called “Riedel goiter”.
  2. If the thyroid gland is enlarged and there is tenderness when palpated, this can be an indication of subacute de Quervain thyroiditis.
  3. Enlarged lymph nodes in the neck area often indicate an inflamed thyroid gland or a malignant tumor.

In atrophic Hashimoto’s thyroiditis, the thyroid gland shrinks over time as the immune system attacks and breaks down healthy thyroid tissue.

However, in certain phases of the disease and in the classic form of Hashimoto’s thyroiditis, the thyroid gland may appear larger because the thyroid tissue swells due to thyroid inflammation.

An enlargement of the thyroid gland is referred to as goiter (goiter). This is divided into the following goiter grades by the World Health Organization (WHO):

City 0 Goiter only visible on sonography
City I Palpatory (tactile) enlargement but not visible
Grad Ia Magnification that is palpable and not visible with maximum neck reclination
City Ib Magnification palpable and visible with maximum neck reclination
City II Magnification that is palpable and visible when the head is held in a normal position
Grad III Strong, easily visible magnification with local limitations
(e.g. swallowing and breathing)

A well-trained physician can thus draw important conclusions from a simple physical examination without any technical aids and commission appropriate laboratory parameters in order to carry out further diagnostics.

Blood values: Important laboratory values ​​for taking blood and laboratory diagnostics of Hashimoto’s thyroiditis

The blood values ​​necessary for diagnosing Hashimoto’s thyroiditis can be roughly divided into two groups. On the one hand there are the absolutely necessary and essential blood values ​​such as the thyroid values ​​and antibodies.

Read More  Progesterone Deficiency: A Cause of Hashimoto's Thyroiditis?

On the other hand, there are supplementary and meaningful blood values ​​that can be requested in order to achieve a better result and well-being more quickly. These include blood lipid levels, selenium, iron, zinc , vitamin D3, etc.

Ideally, of course, all laboratory values ​​are examined, but the doctors often resist and are not willing to request the entire package from the laboratory. In this case, you have to weigh up for yourself whether you can live with the basic blood values ​​or pay for additional blood values ​​out of your own pocket.

In any case, the following blood values ​​should be determined in the blood in order to be able to diagnose Hashimoto’s thyroiditis with certainty, because a sole examination of the TSH value is definitely not sufficient to be able to make a diagnosis in relation to Hashimoto’s thyroiditis or hypothyroidism:

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  • fT3 (free triiodothyronine)
    T3 or triiodothyronine is produced by the thyroid gland and is the most effective and metabolically active hormone in the thyroid gland. Triiodothyronine is composed of bound T3 and free fT3. T3 has a short half-life of one day.
  • fT4 (free levothyroxine)
    T4 is also produced by the thyroid gland and consists of a bound part (T4) and a free, metabolically active part (fT4). T4 has a longer half-life of 7 days.
  • rT3 (reverse T3) Reverse
    T3 can also be formed as a side reaction of the conversion of T4 to T3. rT3 is physiologically inactive, can block T3 receptors and thus weaken or neutralize the effect of T3. rT3 thus acts as a regulator of T4 deiodination in the body.

    At high rT3 levels, too much T4 is likely converted to rT3 instead of fT3. This leads to an underactive thyroid, even though TSH and fT4 levels may appear to be looking good.

  • TSH (Thyroid Stimulating Hormone)
    TSH is produced by the pituitary gland (pituitary gland) and regulates the release of the amounts of T3 and T4 required by the body. In a healthy thyroid, this principle works quite well.

    If, on the other hand, the thyroid gland is already attacked and reduced, it can no longer react to increased TSH and cannot keep up with the production of free thyroid hormones – no matter how high the TSH rises.

thyroid autoantibodies

TPO-AK (anti-thyroid peroxidase antibodies) and MAK (microsomal antibodies)
TPO-AK and MAK are antibodies that attack and destroy the inner wall of the thyroid gland, the so-called thyroid peroxidase. Elevated values ​​indicate Hashimoto’s thyroiditis.

TAK (thyroglobulin antibody) or TG-AK
Thyroglobulin is a thyroid protein and is involved in the thyroid hormone synthesis of thyroxine and triiodothyronine. Elevated antibodies against thyroglobulin indicate an autoimmune disease of the thyroid gland.

TRAK (TSH receptor autoantibodies)
TSH receptor autoantibodies attack the TSH receptors and cause an uncontrolled stimulation of the receptors and thus also the thyroid gland. TRAK are responsible for the clinical symptoms of Graves’ disease, which can also occur simultaneously in combination with Hashimoto’s thyroiditis.

The following standard values ​​are often used for the parameters mentioned:

fT3 (free triiodothyronine) 3.0 – 4.5 pg/ml
fT4 (free levothyroxine) 0.9 – 1.8 ng/dl
rT3 (reverse T3) 90-350 pg/mL
TSH (Thyroid-stimulating hormone) 0.5 – 2.0 mIU / l
TPO-AK / MAK (anti-thyroid peroxidase antibodies / microsomal antibodies) <35 lu/ml
TAK / TG-AK (thyroglobulin antibodies ) <100 U/ml
TRAK (TSH receptor antibodies) <1

Hashimoto diagnosis without antibodies? – Is that possible?

Yes that’s it. Namely in the case of seronegative Hashimoto’s thyroiditis. In this case, no auto-antibodies are detectable in the blood, although there are symptoms of Hashimoto’s thyroiditis and here, too, the thyroid gland disintegrates over time.

In this case, concrete evidence of Hashimoto’s thyroiditis can only be provided by anamnesis, physical examination, ultrasound and a determination of the relevant thyroid values.

Additional blood values ​​for thyroid values ​​and autoantibodies:

  • Blood lipid levels
    Quite often the blood lipid levels are increased in the case of prolonged hypothyroidism. First and foremost it is about cholesterol, LDL cholesterol and triglycerides. These blood values ​​usually normalize under treatment with appropriate thyroid hormones , but should also be determined if Hashimoto’s thyroiditis is suspected. More on that below.
  • Selenium
    Selenium plays a major role in the autoimmune disease Hashimoto’s thyroiditis because it acts as a catalyst in the conversion of inactive T4 into metabolically active T3. In addition, selenium has an antioxidant effect, protects the thyroid gland from autoimmune processes and affects the expression of the HLA-DR gene, which also prevents autoimmunity.
  • Zinc
    A lack of the indispensable element zinc prevents the conversion of T4 into T3 and slows down the protein metabolism. In addition, the liver and especially the pancreas need quite high amounts of zinc to keep digestion going. Almost everyone with an underactive thyroid also has a zinc deficiency.
  • Iron/ferritin
    Iron deficiency is also very common in people with Hashimoto’s thyroiditis. Iron is responsible for the oxygen transport in the body and thus an iron deficiency causes fatigue, difficulty concentrating and a weak immune system. Iron deficiency is also the main reason for hair loss in Hashimoto’s patients.
  • Vitamin D3
    Vitamin D3 has a special task in the human body. It boosts a weak immune system to fight off invaders and regulates an overactive immune system down to normal levels, whichever is the case.

    A deficiency can be observed not only in almost every Hashimoto patient, but also in most healthy people. A measurement of the 25-OH vitamin D3 quickly clarifies the actual supply.

  • Magnesium
    Low levels of magnesium in whole blood are also very common in Hashimoto’s patients. Typical symptoms are an extreme craving for chocolate, twitching of the eyelids or other muscles, loss of appetite, constipation, muscle tension, headaches and insomnia.
  • Vitamin B6
    If there is a lack of vitamin B6 , the liver is disturbed in its detoxification function, which can lead to major problems in the long run. But vitamin B6 also plays a major role in the formation of the red blood pigment hemoglobin and the bile acid required for digestion.

    People with histamine intolerance should make sure they have a good supply of B6, because the active form P5P (pyridoxal-5-phosphate) is extremely important for breaking down histamine.

  • Vitamin B12
    A lack of vitamin B12 can lead to anemia (low blood count) and poor digestion. In addition, a vitamin B12 deficiency causes fatigue and sleep disorders.

    Humans absorb vitamin B12 mainly as animal protein. However, this is only possible with the help of hydrochloric acid and various enzymes in the stomach. However, since Hashimoto’s sufferers very often suffer from a lack of stomach acid (and usually do not know it), a B12 deficiency can develop quite quickly here as well.

The following standard values ​​are often used for the parameters mentioned:

total cholesterol <200 mg/dl
HDL cholesterol >40 mg/dl
LDL cholesterol <100 mg/dl
Triglyceride <150 mg/dl
selenium in serum 74-139 µg/l
Zinc in serum / whole blood 70-120 µg/dl / 4.25 – 5.60 mg/l
Requirements 23-134 µg/dl
Vitamin D3 60-90 ng/ml
Magnesium 0,75-1,06 mmol/l
Vitamin B6 8,7-27,2 μg/l
Vitamin B12 300-900 pg/mL

If the doctor refuses: What are the laboratory costs for self-payers?

Unfortunately, many doctors still refuse to have the necessary thyroid parameters checked in the laboratory at regular intervals. The reason for this is usually that the health insurance companies would not cover the costs of the tests.

This is usually not the case, but who wants to constantly fight the doctor for his rights and thereby alienate an otherwise good doctor?

In such cases, you can consider having the important blood values ​​determined on your own from time to time. The best thing to do is look for a free laboratory in your city on the Internet and drive there during the specified opening times.

You usually don’t need an appointment for this and you can often ask for your blood values ​​over the phone the same afternoon.

Here are the usual prices for relevant blood values:

fT3 16,76 EUR
fT4 16,76 EUR
TSH 16,76 EUR
rT3 is after Labor ca. 30 EUR
TPO-AK 34,19 EUR
TG-AK 60,33 EUR
TRAK 36,87 EUR
blood collection 4,20 EUR
shipping material 5,10 EUR

Sonography: Diagnose Hashimoto’s thyroiditis with the help of an ultrasound examination

An examination of the thyroid gland using ultrasound (sonography) makes it possible to visualize the thyroid gland, poses no risks and can be carried out absolutely painlessly.

In this way, the structure and size of the thyroid gland can be determined quickly and reliably.

A change in the thyroid gland over a longer period of time can also be observed and documented very well in this way.

A healthy thyroid appears bright (echoic) on ultrasound. The surrounding muscles, nodes and cysts, on the other hand, are displayed rather darkly (low-echo).

A typical Hashimoto’s thyroid is also usually hypoechoic or appears very “blotchy”. This also applies to a disease of the thyroid gland with Graves’ disease.

Unfortunately, even with high-resolution color Doppler ultrasound, it is not possible to differentiate between hormone-producing hot nodes and non-hormone-producing cold nodes. However, this is possible with the help of scintigraphy.

Scintigraphy: The visual representation of nodules and the functional status of the thyroid gland

The purpose of scintigraphy is to visualize the functional status of the thyroid gland. This can be achieved with the help of a small amount of radioactive nuclides.

Technetium is usually injected into the patient’s bloodstream to assess the activity of the existing thyroid tissue.

This examination usually takes between 15-30 minutes and is absolutely painless.

Like iodine, technetium has the property of accumulating in the thyroid gland for a short time. Due to its low level of radioactivity, technetium emits a measurable amount of gamma radiation.

This radiation can be made visible in the scintigraphy and show active or less active thyroid tissue in color. In this way, hot or cold knots, among other things, can be unmasked. Radiation exposure during scintigraphy is harmless and falls by 0.5 msv. (millisievert) is very low.

Fine-needle biopsy: Ultrasound-guided fine-needle puncture to remove thyroid tissue

If the attending physician suspects malignant tissue (cold nodules >1.5 cm, hypoechoic and microcalcified) in the thyroid gland or if it is necessary to aspirate fluid from a cyst, fine-needle aspiration or fine-needle biopsy comes into play.

This diagnostic measure is used to take a tissue sample from the thyroid gland using a fine hollow needle, which can then be examined microscopically or histologically in the laboratory.

With an ultrasound-guided fine-needle puncture, the doctor continuously monitors the position of the fine needle using an ultrasound device. In this way, a precise removal of tissue is possible.

Since the hollow needle used in this type of diagnosis is particularly thin, the fine-needle biopsy is basically comparable to a simple blood draw. This also means that this examination is not or hardly painful and lasts only a few seconds.

In this way, the doctor can quickly and reliably determine whether a rare, malignant thyroid cancer is present or whether it is just a benign change in the thyroid tissue.

Further indications of an underactive thyroid due to Hashimoto’s thyroiditis

In addition to the medical diagnostic options mentioned so far, there are also some other indications that may indicate Hashimoto’s thyroiditis.

Of course, these are not to be seen as the sole and final diagnosis, but they may give a decisive indication that Hashimoto’s thyroiditis should be considered at all and, if necessary, to initiate appropriate medical diagnostics.

Measuring the basal body temperature gives quick indications of hypothyroidism

According to the American thyroid expert Broda Barnes, the quickest and cheapest way to unmask an underactive thyroid is to measure the axillary basal body temperature. Thus, this method is also very helpful in Hashimoto’s diagnosis.

He recommends staying in bed as soon as you wake up in the morning and measuring your body temperature with a digital clinical thermometer under your armpit. You should be careful not to measure too short. You should wait at least five minutes before pressing the button for the measurement.

According to Dr. Barnes are present when the morning basal body temperature is below 36.4° Celsius. If the temperature fluctuates by more than 0.1° Celsius daily, this indicates a weak adrenal gland . If the measured values ​​are elevated, it does not necessarily mean that the thyroid gland is overactive.

Elevated body temperature readings can have many different causes. In women in the second half of the menstrual cycle, hypofunction of the thyroid would be suspected from a basal body temperature of 37.2 – 37.4°C.

Typical symptoms indicative of Hashimoto’s thyroiditis

There are a number of typical symptoms that occur with Hashimoto’s thyroiditis. Of course, these can also occur with other diseases, but you should still pay attention and think of Hashimoto’s thyroiditis if the following symptoms occur in a similar constellation:

  • fatigue
  • Depression
  • poor memory
  • weight gain
  • constipation
  • Decreased heart rate
  • feeling weak
  • swollen face
  • swelling of the eye socket
  • Dry, rough skin
  • discomfort
  • muscle cramps
  • Dull, shaggy hair
  • Low sexual desire
  • Decreased potency
  • Menstrual cycle disorders in women

A detailed list of symptoms can be found in the chapter ” Typical Symptoms of Hashimoto’s Thyroiditis ”

Nutrient deficiencies are typical of Hashimoto’s thyroiditis

Hashimoto’s thyroiditis often involves a slowed metabolism and accompanying gastrointestinal problems, which can often result in a massive nutrient deficiency, which should also be examined by whole blood mineral analysis.

This includes vitamin B6 , B12, selenium, zinc , magnesium, calcium, potassium, iron, ferritin and all sex hormones. Typical examples are a severe lack of zinc, vitamin D3 and selenium.

If these deficiencies occur in a proven way in combination, one should already prick up their ears, think of Hashimoto’s thyroiditis and take these nutrients as dietary supplements. Further information can be found in the chapter ” Therapy of Hashimoto’s thyroiditis “.

Elevated cholesterol and blood fats can indicate an underactive thyroid

Blood lipid levels are quite often elevated in the case of prolonged hypothyroidism. First and foremost it is about cholesterol, LDL cholesterol and triglycerides.

The number of receptors responsible for transporting LDL cholesterol from the bloodstream to the liver cells is reduced when there is an undersupply of thyroid hormones and the resulting underfunction. The amount of thyroid hormones available determines the number of LDL cholesterol receptors in the liver cells.

In order to avoid arteriosclerosis due to permanently elevated blood lipid levels, it is particularly important to keep the phase of hypothyroidism as short as possible. Blood lipid levels usually normalize under treatment with appropriate thyroid hormones and appropriate hormone adjustment.

Common misdiagnoses

Hashimoto’s thyroiditis is often only diagnosed in a roundabout way. In the run-up, many patients often receive a hasty misdiagnosis due to the ignorance of numerous physicians in relation to thyroid diseases and their symptoms.

The psyche and the so-called burn-out often play a central role, instead of unmasking the chronic thyroid inflammation and the emerging hypofunction as the cause. In the event of the following possible misdiagnoses, you should continue to think about the thyroid:

Troubled psyche and depression

Especially when the psyche is going crazy and depression is spreading, you should know that Hashimoto’s thyroiditis with an underactive thyroid gland can be the cause of these problems.

Most doctors and endocrinologists often do not have much experience with the Hashimoto diagnosis and are usually satisfied if the thyroid values ​​are within normal values.

The fact that most Hashimoto’s patients only experience an improvement in their condition in the higher normal ranges is incomprehensible to most doctors and is often dismissed as nonsense.

If the patient relies on such statements by the doctor, this is usually followed by long-term treatment with antidepressants . This could very often be avoided if the patient and his doctor had more extensive knowledge of the thyroid and the normal values.

In this regard, however, there is still a great need for information and education, because the package insert of almost every antidepressant expressly states that a thorough examination of the thyroid gland and a Hashimoto diagnosis should be carried out before taking it.

Burn Out

Burn-out is also often thrown into the room too hastily when the doctor doesn’t know what to do next. This is probably mostly due to the fact that the symptoms are very similar. Fatigue, depression, constipation and listlessness occur with both symptoms.

However, if you have these symptoms, you should always have your thyroid checked first. If the TSH is elevated and/or the free thyroid values ​​fT3 and fT4 are reduced, the thyroid is at least already underactive, which can cause the symptoms mentioned.

If the thyroid antibodies are then also increased, everything speaks for Hashimoto’s thyroiditis. If this is the case, no sick leave and weeks or months of rest at home will help, only appropriate treatment.

But also adrenal insufficiency , which is very often also present in Hashimoto’s thyroiditis, causes classic burn-out symptoms. Therefore, as a person affected, one should question such hasty diagnoses and not just accept them, because being burned out, coupled with severe tiredness, usually has an organic cause.

Important tips for visiting a doctor

  1. Write down questions for the doctor in advance Before you go to the doctor, write
    down all the questions you want to ask the doctor. This will prevent you from forgetting something and possibly having to make a new appointment
  2. Have all necessary laboratory values ​​determined.
    Insist that the free thyroid values ​​fT3, fT4 and all antibodies in the blood are determined in addition to the TSH. This is the only way a Hashimoto diagnosis or the exclusion of a subfunction is possible. If the doctor does not want to get involved because he believes that the TSH is sufficient, it is best to find another doctor immediately.
  3. Have copies of the blood
    values ​​handed out Always have copies of the determined blood values ​​handed to you, file them carefully and make small notes on the current condition on the laboratory copies. Even after many months, you still have a good overview of the previous blood values ​​and the associated condition.
  4. Taking thyroid hormones on the day of blood collection
    If you are already taking thyroid hormones, make sure you only take them AFTER each blood collection. If you take the hormones in the morning before the blood is taken, the blood values ​​will be falsified and no longer meaningful.
  5. Write down all medications and vitamins you are taking in advance Make
    a detailed list of all medications and dietary supplements you are currently taking. The respective dose and previous duration of intake are also important. This can be important for appropriate blood tests in order to avoid falsifying the results.
  6. Write down your symptoms and abnormalities in advance
    When you sit in front of the doctor, are excited and don’t have much time, you usually don’t always remember all the symptoms . Therefore, write down a detailed list of your symptoms and the things you have recently noticed in advance.

    These include altered bowel habits, weight changes, decreased libido, changes in sex life, an altered menstrual cycle, but also hair loss, dry skin, and so on. The more detailed such a list is, the easier it is for the doctor to get an idea of ​​your illness.

  7. Take someone with you to the doctor’s visit
    If you’re feeling overly excited or just forgetful and not particularly receptive, which are unfortunately also symptoms of autoimmune disease, ask a family member or close friend if they can accompany you to the doctor’s visit. This way you make sure that you don’t forget anything and get annoyed about it afterwards.


A correct and quick diagnosis is basically relatively easy to accomplish – provided that the patient is in the care of the right doctor. However, it is still the case to date that far too few doctors are sufficiently familiar with the subject and therefore do not exploit the full range of diagnostic options.

In addition, savings are often made in laboratory diagnostics and only the TSH value is determined. This very often leads to unnecessarily wrong diagnoses or no diagnoses at all.

As an affected patient, you should think for yourself and get enough information in advance, otherwise it is possible that you will not receive a reliable diagnosis despite actual Hashimoto’s disease and will continue to grope in the dark with your symptoms and complaints.

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