10 Blood Tests I Commonly Recommend To My Thyroid Patients
In this episode Dr. Eric discusses ten blood tests he commonly recommends to his patients with hyperthyroidism/Graves’ disease and hypothyroidism/Hashimoto’s thyroiditis.
During this episode you’ll learn:
- How frequently should you test the thyroid antibodies
- The effects of thyroid hormone on total cholesterol
- Which markers you want to test for blood sugar
- The inflammatory marker I recommend, and two common reasons why it might become elevated
- The marker that can indicate problems with phase-2 detoxification
- Blood tests I sometimes recommend other than the “top ten”
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Here is the transcript for this episode:
Welcome back to the Save My Thyroid podcast. This is Dr. Eric Osansky, and in this episode, I am going to discuss 10 blood tests I commonly recommend to my patients.
Let’s discuss a few things to know about blood tests. I recommend blood tests to pretty much all my patients. Most other health care practitioners do as well, both conventional as well as alternative health care practitioners. The reason we all do this is because blood tests can provide a lot of valuable information. With that being said, blood tests don’t tell the entire story. While I do recommend blood tests for all my patients, I also recommend other tests, which I won’t be getting into during this episode, but will cover in future episodes.
Before we dive into the 10 different blood tests that I recommend, I want to mention there is a difference between lab reference ranges and optimal ranges. If something is on the high or low side, that can be a cause of concern. Many times, medical doctors will dismiss this. I won’t get into detail with the optimal ranges here. I will talk more about reference ranges in the future.
Let’s start with a thyroid panel with antibodies. A thyroid panel with antibodies has numerous markers. I do count this as a single blood test. When recommending a thyroid panel with antibodies, this would include a thyroid stimulating hormone (TSH). This is pituitary hormone.
Usually, I recommend the free T3 and free T4. These are the free forms of the thyroid hormones. Some practitioners will recommend the total T3 and T4instead of the free hormones or these and the free hormones. Of course, you could do both; it won’t hurt to get both done. I focus mainly on the free T3 and free T4.
As far as thyroid antibodies, for Graves’, the antibody associated with it is the thyroid stimulating immunoglobulins (TSI), which is a type of TSH receptor antibody (TRAB). Some practitioners will recommend the TRAB. The problem with the TRAB is TSI is not the only type of TRAB. If someone has hyperthyroidism and a positive TRAB, that pretty much is diagnostic of hyperthyroidism.
Then there is TPO antibodies, which are thyroid peroxidase antibodies. These are common in both Graves’ and Hashimoto’s. A little more closely associated with Hashimoto’s, but people with Graves’ will test positive for these.
There is also antithyroid globulin antibodies. These are more specific to Hashimoto’s although there are people who have all three of these antibodies.
The TSH, free T3, free T4, and antibodies. I won’t recommend this every single time. I want to look at the thyroid. Many times, I will look at TSH, free T3, and free T4. I can’t recommend retesting the antibodies every single time. Some people do. If you do that, that’s fine, especially if insurance covers it. But if you’re paying out of pocket, they can be pricey. It’s really up to the person, but I think testing it every other time for example is perfectly fine.
There is also a marker called reverse T3. I used to test it on everybody. With hyperthyroidism, I almost consider it a waste because reverse T3 is elevated in most hyperthyroid patients. There are exceptions, but that’s a pretty common finding. It’s not going to change my game plan when working with hyperthyroidism patients. If someone has hypothyroidism, then it’s a pretty good idea to test that reverse T3.
Another marker I don’t test but will bring up is thyroid binding globulin. As the name suggests, that’s where the thyroid hormones bind to. There are situations where I will test for this, but most of the time, I do not.
How frequently do you want to test these? It does depend on the person. I usually want to see a thyroid panel, not including the antibodies, at least every couple of months. If it’s every 4-6 weeks, that’s fine. If someone absolutely can’t do it every two months, and they have to stretch it to three, we’ll make it work.
Then you can test the antibodies every other time you test. If you get the thyroid panel every two months, you can do antibodies every four months. Again, it does depend on the situation. Sometimes we want to keep a closer eye on the antibodies, especially in the beginning at times.
If someone wants to get this tested every month, which sometimes I see, some folks will do it on their own. They will do it through their medical doctor or us. Sometimes I want to see it more than every other month.
That is the first test I recommend to everybody because I deal with people with thyroid and autoimmune thyroid conditions. That’s my specialty.
The next test I recommend to just about everybody is a complete blood count (CBC) with differential. The main purpose of this test is to see if there are any disorders related to the red and white blood cells. This test is common, but it can provide a lot of information. If someone has anemia, polycythemia, a possible infection (it won’t say specifically which type), clotting disorders, nutrient deficiencies, this test will reveal it.
As far as common findings from CBC with differential, low white blood cell count as well as low neutrophils or high lymphocytes. Neutrophils and lymphocytes are types of white blood cells. It’s important to mention that if you just get a regular CBC done without the differential, they won’t look at the neutrophils, lymphocytes, eosinophils, basophils, monocytes. That’s why you want to get the differential. Some medical doctors will just recommend a basic CBC. I do recommend the test with differential to all my patients.
Then there is the mean corpuscular volume (MCV). Seeing this high can indicate nutrient deficiencies, such as B12; a high red cell distribution width (RDW), which can indicate an iron deficiency; or low red blood cell count (RBC). That alone with low hemoglobin and hematocrit can indicate anemia.
The third test I recommend toe veryone is a comprehensive metabolic profile. The main purpose of this test is to see if there are any disorders related to the liver, kidneys, or electrolyte imbalances. It also tests for glucose and some markers related to protein. Some common findings include a high fasting glucose, low serum potassium, low sodium.
Sometimes low calcium, but more frequently, higher calcium levels, which could sometimes indicate hyperparathyroidism. High calcium is very common with hyperthyroidism, too. Doesn’t mean you want to dismiss it and not keep an eye on it because in some cases, someone could have hyperthyroidism and hyperparathyroidism. High bilirubin could also be a factor.
Elevated liver enzymes, ALT and AST. This is definitely common in people with hyperthyroidism who take antithyroid medication. Elevated alkaline phosphatase is also common in those with hyperthyroidism, even those who don’t take antithyroid medication. Sometimes we do see the liver enzymes high due to the hyperthyroidism, but many times, it’s related to methimazole or PTU or whatever antithyroid medications someone may be taking. The elevated alkaline phosphatase is very common, even if someone doesn’t take antithyroid medication.
The fourth blood test I recommend is a lipid panel. The lipid panel looks for total cholesterol, high density lipoprotein (HDL), LDL (low density lipoprotein), triglycerides, very low density lipoprotein (VLDL).
With hyperthyroidism, you commonly see a lower cholesterol. On the other hand, if someone has Hashimoto’s, and their thyroid hormones are on the low side, then cholesterol is commonly high. Same thing with HDL. A lot of people will have low HDL levels. Sometimes it’s on the higher side. LDL, very common to see this high although again in hyperthyroidism, sometimes we do see this on the lower end. It’s not red flagged as low, but lower than I like to see.
Cholesterol, for example, usually I like to see it above 150. Most medical doctors are concerned if it gets above 200; I’m also a bit concerned. You may want to do some additional testing to look at LDL particle size for example. I don’t want to see cholesterol below 150. If it’s related to hyperthyroidism, then frequently, when we correct the hyperthyroidism, the cholesterol levels will increase. I won’t panic over this, but it’s something I don’t want to see on along-term basis because cholesterol is important. Even though it gets a bad rap, you need cholesterol as the precursor for estrogen, progesterone, testosterone, cortisol, etc. It’s important to have healthy levels of cholesterol.
Triglycerides, very common to see higher levels. This is where sometimes it’s within that lab reference range, like it might be 120-130, but ideally you want it less than 100. Most labs, it would be normal according to their range as long as it’s below 150. You want to do this fasting. If you don’t fast, then the triglycerides might be over 150, but you can’t pay much attention to that. Do this test fasting.
Same thing with the comprehensive metabolic panel. If you want to look at glucose, you really want to do that fasting. Quite frankly, when I do these tests, I do these fasting. Not everything, you have to do fasting. Thyroid panel, you don’t have to do fasting. CBC, too. But when I personally do these tests on myself, I will go to the lab pretty much all the time in the morning in a fasting state.
Just a reminder: It’s very common to see cholesterol and LDL high in hypothyroidism, and to see these markers low in hyperthyroidism. Once again, there are exceptions.
The fifth test I recommend is an iron panel. That includes serum iron, ferritin, percent saturation, and TIBC (total iron binding capacity). The reason I recommend this is because many people do have an iron deficiency. When looking at, say, ferritin, it’s the iron stores. Some labs will consider anything over 10 to be normal, or maybe over 15. You really want ferritin to be at least 40-45. Some sources will say 70-90, especially if you’re experiencing hair loss. That’s why you need to pay attention to the optimal reference ranges.
Another reason you want to test for these markers is because some people have an iron overload. It could be genetic, or maybe you’re taking too high of a dose of iron supplementation. I will say that when ferritin is elevated, it might mean that you have an iron overload, but it also might mean that you have a lot of inflammation. It’s what’s called an acute phase reactant, which means it increases in the presence of inflammation. Not all the time. Graves’, Hashimoto’s, these are inflammatory states. Many times, ferritin is looking good or on the lower side. If it’s elevated, and if the serum iron and the percent saturation look okay, then it’s probably related to inflammation. On the other hand, if everything is high, you might be looking at an iron overload. That’s why you want to look at a full panel. Some practitioners will test ferritin by itself. Others will do total iron, or just serum iron on its own. You want to look at the entire panel.
Let’s jump into the second half of the tests I recommend. #6 is 25-hydroxy Vitamin D. Of course, you want to do this because Vitamin D is commonly deficient in everyone, not just those with thyroid and autoimmune thyroid conditions. Vitamin D is known for its importance when it comes to bone health but also plays an important role in immune system health. This is important to everyone, especially those with autoimmune conditions.
There are a few different ways to test for Vitamin D in the blood. You specifically want to test for 25-hydroxy Vitamin D. Another option that labs have is what’s called 125-hydroxy Vitamin D, but this is not a reliable indicator of Vitamin D status. 25-hydroxy is what you want, not the 125-hydroxy.
The seventh test I recommend to my patients is hemoglobin A1C and/or fasting insulin. The blood test will not say fasting insulin; it will be just insulin. You have to do the fasting. Hemoglobin A1C gives an average of the blood glucose levels over a period of two to four months. Although testing the fasting glucose and hemoglobin A1C can be valuable to determine if someone has blood sugar imbalances, doing a fasting insulin can provide some value as well. In fact, some practitioners recommend insulin and don’t pay much attention to looking at hemoglobin A1C or the fasting glucose. For example, Dr. Mark Hyman, a well-known functional medicine practitioner and has a few books on blood sugar, relies more on the insulin and not as much on the hemoglobin A1C or fasting glucose.
The eighth test I commonly recommend is C reactive protein (CRP) and specifically high sensitivity CRP. This is a marker related to inflammation in the body. It relates specifically to what’s called interleukin 6 or IL6. As a result of this, if someone has a normal CRP, which is common, I don’t see CRP elevated in everybody. I would say most of the time, it is looking okay. As a result, the normal CRP does not rule out inflammation in the body.
On the other hand, if you have an elevated CRP, you definitely want to pay attention to this. You want to keep an eye on it. There could be many causes of CRP being elevated. Two common causes of an elevated CRP are eating inflammatory foods and infections. Even not getting enough sleep can be a factor. Once again, there are people who don’t get enough sleep, and their CRP looks fine. Everyone is different.
Another marker related to inflammation is the sedimentation rate, also known as ESR. That’s something you could also do. Some practitioners will recommend both the CRP and the ESR.
The ninth test I commonly recommend is homocysteine. Homocysteine is a sulfur amino acid, and its metabolism requires folate, Vitamin B6, and Vitamin B12. A high homocysteine can indicate problems with methylation, which is part of the phase two detoxification process.
A number of years ago, I had an elevated homocysteine. However, it wasn’t detected until a few years after I was in remission. I can’t say it played a role when I was working on getting into remission, as it was a few years later that I detected it. I wasn’t familiar with it before. That’s why I didn’t test it when I had Graves’. It is a potential cardiovascular risk when it’s elevated. You do want to pay attention to it.
I may want to talk about this in greater detail with an expert. I wouldn’t say it’s advanced, but there is something called MTHFR. A lot of people have a genetic polymorphism with this, including myself. That can lead to high homocysteine levels. It can get a little bit complex. In the future, we will get into more detail on homocysteine.
The tenth and final test I commonly recommend is gamma-glutamyl transferase (GGT). GGT plays a role in glutathione homeostasis. High levels are correlated with glutathione depletion in the liver. Glutathione is the master antioxidant of the body. It plays a big role in detoxification.
An elevated GGT can sometimes be an indication of liver disease although most of the time this isn’t the case. Elevated values can also indicate obstructive jaundice, cholangitis, and cholecystitis. Usually, it’s not. If it’s really high, in the triple digits, you might want to pay more attention to this. Honestly, even if it’s 40-50, depending on the lab, that might be in the normal range but outside the optimal reference range. I would say optimal. You want to see it below 30. Below 20 is even better. I recently did a blood test, and mine was 18, so I was happy with that. Some people are even lower than that.
Those are the 10 blood tests I commonly recommend. Once again, there are exceptions. I can’t say I recommend them to every patient. Of course, if a patient starts up with me, and they recently got some of these tests, then I might not order them again. Depends. If the markers are out of optimal range, it makes sense to look at it again. If it looks good, then I won’t order it again. If they got the CBC with differential a year ago, and it looked good, I might still order a new one because it is a good idea to get it tested at least once a year.
I can’t say I get all these tested every year. CBC with differential, comprehensive metabolic panel, blood sugar, hemoglobin A1C and insulin, a lipid panel, and thyroid testing, I do get every year. Vitamin D is another one.
As far as other blood tests that I didn’t mention here, there are a few. This isn’t all inclusive. Sometimes I will recommend RBC magnesium, which is red blood cell magnesium; Vitamin B12; serum B12. Even though urinary methylmalonic acid is a better indication, a lot of medical doctors aren’t really familiar with it, or they don’t want to test for it. Sometimes I will test for viruses such as Epstein-Barr, cytomegalovirus, and others. You can’t test for all of them. Epstein-Barr is one of the viruses more closely associated with autoimmune thyroid conditions.
Sometimes I will recommend a fatty acid profile using a lab such as OmegaQuant. The regular labs might have them, but I didn’t like what I saw with them. Quest’s wasn’t comprehensive. OmegaQuant does a good one. They are pretty reasonable.
If you live outside the United States, that might not be an option. Genova Diagnostics also has a fatty liver profile. I don’t know if you can do that separately. There is the NutrEval test, and the fatty acid profile is part of that. Genova are also in the U.K. and other locations outside the U.S. I have a number of patients from the U.K.
I want to summarize the 10 blood tests I commonly recommend:
- Thyroid panel with antibodies
- CBC with differential
- Comprehensive metabolic panel
- Lipid panel
- Full iron panel
- 25-hydroxy Vitamin D
- Blood sugar markers, like hemoglobin A1C and fasting insulin
- High sensitivity CRP
That is pretty much all I want to discuss when it comes to blood testing. I hope you found this information to be valuable. I look forward to catching you in the next episode.