a diagnosis of hypothyroidism can be suspected in patients with fatigue cold intolerance constipation and dry flaky skin. a blood test is needed to confirm the diagnosis. when hypothyroidism is present the blood levels of thyroid hormones can be measured directly and are usually decreased. however in early hypothyroidism the level of thyroid hormones (t3 and t4) may be normal. therefore the main tool for the detection of hyperthyroidism is the measurement of tsh the thyroid stimulating hormone. tsh is secreted by the pituitary gland. if a decrease of thyroid hormone occurs the pituitary gland reacts by producing more tsh and the blood tsh level increases in an attempt to encourage thyroid hormone production. this increase in tsh can actually precede the fall in thyroid hormones by months or years. thus the measurement of tsh should be elevated in cases of hypothyroidism. however there is one exception. if the decrease in thyroid hormone is actually due to a defect of the pituitary or hypothalamus then the levels of tsh are abnormally low. this kind of thyroid disease is known as "secondary" or "tertiary" hypothyroidism. a special test known as the trh test can help distinguish if the disease is caused by a defect in the pituitary or the hypothalamus. this test requires an injection of the trh hormone and is performed by an endocrinologist (hormone specialist). blood work confirms the diagnosis of hypothyroidism but does not point to an underlying cause. a combination of the patient's clinical history antibody screening and a thyroid scan can help diagnose the precise underlying thyroid problem more clearly. if a pituitary or hypothalamic cause is suspected an mri of the brain and other studies may be warranted. these investigations should be made on a case-by-case basis.
how is hypothyroidism diagnosed?