Adult thyroid disorder testing algorithm

Screening Symptomatic patients Thyroid ultrasound

1. Current evidence is insufficient for Signs or symptoms suggestive of thyroid disorder include unexplained weight Thyroid ultrasound is indicated to assess
screening asymptomatic adults change, menstrual change, heat or cold intolerance, palpitations, subfertility, visible or palpable thyroid nodules or
2. Screening benefits high risk subgroups, goitre, focal thyroid nodule goitre found during clinical examination.
eg, personal or family history of Ultrasound is not indicated to investigate
thyroid disorder, amiodarone, lithium hypothyroidism or positive antithyroid
treatment, autoimmune disease antibodies.
TSHa
Highb Lowb

Normal
No further testingc
T4 T4
(if TSH < 0.1 mIU/L,
also measure T3)
Normal Low Normal T4 High T4 and/or T3
Subclinicald hypothyroidism Overt hypothyroidism (Normal T3 if TSH < 0.1 mIU/L) Overt hyperthyroidism
Subclinicald hyperthyroidism

TSH ≤ 10 mIU/Le TSH > 10 mIU/L Prescribe levothyroxine _ 0.1 mIU/L

TSH > TSH < 0.1 mIU/L Measure TRAB
treatment Measure TSH and T4 in Refer patient to (If positive indicates Graves disease)
Measure TSH and T4 for dose 4–8 weeks endocrinologist Other tests may be indicated
adjustment at 6–8 weeks. if subacute thyroiditis, post-partum
Measure TSH, T4, TPO antibody in 2–3 months Once stable and in normal range, thyroiditis or amiodarone thyroid
measure TSH yearly dysfunction is suspected (suggest
TSH >_ 0.1 mIU/L Normal discussing with endocrinologist)
and T4 normal No further testing
TSH ≤ 10 mIU/L If TSH, T4 normal,
Repeat testing every 6–12 months
TPO negative
No further testing Prescribe antithyroid
treatmentf and refer to
If TPO positive
endocrinologist
Based on patient preference
Measure T4, T3 and TSH every
and symptoms, either prescribe If TPO negative 4 weeks. Monitoring depends on
levothyroxine treatment or
Measure TSH and T4 yearly clinical situation, eg, some patients
measure TSH and T4 yearly
reach hypothyroid state quickly,
and need frequent measurement
a
TSH is the most appropriate initial investigation for suspected primary thyroid disorder.
Free T4 and/or free T3 are not usually requested in isolation.
b
If TSH is higher or lower than laboratory reference intervals, request free T4.
TSH = thyroid-stimulating hormone, T4 = free thyroxine, T3 = free c
If you suspect pituitary disorder, request both TSH and free T4 on laboratory form initially, Acknowledgements
triiodothyronine, TPO = thyroid peroxidase, TRAB = TSH receptor antibodies as it is essential to interpret TSH in the context of a free T4 measurement.
Developed based on 2017 Royal College of Pathologists of Australasia.
d
Subclinical thyroid disorder identified by testing requires careful clinical assessment of
Note: This algorithm does not apply in pregnancy. If results of thyroid relevant symptoms, thyroid morphology and important comorbidities. Position statement: Thyroid function testing for adult diagnosis and
tests do not match patient presentation, consider non-thyroid illness, e
If patient is symptomatic, offer a 3–6-month trial of levothyroxine treatment without any
monitoring, with input from experts: Associate Professor Shane Hamblin,
recovery from intercurrent illness, interference by heterophile or other antibody testing. Melbourne and Professor Rita Horvath, Sydney
antibodies, or high dose biotin (with certain thyroid assays). f
In subacute thyroiditis, antithyroid treatment is contraindicated. Endorsed by the Endocrine Society of Australia

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