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Treatment For Hashimotoʼs With Normal TSH Levels

Find out when treatment is necessary for Hashimoto's, and how else to manage symptoms.
Treatment For Hashimotoʼs With Normal TSH Levels
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Like many health conditions, thyroid diseases are not always cut and dry. They are unique circumstances and nuances that can make treating the thyroid rather complex. One area where things can get murky is when a person has Hashimoto's thyroiditis, but their thyroid lab results do not indicate they have hypothyroidism yet. Ahead, a look at the complexities behind treating Hashimoto's thyroiditis when your thyroid function is otherwise normal.

What is Hashimoto's thyroiditis?

Hashimoto's thyroiditis is an autoimmune condition where your immune system creates and sends out antibodies that mistakenly attack healthy cells in your thyroid. Autoimmune conditions like Hashimoto's thyroiditis occur when the immune system goes rogue. Unfortunately, the medical field knows very little about why this happens and how we can prevent it.

Most sources believe that a combination of your genetics, sex (females are much more likely to have autoimmune disorders), and exposure to infections and environmental toxins are likely to cause an autoimmune condition like Hashimoto's thyroiditis.

When Hashimoto's is left unmanaged, it can lead to hypothyroidism, the condition in which the thyroid cannot produce enough thyroid hormones. Because thyroid hormones regulate metabolism, growth, and development, people with hypothyroidism experience a general slowing of their body systems. Symptoms of hypothyroidism often include fatigue, muscle weakness, depression, and constipation.

That said, many people who have Hashimoto's thyroiditis still experience similar symptoms even if their condition has not yet progressed to hypothyroidism. Symptoms of Hashimoto's disease may be hardly noticeable at first. However, as the disease progresses, it causes chronic thyroid damage, leading to a drop in thyroid hormone levels and causing more and more symptoms.  

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How is Hashimoto's thyroiditis diagnosed?

Suppose you or your doctor suspects you have a thyroid dysfunction like hypothyroidism. In that case, it's helpful to run a complete thyroid panel that includes thyroid-stimulating hormone (TSH), free T4, free T3, and thyroid peroxidase (TPO) antibodies.

Testing TSH, free T3, and free T4 tell you about your thyroid function and thyroid hormone levels, specifically. Testing TPO antibodies tells you if there may be autoimmune destruction of your thyroid gland. 

Thyroid peroxidase (TPO; also called thyroperoxidase or iodide peroxidase) is an enzyme found in the thyroid gland that plays a vital role in producing thyroid hormones. Without the thyroid peroxidase enzyme, the thyroid gland cannot produce thyroid hormones.

However, thyroid peroxidase (TPO) antibodies block the activity of the enzyme thyroperoxidase, affecting the production of thyroid hormones. 

A TPO antibody test detects antibodies against TPO in the blood. The presence of TPO antibodies in your blood may indicate the presence of an autoimmune disorder like Hashimoto's disease.

Having TPO antibodies does not necessarily mean you have a thyroid disease like hypothyroidism. Still, the presence of TPO antibodies does indicate an ongoing attack against the thyroid. It may increase the risk of future thyroid disorders.

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What does it mean if TSH levels are normal?

Sometimes, people test positive for TPO antibodies, but their TSH and T4 levels are still normal. What this means is you likely have Hashimoto's disease, but you do not have hypothyroidism. In this case, your thyroid gland is still functioning normally. While Hashimoto's does not always cause hypothyroidism, it remains the primary cause of hypothyroidism in the United States. 

What about subclinical hypothyroidism?

In some instances, a person with normal T4 levels but a slightly elevated TSH level may receive a diagnosis of subclinical hypothyroidism. Subclinical hypothyroidism is a mild form of hypothyroidism. 

Before diagnosing subclinical hypothyroidism, doctors may want to measure TSH levels again in a few months to rule out alternatives. There may have been laboratory error, recovery from a non-thyroidal illness during the time of the initial blood draw, or other antibodies that interfered with the TSH test. 

Research does not conclude a definite answer on whether or not subclinical hypothyroidism requires treatment with thyroid hormone replacement medication. Treatment is on a case-by-case basis.

On the other hand, overt hypothyroidism is when a patient has elevated TSH levels and low free T4 levels.  

Neither subclinical hypothyroidism nor over hypothyroidism apply if your TSH and T4 levels are both normal, even if you have TPO antibodies present.

Is medication necessary for normal TSH levels?

Not necessarily. People with normal TSH and T4 levels typically do not need to be treated with thyroid hormone replacement medication for hypothyroidism, even if their lab results show positive TPO antibodies. Normal TSH and T4 levels indicate that the thyroid is still functioning well. The body is not suffering from a lack of thyroid hormone. 

Hashimoto's often progresses into hypothyroidism, which requires treatment with a thyroid hormone replacement medication like levothyroxine. Your thyroid doctor works with you to determine the type and dose of medication you need depending on subclinical or overt hypothyroidism. 


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How else is Hashimoto's thyroiditis managed?

Keeping the damage from Hashimoto's under control is necessary to prevent the development of hypothyroidism. At the root of every autoimmune condition is chronic inflammation. In the case of Hashimoto's thyroiditis, this inflammation can lead to eventual failure of the thyroid. 

One of the main ways to manage your Hashimoto's is to reduce inflammation. Paloma Health thyroid doctors recommend optimizing the four pillars of health to reduce inflammation: diet, exercise, sleep, and stress management.


Avoid food triggers and stick to an anti-inflammatory diet with minimal unhealthy fats or refined sugars. The more dietary stress you put on yourself, the more likely you are to experience inflammation. It can be challenging to determine your nutrient deficiencies or dietary triggers on your own. Working with a thyroid nutritionist to develop a personalized nutrition plan to support your thyroid health may be helpful.


Get regular exercise to help your body regulate hormonal health.


Practice good sleep hygiene, including making sure you stay away from screens and a couple of hours before bed and stick to a consistent sleep schedule.

Stress management

Implement both active and passive forms for stress management. For instance, exercise for active stress management. Or deep breathing, guided imagery, meditation, or a hot Epsom salt bath before bed for passive.

Once you have these four pillars in balance, you might consider adding herbs and supplements to help reduce inflammation and support better thyroid function. It can be helpful to maintain healthy vitamin D levels and take selenium to boost your thyroid function.

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A note from Paloma Health

If you suspect you have a thyroid disorder or something feels off, your first step is to check your thyroid function with a complete thyroid blood panel. Our at-home test kit includes TSH, free T3, free T4, and TPO antibodies with the option to add on reverse T3 and/or vitamin D. The results can help determine if you have an overactive or underactive thyroid or if an autoimmune disease is at play. Order a test kit today to optimize your thyroid health.


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Julia Walker, RN, BSN

Clinical Nurse

Julia Walker, RN, BSN, is a clinical nurse specializing in helping patients with thyroid disorders. She holds a Bachelor of Science in Nursing from Regis University in Denver and a Bachelor of Arts in the History of Medicine from the University of Colorado-Boulder. She believes managing chronic illnesses requires a balance of medical interventions and lifestyle adjustments. Her background includes caring for patients in women’s health, critical care, pediatrics, allergy, and immunology.

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