Thyroid lab tests are commonly run. Oftentimes, the lab results make sense and treatment is straightforward. However, there are a lot of cases where the lab results don’t correlate with your symptoms, or the lab results contradict each other.
This article focuses one possible cause: altered thyroid binding proteins.
Thyroid Binding Proteins
If you review basic thyroid physiology and anatomy, you’ll see that the thyroid gland produces T4 and T3, as depicted in the image below. The thyroid gland produces significantly more T4 than T3.
Upon deeper analysis, most thyroid hormones are bound to carrier proteins. We refer to these carrier proteins as Thyroid Binding Globulins (TBGs), and they include Thyroxine binding globulin, albumin and transthyretin .
Free vs Bound Hormone and TSH
Free thyroid hormone is the unbound hormone, floating free around the blood. Bound thyroid hormone it is attached to the carrier proteins. Total hormone is the sum of the two.
Free thyroid hormone affects TSH most accurately. So if Free thyroid hormone increases, it will decrease TSH.
Altered TBG Binding
Since much of the thyroid hormone (T3 and T4) is bound to carrier proteins, anything that displaces the hormone from the protein carrier would raise free Thyroid hormone (FT3 and FT4). These would transiently elevate FT4 and FT3 concentrations and depress TSH.
Factors that displace T3 and T4 from Binding Proteins 
- furosemide (especially with doses >80 mg/day and when given intravenously) ,, 
- aspirin ,, 
- nonsteroidal anti-inflammatory agents ,, 
- phenytoin and heparin, , 
- Genetic variants of albumin (familial dysalbuminaemic hyperthyroxemia (FDH)) can cause higher albumin, thus causing over estimations of T4 (and less frequently T3) ,, 
Altered TBG Synthesis
Naturally, increases and decreases in concentrations of TBGs are possible. Increased binding molecules would lead to increased Total T4 and Total T3; whereas lowered TBG would lower Total T4 and Total T3. Most blood tests monitoring thyroid hormones would measure free T3 and free T4 rather than total T3 and total T4, so these issues can be easily monitored with blood testing. The following may be causes for abnormal results pertaining to total T3 and T4. Transient alterations in FT4 and FT3 have occasionally been observed , but quickly normalize.
Factors that raise TBG: (these will raise total thyroid hormone, but won't affect free hormone) , 
- Estrogens (oral contraceptives, hormone replacement, tamoxifen)
- Liver disorders
- Rarely hereditary disease
- Drugs: raloxifene, mitotane, fluorouracil, methadone and heroin
Factors that lower TBG: (these lower total thyroid hormone, not free hormone) , 
- Chronic glucocorticoid therapy and nicotinic acid
In most cases, thyroid blood work is straightforward and helps guide treatment. If you’ve got thyroid results back, and they don’t make sense, make sure your doctor is considering any factors which may affect your thyroid binding proteins.
Interested in learning more?
Read on in our series of articles on Thyroid Health!
About the Author - Dr. Johann de Chickera
Dr. Johann is a licensed naturopathic doctor and co-owner of Absolute Health and Wellness. He completed his 4-year degree at the Canadian College of Naturopathic Medicine (CCNM). His clinical focus lies in chronic disease, such as those related to the Gastrointestinal, Endocrine, and Immune Systems.
His approach to medicine relies on working with the patient to come up with a feasible, multi-factorial approach that addresses all complaints at once. He employs a strong background in diagnostic medicine and human physiology and pathology to diagnose and treat. His treatment involve a combination of nutritional counselling, botanical medicine, eastern medicine (acupuncture), nutraceutical supplementation and hands on physical medicine.
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