Thyrotropin levels in a population with no clinical, autoantibody, or ultrasonographic evidence of thyroid disease: implications for the diagnosis of subclinical hypothyroidism

J Clin Endocrinol Metab. 2008 Apr;93(4):1224-30. doi: 10.1210/jc.2006-2300. Epub 2008 Jan 29.


Context: The current debate regarding whether to decrease the upper limit for the TSH reference range to 2.5 microIU/ml has considerable potential impact on the diagnosis and treatment of subclinical hypothyroidism worldwide.

Objective: We report an analysis of TSH distribution in a population with no evidence of thyroid disease, including a normal thyroid ultrasound.

Design: A subset of the Hanford Thyroid Disease Study cohort was used to examine the TSH distribution in a population having no evidence of thyroid disease, seronegative thyroid autoantibodies, no history of thyroid medications, and a normal thyroid ultrasound. The shape of the TSH distribution was compared with the Gaussian and lognormal distributions.

Setting: This study was performed in the general community.

Participants: Of 1861 Hanford Thyroid Disease Study participants with TSH measured by ELISA who also had thyroid peroxidase antibody measurements, 766 comprised the normal reference group 3 (NRG-3) with no evidence of thyroid disease, including no positive antibodies and normal thyroid ultrasound.

Main outcome measure: TSH was measured.

Results: The TSH distribution in the NRG (NRG-3) was right skewed and followed an approximate lognormal distribution. The best estimates of the 97.5th percentile, the percentage above 2.5 microIU/ml, and the percentage above 3.0 microIU/ml for TSH by 3rd generation immunochemiluminometric assay are 4.1 microIU/ml, 20% and 10.2%, respectively.

Conclusion: These results indicate that the TSH reference range should be narrowed and support a value of approximately 4.0 as the upper-reference limit.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Autoantibodies / blood*
  • Enzyme-Linked Immunosorbent Assay
  • Female
  • Humans
  • Hypothyroidism / diagnosis*
  • Iodide Peroxidase / immunology*
  • Male
  • Middle Aged
  • Thyroid Gland / diagnostic imaging*
  • Thyrotropin / blood*
  • Ultrasonography


  • Autoantibodies
  • Thyrotropin
  • Iodide Peroxidase