Episode - 4 Reasons To Avoid Thyroid Surgery


4 Reasons To Avoid Thyroid Surgery

In this episode Dr. Eric discusses four reasons why people with hyperthyroidism should avoid thyroid surgery. If you have a different type of thyroid condition and/or have very large thyroid nodules and are considering surgery you’ll probably also find the information to be valuable.

During this episode you’ll learn:

  • 4 reasons why most people with hyperthyroidism should avoid thyroid surgery
  • Other potential complications of thyroid surgery
  • The different options you have besides thyroid surgery
  • What you need to to do if you choose to get thyroid surgery

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Here is the transcript for this episode:

Welcome back to the Save My Thyroid podcast. This is Dr. Eric Osansky. In this episode, I am going to discuss four reasons to avoid thyroid surgery.

Before diving into the four reasons, I want to start out by telling you there is a time and place for surgery. I am definitely not against thyroid surgery. Everything comes down to risks versus benefits. For example, I would argue most cases of thyroid cancer probably require surgery although there are alternative options for that as well. I can’t say I’m an expert when it comes to treating thyroid cancer naturally. There are other practitioners who do this. Even in some cases of thyroid cancer, surgery might be able to be avoided.

If someone has a severe obstruction that is causing problems breathing or swallowing, if they have an enlargement of their thyroid gland or a large goiter, then that could be an indication of surgery.

If someone has an extremely large goiter, but they are not experiencing obstruction, then it really depends on the situation. I like to think there is a cause for everything, even large goiters. If someone has a severely large goiter, I am not going to say it will always decrease back to original size. In fact, if it’s really large, many times, it can’t. It doesn’t mean that it can’t decrease at all. It depends on the situation. If there is an obstruction, that’s a different story. But without an obstruction, it is still up to the person. I won’t talk anyone out of getting surgery, but the goal of this episode is to give different options. If you do choose to get thyroid surgery, I want you to be comfortable with your decision.

Another situation is if someone has large thyroid nodules. If there is suspicion that they are malignant, that could be an indication for surgery. Even if they are benign but over two centimeters, they may recommend removal. Same thing with the goiter. Nodules can decrease in size. It’s not always easy. The only thing to confirm a nodule decreasing is through a thyroid ultrasound. With a goiter, if it’s large enough, you can tell without doing one. It’s up to the person as to whether or not they get surgery in the case of large nodules. There is a cause of larger thyroid nodules. Some common causes are problems with estrogen metabolism or insulin resistance.

How about hyperthyroidism that is difficult to manage through medication and herbs? I encounter this sometimes. It is a challenging situation when someone is unable to take antithyroid medication, and they may try bugleweed to no avail. But there are other options. Even in this situation, many times, surgery isn’t indicated. I can understand it being a scary situation, and you don’t want to have unmanaged hyperthyroidism.

Next, I want to briefly discuss thyroid surgery compared to radioactive iodine. I won’t go into detail here because I talk a lot about it in episode #5. Check that out. If you are deciding between surgery and radioactive iodine, listen to this presentation and episode #5, and you may try to address the underlying cause of the problem if you haven’t done so already. But if it comes down to you needing to get one or the other, it’s your decision. If it were me, I would choose surgery over radioactive iodine because I can’t picture myself taking radioactive iodine. It is easier; you just take a pill compared to surgery. There are definitely risks of surgery. It’s not an easy decision. Hope I never have to make it.

The first reason why you want to probably avoid thyroid surgery in most cases is that it’s not addressing the cause of the problem. In the case of Graves’ disease, this is an autoimmune condition. If someone has Graves’, and they are told to get thyroid surgery, the surgery is not doing anything for the autoimmune component. If someone has one autoimmune condition, they are at greater risk of developing other autoimmune conditions in the future. This is why you want to try to address the cause of the problem. You want to find and remove the trigger, correct other underlying imbalances, and heal the gut. I discuss this in depth in other episodes.

If someone has toxic multinodular goiter, this also has an underlying cause. When it comes to nodules or goiters, estrogen metabolism problems or estrogen dominance is an issue. Estrogen causes growth of thyroid tissue. We know there is estrogen-dependent breast cancers, too. We want to see if someone with toxic multinodular goiter has problems with estrogen metabolism, insulin resistance, or other causes. If you get the thyroid surgically removed, you are not addressing the cause.

The second reason why you might want to avoid thyroid surgery is because it’s likely to lead to permanent hypothyroidism, especially if you have a complete thyroidectomy. A lot of surgeons won’t want to do a partial thyroidectomy, but a partial thyroidectomy might not result in permanent hypothyroidism. Sometimes it does. But if you get the entire thyroid gland removed, it will result in hypothyroidism, no question. You will need to take thyroid hormone replacement on a permanent basis.

To be fair, many people do fine when taking thyroid hormone. I also work with patients with Hashimoto’s who take thyroid hormone, and many of them do fine. That is the concern though, is that some people don’t do well, especially in a situation where they get their thyroid removed, are put on thyroid hormone, and take weeks or months to adjust to it. A small percentage does not adjust. Sometimes it could be the type of thyroid hormone. Most endocrinologists will recommend synthetic toxic hormone, levothyroxine. Some people do better on desiccated thyroid such as NP thyroid. There are numerous reasons why someone won’t do well on thyroid hormone.

The point is if you could avoid thyroid surgery, you won’t need to take thyroid hormone. But it’s also not the end of the world if someone needs to take it. Everyone is different. For some people, the transition goes smoothly. For others, not so smooth.

A third reason why you might not want thyroid surgery is it can lead to hypoparathyroidism. Most people have four small parathyroid glands that are in close relationship with the thyroid gland. Surgery can result in their direct trauma, devascularization, or in some cases, accidental removal. Parathyroid hormone is crucial in maintaining calcium level homeostasis. Damage to one or more of these glands can result in transient, temporary, or in some cases permanent, hypocalcemia. It’s not 80-90% of people who get surgery get this condition, but it’s a decent percentage. It’s not a small percentage. It’s not 1 in 10,000. Just something else to consider when thinking about getting thyroid surgery.

A fourth reason is recurrent nerve injury. The recurrent laryngeal nerve is a branch of the vagus nerve, which supplies most of the muscles of the larynx. Identifying the recurrent laryngeal nerve during thyroid surgery is the key to avoiding injury. This can be challenging when someone has a large goiter or a malignancy or if they are doing a second operation. Sometimes it’s difficult to identify, especially if the surgeon is inexperienced. I will talk about this more shortly.

Another thing to consider when it comes to the recurrent laryngeal nerve is there are many anatomic variations of its course in branching. That also makes identification more difficult.

Injuries can be subdivided into transient and permanent. Transient means temporary. Symptomatic injuries lasting more than one year are considered permanent. If someone has damage for six or nine months, it’s transient, but that is still a long time.

As far as the percentage, permanent injuries to the laryngeal nerve have been identified as .5%-5% of patients. Transient injuries are observed between 1-30% of patients. That is a pretty big range. If we are thinking permanent, even if it’s .5%, that is 1 of 200 people getting surgery. 5% would be 5 out of every 100. Another reason why you want to be very cautious and careful when choosing your surgeon if you do end up getting surgery. More experienced institutions and surgeons report much fewer injuries of the recurrent nerve.

There are other thyroid complications. Some of them are minor, and some of them are major. You could have scarring; post-operative dysphagia, which is difficulty swallowing; post-operative bleeding; post-operative hematoma.

You might be wondering about other options. Reminder: risk versus benefits. I am not trying to talk people out of getting thyroid surgery, but I want to talk about other options, especially when dealing with hyperthyroidism. If someone has difficulty managing the hyperthyroid symptoms, I mentioned a scenario when someone might be unable to take antithyroid medication, and the herbs don’t work.

Let’s say methimazole causes a negative reaction. There is a decent chance that another type of medication such as PTU will also cause a negative reaction, but that is not always the case. It might be worth switching to PTU. There are also natural agents such as bugleweed, L-carnitine, or lithium. Some people don’t do well with either one. If you haven’t tried the natural agents, it might be worth trying. Bugleweed worked well for me when I had Graves’.

Potassium iodide, I am bringing this up here not as a recommendation. It’s a tough situation. Higher doses of iodine can cause problems. In some cases, it can lower thyroid hormone levels. Some people use it as a way of managing hyperthyroid symptoms. But iodine exposure can also flare things up. If you’re facing surgery, and you’re looking at options other than antithyroid medication and herbs, potassium iodide is something to consider. I would speak with a practitioner first. It is unpredictable, and it can make things worse.

There is also LDN, low-dose naltrexone, which I have another episode about. LDN would be more specific for someone with an autoimmune condition such as Graves’, where it calms down the immune system. It’s hit or miss. When it works, it can work well. If someone is thinking about surgery, it is an option to consider, if you have Graves’, that is.

There is cholestyramine. I don’t have a separate episode yet dedicated to it, but I have discussed it before. It is another agent for symptom management. Cholestyramine isn’t typically used for hyperthyroidism, but there are some studies that show it can help lower thyroid hormone levels. I have had a few patients take it. it does require a prescription. Those patients usually got it from their endocrinologist. Some endocrinologists won’t be open to it, but if you present the research to an endocrinologist, they may listen. It’s worth at least trying if nothing else works.

I am going to be biased when I tell you that you should work with a natural healthcare practitioner to try to address the underlying cause of the problem. In many cases, you can address the cause of the problem, and surgery won’t be necessary.

If you do choose to get thyroid surgery, I want you to be comfortable with your decision. I don’t want you to get it because you are giving into peer pressure. Your friends or family are pressuring you to get surgery maybe. Your endocrinologist will commonly pressure you to get thyroid surgery. I want you to be comfortable with your decision. Make sure it’s your decision if you do get surgery.

You also want to choose your surgeon carefully. You want to try to choose a surgeon that performs at least 30 thyroidectomies a year. 50 or more would be even better. This is from the research I have done. If you choose someone who does 50 a year, and they have been in practice for 10 years, that’s 500. If you could choose someone who has done a few thousand, that is even better. You don’t want to choose someone who has only done five a year and has only done a dozen or so for the entirety of their practice.

One study showed there was an 87% chance of complications in surgeons who have done one operation a year. 68% for 2-5. 42% for 6-10. 22% for 11-15. 10% for 16-20. Only 3% for 21-25. Those who did more had a similar rate of complications. Here, it’s saying 21-25 operations, only 3%. Of course, if you get someone who does 50 or more, to me, the more, the better.

I’d like to give a brief summary of this episode. Once again, there is a time and place for thyroid surgery. The goal of this presentation was to educate you and not necessarily talk people out of getting surgery, but to give you different options and outline the risks.

One reason is that it doesn’t address the cause of the problem. Second reason is it will result in permanent hypothyroidism if you get a complete thyroidectomy. The third reason is it can cause hypoparathyroidism. The fourth reason is it can cause a recurrent nerve injury. Other complications are possible as well.

Consider some of the other options. Maybe the other options aren’t a good fit for you, but they may also be something to consider. If you absolutely need to get thyroid surgery, choose your surgeon carefully.

This wraps up my presentation on why you should avoid surgery. Sometimes it’s necessary, but I wanted to let you know about the potential risks associated with surgery, give other options, and hopefully provide some useful information to help you be comfortable with your decision either way. I hope you found this information to be valuable, and I will catch you in the next episode.