Episode - Thyroid Nodules: What You Need To Know


Thyroid Nodules: What You Need To Know

Many people have thyroid nodules, and in this episode Dr. Eric discusses some of the common causes of these, when a biopsy should be considered, and what can be done to shrink thyroid nodules.

During this episode you’ll learn:

  • What causes thyroid nodules to form
  • When is a biopsy necessary?
  • Whether a radioactive iodine uptake test can confirm the presence of malignant thyroid nodules
  • How to shrink thyroid nodules

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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 what you need to know about thyroid nodules.

Let’s start by discussing how many people have thyroid nodules. One journal article mentioned that 4-7% of the population have palpable thyroid nodules, but ultrasonography reveals that up to 67% of the population has them. Another study mentioned that up to 35% of the population have thyroid nodules show up on an ultrasound. Incidence of thyroid nodules increase as we age, and the prevalence is higher in women although they are more likely to be malignant in men, especially those over 70 years of age.

The good news is that most thyroid nodules are benign. Only 5% of thyroid nodules detected through palpation are malignant. But most thyroid nodules are not detected through palpation. For those thyroid nodules evaluated by a biopsy, the prevalence of malignancy ranges from 4-6.5%. The incidence of thyroid cancer has increased substantially in the United States over the past four decades. The American Cancer Society estimated that 62,450 people in the United States were diagnosed with thyroid cancer in 2015, a few years ago admittedly.

Most people with thyroid cancer are diagnosed with papillary thyroid cancer. According to the American Cancer Society, both Stage I and Stage II papillary thyroid cancer have a five-year relative survival rate of nearly 100%. In Stage III, it’s 93%. Ideally, you would not want to have a malignant thyroid nodule. If you do, there is a very good chance it’s papillary thyroid cancer, and the five-year relative survival rate is very high. In Stage IV, the rate drops down to 51%.

There is also follicular thyroid cancer. This also has a near-100% five-year relative survival rate in stage I and II. It drops down to 75% in stage III and 50% in stage IV.

There is also medullary thyroid cancer. This has a pretty good five-year relative survival rate in stages I through III. It however only has a 28% relative survival rate in stage IV.

There is also anaplastic thyroid cancer, which has a five-year relative survival rate of only 7%. Fortunately, only 1-2% of thyroid cancers are anaplastic.

While there is a risk of untreated thyroid cancer, the good news is the progression is much lower when compared to other cancers. Overall, the five-year relative survival rate is pretty good. Even though the focus of this episode is on thyroid nodules, a small percentage will be malignant. Even when that is the case, it’s usually slow growing. Most people have papillary thyroid cancer. Obviously, there are exceptions to the rule. I wanted to offer a little bit of reassurance.

With that being said, I’d like to discuss when a biopsy might be necessary. A report involved 8,806 patients focusing on three ultrasound nodule characteristics. This included microcalcifications, a size greater than two centimeters, and an entirely solid composition. They determined these were the main findings associated with the risk of developing thyroid cancer. The authors of the study wanted to see that rather than performing a biopsy of all thyroid nodules larger than five millimeters, one should instead require two abnormal nodule characteristics to determine if someone should require a biopsy. For example, if someone has microcalcifications and a thyroid nodule greater than two centimeters, this would indicate doing a biopsy. If they only had microcalcifications, then this wouldn’t indicate that they should do a biopsy. They mentioned how taking this approach would reduce unnecessary biopsies of 90% while maintaining a low risk of cancer.

You may be wondering about the radioactive iodine uptake test. This is commonly used by endocrinologists to determine if someone has thyroid nodules. Can the uptake test confirm malignant thyroid nodules? For those diagnosed with hyperthyroidism, the radioactive iodine uptake is commonly recommended. Endocrinologists will say they want to use this test to confirm if someone has Graves’ as well as nodules, too. I would much rather rely on antibody testing. If someone has hyperthyroidism and elevated TSI (thyroid stimulating immunoglobulins, the antibodies associated with Graves’), then in my opinion, you wouldn’t need to do a radioactive iodine uptake test for this purpose. You already know you have Graves’ if you have hyperthyroidism in the presence of an elevated TSI. Some practitioners will do the TRAB (thyroid receptor antibodies.) test. If someone has positive TRAB in the presence of hyperthyroidism, this usually is a clear diagnosis, too.

Another reason why endocrinologists will recommend the radioactive iodine uptake test is to determine if someone has thyroid nodules and also to give an idea if they are malignant. It’s not going to confirm whether someone has a malignancy, but they will say that they want to use this to differentiate between benign and malignant nodules.

About 80-85% of thyroid nodules show up as being cold on the uptake test. About 10% of those nodules are malignant. That depends on the source. Some sources say as low as 5%. Hot nodules account for only 5% of nodules although the likelihood of these being malignant is less than 1%. Essentially, you’re hoping to see a hot nodule but are far more likely to see a cold nodule. 90% of these will be benign.

It’s important to mention that neither a radioactive iodine uptake test nor a thyroid ultrasound are perfect methods for confirming or ruling out malignant nodules. This doesn’t mean they don’t have any value, but I can’t say that I’m a big fan of the radioactive iodine uptake test to look at nodules. I would much rather get an ultrasound. That’s what I did when I had Graves’. In all honesty, the endocrinologist didn’t even want to do an ultrasound, nor did she want to do the uptake test. She just wanted to rely on palpation. She felt like there was no nodules. I wanted to get a thyroid ultrasound. Sure enough, there weren’t any thyroid nodules. But that is usually what I would recommend if someone is thinking about getting an uptake test. Of course, that’s your decision.

If someone has already received an uptake test, I wouldn’t stress out about it. It’s not the end of the world, but it’s more invasive in that you’re taking radioactive iodine. To me, it’s not giving that much more information when compared to an ultrasound.

What causes thyroid nodules to form? There are a few different factors to discuss here. According to the research, estrogen is a potent growth factor for both benign and malignant thyroid cells. Estrogen is also a factor with uterine fibroids. There is a study that involved 1,444 participants, looking at the relationship between thyroid nodules and uterine fibroids. The authors concluded that uterine fibroids in women were definitely associated with the presence of thyroid nodules. Estrogen might play a pivotal role in the occurrence of both of these.

One of the best ways to support estrogen metabolism is by eating plenty of cruciferous vegetables such as broccoli, kale, cauliflower, cabbage, and Brussels sprouts. Broccoli sprouts are great, too. If you can get them at a health food store or farmer’s market or grow your own, that’s great. These help to support estrogen metabolism due to the compounds indole-3-carbinol as well as diindolylmethane, or DIM. Another option is to take DIM in supplement form.

Insulin resistance can also be a cause of thyroid nodules, or at least a contributing factor. One study examined the prevalence of insulin resistance in a case-controlled study of patients with benign thyroid nodules. The study showed there is an association between insulin resistance and benign thyroid nodules.

Another study looked at the association between insulin resistance and avascularization of thyroid nodules. The authors of the study concluded there is a vital role of insulin resistance in the distribution, construction, and density of thyroid nodule vascularization. This in turn might contribute to the growth and progression of thyroid nodules.

Another study looked at the relationship between insulin resistance and those with euthyroid nodule goiter. Euthyroid means you have normal thyroid hormone levels. Nodule goiter means you have a large thyroid gland, which is where the goiter is, in the presence of nodules. The results showed that insulin resistance may cause an increase in thyroid cell proliferation, nodule volume, and nodule formation.

One more study looked to see if there was a correlation between insulin resistance and thyroid nodules in those with type 2 diabetes. The results of the study demonstrated that insulin resistance was a risk factor for thyroid nodule formation in patients with type 2 diabetes.

Another thing to consider is you might just want to do some testing to determine if you have insulin resistance or type 2 diabetes. One more common test is hemoglobin A1C. It’s not a perfect test, but it is a test to consider doing. Fasting insulin is another test as well. A lot of people rely on fasting glucose. This also has some value, but I wouldn’t rely on a single fasting glucose. You could get your own glucometer and measure your fasting glucose daily. That will have more value than a single fasting glucose measurement. You also might want to look at the other two tests I mentioned. If that is the case, then you would want to address the insulin resistance problem.

A few studies also show a relationship between iodine deficiency and thyroid nodules. Iodine is very controversial in the world of thyroid health. I am not going to get into great detail on this here, but perhaps in a future episode.

You are probably wondering if it’s possible to shrink thyroid nodules. There is no specific natural treatment to shrink all thyroid nodules, so there is not a single supplement or herb that someone could take that works. This includes not only nutritional supplements, but some people use essential oils such as myrrh or frankincense, which can have some benefits, but I can’t say across the board that essential oils will shrink all thyroid nodules. Some people have had success with caster oil packs.

However, you can shrink thyroid nodules if you address the cause of the problem. If someone has a problem with estrogen metabolism or insulin resistance, then it makes sense that if you address these problems, the nodule will decrease over time.

In addition to what I covered here in this episode on some of the causes, you also might want to refer to the episode I had on toxic multinodular goiter, as I mentioned three other methods which can help shrink thyroid nodules. They are not natural, but they are also not conventional medical treatments.

Let’s go ahead and discuss action steps you can take. If you haven’t yet been diagnosed with thyroid nodules, you might want to consider getting a thyroid ultrasound. That’s up to you. When I dealt with Graves’, I wanted an ultrasound to confirm or rule out thyroid nodules even though the endocrinologist was pretty confident I didn’t have them. But I didn’t want to rely on palpation alone, so I decided to get an ultrasound, paying out of pocket for it. It was a couple hundred dollars. Even though it was negative, I was still happy I got the ultrasound.

If you do have one or more thyroid nodules, then you need to ask if you have two of the three characteristics, especially if the doctor who ordered the ultrasound is recommending a biopsy. If the doctor doesn’t recommend a biopsy, then you might not want to consider it. But you could still look at the report and see if you have two of the three characteristics I mentioned earlier. Those are microcalcifications, a size greater than two centimeters, and an entirely solid composition. If you have two of the three, then a biopsy, according to the journal article I mentioned, would be indicated. Of course, it is still up to you and something to discuss with the ordering doctor.

I spoke about the radioactive iodine uptake test. You might wonder should you get the test? I gave my reasoning for why most people with hyperthyroidism probably don’t need the uptake test. Once again, if you already received the test, I wouldn’t worry about it. but if you haven’t had it yet, something to consider. I won’t tell you not to get it because it’s your decision. Most cases, you could get what you need from a thyroid ultrasound. The uptake test will say if you have hot or cold nodules, which you won’t get from an ultrasound. Cold or hot nodules aren’t going to confirm if someone has malignancy or not.

Another action step is to address the potential causes I mentioned. That includes estrogen dominance, or really problems with estrogen metabolism. When I say estrogen dominance, a lot of people think high levels of estrogen. If someone has normal estrogen and low progesterone, that is a case of estrogen dominance. But also problems with estrogen metabolism.

As far as how to determine, because I didn’t get into detail here, and I won’t, there are a few options. One is blood testing. You can look at estradiol, which is a dominant estrogen, or total estrogens. There is also a really good test called a DUTCH test, which is a dried urine test. There is a page of that test that looks at the sex hormones, specifically a section that looks at estrogen metabolism. If someone has what’s called 4-hydroxyestrone metabolites, you might want to take DIM or eat broccoli sprouts.

Insulin resistance, you can test hemoglobin A1C, fasting insulin, or getting a glucometer and testing your fasting glucose on a daily basis.

Iodine deficiency. Very controversial. Doing iodine testing in the blood isn’t really accurate. I like urine testing event hough there are questions about that being completely accurate. It’s not completely accurate, but I certainly prefer urine testing over blood testing if I am going to test for iodine. I can’t say that I test all my patients for an iodine deficiency.

If your thyroid nodules are very large, then you might still want to address the cause of the problem. There is a cause of the thyroid nodule no matter how large it is. If you have a problem with estrogen dominance or estrogen metabolism, or with insulin resistance, of course you want to address this. You also might want to refer to the episode on toxic multinodular goiter because many doctors will just tell the person they should get surgery. There are other options, too, that I mentioned.

That’s all I wanted to discuss with regards to thyroid nodules. Ihope you learned a lot and found this episode to be valuable. I look forward to seeing you in the very next episode.