Episode - Toxic Multinodular Goiter: What You Need To Know


Toxic Multinodular Goiter: What You Need to Know

While most people with hyperthyroidism have Graves’ disease, some have a condition known as toxic multinodular goiter.  As the name suggests, this condition is characterized by multiple thyroid nodules and a goiter, in the presence of hyperthyroidism.  In this episode Dr. Eric will discuss both conventional and natural approaches to this condition.

  • During this episode you’ll learn:
  • How toxic multinodular goiter is diagnosed
  • What causes toxic multinodular goiter
  • Common signs and symptoms of toxic multinodular goiter
  • Conventional and natural treatment options
  • Three other treatment options specific for 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 talk about toxic multinodular goiter.

Let’s start by discussing what is toxic multinodular goiter. Multinodular goiter is the most common of all the disorders of the thyroid gland. This involves a goiter, which is the swelling of a thyroid gland. A multinodular goiter is a goiter in the presence of multiple thyroid nodules. Toxic multinodular goiter involves a multinodular goiter in the presence of hyperthyroidism.

How is toxic multinodular goiter diagnosed? The toxic part indicates that the person has hyperthyroidism. Sometimes, the person has a noticeable goiter whereas other times the practitioner will need to rely on palpation or do a thyroid ultrasound. If the goiter is large enough, this can result in symptoms such as difficulty swallowing, cough, or hoarseness. If someone has large nodules, this may be detected through palpation. But once again, a thyroid ultrasound may very well be indicated.

When I went to an endocrinologist when I was dealing with Graves’ back in 2008, she palpated my thyroid and she didn’t think I had thyroid nodules. I insisted on a thyroid ultrasound. Sure enough, it didn’t show thyroid nodules. But sometimes an endocrinologist can’t tell by palpation, and they need to do an ultrasound.

What causes a multinodular goiter? Anything that elevates the TSH, which is thyroid stimulating hormone. A temporary elevation may not be a big deal, but if it’s elevated for a few weeks or months, this can cause a goiter. One of the factors that can cause an elevation of TSH is iodine, which is controversial in the world of thyroid health. If someone does have an overt iodine deficiency, this can cause hypothyroidism and can cause an elevated TSH.

Goitrogens as well. Cruciferous vegetables are considered to be goitrogenic foods. Quite frankly, most people will do okay with cruciferous vegetables. With hyperthyroidism, some people try to manage it by eating cruciferous vegetables, which doesn’t usually help. Soy also is considered to be a goitrogen.

There are also genetic factors, like inborn errors of thyroid synthesis.

According to the research, smoking, stress, and certain drugs can all be factors. Also according to the research, and I have seen in my practice problems with estrogen dominance and estrogen metabolism. Insulin growth factor 1 and other thyroid stimulating factors. Insulin resistance can be a factor as well with both goiter and nodules.

What are some of the signs and symptoms of toxic multinodular goiter? You’re dealing with hyperthyroidism, so it’s going to be the same signs and symptoms when compared to someone with Graves’ Disease or subacute thyroiditis or hashitoxicosis. You’re going to typically see increased heart rate, heart palpitations, tremors. Some people will experience weight loss. I lost 42 pounds when I dealt with Graves’ Disease. But not everybody dealing with Graves’ Disease experiences weight loss. Some people experience weight gain. A lot of people experience heat intolerance, anxiety, loose stools, hair loss. You won’t experience all of these symptoms. Maybe you will, but some people will experience only a few of these symptoms. So these are some of the signs and symptoms when it comes to toxic multinodular goiter.

Because of the goiter, people might also experience other symptoms such as discomfort of the neck, difficulty swallowing, and maybe in some cases, difficulty breathing, especially if they have a very large goiter.

Next, I’d like to discuss having both toxic multinodular goiter as well as an autoimmune condition like Graves’ Disease or Hashimoto’s. Many people with toxic multinodular goiter don’t have an autoimmune component, but some people do. There are different types of thyroid antibodies. This includes thyroid peroxidase antibodies or TPO antibodies, thyroglobulin antibodies, and thyroid stimulating immunoglobulins.  Thyroid stimulating immunoglobulins are specific for Graves’ Disease.

TPO antibodies, we see both in Graves’ and Hashimoto’s. They are more closely associated with Hashimoto’s, but according to the research, 60-80% of people with Graves’ also will have TPO antibodies.

Thyroglobulin antibodies are more closely associated with Hashimoto’s although some people have all three of these antibodies. I have had some patients with toxic multinodular goiter who have had elevated TSI levels, so they have the antibodies for Graves’ and toxic multinodular goiter. I have also had some patients with toxic multinodular goiter who had negative TSI levels but had elevated TPO antibodies and/or thyroglobulin antibodies.

If someone has toxic multinodular goiter, and they have an autoimmune condition, not only do you want to address some of the factors I already mentioned that can cause the toxic multinodular goiter such as estrogen dominance, but you also want to address what is causing the autoimmune component.

Let’s discuss some of the conventional treatment options for toxic multinodular goiter. There is antithyroid medication. That is commonly given to help manage the symptoms and lower the thyroid hormone levels.

Some people might want to know about low dose methimazole. In the United States, you don’t see low dose methimazole used as an option as frequently as you do in other countries. But it is an option to consider, especially because a lot of doctors will just jump into radioactive iodine or thyroid surgery, and they may not want to put the person on antithyroid medication. For Graves’, they might take the antithyroid medication and go into remission, even though the remission is usually temporary because the cause has never been addressed. Still, they might go into that temporary state of remission.

It’s a little different with toxic multinodular goiter. Some endocrinologists won’t want to give antithyroid medication, at least not on a long-term basis. They may want to jump into surgery or radioactive iodine. But low dose methimazole might be something to consider. I would recommend trying to address the cause of the problem, but we are focusing on conventional treatment options here.

Radioactive iodine wouldn’t be my first choice, but I need to mention it here because it is a conventional treatment option, as is thyroid surgery. Many endocrinologists will recommend these two options to their patients with toxic multinodular goiter.

There are three other treatment options specifically for thyroid nodules I want to discuss. One is percutaneous ethanol injection. This technique involves injecting ethanol into the toxic nodule under ultrasound guidance. Studies show that it can be very effective in shrinking benign, cystic and mixed thyroid nodules. One study involving 20 autonomously functioning thyroid nodules show that 17 of 20 patients had significant shrinkage of their thyroid nodules after percutaneous ethanol injections. Another study showed that it can be effective for the treatment of large toxic thyroid nodules. Pain is the most common side effect, but other less common side effects involve facial flushing, drunken sensations, headaches. Some people experience mild dizziness, perithyroidal or perinodule ethanol leakage, local hematoma, secondary infection, vocal cord paralysis in rare cases. These are symptoms that can occur during or after percutaneous ethanol injection for cystic thyroid nodules.

Next, let’s discuss percutaneous laser ablation. This treatment is also done under ultrasound guidance. The advantage of this is it is minimally invasive. A few studies show that laser ablation is safe and effective in reducing nodule volume and neck symptoms. The downside is also it doesn’t do anything to address the cause of the thyroid nodule. As a result, regrowth of the thyroid nodule can occur. It doesn’t always occur, but it is a possibility.

A few studies show that it can help to reduce the size of autonomously functioning thyroid nodules that are associated with toxic multinodular goiter. This treatment also might be an option for malignant thyroid hormone nodules. If you happen to have one or more malignant thyroid nodules, maybe speak with another practitioner. I can’t say I’m an expert when it comes to percutaneous laser ablation. I’m just diving into some of the research here.

As for the side effects, one journal article showed complications occurring in .5% of cases. All consisted of voice changes due to vocal card palsy with complete recovery after three months.

The third method I’d like to discuss is percutaneous radiofrequency thermal ablation. This is yet another treatment that is performed under ultrasound guidance. It involves thermally ablating the thyroid nodules. This treatment can be used for autonomously functioning thyroid nodules. Potential side effects include a transient voice change, hyperthyroidism, hematoma, skin burn, edema, coughing, nausea, vomiting.

Let’s discuss action steps you can take for toxic multinodular goiter. I am going to talk about addressing the cause of the problem. If you have to take medication to help manage the symptoms, of course, you want to be safe. If you need to take antithyroid medication such as methimazole or carbimazole or PTU, that is perfectly fine. You might consider taking an herb such as bugleweed, which is an herb with antithyroid properties.

Whether you are taking antithyroid medication or an herb such as bugleweed, you also want to do things to address the cause of the problem, such as supporting estrogen metabolism. I mentioned earlier how estrogen dominance or problems with estrogen metabolism can be a big factor with toxic multinodular goiter. You want to do things to support the estrogen metabolism.

You might even want to do some testing to see if you have an estrogen metabolism problem. I like dried urine testing to look at the actual estrogen metabolites. You can also of course test for the levels and look at estradiol, total estrogens, progesterone. Estrogen dominance is not just high estrogen, but if someone has low progesterone, that is considered a state of estrogen dominance. Dried urine testing has advantages in that it also looks at the estrogen metabolites.

As far as what specifically to do, you could eat broccoli and other cruciferous vegetables. Broccoli sprouts are really good for supporting estrogen metabolism. Maybe have half a cup to a cup of broccoli sprouts. You can buy them locally or maybe even grow your own.

Some people will take a supplement called diindolylmethane or DIM. That is something to consider. I would do as much as you can through food though. There are times where I will give a DIM supplement, especially if I do a test for estrogen metabolism. I would do dried urine testing, and the person has an obvious problem with estrogen metabolism, and we’re not guessing. In that case, I might have them take a DIM supplement.

Healthy estrogen metabolism is also dependent on healthy methylation, sulfation, and glutathione. So you want to make sure that all these are in order. Methylation is a very advanced topic. Maybe I will do a future episode on it. It’s dependent on nutrients such as folate, Vitamin B12, Vitamin B6.

Healthy sulfation is also important. Relying on sulfur-based foods such as broccoli, kale, garlic, and onions.

Also, healthy glutathione is important for healthy estrogen metabolism. Cruciferous vegetables as a food source are precursors to glutathione. Same thing with garlic. Also, supplements such as NAC is a precursor to glutathione production. Selenium is a cofactor for glutathione. Some people will choose to take a glutathione supplement such as liposomal glutathione or acetylated glutathione. Those are options, too.

Also, glucuronidation. I won’t get into it, but that’s another phase two detoxification pathway. All of these things are important for supporting estrogen metabolism as well as overall detoxification also could make a big difference. What I just mentioned, methylation, sulfation, glutathione, glucuronidation, these are all phase two detoxification pathways. Even doing things like infrared sauna will help. Also, make sure you have regular bowel movements. That you’re not recycling estrogen by being constipated.

Insulin resistance could be a big factor. If someone has insulin resistance, type 2 diabetes, that is also important. Diet is huge when it comes to insulin resistance. Eating a low carbohydrate, ketogenic diet. In some cases, a ketogenic diet may help. Ketogenic is high fat, very low carbohydrates, so 50g or less. If someone has Graves’ disease I will recommend autoimmune paleo, which is also low carbohydrate. Either way, I would focus on whole healthy foods. I would recommend a low carb diet if you have insulin resistance. This doesn’t mean you have to go less than 50g per day. But definitely less than 150g a day of carbohydrates. Again, probably a good idea to work with a practitioner.

Because with insulin resistance, there could also be an inflammatory process present as well. So diet alone may not help. Of course, either way you want to start with diet. Sometimes taking nutrients or herbs such as chromium or alpha lipoic acid or herbs such as gymnema might help. Berberine might also help. But it depends on the person.

If you do address these factors, try to address the cause of the problem. If this doesn’t help, then you might want to consider the three treatment options I mentioned. I will say that in some cases, there might be justification for jumping into one of the three treatment options. Maybe even in some cases into thyroid surgery, but surgery should be a last result. If someone is having difficulty breathing or swallowing, then they might not have time to address the cause of the problem. But if you do choose one of the other three options I mentioned, you also want to address the cause of the problem.

Because when it comes to using one of those options for removing nodules, there is the chance that the nodule will grow back. If you didn’t address the estrogen metabolism problem or insulin resistance problem, then it might grow back in the future. You always want to try to address the cause of the problem when dealing with toxic multinodular goiter.

That is all I want to discuss with regard to toxic multinodular goiter. I hope you learned a lot, and I look forward to catching you in the next episode.