I recently had the pleasure of connecting with a lovely lady who was very concerned about her thyroid nodules. She was a new mom who had just given birth and found that the nodules she had on her thyroid had grown. She was planning on getting them biopsied and potentially removing her thyroid, and wanted to know what her options were for addressing this concern.
I frequently receive these types of questions about thyroid nodules — why they happen, and what to do about them. While I personally did not present with thyroid nodules, I have had a few clients and readers with Hashimoto’s and nodules, and was pleasantly surprised when they shrunk their nodules using my recommendations for Hashimoto’s. Don’t you just love these kinds of surprises? 🙂
Up to 50 percent of our population has thyroid nodules. Nodules are also more common in those with Hashimoto’s — so chances are, if you’re reading this article, you may have a nodule (or even multiple thyroid nodules).
This article will cover:
- What thyroid nodules are and why they happen
- Testing for benign and cancerous nodules
- How to shrink thyroid nodules
- The lab results of one of my readers who had been exposed to Chernobyl and was able to get 3 nodules to disappear!
What Are Thyroid Nodules?
Nodules are defined as “solid or fluid filled lumps” within the thyroid gland and can vary in size and location. Most nodules will not cause symptoms and will only be discovered during a manual examination of the thyroid gland or during a thyroid ultrasound.
However, large nodules may result in a visible swelling of the thyroid or neck; and they can cause pain, difficulty swallowing, and/or difficulty breathing.
Some types of nodules can actually produce thyroid hormones, which can result in hyperthyroidism.
Many people with Hashimoto’s have thyroid nodules, and in fact, detecting the presence of thyroid nodules is a common way to diagnose autoimmune thyroid disease.
Having thyroid nodules is one of the most common endocrine conditions in the United States. About 50 percent of American adult ultrasonographic examinations (a safe medical procedure where sound waves bounce off bones and tissues in the body to produce a black and white image on a monitor) reveal thyroid nodules (4).
Women are three times more likely to have nodules: about 30 percent of women in their 30s will have at least one, and most women will develop a thyroid nodule by the time they are 50.
Types of Thyroid Nodules
There are various types of benign nodules, which I’ve outlined in the following infographic:
Are Nodules Cancerous?
While over 90 percent of thyroid nodules are benign (non-cancerous), certain nodules may be malignant (cancerous).
Some thyroid nodules are actually cysts filled with fluid, rather than thyroid tissue. Purely cystic thyroid nodules (thyroid cysts) are almost always benign.
The complications stemming from inflammation associated with Hashimoto’s can put you at greater risk for other autoimmune diseases, as well as thyroid cancer (including thyroid lymphoma). Research shows people with Hashimoto’s have a much higher risk for thyroid cancer than those without Hashimoto’s (around 22.5 percent versus 2.4 percent) (8).
The risk of having thyroid cancer increases if you have a family history of thyroid or endocrine cancer, if you’re younger than 30 or older than 60 years old, if you are male, or if you have a history of radiation exposure (including dental and chest X-rays). There is typically a delay of 20 years or more between radiation exposure and the development of thyroid cancer.
To learn more about diagnosis, please read my article on thyroid cancer. I’ll detail how to test for cancerous nodules below.
Signs and Symptoms of Nodules
The signs and symptoms of nodules aren’t always so apparent. You may notice them yourself as a lump on your neck, while buttoning your collar. Or, your doctor might only discover nodules during a physical exam or on imaging tests like ultrasounds or CT scans for other reasons.
Fortunately, most nodules are asymptomatic, but rarely, these symptoms can manifest:
- Pain in your neck, jaw, or ear
- Trouble breathing, swallowing, or feeling a tickle in your throat (if the nodule is large enough)
- Hoarseness if the nodule irritates the nerve that controls the vocal cords (Note: This can be related to thyroid cancer.)
- The production of excessive levels of thyroxine, creating symptoms of hyperthyroidism, including tremors, nervousness, unexplained weight loss, and erratic heartbeat
Abnormal thyroid test results may also be an indicator that a person should be examined for nodules.
Testing for Nodules
If you’re wondering how you can test for thyroid nodules, there are several options you can pursue:
1. Conduct a physical self-exam. I created an infographic that details how to perform a simple self-check at home:
2. Check your thyroid hormone levels to ensure they’re in the optimal ranges. Note: Be sure to request a full thyroid panel (TSH, free T4, T3, reverse T3). You can read my article on the top 10 thyroid tests for more information on how to order your own thyroid panels and interpret your results. Should you suspect nodules from your physical self-exam or from suboptimal thyroid hormone levels, you may wish to consult your physician to order an ultrasound.
3. Order an ultrasound from your doctor. Ultrasonography will provide information about the structure or shape of your nodules. It can also help your doctor determine whether a lump is a cyst or a solid nodule, and whether you have multiple nodules. Radiologists can then make recommendations regarding next steps. Benign and “non suspicious” findings don’t need to be biopsied. Other nodules, however, may need a biopsy or repeat ultrasound depending on size. The goal here is to avoid unnecessary biopsies. However, if there any suspicious findings, you may have to…
4. Follow up with a fine needle aspiration (FNA) biopsy. If your doctor suspects a nodule might be malignant, he or she might perform a fine-needle aspiration (FNA) biopsy. A FNA is usually only considered when nodules are larger than 10 mm in diameter, unless ultrasound results are otherwise suspicious. Additionally, nodules ≤5 mm are generally monitored rather than biopsied.
A FNA biopsy involves the insertion of a very thin needle into the thyroid, and cells are aspirated (removed) for further evaluation. A FNA biopsy helps determine whether the nodule is a true nodule (malignant) or a pseudo-nodule (benign).
While this is the gold standard to differentiate between benign, inflammatory, or malignant nodules (classifying them as either true nodules or pseudo-nodules), it is invasive. A more non-invasive technique to differentiate pseudo-nodules and true nodules is sonoelastography, where ultrasonography imaging is used to evaluate the mechanical properties of soft tissue.
Research shows sonoelastography can be an effective alternative to avoid using invasive biopsies or surgical interventions to detect a true nodule diagnosis (12). Once your physician determines you have nodules, he or she will likely refer you to an endocrinologist for further treatment.
Newer tests can also help specialists better determine whether nodules are benign or cancerous. One of them is the American College of Radiology (ACR) Thyroid Imaging, Reporting, and Data System (TI-RADS). This test scores various features of nodules on an ultrasound, and assigns points to help users of the report with recommendations. The higher the total score, the higher the chances of malignancy.
The American College of Radiology’s TI-RADS (Thyroid Imaging, Reporting and Data System) assigns points to thyroid nodules based on five features:
- Composition (how “cystic” a thyroid looks)
- Echogenicity (the ability to bounce back an echo during an ultrasound exam)
- Shape (wider-than-tall, or taller-than-wide)
- Margin (how far the thyroid extends around surrounding organs)
- Echogenic focus (bright spots or shadows seen on an ultrasound)
Based on that ratings scale, nodules are then classified as:
- Benign (non-cancerous)
- Not suspicious
- Mildly, moderately, or highly suspicious
5. Another method of diagnosis is to get a thyroid scan done. An isotope of radioactive iodine is injected into a vein in the arm to find nodules that produce an excess of thyroid hormone. (These will take up more of isotope then normal thyroid tissue.) You may find cold or hot nodules. Cold nodules are non functioning and appear as defects or holes in the scan. Hot nodules are almost always non-cancerous, while only some cold nodules are cancerous.
The Conventional Approach to Thyroid Nodules
Most conventional doctors will recommend the following options for treatment of thyroid nodules:
1. Observation. When you have benign nodule, most doctors will recommend monitoring your thyroid with regular checkups (ie. physical exams, thyroid tests, and follow up biopsies) to check for malignancy. This is especially important for those with Hashimoto’s, as they are at an increased risk of thyroid cancer. An increase in size or symptoms may demand a repeat biopsy or another treatment, but nodules that don’t change over the years might not require any additional treatment.
2. Thyroid hormone suppression therapy. Prescribing thyroid hormone replacement medications can lower the production of TSH from the pituitary gland, and thus decrease the growth of thyroid tissue. Some practitioners may even attempt to suppress TSH with thyroid medications, to reduce nodule size. One double-blind, placebo-controlled study looked at 123 patients with a single palpable benign nodule, using levothyroxine therapy to suppress their TSH below 0.3 mIU/L over 18 months. The study found that those in the medication group had a significant decrease in the size of their largest nodules, while the placebo group saw an increase in nodule size (23).
3. Surgery. Surgery may be recommended when a benign nodule is large in size and causing difficulty when breathing or swallowing, when there are diagnosed large multinodular goiters, or when goiters constrict airways, the esophagus or blood vessels. Surgery is also recommended when nodules are suspected to be cancerous. Options include a total thyroidectomy (where the entire thyroid gland is removed) and a partial thyroidectomy (where only parts of the thyroid are removed).
I’ve seen countless times where people have had their thyroid glands removed due to thyroid disease (most commonly Graves’ and thyroid cancer). In the case of autoimmune thyroid disease, removing the thyroid with a thyroidectomy eliminates thyroid antibodies, as there is nothing left to attack. However, life is not always roses with a thyroidectomy, as it does not remove the autoimmunity. Furthermore, a thyroidectomy may result in difficulty breathing, bleeding or infection, injury to the parathyroid glands near the thyroid (which could cause low blood calcium levels or neuromuscular symptoms), and permanent hoarseness or voice changes due to nerve damage. You can check out my article about getting a thyroidectomy for Hashimoto’s for more information.
While those with co-occurring Hashimoto’s and thyroid cancer may wish to follow this approach, I do not generally recommend this strategy for Hashimoto’s in most cases, as there are so many dietary and lifestyle interventions that can be implemented to prevent the progression of autoimmunity and reduce the size of nodules. (I’ll discuss this more below!)
The Root Cause Approach to Thyroid Nodules
Although the above treatment options can reduce or remove thyroid nodules, I have heard many success stories of people reducing or eliminating their nodules with dietary and lifestyle interventions.
Shrinking Nodules – A Success Story
I’d like to share the success story of a client who was able to reverse her nodules with nutrition, supplements and treating Blastocystis hominis. Her thyroid antibodies are also now in the remission range (she is not taking any thyroid medications). This 60 year old woman with asthma, Hashimoto’s and past exposure to Chernobyl had consecutive ultrasounds on an annual basis to monitor her thyroid nodule. As of 2018, this person still does not have any nodules on her thyroid ultrasound. She did, however, have a flare in asthma and thyroid antibodies in 2017 after having dairy. As a side note, I think the significant dairy reactivity may be due to the Chernobyl exposure and the radioactive toxins concentrated in the milk from cows in Eastern Europe. My theory is that this exposure made people highly sensitized to dairy proteins.
Here are the results from her first test:
11/5/10: First ultrasound (before diet)
FINDINGS: There is a 6 x 3 x 4 mm hypoechoic solid nodule in the right lobe with multiple small but discrete hyperechoic foci likely due to calcifications. There is a 2 x 4 x 2 mm partly calcified solid nodule in the left lobe that demonstrates shadowing.
IMPRESSION: There are bilateral calcified thyroid nodules. The nodules measure under 1 cm in diameter. The nodules are nonspecific in appearance and results should be correlated with clinical and laboratory data. Follow up ultrasound needed in 12 months due to the calcifications.
She started with having elevated TPO antibodies and saw that her nodule had consistently increased in size with every subsequent ultrasound scan. Deciding to take her health into her own hands, she removed gluten and dairy (two common food sensitivities in those with Hashimoto’s) from her diet. Six months after starting the gluten free diet, her ultrasound showed a decrease in the size of her nodules:
11/20/14 – After starting a gluten and dairy free diet
FINDINGS: The right lobe of the thyroid measures 1.4 x 1.3 x 3.8 cm. Left lobe of the thyroid measures 1.6 x 0.9 x 3.9 cm. The isthmus measures 3 mm in thickness.
Right lobe: Lower pole, posterior, lateral, well circumscribed intermediate echogenicity. Central calcification. No increased vascularity. 0.3 x 0.4 x 0.3 cm. Prior studies do not demonstrate a nodule in this location, however a larger calcified nodule was identified previously in a more superior location of the thyroid gland. The previously measured nodule is not demonstrated on this exam. It is possible that the small nodule measured today represents a decrease in size of the previously seen nodule in the change in location relates to imaging technique. This nodule is indeterminate. Continuing thyroid ultrasound follow-up is recommended.
Left lobe: Mid thyroid, mid gland well-circumscribed. Intermediate echogenicity. Calcified. 0.2 x 0.3 x 0.1 cm. Previously measured 0.3 x 0.2 x 0.1 cm. This calcification/nodule is stable to decreased in size compared to prior ultrasound consistent with a benign finding.
IMPRESSION: I suspect that the right sided calcified nodule described above in the lower pole today represents the previously measured thyroid nodule and has decreased in size consistent with a benign finding, however the differences and described location of the nodule may direct correlation difficult. Continued ultrasound follow-up is recommended.
After being gluten free for 1.5 years, her thyroid nodule shrunk! Her TPO levels also decreased from 120.7 IU/mL to 42.6 IU/mL. Here’s what her most recent ultrasound test said:
1/29/16 – After treating Blastocystis hominis
FINDINGS: The right lobe measures 3.4 x 1.2 x 0.8 cm. The left lobe measures 3.8 x 1.0 x 0.9 cm. The isthmus measures 0.3 cm in AP dimension. The gland is mildly heterogeneous. Color imaging demonstrates increased vascular flow bilaterally. A coarse calcification in the left lobe measures 3 mm, interpolar. This is stable. There is no discrete nodule.
IMPRESSION: No suspicious nodule identified. The previously described right thyroid nodule is no longer seen. A coarse calcification on the left measures 3 mm, nonspecific but stable and of doubtful significance. This is unchanged dating to the earliest available exam of 11/05/2010.
As you can see, her latest ultrasound test showed that her nodule had disappeared!
What Causes Nodules?
Many people with Hashimoto’s have nodules, as the root causes of thyroid nodules are often the same root causes of their own autoimmune condition, including:
- Chronic inflammation of the thyroid (thyroiditis) – The chronic inflammation associated with autoimmune thyroid conditions increases the risk for thyroid nodules (7), and the inflammation associated with autoimmune thyroiditis can further enlarge nodules. With Hashimoto’s, the body develops antibodies to normal proteins produced by the thyroid gland, which in turn can result in the development of malignant (possibly cancerous) nodules. Your thyroid might also form pseudo-nodules (or benign nodules) that come and go.
- Nutrient deficiencies in iodine, selenium, and vitamin D – Iodine deficiencies typically occur in diets lacking iodine, and can result in a multinodular goiter. However, this is unlikely to occur in North America where iodine is added to foods, as is the case with iodized salt. With Hashimoto’s, iodine excess is far more likely to create nodules. You can read more about how iodine affects Hashimoto’s. That said, vitamin D deficiency is quite common. This vitamin controls the way in which cells grow and divide, and insufficiency increases one’s risk of nodules, fibrosis and polyps in many areas of the body. Selenium deficiency is also a potential cause of nodules, as studies suggest that selenium supplementation can result in improved thyroid ultrasound features and smaller nodules (25).
- Toxins – This is oftentimes an overlooked culprit for nodules. A 2015 study in Sicily found that people living closer to a petrochemical complex, and thus are subject to its pollution, were more likely to have a greater frequency of thyroid nodules as well as Hashimoto’s (6). Radiation exposure, such as being exposed to Chernobyl, can also cause nodules (38). Additionally, a 2017 study found that thyroid nodules were more likely to be found in those with both autoimmune thyroid disease and a nickel allergy (20). Further research is needed, but this supports the idea that toxic exposure, like nickel toxicity, may play a role in the development of nodules in those with Hashimoto’s.
- Pregnancy and hormonal changes – Often times, women develop thyroid nodules during pregnancy, and pre-existing thyroid nodules may grow during pregnancy (26). A recent study done in Hong Kong saw an increase in the number of the thyroid nodules and well as their size over a period of 10 to 12 weeks apart each trimester of pregnancy. The growth of the nodules appeared to be much faster than what is normally seen in non-pregnant women. While the cause of nodules during pregnancy remains unclear, the study suggested that this could be due to negative iodine balance associated with pregnancy (26).
- H. pylori infections – H. pylori infections have been considered a trigger of Hashimoto’s and have been found in almost 50 percent of patients with Hashimoto’s in one Iranian study. (You can read more about that in my article on Hashimoto’s and H. pylori.) A 2013 study found that H. pylori infections were associated with the presence of thyroid nodules in individuals, despite having normal thyroid function (27). Given that the theory of molecular mimicry suggests that the immune system may attack its own thyroid gland when it is infected with a pathogenic organism that looks similar to components of the thyroid gland, it’s possible that such an infection increases the autoimmune attack on the thyroid, resulting in the development of thyroid nodules.
- Blastocystis hominis infections – I have heard anecdotal stories from my clients and readers claiming that addressing a Blastocystis hominis infection resulted in the elimination of their nodules. I suspect the reason behind this is similar to why H. pylori infections are associated with the development of thyroid nodules. Another hypothesis I have relating to the role of infections in thyroid nodules, is that nodules may be created when a foreign substance (like bacteria) is inserted into the body and the body reacts by trying to wall it off by forming a capsule of scar tissue around it.
- Food and diet – We know that food sensitivities can exacerbate the attack on the thyroid and increase one’s levels of chronic inflammation, which, as I mentioned earlier, has been linked to the development and enlargement of nodules. Additionally, based on anecdotal stories from clients who have shrunk their nodules through dietary interventions that remove common inflammatory foods, it’s possible that food sensitivities contribute to the development and growth of thyroid nodules. I’ve received numerous reports from clients and readers who were surprised that their nodules disappeared after following the Paleo or Autoimmune Paleo diets. Please note: this approach works over months, sometimes years. Additionally, blood sugar imbalances can also lead to a greater risk of thyroid nodules (39).
Ways to Shrink Benign Nodules
That is why I believe that a number of dietary and lifestyle changes can help improve symptoms of Hashimoto’s and reduce the size of thyroid nodules.
As mentioned above, many root causes of Hashimoto’s are associated with the development of thyroid nodules, so addressing them may reverse their growth and shrink them! Here are some tips that may help to reduce the size of your thyroid nodules:
- Address nutrient deficiencies in iodine, selenium, and vitamin D – While iodine deficiency is rare in those with Hashimoto’s, those that are indeed low in iodine may benefit from taking a multivitamin with iodine, like Nutrient 950 from Pure Encapsulations. A dose of up to 250 mcg of iodine per day has been found to be helpful and beneficial in people with Hashimoto’s; however, doses above 300 mcg can be potentially inflammatory. Vitamin D and selenium supplementation may also help. You can read more about addressing vitamin D and selenium deficiencies in my articles.
- Clear out toxins – Supporting your liver’s detoxification pathways as well as opting for non-toxic, natural personal products can greatly reduce your body’s toxic burden and result in optimal thyroid health. Check out my article on liver support for more information.
- Address underlying infections – As I mentioned earlier, infections like H. pylori and Blastocystis hominis are a common root cause and trigger for Hashimoto’s, and can contribute to thyroid nodules. Addressing these infections may eliminate your thyroid nodules, as well as the autoimmune attack on the thyroid. (You can read more about treating Blasto and H. pylori infections.)
- Change your diet and remove food sensitivities – Balancing your blood sugar can help with shrinking thyroid nodules. Removing common food sensitivities like gluten and dairy can also help reduce the size of your nodules. Check out my article on food sensitivities for more information on how to identify them.
- Consider smart supplementation – Some of my readers have reported an elimination of nodules utilizing the systemic enzyme Wobenzym, and others with turmeric.
- Address estrogen dominance – Excess estrogen can be a trigger for thyroid nodules. In the case of excess estrogen due to pregnancy or using birth control pills, the estrogen will likely rebalance on its own with time after you have your baby or stop the pill. If a year has passed since you had a baby or stopped the pill, or if your estrogen dominance is due to other reasons, consider using food, supplements and progesterone to balance out your hormones. I’ve written an article on how to recognize the symptoms of estrogen dominance, and one on the birth control pill.
- Consider echotherapy (HIFU ablation) – New research suggests that a single session of high-intensity focused ultrasound (HIFU) ablation, which uses focused ultrasound energy to induce thermal ablation (removal), may be more beneficial (and safer) than a thyroidectomy for symptomatic but benign thyroid nodules. In one study, patients who underwent HIFU ablation did not scar, had a shorter hospital stay, and were less likely to have voice pitch issues a month after their treatment. Furthermore, those in the study saw a greater improvement in symptoms and a lower prevalence of subclinical hypothyroidism compared to those who had surgery. While this treatment is currently only available in a few clinics in Europe, further studies may be conducted in the future to explore its efficacy as a possible thyroidectomy alternative (36).
Nodules are often present in those with Hashimoto’s and may be detected with a thyroid panel and ultrasound tests, but most nodules are benign. While thyroid medication can help address thyroid hormone imbalances, they may not always get to the root cause of the nodules alone.
Fortunately, benign nodules may be reduced or even eliminated with dietary changes, strategic supplements, and other innovative lifestyle changes that address the underlying root causes of Hashimoto’s, as discussed in my book Hashimoto’s Protocol. This comprehensive plan has helped many patients feel better and get their thyroid disease into remission, and I hope these changes help you as well!
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