If your doctor just told you that you have a thyroid nodule, your first instinct might be to freak out. I get it. I’ve been there. I was diagnosed with thyroid cancer at 21 and I’ve been on full-dose replacement thyroid hormones ever since.
But here’s what most people don’t know. Even some doctors don’t really know or get wrong about thyroid nodules and when they’re a problem and when they’re not.
So let me take you through the whole process and give you questions that could change your entire treatment plan.
They’re way more common than you think
If I grabbed my ultrasound and walked down the street and scanned 1,000 random people, I’d find 500 to 600 nodules. Some people make none. Some make one. Some make so many that the thyroid looks like a cluster of grapes.
Your thyroid might be a little lumpier than you suspect. And 95% of those nodules are benign. All comers. Whether you have risk factors or not.
So if they’re so common, why do doctors make such a big deal? Because we find a ton of them by accident. We’re very fond of doing CT scans on everybody who wanders into the ER. We find these little nodules and we call them incidentalomas. But once we find one, the standard is still to get an ultrasound because that’s the best way to measure it and understand its characteristics.
Why do some thyroids make nodules and others don’t?
The short answer is we’re not totally sure. It doesn’t specifically correlate with thyroid function. Hyperthyroid people don’t necessarily make more or fewer nodules. Same for hypothyroid or Hashimoto’s. Thyroid nodules frequently just exist independent of thyroid function or dysfunction.
The risk factors I always check
There are specific questions I ask every patient that are critical for understanding risk.
Radiation history. Have you ever had radiation therapy to the head, neck, or chest?
Where you’ve lived. Certain places carry higher risk for thyroid nodules and cancers, traditionally areas with nuclear exposure. Hotspots include New Mexico (atomic testing, uranium mines), the eastern side of Washington State (Hanford Reservation, Manhattan Project), the Fukushima area in Japan, and areas downwind of Chernobyl.
Occupational exposure. Have you worked a job that exposed you to radiation?
Family history. Is this a trend in your family? Have you inherited a trait that might produce thyroid cancer? We ask who in the family has thyroid issues and what kind.
Having a nodule doesn’t mean your thyroid is defective. So many of these are benign and don’t have any impact on thyroid function, lifespan, or health span.
TIRADS scores: What your ultrasound report actually means
TIRADS scores tell us how suspicious a nodule looks. It’s based on features. Does it look smooth and round and even? Lower score. Does it look lumpy, have fingers, have salt-and-pepper spots on the inside? Higher score.
TIRADS 4 is moderately suspicious. Somewhere between 12% and 40% of those nodules can end up being cancer.
TIRADS 5 is highly suspicious. These have very specific features, frequently trying to get outside of the thyroid gland, with fingers and salt-and-pepper marks. They can carry up to an 80–85% chance of thyroid cancer.
But here’s what I need you to hear: just because you have a TIRADS 4 or even 5, especially with no clinical risk factors, it is still common for these biopsies to come back benign. You are not condemned to a cancer diagnosis.
There’s been a movement among thyroidologists in recent years to reclassify things and not be so quick to take out somebody’s whole thyroid gland and force them into lifelong thyroid hormone replacement.
When do we biopsy?
TIRADS gives us guidelines about how big a nodule has to be before we biopsy it. We’re typically not worried about anything under one centimeter.
TIRADS 5: biopsy at 1 cm
TIRADS 4: biopsy at 1.5 cm
TIRADS 3: biopsy over 2 cm
TIRADS 2 and 3 are basically low to no risk. They’d have to be pretty big before we think something might be going on.
And cysts? Cysts are boring. I love boring. They’re just full of fluid. They don’t have the potential to turn into cancer. At worst, a cyst can blow up like a balloon and get in your way. You can drain it or ablate it. No surgery needed.
What a biopsy actually looks like
It’s kind of like going to the dentist for a cavity. We have the ultrasound going. We know exactly what we’re looking at. We do lidocaine to the area, just like a dentist does. Then we get six different passes from the nodule, sampling different areas for a good variety of cells.
The pathologist looks at it under a microscope and can tell you several things. It looks benign, let’s move on. It looks like cancer, let’s talk about next steps. Or it looks atypical but hard to classify. That’s called atypia of undetermined significance, and we send it straight to genetic testing for a percentage risk of cancer.
If a biopsy comes back benign, there’s still a residual risk of up to 3%. That’s why we don’t lose track of you. You go into surveillance mode. If a nodule grows in a systematic, predictable way, that’s fine. If it changes how it’s growing, decides to go long, makes fingers, or tries to bulge out, we check again.
If it is cancer
In most cases, the standard of care is to remove the thyroid. This is typically a day surgery now. It used to require a hospital stay, but that’s not so common anymore except in advanced cases. Sometimes we just take the half that’s affected.
If it’s small, contained, and low-risk, you might just be done. No chemo. No radiation therapy. This isn’t oncology. This is almost always managed by endocrinology.
95% of thyroid cancers are papillary thyroid cancers. They’re kind of like bumblebees. They sit there and don’t do a whole lot. They might be big, but they don’t try to hurt you. If we take care of it early, most people do really well.
Radiofrequency ablation: a non-surgical option
For benign nodules that are big, annoying, cosmetically not great, affecting your voice, your swallowing, or making you feel like something’s choking you at night, there’s another option. You don’t have to have cancer to get treatment.
Radiofrequency ablation has been used for decades in other countries. We got it in America around 2018. It’s like getting a biopsy done, except instead of pulling a sample out, a probe goes in and we slowly heat the inside of the nodule in all three dimensions. As it heals, it scars down. We’re aiming for a 50–80% reduction in volume.
What about surgery?
Usually a day surgery. The incision is typically very small now, not the big smile it used to be. The surgeon monitors the recurrent laryngeal nerve the entire time to protect your vocal cords, and carefully identifies and preserves your four parathyroid glands so you don’t have calcium problems afterward.
If you lose your thyroid, you’ll need thyroid hormone replacement every day. I’ve been on it since I was 21. It gets old. I hate having to take something every day. But I take it, I feel fine, I’m living my best life, and my functional status is otherwise fine. Patients who maintain normal thyroid function move on with their lives.
Living with thyroid nodules
If your nodules are benign, you go into surveillance mode. Typically an ultrasound once a year and thyroid function tests once a year or more if you have symptoms. Every year we decide if things look stable, if a TIRADS score has changed, and if a biopsy is warranted.
If nodules have been stable for several years and are uninteresting, we increase the interval. Every two years. Then three. Then we might stop altogether. It’s case by case.
Stop buying thyroid supplements
Can you change the outcome of your thyroid nodules with diet, exercise, lifestyle, or supplements? The short answer is no. There are plenty of clinics online that like to turn this into a complex situation and sell you things. But we don’t have any evidence that a supplement, a small dose of thyroid hormone, or iodine support has any bearing on reducing thyroid nodules.
You can actually make things worse. Thyroid support supplements are sometimes ground-up animal gland. If you take those and then we test you, are we testing you or the cow? We don’t know.
The one exception is selenium, which does show benefit for thyroiditis like Hashimoto’s and Graves’ disease. But skip the expensive bottle. One Brazil nut a day. That’s it.
The bottom line
Overwhelmingly, thyroid nodules are benign, even giant ones. If they’re not benign, this is overwhelmingly a slow-growing, manageable kind of cancer. You will not be subjected to the horrors of chemotherapy, radiation, surgery after surgery. This is almost always managed by endo, not oncology.
It’s looking up.
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Thyroid Nodules: What You Need to Know – Dr. VanDyke
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Dr. Lindsey VanDyke, DO | Board-Certified Endocrinologist
AIDENDO: Advanced Institute for Diabetes & Endocrinology
Telehealth available in CA, TX, CO, OR, WA, OK, NM
📲 817-380-4880 | aidendo.com