Thyroid Nodule

Thyroid nodules

ImageThyroid nodules are round or oval-shaped growths in the thyroid gland. The thyroid gland is in the middle of the neck. The thyroid is a butterfly-shaped gland in the middle of the neck. It sits just below the larynx (voice box). The thyroid makes two hormones, called T3 and T4, which control how the body uses and stores energy. The parathyroid glands are four small glands behind the thyroid. They make a hormone called parathyroid hormone, which helps control the amount of calcium in the blood.
Thyroid nodules are common and are not usually harmful to a person’s health. But sometimes, thyroid nodules are caused by a serious condition, such as cancer.
The thyroid gland makes a hormone called “thyroid hormone.” Most thyroid nodules do not change the amount of thyroid hormone in the body. But some cause the thyroid gland to make too much thyroid hormone. This can cause symptoms.
Some people do not have any symptoms. They might find out that they have a thyroid nodule when their doctor or nurse feels it during a routine exam. Or a doctor might find nodules on an imaging test that was done for another condition. (Imaging tests create pictures of the inside of the body.)

Other people have symptoms. For example, they might feel or see a lump in their neck. Or they have symptoms from having too much thyroid hormone, such as:
  • Feeling worried, upset, or having trouble sleeping
  • Feeling weak or tired
  • Losing weight without trying
  • Having a fast heartbeat
  • Having frequent bowel movements
Yes. Your doctor will want to make sure that the thyroid nodule is not a threat to your health. Diagnostic tests can determine if a thyroid nodule is benign or malignant (cancerous); this information can help to guide treatment decisions. There are several diagnostic tests, and each provides unique information about the thyroid nodule. However, not every person with a thyroid nodule needs all of these tests. Often, a test will provide a definitive answer about the type and cause of a nodule. In other cases, a test may be inconclusive, and further testing will be required. Your health care provider can talk to you about which tests you will need and what the results mean.

Thyroid-stimulating hormone — Thyroid-stimulating hormone (TSH) can be measured with a blood test.
  • If the blood test shows that your TSH level is normal, the next step is to have a thyroid ultrasound. Depending upon the appearance of the nodule on ultrasound, a fine-needle aspiration (FNA) biopsy may be recommended.
  • Low levels of TSH in the blood may indicate that a nodule is producing high levels of thyroid hormone. If your TSH level is lower than normal, the next step is to have a thyroid scan.
  • High levels of TSH may indicate autoimmune inflammation of the thyroid (called Hashimoto’s thyroiditis). Another blood test, to measure levels of thyroid antibodies, is sometimes recommended in this case. An FNA biopsy may also be needed.
Thyroid ultrasound — A thyroid ultrasound should be done if you have a suspected thyroid nodule or nodular goiter after a physical examination. Ultrasound should also be done if nodules are found through imaging studies done for other reasons (for example, carotid ultrasound, computed tomography [CT], magnetic resonance imaging [MRI], or positron emission tomography [PET] scan). Thyroid ultrasonography provides information about the size and anatomy of the thyroid gland and nearby structures in the neck as well as the characteristics of the nodule. This information can be used to identify which nodules require FNA biopsy.
Fine-needle aspiration — In most cases, the TSH level is normal, and if the ultrasound shows features that are suspicious for cancer, the next step is fine-needle aspiration (FNA). FNA uses a thin needle to remove small tissue samples from the thyroid nodule. The tissue is then examined with a microscope. FNA biopsy can be done in a doctor’s office with a local anesthetic (medicine to numb the area). It can be performed by palpation (meaning the doctor uses their fingers to feel the nodule) but is usually done using ultrasound guidance. You may feel mild discomfort as the anesthesia is injected, and you may feel some pressure during the biopsy, but it should not be very painful. The results of a biopsy will be one of the following:
  • Benign (noncancerous)
  • Malignant (cancerous)
  • Suspicious for malignancy
  • Indeterminate – This means that the findings are neither clearly benign nor malignant, the risk of malignancy is low, and further testing may be advised. The following classifications are considered indeterminate, and require further evaluation:
    Follicular neoplasm (microfollicular nodules, including Hürthle cell lesions)
    Follicular lesion or atypia of undetermined significance (nodules with atypical cells)
  • Nondiagnostic or insufficient – In this case, the biopsy does not contain enough tissue to make a diagnosis, and a repeat biopsy is necessary.
“Indeterminate” results make up approximately 15 percent of cases. Surgical removal of a nodule may be recommended for indeterminate nodules for a definitive diagnosis. However, in most cases in the United States (and some other countries where the technology is available), a biopsy sample is tested for specific “molecular markers” (genetic characteristics that affect how likely a nodule is to be malignant) instead of being removed with surgery. This information is used to determine whether the nodule should be observed or removed surgically for closer examination.

Thyroid scan — While most people do not have to have a thyroid scan, it may be recommended if a blood test shows that your TSH level is low. In this case, the thyroid scan (rather than a biopsy) is the first step after the blood test. A thyroid scan can help to determine if a thyroid nodule is “hot,” meaning it produces too much thyroid hormone, or “cold,” meaning it does not. The scan is typically performed after taking a small dose of radioactive iodine (in the form of pill); alternatively, a substance called technetium may be injected into a vein, but this is less reliable. Because the dose of radioactive iodine (or technetium) is small, the amount of radiation exposure you get from a thyroid scan is relatively low. The risk of exposure is considered small compared with the benefit of knowing if you will need treatment. However, if you are pregnant or breastfeeding, you should not have a thyroid scan
  • Thyroid nodules that absorb the radioiodine are usually not cancerous (called autonomous, hot, or toxic).
  • Thyroid nodules that do not absorb the radioiodine are called cold and have a 5 percent risk of being cancerous. Approximately 95 percent of thyroid nodules are cold.
Thyroid nodules are treated in different ways, depending on their cause and how much thyroid hormone is in the body. Different treatments include:
  • Watching and waiting – Doctors don’t always treat thyroid nodules right away. Your doctor might watch a thyroid nodule if it is small and doesn’t look serious. But they will follow it closely to see if it grows bigger or needs to be treated. This means you might have another thyroid ultrasound and sometimes another fine needle aspiration.
  • Surgery to remove one or both sides of the thyroid
  • Medicines – Some doctors try to shrink thyroid nodules using thyroid hormone medicines. If you take thyroid hormone medicines, your doctor or nurse will check your thyroid hormone levels on a regular basis. This treatment is not commonly used in the United States.
  • Radioactive iodine – Radioactive iodine comes in a pill or liquid that you swallow. It has a small amount of radiation and can destroy a lot of the thyroid gland. It is used only to treat nodules that make too much thyroid hormone. It is not safe for women who are pregnant or breastfeeding.
  • A procedure to drain fluid from the thyroid nodule, if it is filled with fluid
The appropriate thyroid nodule treatment depends upon the type of thyroid nodule that is found.

Benign thyroid nodules — Benign thyroid nodules usually develop as a result of overgrowth of normal thyroid tissue. Surgery is not usually recommended, and a benign nodule can be monitored with ultrasound over time. If it grows, a repeat biopsy or surgery may be recommended. Some surgeons recommend excision of nodules over 4 cm.

Suppressive (thyroid hormone) treatment — If a thyroid nodule is not cancerous, but the nodule is large, some health care providers will suggest a trial of thyroid hormone (thyroxine [T4]) to shrink the nodule; this is called suppressive treatment. The American Thyroid Association guidelines do not recommend this treatment, because only a small percentage of nodules shrink and suppressive therapy may have side effects (eg, abnormal heart rhythm or loss of calcium from bone). Thyroid hormone levels should be monitored carefully during suppressive treatment.

Malignant thyroid nodules (thyroid cancer) — Only approximately 5 percent of all thyroid nodules are malignant. Most people with thyroid cancer have an excellent chance of cure or long-term survival. The exact treatment approach will depend on the type and size of cancer. Thyroid cancers require surgical removal of all or part of the thyroid gland and sometimes one or more treatments with radioiodine, followed by thyroid hormone (T4). The goal of taking thyroid hormone is to keep your thyroid-stimulating hormone (TSH) in the lower portion of the normal range or even slightly below normal. If your entire thyroid is removed with surgery, you will need to take daily thyroid hormone for life.

Suspicious for malignancy — Nodules in this category have a 50 to 75 percent risk of malignancy. People with nodules that are suspicious for malignancy frequently have a lobectomy (in which part of the thyroid is removed) or a total thyroidectomy (removal of the entire thyroid) because the chance that the nodule is a cancer is higher than the chance it is benign.

Follicular neoplasm — If your biopsy shows follicular neoplasm, your health care provider may perform a thyroid scan, especially if your TSH level is in the lower portion of the normal range. Fifteen to 20 percent of follicular neoplasms prove to be cancer. If the scan shows a “cold” (non-hormone-producing) nodule or your TSH is not low, your provider may test a biopsy sample for certain molecular markers (if available). This information is used to determine whether the nodule should be observed or removed surgically for closer examination. If surgery is necessary, a hemithyroidectomy (removal of half of the thyroid) or a total thyroidectomy may be recommended depending on the results of the molecular testing, the size of the nodule, and your preferences. “Hot” thyroid nodules are usually not cancerous, and treatment options are based on the results of thyroid function tests and other factors.

Follicular lesion or atypia of undetermined significance — Most people whose biopsy shows nodules with atypical cells require repeat fine-needle aspiration (FNA). The optimal treatment depends upon individual factors, such as your personal risk for thyroid cancer and your past test results (including biopsy, molecular testing, and ultrasound). Molecular markers are frequently used to select low-risk nodules for observation rather than surgery.

Nondiagnostic — A nondiagnostic (or insufficient) biopsy does not have enough cells for interpretation. It should not be considered a negative biopsy. If your biopsy came back as nondiagnostic, the FNA should be repeated using ultrasound guidance.

“Hot” thyroid nodules — Some thyroid nodules produce thyroid hormone, similar to the thyroid gland, but do not respond to the body’s hormonal controls. These nodules are called “hot” or “autonomous” thyroid nodules. They are almost always benign, but they can produce too much thyroid hormone, a condition known as hyperthyroidism. If you have an autonomous thyroid nodule and high levels of thyroid hormone, you will probably be advised to have surgery to remove the thyroid nodule, or to undergo radioactive iodine treatment to destroy the nodule. Long-term treatment with the antithyroid drug methimazole is also an option, although methimazole cannot be taken during pregnancy.
If you have an autonomous nodule and normal thyroid function or minimal hyperthyroidism, the appropriate treatment will depend on your age and other health factors:
  • In young adults, autonomous nodules may be monitored over time.
  • In older adults, radioactive iodine treatment or surgery may be recommended because high thyroid hormone levels pose a risk of an abnormal heart rhythm (atrial fibrillation) and bone loss (osteoporosis).
Cystic thyroid nodules — Cystic thyroid nodules are usually benign nodules that have filled with fluid. These nodules may simply collapse when the fluid is removed. Cystic nodules are usually monitored for changes. If the cyst reforms or if the nodule bleeds more than once, surgery can be performed to remove the thyroid nodule.
If you want to get pregnant, talk with your doctor or nurse. Women who are pregnant should not be treated with radioactive iodine. That’s because radioactive iodine can cause serious harm to a baby. If a woman is treated with radioactive iodine, she needs to wait at least 6 months before trying to get pregnant. That way, her doctor can make sure that her nodule is no longer making too much thyroid hormone.
A multinodular goiter is a swelling in the neck. It is caused by abnormal growth of the thyroid gland, plus one or more growths called “thyroid nodules.” Thyroid nodules are round or oval-shaped growths in the thyroid gland. The thyroid gland is in the middle of the neck.

Thyroid nodules are common and not usually harmful to a person’s health. But sometimes thyroid nodules are caused by a serious condition, such as cancer.

The thyroid gland makes a hormone called “thyroid hormone.” Most thyroid nodules do not change the amount of thyroid hormone in the body. But some thyroid nodules cause the thyroid gland to make too much thyroid hormone. If a multinodular goiter has this type of thyroid nodules, it can cause symptoms.
Most people with a multinodular goiter do not have symptoms. The swelling might be found during an imaging test, such as an ultrasound, that is done for another reason. Or a blood test to check thyroid hormone levels might show that a person has too much thyroid hormone. Having too much thyroid hormone can be a sign of a multinodular goiter.
Some people with a multinodular goiter feel or see a lump in their neck. Or they have symptoms from having too much thyroid hormone, such as:
  • Feeling worried or upset, or having trouble sleeping
  • Feeling weak or tired
  • Losing weight without trying
  • Having a fast heartbeat
  • Having frequent bowel movements
If a multinodular goiter presses on the throat or airway, it can cause:
  • Trouble breathing – Especially during physical activity, at night, or when reaching or bending
  • Wheezing
  • Coughing
  • A choking feeling
  • Trouble swallowing
Yes. Your doctor will want to make sure that the multinodular goiter is not going to harm your body. You need tests to find out if nodules in the goiter are causing your thyroid gland to make too much hormone. Your doctor will also check the nodules to see how big they are and if they need to be taken out. Tests usually include blood tests and an imaging test of the thyroid called an ultrasound. This test uses sound waves to create a picture of the inside of your body.
Sometimes, people need more tests. These include:
  • Fine needle aspiration – For this test, a doctor uses a thin needle to remove a small sample of tissue from one nodule in the goiter, usually the largest. They might take tissue from more than one nodule. Then, another doctor looks at the tissue under a microscope.
  • Thyroid scan – People get this test only if they have too much thyroid hormone in the body. For this test, a person gets a pill or a shot with a small amount of a radioactive substance. Then a special camera takes a picture of the thyroid gland. This test is not safe for women who are pregnant or breastfeeding.
Many multinodular goiters do not need treatment. If the nodules are small and do not look harmful, your doctor might watch and wait to see if the swelling gets bigger or needs to be treated.
A multinodular goiter needs treatment if:
  • It causes the thyroid gland to make too much hormone
  • It causes problems with breathing, swallowing, or other body functions – or is very large
  • It contains cancer
Treatments for multinodular goiter include:
  • Antithyroid medicines – If your thyroid blood tests show that the thyroid gland is making too much thyroid hormone, doctors can use medicines such as methimazole (and propylthiouracil (also called “PTU”) to lower the amount of thyroid hormone it makes. These medicines control thyroid hormone levels until doctors can do other treatments.
  • Medicines to help with symptoms caused by too much thyroid hormone, such as atenolol.
  • Surgery to remove the multinodular goiter
  • Radioactive iodine – Radioactive iodine comes in a pill or liquid that you swallow. It has a small amount of radiation in it. The radiation treats the problem by destroying a lot of the thyroid gland, so it does not make so much hormone. Radioactive iodine is used only to treat nodules that make too much thyroid hormone. It is not safe for women who are pregnant or breastfeeding.
  • Injections of alcohol to shrink nodules, or laser treatment to destroy them. The alcohol used in this treatment is not the kind people drink.
If you want to get pregnant, talk with your doctor or nurse. They can make sure your multinodular goiter is not making too much thyroid hormone before you get pregnant.

Women who are pregnant should not be treated with radioactive iodine. This is because radioactive iodine can cause serious harm to a baby.
Hyperthyroidism is a condition that can make you feel shaky, anxious, and tired. It happens when a gland in your neck, called the thyroid gland, makes too much thyroid hormone. This hormone controls how the body uses and stores energy.

Hyperthyroidism is the medical term for when a person makes too much thyroid hormone. People sometimes confuse this condition with HYPOthyroidism, which is when a person does not make enough thyroid hormone.
Some people with hypothyroidism have no symptoms. But most people feel tired. That can make the condition hard to diagnose, because a lot of conditions can make you tired. Other symptoms of hypothyroidism include:
  • Lack of energy
  • Getting cold easily
  • Developing coarse or thin hair
  • Getting constipated (having too few bowel movements)
  • If it is not treated, hypothyroidism can also weaken and slow your heart. This can make you feel out of breath or tired when you exercise and cause swelling (fluid buildup) in your ankles. Untreated hypothyroidism can also increase your blood pressure and raise your cholesterol – both of which increase the risk of heart trouble.

    In women, hypothyroidism can disrupt monthly periods. It can also make it hard to get pregnant. In women who do get pregnant, hypothyroidism can cause problems. For instance, it can increase the chances of having a miscarriage. (A miscarriage is when a pregnancy ends on its own before the woman has been pregnant for 20 weeks.)
Yes. Your doctor or nurse can test you for hypothyroidism using a simple blood test.
Treatment for hypothyroidism involves taking thyroid hormone pills every day. After you take the pills for about 6 weeks, your doctor or nurse will test your blood to make sure the levels are where they should be. They might adjust your dose depending on the results. Most people with hypothyroidism need to be on thyroid pills for the rest of their life.

Thyroid hormone pills come in different brand name and generic forms. All the pills work equally well. But you should not switch from one generic or brand name to another. Switching between pills can cause your levels to go up and down.

Never change your dose of thyroid hormone on your own. Taking too much thyroid hormone can cause heart rhythm problems and even damage your bones.
You can try to get pregnant. Many women with hypothyroidism have healthy pregnancies. But your doctor or nurse will most likely need to change your dose of thyroid hormone once you are pregnant. That’s because you need more thyroid hormone during pregnancy. They will also measure your levels of thyroid hormone 4 weeks after any change in your dose, and at least once during each trimester of pregnancy.
Thyroiditis is a condition that happens when a gland in the neck called the thyroid gets inflamed. This gland makes thyroid hormone, which controls how the body uses and stores energy.
The thyroid gland sometimes makes too much or too little thyroid hormone. Hyperthyroidism is the medical term for when this gland makes too much thyroid hormone. Hypothyroidism is the medical term for when this gland makes too little thyroid hormone.

Thyroiditis after pregnancy can cause hyperthyroidism, hypothyroidism, or both (one after the other). This condition happens within a year of being pregnant. That means it can happen after a woman has a baby, miscarriage (when a pregnancy ends on its own before the baby can live outside the womb), or abortion (when a woman chooses to end a pregnancy).

The medical term for thyroiditis after pregnancy is “postpartum thyroiditis.”
Thyroiditis after pregnancy can cause symptoms of hyperthyroidism or hypothyroidism. Sometimes people have symptoms of hyperthyroidism and then symptoms of hypothyroidism. Common symptoms of hyperthyroidism include:
  • Feeling tired or weak
  • Losing weight, even when you eat normally
  • Having a fast or uneven heartbeat
  • Sweating a lot and having trouble dealing with hot weather
  • Feeling worried
  • Trembling
Common symptoms of hypothyroidism include:
  • Having no energy
  • Feeling cold
  • Trouble having bowel movements (constipation)
  • Not making enough breast milk, if you are breastfeeding
Yes. To check if you have this condition, your doctor or nurse will ask about your symptoms, do an exam, and order blood tests.

Sometimes doctors order other tests, such as an ultrasound of the thyroid gland. An ultrasound uses sound waves to create pictures of the inside of the body.
In many cases, women don’t need any treatment. The condition usually gets better on its own, and the thyroid gland works normally again. This usually takes 6 months to 1 year. Until you get better, your doctor will:
  • Do blood tests on a regular basis to check your thyroid hormone levels. If your condition worsens, you will need treatment.
  • Treat your symptoms. Symptoms from hyperthyroidism are treated with medicines called “beta blockers.” Symptoms from hypothyroidism are treated with thyroid hormone pills.
Although uncommon, thyroiditis after pregnancy sometimes causes long-lasting hypothyroidism. If this happens, you will need life-long treatment with thyroid hormone pills.
Women with thyroiditis after pregnancy are likely to get this condition again after future pregnancies. If you get pregnant again, let your doctor or nurse know so that they can monitor your thyroid hormone levels.