In this episode, Dr. Eric Osansky welcomes back Dr. Angela Mazza, a triple board-certified endocrinologist specializing in thyroid health, metabolic medicine, and integrative endocrine care. The discussion centers around two topics Dr. Mazza has recently published journal articles on: iodine and thyroid nodules. Together, they explore why iodine remains one of the most controversial nutrients in thyroid medicine and why individualized care is critical when determining whether supplementation is appropriate.
Dr. Mazza explains the delicate balance of iodine intake, discussing why both deficiency and excess can create thyroid problems. She also shares her approach to iodine testing, addresses common misconceptions about iodine supplementation, and discusses special considerations for Hashimoto’s thyroiditis, Graves’ disease, pregnancy, and breastfeeding. The conversation then shifts into thyroid nodules, where Dr. Mazza explains the most common causes of nodule formation, the role of inflammation, estrogen, insulin resistance, environmental toxins, and genetics, along with how toxic nodules differ from non-functioning nodules.
The episode wraps up with an in-depth discussion on goiters, radiofrequency ablation (RFA), thyroid cancer, and modern alternatives to surgery. Dr. Mazza also explains how she evaluates thyroid nodules using ultrasound and shares her perspective on personalized treatment approaches. If you want a clearer, more balanced understanding of iodine, thyroid nodules, and goiters, you’ll get a lot out of this episode.
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Dr. Eric Osansky:
Welcome back, Dr. Angela Mazza. Very excited to chat with you again. Hope you have been doing well. Really looking forward to doing a deep dive into iodine, thyroid nodules, and goiters. How are you doing today, Dr. Angela?
Dr. Angela Mazza:
I’m doing really well. Thanks so much for having me on your podcast. I’m excited to be back again.
Dr. Eric:
I am going to read your bio just in case someone hasn’t heard the previous interviews I’ve done with you. Then we will get into the conversation.
Dr. Angela Mazza is a triple board-certified endocrinologist specializing in thyroid health, metabolic medicine, and anti-aging care. She is certified in neck ultrasound and biopsy and is one of the few physicians in central Florida performing radiofrequency ablation, also known as RFA, for thyroid nodules.
Dr. Mazza has served as an investigator on major endocrine clinical trials and has authored publications and international presentations. She is the founder of Metabolic Center for Wellness in Oviedo, Florida; host of The Thyroid Talk podcast; and author of Thyroid Talk: An Integrative Guide to Thyroid Health, dedicated to personalized integrative endocrine care.
One question I have for you. Whenever I mention RFA, I usually mention you. Do you notice anybody getting confused between RFA and radioactive iodine? I always try to make it clear. I was just having this conversation. Maybe there should be a different name. When thinking about ablation, radioactive iodine is ablating the thyroid. I always clarify it’s not the same.
Dr. Angela:
It’s really confusing for a lot of people. That ablation can mean a few different things. I will have patients come to me asking about radioactive iodine. This is different. Unfortunately, the term “radioactive iodine ablation” was around before RFA. You’re right. We should probably make distinctions with that. Two different animals.
Dr. Eric:
I’m having you back on because, as we discussed prior to pressing record, I have been following you. I have been seeing all these journal articles you’ve written. I wanted to get updated information from the person who is putting out the research. I was very impressed by your journal articles on iodine and thyroid nodules, so that’s why we will be focusing on those.
Let’s start off with why did you decide to write the journal articles? Thyroid nodules is understandable because you do RFA and see a lot of people with thyroid nodules. What motivated you to write specifically the journal article on iodine?
Dr. Angela:
When I lecture, there will be questions that come up about iodine from other practitioners. There is a little bit of misunderstanding.
I will also say that whenever I am seeing a new patient who has a thyroid nodule or some sort of thyroid issue, guaranteed, I look through all supplements. I’m sure you do the same thing. I ask people to bring in all regular supplements, and I look at all of them. It never fails that someone who has or thinks they have a thyroid issue is on some sort of thyroid support. Sometimes, these thyroid support products have very high levels of iodine. We will talk about the extremes of that.
Between practitioners and patients asking about iodine, I figured it is obviously an important topic, and there are a lot of misunderstandings. Let’s make it easier. We don’t want people not to have enough iodine. We don’t want people to have too much iodine. It’s moving past those extremes of thyroid care because you and I know that it’s really about individualized care. Iodine is no different than thyroid hormone replacement or thyroid treatment or a thyroid protocol for a person. It has to be individualized. That was my goal for writing the article.
Dr. Eric:
There is definitely a lot of confusion. You have different sides of the story. You still have some practitioners recommending large amounts of iodine supplements. You have other practitioners who recommend for those with thyroid patients to completely avoid iodine. There are different perspectives when it comes to Hashimoto’s versus Graves’ as well. It’s confusing because someone could go on YouTube or another social media platform and find five different videos with five different perspectives.
Dr. Angela:
What’s the right one?
Dr. Eric:
Supplement with Lugol’s solution, says one. Another one says stay completely away.
I am not opposed to iodine these days. It is obviously important. I was on the high dose iodine bandwagon years ago with Dr. David Brownstein.
Dr. Angela:
Right.
Dr. Eric:
I was one of the ones who took high doses of iodine. Quite frankly, I did okay with it. I didn’t experience any side effects. As you see patients, you realize everybody is different. There are some people who might be able to get away with large doses of iodine. Others who can’t.
The question is do we need massive amounts, 50mg doses, or 25mg doses, of iodine? Even if we can’t tolerate it, is it actually necessary?
I don’t know where you want to start. If you want to talk about your approach or some of the common myths and misconceptions people have about iodine. I’ll let you take the lead and go wherever you want to go with this.
Dr. Angela:
I think you hit the nail on the head. When you have been taking care of thyroid patients long enough, you say that the same thing could cause a real problem. That high dose of iodine could set someone into a bad place. Even dealing with patients with thyroid nodules, it can actually cause issues.
If we want to talk about why iodine is important, it’s because it makes up the bulk of the thyroid hormone. We can’t have thyroid hormone if we don’t have iodine. The theory around when people use high doses of iodine is if a little bit is good, more should be better. But there is this U-shaped curve of the sweet spot for iodine.
If we want to talk about a bunch of myths out there, starting with if some is good, more is better. That is probably a myth that we want to talk about.
Another thing is if you have Hashimoto’s, should you avoid it altogether? It is individualized. This is an oversimplification of a more complicated question. Even natural iodine supplementation isn’t necessarily harmless.
When we talk about seaweed or kelp, that is a natural form, but it can have a huge array of iodine in it. If you have some kelp flakes, it might be 50-100mcg. If you have a whole sheet, it can go up to 1,000-1,500mcg. There is quite a nuance when it comes to iodine.
We have to take it in context of the person. My patient in front of me, I have not only to get their good history, get an idea of what their dietary intake is, but what are the other medicines they are on? Are they on medicines like amiodarone? It is used for cardiovascular patients as an antiarrhythmic. But it is super high in iodine. It hangs around in the system for a very long time. It might not cause a problem right away, but it can cause either hyper or hypo.
When we have too much iodine, it can cause one of two issues. It can either shut down thyroid hormone replacement for a while because the system gets overloaded, or it becomes such a rich substrate for making thyroid hormone that the thyroid can become overactive. We don’t necessarily know what is going on with our patient right away. To give them a huge dose of iodine is not necessarily the wisest thing to do.
If you are dealing with a pregnant patient or a patient who is breastfeeding, her iodine requirements will be higher than a person who is not.
I like to get a good picture of a background for a patient from that context.
Testing gets into another question. Is there a really good test for iodine? In functional medicine, we like to test, not guess. There is not a great test for iodine. Serum testing isn’t very accurate. Probably the best is if you did a 24-hour urine collection for iodine, which that can be pretty tedious. I don’t like putting patients through a 24-hour urine collection, especially if you will do it frequently. It’s a pain in the butt to do.
What I generally do, and it’s not perfect either, is I will get a random urine for iodine to creatinine. That helps me extrapolate out what a 24-hour urine would be. I don’t necessarily make a kneejerk reaction off of that either. Ideally, we want that to be between 100-250. If something is a little bit higher or lower, I question a little bit more.
Just the other day, I had someone come in, and I did a random urinary iodine to creatinine. It was off the charts, 1,200. The urinary iodine will only give you a few days to a week idea. It’s not a long-term idea of iodine intake. She happened to have had a CAT scan within that week. CAT scans do deliver a high dose of iodine.
Do we want to stay away from CAT scans if we have a patient with thyroid issues? No, because they’re necessary for certain things, as far as imaging and diagnosis. It’s generally a short-lived thing. It gives you an idea of what is going on.
If you have someone who is coming in on a regular basis, and their random urinary iodine is really low, you talk to them. They may have a very low salt diet. You can get a gestalt of what is going on with them. Maybe that is the person you want to tell to maybe do an iodine supplement a few times a week to supplement for iodine.
That is my general approach to iodine. It’s all very individualized. It’s not necessarily if we check it one time, that is the be all, end all. That person doesn’t have to be on iodine for the rest of their life. My main concern is I don’t want to cause an issue in someone who already has a thyroid issue.
Dr. Eric:
Understandable. What are your thoughts on the iodine loading test?
Dr. Angela:
I think there is a lot of value to an iodine loading test. It can be pretty cumbersome. If you have a high dose of iodine, then reevaluate from a urinary excretion standpoint. I tend not to do them. If you will do anything, because you will have to do it repeatedly to get an idea on a regular basis of what someone’s iodine is generally going to be. That’s why I go for the random.
Dr. Eric:
You’re right. The inconvenience of the collection is one thing. I should have specified. Are there concerns with taking the 50mg tablet of iodoral prior to that? There are people taking 50mg daily of iodoral compared to that one single tablet before. Could that one tablet cause problems with the loading test?
Dr. Angela:
Probably not that one tablet. We get into the same thing with the contrast. Probably not one dose will cause too much of an issue. If it is, it probably will be temporary.
Dr. Eric:
You said the contrast with CT scans is also not a big concern.
Dr. Angela:
I never promote imaging that isn’t necessary. If someone has to have imaging done, I am not going to say don’t do it because of your thyroid issue.
Dr. Eric:
Have you come across cases of hyperthyroidism or Hashimoto’s that seem to be induced by iodine? If so, what seems to be the most common causes?
Just to give my background, I have probably had at least a few patients per year who, at least according to the health history, they will bring it up to me. They started supplementing with high dose iodine, not just taking it once. I don’t think I had anybody say they did an iodine loading test and then developed hyperthyroidism or Hashimoto’s. Instead, they were taking high dose iodine supplements for a while.
Also, I’ve had a few patients with amiodarone where that caused hyperthyroidism. Not a lot. I can probably count on a single hand how many people. It does happen. I don’t think I’ve had anybody who had the iodine contrast come to see me because they developed hyper or hypothyroidism.
In your experience, when someone comes to you with iodine induced hyperthyroidism, is it the same thing, where they have been experimenting with higher dose iodine?
Dr. Angela:
Usually. It can be either end of the spectrum. I’ll have patients who were actually undiagnosed with Hashimoto’s, and they’re sent to me for evaluation of hypothyroidism. They had been taking some sort of high dose iodine supplement. They shut down their thyroid function. Luckily, for most cases, that resolves as you take away the iodine.
If you think about it, with autoimmune thyroid issues, especially Hashimoto’s, making thyroid hormone in and of itself is an oxidative process, an inflammatory process. If you are giving iodine, it’s causing inflammation if you don’t have enough selenium or glutathione to combat that reactive oxygen species that is going on. It can cause an issue.
I learned the hard way with thyroid nodules and hyperthyroidism. I had a patient who I was following for thyroid nodules. I always check a complete thyroid panel on my patients with thyroid nodules. Her thyroid levels were normal when I first saw her. Then I did a follow-up. Her TSH was .02, T4 was okay, and T3 was high. This wasn’t an overactive nodule before. Digging in, it turned out. It’s not always right at the surface that they are adding a supplement in. The patient said, “Oh yeah, I added in some Lugol’s solution.” Now, not only are you hyperthyroid because of this nodule that has become overactive, but this nodule has grown.
Unfortunately, taking the iodine away didn’t cause the nodule to get smaller. She did return to a normal thyroid state. I learned the hard way about the supplements, even in just the thyroid nodule follow-up.
Dr. Eric:
In this situation that you just described, the iodine caused the thyroid nodule to be a toxic nodule? Or was there a different cause?
Dr. Angela:
It caused the thyroid to become overactive. It caused the thyroid nodule to grow.
Dr. Eric:
It caused the thyroid nodule to get larger and caused hyperthyroidism. Okay. I understand. When she stopped the iodine, her thyroid hormone levels normalized, but the nodule didn’t shrink.
Dr. Angela:
Yeah.
Dr. Eric:
How about goiters? I want to talk to you about goiters. If you have hyperthyroidism or hypothyroidism, you could have a goiter. An iodine deficiency could also be a cause of a goiter through causing hyperthyroidism. If you had to put a number on it, what percentage of goiters care caused by an iodine deficiency? This may be a guess on your part.
Dr. Angela:
The number is pretty low. It would have to depend upon where you practice. If you are in a place where there is iodine deficiency, it being a cause of goiter would be higher. I tend to see more goiter related to some sort of underlying autoimmune thyroid issue. The TSH is hypertrophic in hypothyroidism. If you have hyperthyroidism, which the most common cause is Graves’, that stimulation of TSH receptor causes thyroid enlargement and inflammation.
I think it would have to depend. If you ask an endocrinologist in the Midwest, they might say a much higher number. It’s pretty low for where I’m at in central Florida.
Dr. Eric:
Okay. I am going to stick with this topic because it does happen. Even if they don’t have a goiter, but they have a thyroid issue. Maybe it’s a goiter or a thyroid nodule or hyperthyroidism without a goiter or nodule. They do a urinary iodine test, and they are pretty deficient according to urinary iodine testing. Would you say to increase food sources without going overboard with the kelp? How would you recommend for them to correct that?
Dr. Angela:
There are a couple different ways. Kelp flakes, put it on your salad a few times a week. If you do choose to do a supplement, potassium iodide, even a few times a week. Any sort of supplement, you don’t need every day, if you think someone is low on iodine. There is no harm in rechecking. That is my route. If we can do dietary, that would be my preference. If you have a good supplement, that’s good.
Dr. Eric:
Do you test everybody for iodine deficiency? Does it depend on the person?
Dr. Angela:
I test everyone, so I have an idea. I’m still going to try to get a detailed personal history. Get an idea of what their lifestyle dietary intake is.
Dr. Eric:
Let’s say you test someone, and their iodine looks normal. Are you at all cautious about giving someone with Hashimoto’s or hyperthyroidism/Graves’ a multivitamin with iodine in it? Whatever amount it has. It can have anywhere from 50-75mcg, sometimes 150-200mcg. Are there any concerns? Or does it depend on the person? Most people can tolerate it, but every now and then, there might be someone who is more sensitive to iodine.
Dr. Angela:
Great question. I have done a few different ways. You want them to get the benefit of the multivitamin. If it’s someone who I’m a little concerned about, especially some with underlying autoimmune, do the multi. Only do it every other day.
It is tough, too. You can’t find a lot of multis without iodine in them. It’s hard. Even the same thing goes for the thyroid supports. They’re not available, but you still want someone to get the benefit, especially if you’re feeling like they’re micronutrient deficient. You want them to get the multi. That’s why I say do it every other day if you can, and then recheck.
Dr. Eric:
Now, someone who is pregnant with Hashimoto’s or hyperthyroidism, and you are giving a prenatal. I don’t know of any prenatal that doesn’t have iodine. Even if there was a prenatal that existed without iodine, iodine is also important for the baby. You want to make sure the baby has sufficient iodine. This is one of these risk versus benefit scenarios. How do you approach pregnant women when it comes to iodine, not separate supplementation but simply a prenatal or having regular food sources of iodine?
Dr. Angela:
I would go with the prenatal vitamin in that case. Her needs are higher. You have some buffer with that.
Do I check urinary iodine levels in pregnancy? Not as much. I’ll follow thyroid function tests really strictly, at least through week 24, and then a little bit less. Since I’m following thyroid function so closely, I don’t overtest on the iodine then.
If she’s breastfeeding afterwards, her needs go up even higher. Breastfeeding, I tend to check a little more the urinary iodine, just because I want to make sure she has enough because her needs are so high.
Dr. Eric:
I’m asking these questions because especially in the case of someone who is pregnant, I don’t want them to completely restrict iodine from the diet. “There is iodine in my prenatal; I won’t take a prenatal. I will avoid all food sources of iodine.” I’d like to think most endocrinologists won’t tell a pregnant woman to stop iodine completely.
Dr. Angela:
I would hope not.
Dr. Eric:
Thyroid nodules. You also wrote a journal article on thyroid nodules. Not a surprise since you deal with a lot of thyroid nodules. Like you said, one of the few practitioners in central Florida who does RFA. Why do people develop thyroid nodules in the first place?
Dr. Angela:
That’s the question that drove me to write this article. I take care of new patients daily with thyroid nodules and thyroid biopsies. Pretty much every single person asks me why they got this nodule. I didn’t have a great answer to this question in the past. Over time, I did some research and dug into it a little bit more, especially considering the frequency that we’re finding of thyroid nodules.
I used to say it was related to iodine deficiency or too much iodine. We know that’s probably not a huge chunk of thyroid nodules. Yes, we get concerned about thyroid cancer because we don’t want to miss thyroid cancer. There are genetic abnormalities that can cause thyroid nodules.
Probably far and away the biggest cause of thyroid nodules is inflammation going on in the body that drives thyroid nodule growth. Whether it’s estrogen related, because we find a lot of thyroid nodules in women, and it can be related to changes and fluctuations in estrogen. It can be related to things we’re exposed to. We’re exposed to how many different chemicals on a regular basis.
The thyroid itself is super sensitive. It’s important, but it’s influenced by so many things. When there is something like an endocrine disruptor that can drive the growth. It can be related to history of radiation exposure.
There are a lot of things that can drive thyroid nodule growth. If you had to narrow it down to one big group, it would be something that drives inflammation.
The other question I get a lot is the concern about GLP-1s and thyroid nodules and thyroid cancer. The concern about thyroid cancer and GLP-1s has been around for a while. That was based off of rat studies. When we look back at the current state of affairs, we know that GLP-1s don’t cause thyroid cancer, but decreasing inflammation and weight loss can actually decrease thyroid nodules and thyroid cancer risk.
Dr. Eric:
In that respect, GLP-1s might benefit some people with thyroid nodules.
Dr. Angela:
In some people, yeah.
Dr. Eric:
But they don’t directly cause thyroid cancer? There is no evidence of that.
Dr. Angela:
No.
Dr. Eric:
That’s good to know. How about insulin resistance? Blood sugar imbalances, insulin resistance. There is some evidence showing-
Dr. Angela:
Definitely. I put that into the inflammation bucket, if you will. Along with insulin resistance, we tend to see obesity. There are hormones that come from our adipose tissue. Lectin feeds back and can cause elevations in TSH, and that TSH can drive thyroid nodule growth from that respect. Without a doubt, insulin resistance and obesity fall into the inflammation category for me.
Dr. Eric:
Toxic nodules. What are toxic nodules, and how are they differentiated from regular thyroid nodules?
Dr. Angela:
Toxic nodules can be really frustrating, for lack of a better explanation. Toxic nodules are overactive nodules. You might also hear “autonomously functioning thyroid nodules.” They are nodules that have developed different genetic mutations that don’t allow it to listen to the signal to shut down, like the rest of the thyroid. It can actually take over function for the whole thyroid, essentially shutting down the rest of the thyroid. What the thyroid nodules have is this really rich blood vessel supply that is in turn feeding that nodule.
Do they necessarily become very large? Not always. There can be small toxic nodules. With RFA, we can treat them well. There can be larger toxic nodules. They can cause compressive symptoms in addition to the symptoms that go along with hyperthyroidism, like anxiety, sleep problems, palpitations, weight loss, those sorts of things. They can be super frustrating. They don’t tend to respond to all our good functional medicine tricks.
Dr. Eric:
Do they have the same causes as far as inflammation?
Dr. Angela:
They can. They tend to have a genetic mutation that drives it a little more than a regular nodule.
Dr. Eric:
You said that they do respond pretty good to RFA in most cases?
Dr. Angela:
They do. The caveat is how large they are. Smaller thyroid nodules, we can treat them very easily with one session of RFA. Sometimes, larger overactive nodules, we need 1-2.
When we look at studies that look at RFA and toxic nodules, there are two key tricks. You have to get the nodule to at least 80% of its size. Whether you are starting out with a nodule that is 10ml or 5ml—we tend to think in terms of volume with nodules—or 25ml, it has to be at least 80% the size.
When you are dealing with something, the delta is a lot bigger to get it smaller, and that blood supply I mentioned, really important when we are dealing with a toxic nodule is we want to zap the blood vessels that are feeding it. If you don’t get those blood vessels, then it’s tough to get that toxic nodule under control. You want it smaller in size, but you want to decrease the vascularity.
Dr. Eric:
Is it the same with cancer? When I had you first on the podcast, I am going by memory here, so I might be wrong. I don’t think at the time, RFA was approved for thyroid cancer.
Dr. Angela:
Right.
Dr. Eric:
When I had you on the Thyroid Summit I had in the past, I’m pretty sure for certain types of thyroid cancer, you said that RFA has been approved or at least has been shown to help with thyroid cancerous thyroid nodules.
Dr. Angela:
I think you’re right. Since then, we do have an indication for thyroid cancer nodules.
The difference with RFA for thyroid cancer, it has to be a fairly smaller size, about 1.5 centimeters. It has to be in an area where it is easily accessible. You not only have to ablate the nodule, but you have to ablate the entire surrounding area. If the nodule is right against the capsule of the thyroid, there is no space to ablate around it. You’re essentially going to ablate the capsule. It has to be in a certain area within the thyroid, and you have to obliterate the whole thing, including the area around it.
For the right nodules, it’s a great option. It’s great for people who can’t have surgery, don’t want surgery, or are not a good candidate for surgery.
Some of these nodules, the other option is observation. Just watch the nodule. Check it every six months. Check it every year on the long end. Part of the problem with that is if you are the patient, and you know you have cancer, do you just want to watch it? Even though capillary thyroid cancer, which is the most common cause of thyroid cancer, is slow growing, I don’t know. I think it is disconcerting for people to know they have cancer and not do anything about it.
Dr. Eric:
It’s great that there is another option because still probably most endocrinologists would recommend thyroid surgery. Just remove the whole thyroid gland. For those who maybe surgery is not an option, just because of other health issues, or maybe they want to save their thyroid and don’t want to get the whole thyroid taken out, to attempt RFA or at least get evaluated by someone like you and see if they are a candidate and give that a try to potentially save their thyroid.
Dr. Angela:
I think it’s a great option for the right nodule or cancer.
Dr. Eric:
Getting back to toxic nodules. Is there a way to diagnose toxic nodules other than doing an uptake test? Is that really the only way?
Dr. Angela:
I can tell you in the past 10 years, I have not ordered one single radioactive iodine uptake test. Using an ultrasound in the hands of a skilled ultra sonographer, you can see with the vascularity.
Say you just have one nodule. That narrows it down. You can see the vascularity. You have already ruled out Graves’. Even if you have two nodules, you can look at the vascularity and compare one nodule to the other, and you are able to narrow down if it is one nodule that is overactive or two. Sometimes, that can happen. It is a little more rare. Ultrasound is a great technique of localizing a toxic nodule without the use of radioactive iodine.
Dr. Eric:
We had this conversation, too. I know I told you in the past I am not a fan of the radioactive iodine uptake test or treatment. I was surprised by your response. You said, “I’m not a big fan either.”
Dr. Angela:
No.
Dr. Eric:
I never asked you about the toxic nodules and how you diagnose. Honestly, I haven’t seen other endocrinologists or anyone else diagnose a toxic nodule just with the ultrasound. Maybe they take the easy way out or whatever their reason is for doing the uptake. Maybe it’s more profitable. We don’t have to get into that.
The point is, I have been asked that question. Honestly, I wasn’t sure if an ultrasound can actually diagnose toxic nodules. You confirmed that is the case, which is great. The challenge is if you are working with an endocrinologist, maybe they are not as skilled as you are.
Dr. Angela:
True.
Dr. Eric:
They might say, “No, this is the only way,” or perhaps it is the only way they know how to diagnose a toxic nodule.
Dr. Angela:
I have had patients come to me for RFA, and they don’t want to have to do the uptake scan. I’m okay with that. Honestly, a toxic nodule doesn’t technically even need a biopsy because the chance of it being cancer is close to zero.
If you’re going to do an RFA, we have to have the biopsy beforehand. If anybody is thinking about that, we do need a biopsy for that.
Dr. Eric:
Makes sense. On the topic of nodules, how about cold versus hot nodules? That also ties into the uptake test. That is the justification that some endocrinologists use. We want to do it just to see if it’s a cold or hot nodule. I might be wrong, but I think if it’s a cold nodule, it’s a little bit greater chance of being malignant, maybe 5%. Still very low. You can also look at the ultrasound characteristics of the nodules and get an idea if there is a malignancy. It’s not perfect, but neither is the uptake test.
Dr. Angela:
No. That cold nodule being a little more suspicious, yeah, that’s fallen to the wayside. You’re exactly right.
Back to the uptake scan. It depends upon the institution you’re having it done at and who is reading it. It’s very misleading. They will say, “Oh, at 10 hours, it’s this percentage.” You could have that same person go to another place, and it will be read completely differently. There is little standardization.
Dr. Eric:
Good to know. If someone is listening to this and already got the uptake test, it’s not the end of the world. You got it. You did it. That’s fine.
If someone is on the fence, “I really don’t want to get it, but my endocrinologist is pressuring me to do it,” in both of our opinions, it’s not necessary.
Dr. Angela:
Right. I always encourage patients to be proactive. If you feel like you want a second opinion, there is no harm in getting one.
Dr. Eric:
Exactly. It’s funny. I don’t want to say I criticize endocrinologists a lot. I get nightmare story after nightmare story from people I work with. Probably moreso those with hyperthyroidism and Graves’ than those with Hashimoto’s.
Usually with Hashimoto’s, giving thyroid hormone replacement. They sometimes don’t see the endocrinologist because the primary just gives the thyroid hormone.
With hyperthyroidism/Graves’, nightmare story after nightmare story. I say the same thing. You can always get a second opinion. The second opinion might be the same as the first because they are just recommending antithyroid meds, radioactive iodine, or thyroid surgery. Most of them do recommend the uptake test. They tend to give similar recommendations.
Dr. Angela:
Unfortunately, yeah.
Dr. Eric:
They won’t dig deeper if they can’t work with someone like you. It’s frustrating because you’re obviously open-minded, which is why you’re on the podcast. A return guest on the podcast. Unfortunately, it seems like most endocrinologists aren’t open-minded. Someone else might have to get a third or fourth opinion before they find someone who connects with them.
Dr. Angela:
You have to feel good about your options. We are trying to train physicians and educate providers on a regular basis. Hopefully, someday, things will be better.
Dr. Eric:
Hopefully heading in the right direction. This might be the last question with nodules. As far as addressing underlying causes like inflammation, estrogen imbalances, things like that, where do castor oil packs fall? I get that question, too. Can I use castor oil packs for nodules, even goiters? Do castor oil packs actually help? Is it woo woo?
Dr. Angela:
I get this question a lot, too. I wrote something up on it.
Dr. Eric:
Be honest. If it means hurting people’s feelings and being like, “In my experience, they just don’t work.” I don’t know what your answer is going to be. Maybe you think they’re great. Be up front. Let us know.
Dr. Angela:
I will say that I have not seen them help anyone. If it’s part of your normal routine, and you feel like it is helping you feel better in general, there is no harm in them. I can also tell you that there are not any studies or data on them either.
There is a lot of things out there. Does spirulina help? Dill? Frankincense? We don’t have any studies to show. Are they harmful? No.
Dr. Eric:
If someone wants to do castor oil packs, by all means-
Dr. Angela:
You’re not causing any harm.
Dr. Eric:
Goiters. What are some of the causes of goiters? Is it similar to nodules? Is there an overlap of causes with goiters? Hyperthyroidism and hypothyroidism can cause them. Let’s talk about that.
Dr. Angela:
Any sort of thyroid enlargement far and away is more related to underlying autoimmunity for the most part. Hashimoto’s, that stimulatory effect of TSH on the thyroid. For Graves’, it’s that increased inflammation within the thyroid and TSH receptor activation.
Again, if you look in different areas of the country or the world, where iodine deficiency is more common, you may see more goiters. The tough thing is, and I think we touched on this earlier, as far as treating the underlying cause for goiter or thyromegaly, does that always make the situation better from a cosmetic or compressive standpoint? It depends where we are on the spectrum of its formation honestly.
There is a lot of fibrotic changes that went along with the underlying autoimmune issue. The chances of it getting smaller is less. If it’s a fairly new process, especially with Graves’, it came on suddenly, the chance of that thyromegaly going away is higher. Those are the big things.
There are rarer things, like infiltrative processes like sarcoidosis that can cause thyroid enlargement, too. Far and away, it’s more of an underlying autoimmune issue.
Dr. Eric:
If it happened around the time that someone developed Graves’, there is an increased likelihood of that goiter decreasing over time.
Dr. Angela:
Yeah.
Dr. Eric:
I did have a mild goiter when I dealt with Graves’. That did resolve.
Dr. Angela:
They tend to go away in that circumstance very nicely.
Dr. Eric:
You can get a goiter related to the TSH stimulation with Hashimoto’s, moreso than the underlying autoimmune process, compared to Graves’?
Dr. Angela:
It’s a combination. What we tend to see over time is the TSH stimulation. That infiltrative process that goes along with Hashimoto’s, that lymphocyte infiltration, it starts to affect the architecture of the thyroid itself. It can cause some fibrotic changes that can cause some enlargement. Over time, it shrinks down.
If we are at the end game, if you will, of Hashimoto’s, they tend to have a very atrophic looking fibrotic thyroid.
Dr. Eric:
Here is a question as far as someone that I have been working with who has a history of Graves’ on antithyroid meds, methimazole. In my opinion, it can exacerbate the goiter. I’d love to get your opinion. On the antithyroid meds, she more recently is really hypo. Her last TSH was 24. Prior to that, it was over 3, which is more on the hypo than hyper side. In the past, when she first dealt with Graves’, her TSH was depressed, less than .01. She keeps on fluctuating between hyper and hypo. As we discussed, either one can cause a goiter. The underlying autoimmune process also can cause a goiter.
In her case, obviously, I am trying to do things. She is working with an endocrinologist for the methimazole. I am working on the autoimmune component, trying to improve her health. It seems like it’s a difficult time getting that thyroid normal with the methimazole.
I am throwing you a curveball here because you didn’t expect this question, but I am sure you can handle it. One thing I brought up to her, as the goal is ultimately to get to the point where you are not on any thyroid hormone medication, is if someone in her case, where she keeps swinging back and forth, while trying to work on improving her health, I mentioned block and replace therapy. This is not commonly recommended in the United States. Sometimes, it is. Her endocrinologist shot it down.
I wanted to get your opinion on that. Again, if you’re not a fan of it, let me know. We didn’t prepare this question. I usually don’t recommend it. I don’t have prescribing rights, so I was just telling her to ask her prescribing doctor about block and replace therapy. The extreme swings between hypo and hyper. I wanted to ask that question.
Dr. Angela:
That’s a really good question. Most patients with Graves’ also have antibodies for Hashimoto’s. Whatever process is taking the lead at the time drives the train, if you will.
First thing. When I see a patient swinging back and forth on methimazole, that always makes me question the dose itself. What will happen a lot of the time is when you’re on methimazole, with all the good functional stuff, too, you have to stay ahead of the curve with the methimazole. You can’t wait for the TSH to change before you start cutting back.
Say she started out with undetectable TSH and high T3 and T4. Say her endocrinologist started her on 30mg of methimazole, which is a pretty standard dose. When we check the labs the next time, if the T4 and T3 are even in the mid or approaching the higher range, even though the TSH is still suppressed, we have to start cutting back at that time. That’s part of the process.
To answer your question about block and replace, I have only done it a handful of times. We get to a point where one immune process takes over. Then we are left with one or the other. In that case, it’s more of a dosing problem. I don’t usually have to go to block and replace.
Dr. Eric:
I usually don’t recommend it either.
Dr. Angela:
For someone who is swinging back.
Dr. Eric:
It’s pretty common, where someone is on a higher dose of methimazole. They become hypo, and then the doctor will reduce the dose. Maybe either they will still be hypo, or maybe they will swing to hyper, depending on how low the dose. I do see those fluctuations pretty frequently.
Here, it’s been going on for a while. She is not on a real high dose now of methimazole. I think she is on 10 or 15mg, which is not a low dose, but it’s in the middle. 10mg is on the lower side.
I didn’t even mention what block and replace therapy is. It’s taking antithyroid medication, but giving some thyroid hormone replacement.
Dr. Angela:
On top of it.
Dr. Eric:
In her case, she has recently been more hypo. Again, she decreased the methimazole. Then she has become hyper again.
For the goiter, it’s a unique situation for her because she has a larger goiter. I figured that’s not helping to have those extreme swings, where she is extremely hypo and then switches to hyper. That’s the only reason. I’m with you. Most of the time, I am looking to refer them back to an endocrinologist, and if someone is super hypo, reduce the dose of methimazole. I didn’t know your perspective on block and replace, but it sounded like you’ve done it a few times. Again, it’s not-
Dr. Angela:
It’s really complicated.
Dr. Eric:
Makes sense. Wrapping up goiters. Thyroid hormone balance is important. The autoimmune component and inflammation is important. RFA, is that an option for larger goiters?
Dr. Angela:
It’s not FDA-approved treatment. It gets tricky if patients are trying to get insurance to cover it. It becomes an option if you say you have one side that is a lot larger. With a thyromegaly, if the left side is a lot larger, you can treat that left side to match the other side. That is pretty doable.
You can really do RFA on one side at a time per session. Say someone had symmetric thyromegaly. You could still only work on one side versus the other side. You’d have to wait six months to work on the other side. It will be lopsided. As long as patients are on board with that.
It gets tricky with the insurance covering for just that. Usually, they will want to know if it’s a thyroid nodule or thyroid cancer. You could even get away with nodular replacement. If we just say it’s for thyroid enlargement, they don’t always cover that.
Dr. Eric:
You have seen it work for larger goiters.
Dr. Angela:
Yeah.
Dr. Eric:
It will be one side at a time, so the person must be comfortable having the asymmetric thyroid for six months. Everybody is different. When you say, work on it and then work on it again six months later, is it multiple sessions working on one side?
Dr. Angela:
Depends upon how large it is. It would just be one session. It takes a good six months to a full year to some patients to see the full effect of one session of RFA. Essentially, you’re causing some cell destruction. The body itself has to take up those destroyed cells and essentially think about a ball shrinking down on itself. That takes time. You start seeing changes within a few weeks, but we don’t see the full effect of one treatment of RFA until at least six months.
Dr. Eric:
It’s not the same with nodules though, right? People would see changes quicker with thyroid nodules, or is that also a process?
Dr. Angela:
It’s still a process, too. Some people notice it right away, and the nodule responds really quickly. We always do an ultrasound at three months, six months, and a year. Sometimes, three months, we’re good. Some nodules take a little bit longer.
Dr. Eric:
One more question. We’ll then wrap it up unless you have anything else to add. Do you do a thyroid ultrasound on every thyroid patient you see?
Dr. Angela:
I tend to. Even if it’s Hashimoto’s, I want to know the extent of any sort of thyroid destruction. It helps me correlate where we’re at with thyroid antibodies. Patients always ask, “Can I get off of thyroid medicine? What are my chances?” That helps me figure it out. I also don’t want to miss a nodule that’s there.
Dr. Eric:
I understand. I don’t know if I told you this story, but when I was diagnosed with Graves’, the endocrinologist I saw didn’t think I needed an ultrasound. She palpated my thyroid and didn’t think there were any nodules. At the time, I didn’t have health insurance, so she might have been more sensitive to that. I was willing to pay, so I asked her for one. “I know you feel like there’s nothing there, as far as nodules go, but I still want to pay for the ultrasound for peace of mind.” She was right. In all fairness, she did the ultrasound, and I had a smaller goiter but no nodules.
I was curious because in my case, the endocrinologist- Same thing with working with other people. A lot of endocrinologists will, but some won’t. I was just curious what you do.
Dr. Angela:
If you talk to some endocrinologists, they will say, “We will find nodules that were never going to cause a problem and cause unnecessary biopsies.” I’d rather know it’s there than not know.
Dr. Eric:
I agree. All right. This was awesome. We could easily talk for another hour. Anything that you were hoping that I would ask you about iodine or thyroid nodules or goiters that I didn’t ask you?
Dr. Angela:
No, I think we ran a full spectrum on these topics. One thing I hope people take away is that everybody is different. Everybody’s options are different. Thyroid health is personalized medicine; it has to be personalized.
Dr. Eric:
Can you remind people where they can find you?
Dr. Angela:
Sure. Our website for the clinic is MetabolicCenterForWellness.com. You mentioned my book Thyroid Talk: An Integrative Guide to Optimal Thyroid Health. I have a YouTube channel. I’m on Instagram and LinkedIn. That’s about it. That’s enough.
Dr. Eric:
This was wonderful. Thanks, Dr. Angela. Always a pleasure speaking with you. I’m sure the audience learned a lot. I learned some things as well.
Dr. Angela:
Wonderful, thanks so much, Dr. Eric. Keep doing all the good work you’re doing.
Dr. Eric:
Thank you so much. You do the same.