Recently, I interviewed Dr. Brittany Henderson, and we discuss her integrative approach to thyroid care, the differences between thyroid nodules and cysts, diagnostic criteria, toxic nodules, subacute thyroiditis, the role of iodine in thyroid health, conventional treatment options, minimally invasive alternatives like alcohol ablation and radiofrequency ablation, and more. If you would prefer to listen to the interview you can access it by Clicking Here.
Dr. Eric Osansky:
I am super excited to chat with Dr. Brittany Henderson, as we are going to talk about thyroid nodules, thyroid cysts. It’s going to be a great conversation.
Let me dive into Dr. Brittany’s bio here: Dr. Brittany Henderson, M.D. is a dual board-certified physician in both internal medicine and endocrinology. She is a thyroid expert working to bridge the gap between functional and conventional medical approaches to thyroid care.
It’s a short but sweet bio. Welcome. Thanks for joining us, Dr. Brittany.
Dr. Brittany Henderson:
Thank you. I’m excited about the conversation.
Dr. Eric:
Let’s get a little bit more into your background. I always appreciate a brief bio compared to spending five minutes on a bio. We were chatting before this, and I know there’s a lot more to your background to what motivated you to become an endocrinologist. You don’t only help people with thyroid nodules and cysts, but you do things that are different compared to a lot of endocrinologists, including overall taking an integrative approach. How did you make that transition, that you would do things differently than most endocrinologists?
Dr. Brittany:
I was conventionally trained. I am an MD by training. Did the classic T32 fellowship at a major institution. Did basic science research in thyroid. Ended up joining the faculty. My focus has always been on the thyroid. A lot of that goes back to medical school and residency when I had a lot of good influences as far as endocrinology. I have a chemistry background; I really liked it.
I just listened to my patients. That’s what it boils down to. Thyroid care in the U.S. is not done well. Actually, thyroid care internationally is not done well. By that, people don’t know how to diagnose it well. People don’t know how antibodies affect thyroid symptoms for people. They don’t know how to dose medication correctly. There are millions of people on thyroid medicine; I think it’s one of the most prescribed medications in the U.S. Over 20-25 million prescriptions a month.
The conventional medicine world, it’s a one size fits all approach. Everybody gets on the same medication, and you’re just supposed to be well. But that isn’t the case in real life. A lot of the recommendations from the American Thyroid Association are very outdated.
I just felt drawn to help people in this field really try to do thyroid care right by looking at a full thyroid panel and dosing things appropriately. In our practice, we also integrate thyroid ultrasound for all of our patients. We really think it’s important, just like a stethoscope for a cardiologist.
We need to see the thyroid itself, see the how the gland looks, blood flow, whether or not there are cysts or nodules. Those are things that you can’t always detect via physical exam. There are nodules that sit far back, and you can’t feel them. I never want to miss a cancer. I always want to make sure we know exactly what’s going on with the full picture because thyroid care is complicated.
I started listening to my patients. I did a lot of my own research. I started integrating a lot more functional medicine into my practice. Integrating supplements, vitamins, lifestyle measures, gut microbiome work, looking at food intolerances. All of those things are so important. Wellness and decreasing systemic inflammation, which helps the autoimmune process and the nodules, too.
That’s what we do. We try to do thyroid care right. I think there’s only one right way to do it. That’s what we’ve integrated both into our brick-and-mortar practice in Charleston, South Carolina and our online practice.
Dr. Eric:
Wonderful. You do ultrasounds on every patient who walks through your door?
Dr. Brittany:
Yeah.
Dr. Eric:
That’s good. I was diagnosed with Graves’. When I spoke to the endocrinologist, she palpated my thyroid and said she didn’t think there were nodules. She actually didn’t recommend an ultrasound. I asked her for one specifically. “It’s not that I don’t trust your palpation skills, but I’d still feel more comfortable.” I was paying out of pocket, and that might have been part of the reason, too. They are not crazy expensive paying out of pocket for the ultrasound.
Dr. Brittany:
It’s so much information. It’s so worth it. If you have somebody who knows how to interpret it correctly.
Dr. Eric:
Exactly. I’m with you that it’s probably a good idea to get that thyroid ultrasound. If you have a thyroid problem, it makes sense to look at it. Apparently, there are some doctors, even endocrinologists, who don’t order ultrasounds on all their patients.
Dr. Brittany:
In the same vein as the stethoscope used for hearts, people image the heart all the time. They do echos, cardiac caths. Same thing. When you have a thyroid condition, to look at it, structurally, it’s important.
Dr. Eric:
I agree. For those who are unfamiliar with thyroid nodules and thyroid cysts and the difference between the two, can you explain what thyroid nodules are and how they differ from thyroid cysts?
Dr. Brittany:
I get that question all the time, whether a thyroid nodule is a nodule next to the thyroid or within the thyroid. A thyroid nodule is an accumulation of either fluid, which is what a cyst is, or cells—which is what a nodule is. It’s more of a solid component—within the thyroid gland.
Within the structure of the thyroid gland, you can get these little bumps. You can sometimes feel them. You can feel them on your own self if you look into the mirror, drink a glass of water, and swallow. When you swallow, the thyroid moves. Sometimes, you can feel it. The thyroid sits right at the base of your neck before your sternum. Not always though. You don’t always feel thyroid nodules.
The reason that people get these is because of gland inflammation typically. The thyroid gland receives blood flow just like every other organ in the body. When there is inflammation within the thyroid itself due to Hashimoto’s, Graves’, trauma to the thyroid, or if the thyroid is not functioning properly, like if someone has iodine or iron deficiency, or lots of chemicals in the environment can increase the risk for these nodules to occur because of inflammation of the gland, the gland doesn’t drain the way it’s supposed to.
The cells don’t behave the way they’re supposed to because they’re inflamed. Because there not continuous, normal drainage pathways, you can get an accumulation of fluid within the thyroid itself, which is a cyst, or you can get a proliferation or expansion of thyroid cells, which is a nodule. Those thyroid nodules can have gene mutations, which means the cells start behaving erratically or irregularly. That can lead to thyroid cancers or thyroid precancers.
Dr. Eric:
How common are thyroid nodules? I imagine in your patient population, it’s common because a lot of people come to see you specifically for that problem. There are other cases as well. Just in the general population, do you know the percentage?
Dr. Brittany:
Yeah, it’s super common. It goes up with age. I always tell people 30% of 30-year-olds, 40% of 40-year-olds, 50% of 50-year-olds, and so on. They have done autopsy studies, where they found up to 80% of people who die, especially in their 80s, have thyroid nodules. They just pass away with them. They never know about them.
The good news is 95-99% of them are benign. They are not cancerous. There are cancerous thyroid nodules, and it is one of the fastest-growing cancers in the world. Women get thyroid nodules much more commonly than men do. When men have thyroid nodules, we take it a lot more seriously because they are more prone to cancer, and more prone to aggressive forms of thyroid cancer. We don’t know why.
Dr. Eric:
That’s interesting. I know in general, or at least I’m pretty sure in general, most thyroid cancers- There are four types of thyroid cancers, I believe. Two of them are not aggressive, and most people have the non-aggressive forms. I did not know that men with thyroid cancer, not all the time, but are more prone to having the more aggressive forms. Whether it’s a woman or a man, you have to look at certain characteristics of the nodules.
Let’s talk about that. How do you determine who gets a biopsy and who doesn’t?
Dr. Brittany:
If you have a simple thyroid cyst, meaning a fluid accumulation with no solid component, typically, those are benign. Almost always. But they can be really annoying and can cause issues. We can get into that in a little bit.
When we look by thyroid ultrasound, we use several criteria to figure out who gets a biopsy or which ones we can just follow with serial ultrasound. The first criteria is the American Thyroid Association and the American College of Radiology have determined how big does the nodule have to be before you recommend a biopsy? It’s either one centimeter, usually the lowest size.
It depends on the echo texture of the nodule, meaning on ultrasound, is the thyroid nodule dark, hypoechoic, or bright, hyperechoic? Or is it mixed solid cystic? It just depends what it looks like by ultrasound.
We have different criteria for size based on how it looks. How dark is it? How big is it? Does it have suspicious features? Does it have calcium deposits in it? We call those microcalcifications, which is a sign for cancer. Or linear calcifications, ram calcifications. There are different types of calcium deposits.
We also look at blood flow. Follicular nodules or follicular carcinomas, which is one of the more common cancers, can have a lot of blood flow by doppler on ultrasound. That is a more aggressive sign as well. Versus papillary thyroid cancers, which don’t necessarily have blood flow.
We also look at the edges. If a nodule is very round and smooth versus a nodule that is very irregular-looking or growing into muscle or trachea or other things. There are lots of criteria we use.
Ultrasound is the most sensitive modality to look at this, better than MRI and CT scan, which is why we use it in the practice. It’s so easy and cost-effective. It doesn’t expose anybody to radiation, and it gives us a lot of information.
Then we recommend biopsy or serial ultrasound to monitor for growth. Even benign nodules can grow with time.
There is so much that has come out in the last 5-10 years for personalized medicine to figure out risk stratification for patients and how aggressive might a cancer be versus how not aggressive a cancer might be. A lot of that is using genetic testing. There are genetic tests we use when we do a biopsy, which can tell us if the nodule has a gene mutation that is suspicious for cancer or not.
There are so many decision pathways. Really, it’s come a lot farther than what we used to do, which was just to suggest everybody have it removed. Before you remove a very important endocrine gland, which is really hard sometimes to dose and get right and mimic with our imperfect human medicines, it’s worthwhile to get a second opinion or a third opinion or really figure out if this is the right course of action before making a dramatic decision like surgery.
Dr. Eric:
Makes sense. If you do a thyroid ultrasound and detect nodules, you don’t just decide that the person doesn’t need a biopsy. It sounds like you do follow up with another ultrasound in the future. I don’t know if you do that across the board, to make sure the nodules aren’t getting bigger.
Dr. Brittany:
We do. Usually, it depends on the size of the nodule and the appearance as to how often we follow that. Primarily, it’s about a year that we look.
Dr. Eric:
Okay. Usually, a year. Any indication sometimes for six months?
Dr. Brittany:
If it looks hypoechoic, or dark, or it has suspicious features, and it’s smaller than a centimeter, we will recommend a closer follow-up, like the six-month mark. If there is a nodule that is actively growing, and we have a fearful patient who isn’t a fan of needles, which who is? But sometimes, we will do a closer follow-up in 3-6 months to make sure we are on top of it.
If someone does have a thyroid cancer history, we always look by ultrasound every six months for the first two years and then every year after that.
I we see anything like lymph nodes, which thyroid cancer primarily goes to lymph nodes when it spreads somewhere, then we either recommend biopsy of the lymph nodes or serial ultrasound surveillance every 3-6 months, depending on the aggressiveness of the original tumor.
Dr. Eric:
When you do a biopsy, you also do genetic testing as well, just to determine what type of cancer it is?
Dr. Brittany:
Yes. There are three ways a nodule can come back after a biopsy. There is benign, which is the most common; cancer, which is the least common; or in the middle, indeterminate. That happens about 10-20% of the time. It just means that the cytologist can’t say 100% there is a benign nodule here because the cells overall look good, but there are some funny features. They’re either bigger than normal or inflamed-looking or have some suspicious features for thyroid cancer. They can’t say either way.
In that situation, we collect a special test, which basically runs all of the known gene mutations for thyroid cancer and gene fusions and other things. Then we can tell somebody, “You had an initially 10-20% chance of cancer. We ran this gene test. It’s telling us that you have a genetic mutation in the tumor that says that you have a 50/50 chance or a 95% chance of cancer.”
That really helps us to risk stratify people and give them a good idea of whether they should have half the thyroid removed, the full thyroid removed, lymph node dissection, depending on the aggressiveness of the mutation. We run that mutation as well for suspicious for thyroid cancer patients. It does help with understanding how aggressive the tumor might be.
Dr. Eric:
If someone comes back with a biopsy, and you conclude it’s benign, you don’t do the genetic testing. Is that correct?
Dr. Brittany:
Yes.
Dr. Eric:
Just wanted to clarify. What are toxic thyroid nodules?
Dr. Brittany:
Toxic thyroid nodules are just nodules that are overactive. It sounds terrible. It actually feels terrible for people because the thyroid is then no longer under the control of the brain and the pituitary system, which is the master gland. That is supposed to be tightly regulating thyroid hormone production.
Sometimes, if thyroid nodules have been there for a long time, they develop mutations that affect the TSH receptor. Instead of allowing the pituitary gland to signal with a TSH, signal to the thyroid nodule to produce thyroid hormone, the thyroid nodule starts producing thyroid hormone all the time by itself because it hits the on button for the TSH signaling and just always is producing thyroid hormone.
It doesn’t produce thyroid hormone in a good way. It just basically spits out thyroid hormone randomly whenever it makes some. That can feel like a person is having hyper symptoms, hypo symptoms. They can feel terrible. It doesn’t feel good.
Over time, especially in older patients, people can be at a higher risk for osteoporosis because of the thyroid secreting extra hormone. They can have a higher risk for atrial fibrillation or heart arrythmias because of that. It really contributes to all of the symptoms of thyroid: heart racing, heart jittering, anxiety, insomnia, weight gain, fatigue, brain fog, all of the different hypo and hyper symptoms because of the thyroid nodule behaving irregularly.
Dr. Eric:
Whereas just a regular thyroid nodule or cyst are quite common, is it safe to say that toxic nodules are not as common?
Dr. Brittany:
I would say that’s probably true. By the way, most toxic nodules are benign. They are not cancerous typically. Some can be, but most of them are not.
I see those primarily in regions where people grow up with not as much iodine, or they have had long-standing iron deficiency. That is because the nodules typically have been there for a very long time. Those patients who are nutrient deficient many times will have them from childhood or teenage years. They are the ones who typically develop them.
But of course, there are many factors and variables. We don’t know every single variable that predisposes a person to have a toxic nodule.
You can by the way have more than one. You can have a toxic multinodular goiter, which are many nodules that are overactive. Typically, these are patients who grew up not eating seafood or seaweed. They grew up in the mountains, where they didn’t have a lot of fresh fish or iodine exposure. Or they have had a lot of heavy periods as women and haven’t eaten a lot of red meat, so they’re iron deficient. Those are the people I see most often.
Dr. Eric:
Hot and cold nodules. Do you do the uptake test at your clinic?
Dr. Brittany:
Not at the clinic. Usually, a nuclear medicine department at a hospital is who does that. There are some free-standing clinics that do it, but not very many.
A thyroid uptake scan is a scan where the person ingests iodine. It’s not radioactive iodine. It’s just iodine attached to a radiopharmaceutical, so they can actually image the thyroid.
What it’s doing is concentrating primarily in hot nodules and not in cold nodules. Cold nodules are nodules that do not pick iodine up very well. Those are nodules that don’t make thyroid hormone.
With a scan, you can actually figure out is a nodule hot on one side of the thyroid and then maybe cold on another side of the thyroid? That can help you understand if a person has hot nodules, do they require treatment on one side of the thyroid gland? Do they need their whole thyroid removed if there are hot nodules all over the place? It can really help you identify where the problem is.
We use thyroid uptake scans all the time, not just for nodules, but for a form of Hashimoto’s called Hashitoxicosis. For Graves’ patients, it is helpful when it’s helpful. Even if it’s normal, sometimes it doesn’t completely rule out a problem. For toxic nodules, it is a helpful test.
Dr. Eric:
Good to know. For those with Hashitoxicosis, Graves’, you recommend for that category of patients to get the uptake.
Dr. Brittany:
Yes, those are the people it really helps with. Or people who have something called acute or subacute thyroiditis, which is where you get a viral infection like COVID, for example, and your thyroid spits out all its thyroid hormone. You get really hyperthyroid. The uptake scan will look like low uptake on the scan because it’s been completely destroyed by the virus, really by the immune system. We see that occasionally as well.
Dr. Eric:
Speaking of subacute thyroiditis, just curious, what is your treatment approach? Usually, they’re transiently hyperthyroid but eventually become hypo. I know some endocrinologists are hesitant to give antithyroid medication because they know eventually the person will become hypo. At the same time, you do want to do things to manage hyperthyroid symptoms. I don’t know if you recommend antithyroid meds or a beta blocker or another approach.
Dr. Brittany:
Antithyroid meds in subacute thyroiditis don’t work because they work primarily on stopping the thyroid from making thyroid hormone. You could use PTU because it stops T4 to T3 conversion, but I don’t usually do that.
For someone who has subacute thyroiditis, we just treat symptoms. We put people on beta blockers to treat heart rate issues. We put people on prednisone if there is pain. It’s really waiting it out and letting the disease take its course. Typically, people will become hypothyroid, but many of those people can go back to euthyroidism. They can go back to normal thyroid function. It takes a little bit, 3-6 months. It’s a thing. We see it not very infrequently.
Dr. Eric:
You mentioned iodine. Very controversial in the world of thyroid health. You mentioned that it could be a factor when it comes to thyroid nodules and even toxic thyroid nodules. I guess your approach, when it comes to iodine, because there is a lot out there. Some practitioners recommend massive amounts of iodine supplementation. Others recommend the opposite, to restrict iodine supplementation. It depends on the practitioner. It’s not just hyperthyroidism; some suggest that with Hashimoto’s, too. What are your thoughts on iodine and hyperthyroidism, Graves’, Hashimoto’s?
Dr. Brittany:
Iodine is one of the micronutrients that follows the Goldilocks rule. It has to not be too much or too little; it has to be just right, and it’s patient-specific.
With thyroid nodules, most of the time, I recommend the recommended daily allowance of iodine. Unless somebody is iodine-deficient, and you can measure that typically in the 24-hour urine iodine. It doesn’t make sense to check serum iodine levels in people because it’s transient. If you eat something that has a big load of iodine, your serum levels will go up acutely. Then the iodine is transferred into cells. Serum level doesn’t mean anything.
A urine level can be helpful. People who are iodine-deficient, people who don’t eat seafood or are vegans or vegetarians, they tend to get thyroid nodules and goiters or enlargement of the thyroid because the thyroid is working overtime to try to make thyroid hormone with only having a little bit of iodine to make it.
In those situations, we do recommend a little bit higher dose of iodine. By that, I don’t mean 12,500mcg. 300-500mcg short-term, and the recommended daily allowance for adults in the U.S. is 150-250mcg. Higher for breast-feeding or lactating women.
In autoimmune thyroid disease, it depends. We know there is an effect called the Wolff-Chaikoff effect in Hashimoto’s. The thyroid tissue is being attacked by the immune system. Too much iodine in a patient who has Hashimoto’s can stun the thyroid tissue and actually make it not produce any iodine, just stop completely.
We know that too much iodine can actually worsen some of the Hashimoto’s antibodies, like thyroid globulin antibodies, which can get tagged with iodine and alert the immune system to worsen the autoimmune attack on thyroid.
In those situations, we don’t recommend an excess amount of iodine. I never recommend super low iodine states. I don’t think that really helps to reverse things. A recommended daily allowance, 150mcg, whether it’s through a vitamin or normal exposure is fine.
There is data as well to show that Graves’ patients, hyperthyroid patients do take iodine. Their glands are overactive, so they take the iodine, and their thyroid glands make tons of thyroid hormone. In order to help get Graves’ into remission, usually we do try to restrict too much iodine. We try to avoid it or reduce it.
In those situations, a lower iodine diet for a short time might help get into remission. Once remission is achieved, normal iodine intake is probably fine. That’s my approach.
I think it’s really highly personalized medicine. It depends on the patient’s clinical picture. I don’t have a lot of patients where I use a ton of high doses of iodine to try to help.
Dr. Eric:
That makes sense. For thyroid nodules, the same approach. I don’t know if it depends on the situation. As far as there is a chance that in some cases, not all cases, iodine deficiency can be a factor for thyroid nodules. I don’t know if you recommend- You mentioned sometimes urinary iodine testing to see if that might be an underlying factor. If it is, you don’t go to massive amounts of iodine, but maybe have them take a little bit more.
Dr. Brittany:
If they’re deficient and have a thyroid goiter or multiple nodules that are not toxic, just normal, it makes sense to go ahead and give them more iodine. Maybe not a crazy amount, but higher than the recommended daily allowance.
Toxic nodules have been shown in the literature that after a high iodine load, they can really start revving up. They use that iodine to make lots of thyroid hormone. That can actually cause “thyroid storm” or excess hyperthyroidism. I have never seen that.
Usually, a thyroid storm is reserved primarily for Graves’ patients. It is theoretically possible in a big thyroid nodule that is toxic, that it uses iodine load to make a lot of thyroid hormone. I usually don’t recommend high iodine loads for people with toxic nodules.
Dr. Eric:
Let’s talk about treatment. As far as conventional treatments, regarding most endocrinologists, most of them don’t need treatment. Most are benign and won’t do anything. if they meet the criteria of certain characteristics that you discussed, typically, it’s partial or not as common to see partial thyroidectomies. A lot of times, with cancer, it’s understandable. Sometimes, I see in cases where someone is benign, but it’s a really large thyroid nodule, they will recommend for the person to get surgery. Is that the conventional approach? Either surgery or no surgery?
Dr. Brittany:
I would say that’s true. I would say that most cases, a conventional endocrinologist will recommend total thyroidectomies for most people. Knowledgeable endocrinologists who specialize in the thyroid will make a less aggressive approach to this. They will recommend more of the hemithyroidectomies if it is a benign nodule. If it is a big nodule causing a person to choke or feel like they’re choking, they will recommend just half. If it’s a low-risk thyroid nodule, meaning we did the biopsy and have the genetic test and know that the mutation is typically low risk, we will recommend half of the thyroid. I think that’s the better approach.
That’s the approach that we take in our practice. We always try to preserve as much thyroid tissue as possible because it’s a big deal to take out the thyroid gland. We used to just say, “Oh, it’s fine. We have Synthroid.” Replacement medicine is not the same as your own endogenous endocrine gland, which controls everything. There are thyroid hormone receptors in every bodily system. Before removing a very important organ, it makes sense to think through that.
Even in thyroid cancers, for example, in my practice, if it’s intrathyroidal, meaning it’s not growing outside the thyroid, and I don’t see a lot of lymph nodes—I always do the ultrasound before surgery to make sure I know what to tell the surgeon as far as if there are any lymph nodes underneath the thyroid that have cancer or over to the side in the lateral neck, and how to direct them as how to perform the surgery correctly. It’s very important that the surgery be done right the first time.
Even for thyroid cancers that are within the thyroid, they don’t have a lot of lymph nodes present, we sometimes recommend hemithyroidectomy. I don’t always recommend a complete thyroidectomy, even if it’s a higher stage or there are a couple lymph nodes present. I love to be able to preserve thyroid function for patients and minimize the amount of tissue that we’re removing.
Dr. Eric:
That’s wonderful. There aren’t a lot of endocrinologists who do that. It’s good to know that if absolutely necessary, you will recommend a complete thyroidectomy. There is a time and place for that. You will do everything you can to try to preserve some of the thyroid tissue and recommend a partial thyroidectomy if you feel that’s warranted.
I didn’t realize in cancer, too. Probably just because the approach is usually to remove the whole thyroid gland. I don’t hear about endocrinologists who try not to do that, so that’s great that there’s that option.
I wanted to talk about alcohol ablation. That’s something that most endocrinologists don’t do. That’s something that you offer. Can you discuss what alcohol ablation is, when it’s indicated?
Dr. Brittany:
Along the same lines, we like to use minimally invasive approaches to care. We want not to disturb regular normal thyroid tissue. If I see a thyroid that looks beautiful, and it’s working optimally, I don’t want to remove it.
Even for thyroid cysts. If it’s a simple cyst, meaning it’s just a pocket of fluid, and we see that on ultrasound. That is how we figure out if it’s a cyst. The best way to approach that, the most effective way without disturbing any thyroid tissue or having to go on thyroid medicine lifelong, is a minimally invasive approach called alcohol ablation therapy, or sclerotherapy.
Not every endocrinologist does this. There are very specialized endocrinologists who know how to do it throughout the U.S. I think they have some at the Mayo Clinic. There are some specialty practices. Very few people are trained on how to do it unfortunately because it’s a very effective treatment option for thyroid cysts. It’s very low risk as far as any complications.
The way that we do it is we drain the thyroid cyst. If you have a cyst, your endocrinologist can just drain it. They can just take a needle, stick it in the thyroid cyst, and drain the fluid. Many times, in big thyroid cysts especially, which are causing people to feel like they’re choked or you can see it, that cyst fluid just comes back. The reason it comes back is because the cyst probably has been there for a long time and has a thick wall that stops fluid from being allowed to be drained. It just fills back up.
With alcohol ablation or sclerotherapy, we do the same thing. We drain it. But at the same time, we will inject the cyst with pure alcohol, ethanol. One of the side effects is feeling a little bit weird. That doesn’t usually happen. It stays within the cyst wall, so you shouldn’t feel any effect from that. The alcohol kills off the blood supply to the cyst wall, so the wall involutes within itself over time, and the cyst goes away.
I just had a patient that we did this on a couple months ago. This person came back yesterday to my clinic actually. He had a huge cyst. Trouble swallowing. Had it drained multiple times, and it just kept coming back. 65ccs, which is a big nodule. That is a lot of fluid in somebody’s neck. This is not a big space. We did the alcohol ablation, one round of it. He came back yesterday, and it’s down to less than 2ccs, 96% volume reduction. No symptoms. Doesn’t see it anymore. Completely normal thyroid function. Not having to be on thyroid medicine.
That is a very easy, minimally invasive way to take care of this. Conventional doctors, if it comes back after it’s been drained, will recommend surgery. That is not the right approach to these cysts. This is such a better option for people.
Dr. Eric:
Anything you can do to save the thyroid. Sounds like low risk, too. Are there any contraindications?
Dr. Brittany:
I always tell people the main complication would be if the alcohol leaks outside the cyst and causes pain at the site or theoretically affects the nerve that goes to the voice, so you get hoarse voice. That would be transient. It would come and go. I have never seen that ever. The cyst fluid stays within the cyst, so the likelihood of it leaking out should not happen.
Most patients don’t have any pain with it because there is no nerve endings within the thyroid, so it doesn’t hurt. It takes about 15-20 minutes, and you’re off to the races. Really minimal side effects, if any.
Dr. Eric:
You’ve been doing this for quite some time, correct?
Dr. Brittany:
I have been doing this procedure for almost 10 years with my practice. We do it regularly. We have people who fly internationally to come see us to have it done. It’s hard to find people in your local area who know how to do it or know how to do it well. It’s so easy, and it’s so effective. It should be the standard of care honestly.
Dr. Eric:
Is it just for cysts, or can it help with nodules as well?
Dr. Brittany:
It’s just for cysts. Sometimes, I have people if they are interested send their images to me, and I can look at them on a secured email, so I can make sure it’s a candidate before they travel. It usually is just reserved for cysts, not solid nodules.
We do use it for some isolated thyroid cancer lymph nodes. Usually, that is best reserved for older patients who are not surgical candidates. Surgery to remove a cancerous lymph node is probably better. It does work effectively for cancerous lymph nodes as well if someone only has one or two. If they have lots, surgery is better.
For solid nodules, somebody could consider something called radiofrequency ablation, which is a different minimally invasive option for these solid nodules. Solid nodules can’t be drained. They are full of cells. They are usually more vascular, so they have a lot of blood flow.
With radiofrequency ablation, the way that works is the needle tip has a positive and negative electrode. The physician will place that needle tip within the solid nodule, and the positive and negative electrode cause heat. They are thermal ablation, pretty much. That heat kills off the blood supply from inside out and causes the nodule to involute and go away.
It’s more invasive, a little bit, and a bigger, longer procedure than the alcohol ablation. For people who have solid nodules and don’t want surgery or want to preserve thyroid function or have a toxic nodule, which is the overactive nodule, radiofrequency ablation can sometimes be a minimally invasive option to fix that.
Dr. Eric:
Okay. Alcohol ablation is for cysts. If you have a solid nodule, then maybe look into radiofrequency ablation, including in some cases, toxic nodules. That’s great.
Unlike draining a cyst, when you use the alcohol ablation, it’s unlikely to come back?
Dr. Brittany:
It’s unlikely to come back although if you start with a cyst that is really big, and by that, I mean over 20ccs. That’s the cutoff in the literature. If it’s over 20ccs, it’s more likely to need a couple courses of alcohol to kill it off. That’s because those bigger cysts have thicker walls. The alcohol doesn’t always get throughout the whole cyst wall, and it can still accumulate. Usually, it will go down after the first treatment.
With those huge cysts, I can do up to three treatments. By that point, it will usually have shrunk enough that the patient says, “This is great. I don’t have any symptoms anymore. Even if it’s still there a little bit, it’s okay.” We can always do it down the road again. For most nodules, it works the first time.
Dr. Eric:
You just gave an example of a patient. I think you said it was 65ccs. It went down to 2ccs. What’s the follow-up procedure? Is it a few weeks later that you reevaluate?
Dr. Brittany:
Usually, I give it a good 2-3 months before we reevaluate with the ultrasound. The patient should notice an improvement the minute they leave the door. They should notice that it’s gone, that they’re able to swallow again, that they don’t feel like they’re being choked. That should persistently get better.
The thyroid cyst over time involutes, so it takes about six months to see the final result. I usually look at that halfway mark. I’m happy when there is at least a 50% volume reduction in the cyst. Usually, we’re getting 80-90% reduction. It’s still going to be there. It will have involuted enough that it’s not going to do anything. Sometimes, it goes away completely. Those are really good results.
I always tell patients after you’ve had that procedure, when you have had another endocrinologist look at it with an ultrasound, they will say, “Oh my gosh, this looks terrible. You have thyroid cancer.” You just have to know that it looks involuted. It doesn’t look like nothing. Education of outside providers that are not comfortable or familiar with alcohol ablation by the patient even sometimes is helpful to prevent additional workup that is not needed down the road.
Dr. Eric:
It’s great to have an alternative. In this situation, if that person went to a conventional endocrinologist with a 65cc cyst, they will probably be told to get a thyroidectomy. Is that correct?
Dr. Brittany:
Yeah, most of the people who come to see us have been told to get a total thyroidectomy, or at least a hemithyroidectomy, and they don’t want to lose their thyroid, smartly and after some research, they decide to pursue another opinion. It is usually a great option for people.
Dr. Eric:
You covered a lot. Is there anything else that I should have asked you that I didn’t ask you? Anything else you want to share when it comes to nodules or ethanol ablation?
Dr. Brittany:
We are happy to look at cysts if patients want me to look at their images. I usually want to look at the images.
Also, if people want to learn more about thyroid nodules, goiters, iodine deficiency, iron deficiency, or anything thyroid, we just launched a new online patient course. It’s a six-week, learn at your own pace, patient course directed to people. Everything from what is the thyroid? Where is it located? How do you feel with thyroid nodules? How do I know if I’m on the right thyroid medicine? We talk about all of that. We talk about Hashimoto’s, Graves’, antibodies, lifestyle measures, all of it. it’s called Everything Thyroid. If people want more education, they want to be more knowledgeable about their thyroid issues, I think it’s a good starting place as well.
Dr. Eric:
You have a brick and mortar in Charleston, SC. That website is CharlestonThyroidCenter.com.
Dr. Brittany:
That’s right.
Dr. Eric:
A virtual practice, MyThryoidDoctor.com. Yes?
Dr. Brittany:
That’s right, yes. The virtual thyroid practice, we see patients in select states all throughout the Southeast. We’re in the Carolinas, Tennessee, Virginia, Florida, Georgia. We are also licensed in Minnesota and Arizona. If patients are located in those states, or their loved ones are, they can see us and get our professional opinion and treatment from us online without having to come in person.
Dr. Eric:
Sounds great. Any other places? Instagram, Facebook? I don’t know if you’re on social media.
Dr. Brittany:
Our biggest presence is on Instagram. We provide videos all the time about thyroid care, thyroid nodules. We have a whole series on thyroid ultrasound and nodules on our social media. You can follow us, @DrHendersonMD. We’re also on TikTok and Facebook.
Dr. Eric:
Thank you so much, Dr. Brittany. This was amazing. You provided some great information when it comes to nodules. I’m glad you’re also trying to help save people’s thyroids through the alcohol ablation. Keep up the good work. I’ll definitely have to have you back on the podcast in the future.
Dr. Brittany:
So much fun. Anytime we can spread awareness and knowledge for people and help change the course of their health, I’m all for that. That’s great.
Dr. Eric:
I agree. Again, thank you so much.
Dr. Brittany:
You’re welcome. Thanks for having me.
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