I think it’s safe to say that most people, and even most healthcare practitioners, don’t understand how important the vagus nerve is to our overall health, let alone our thyroid health.  As you’re about to learn by reading this post, if you have vagus nerve dysfunction, this not only can directly affect your thyroid health, but it can also affect your gut and immune health, and thus be a factor in autoimmune thyroid conditions such as Graves’ disease and Hashimoto’s.

Although I will discuss some of the basics of vagus nerve function in this blog post, I want to let you know that on Monday June 15th there is an upcoming Vagus Nerve online summit you might be interested in attending.  When you register you’ll also receive Dr. Eva Detko’s 25-page eguide entitled “4-Week Program to Strengthen Your Vagus Nerve and Boost Your Immune System”.

Click Here to register for the free Vagus Nerve Summit

In order to understand the importance of the vagus nerve I think it makes sense to briefly discuss it’s role.  There are twelve cranial nerves, and the vagus nerve is the longest, and most complex of these.  The vagus nerve is part of the autonomic nervous system.  The two components of the autonomic nervous system are the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). The SNS is involved in the “fight or flight” response, while the PNS is known as the “rest and digest” system.  The vagus nerve is part of the PNS.

How Does The Vagus Nerve Affect Thyroid Function?

As for the relationship between the vagus nerve and thyroid health, the thyroid gland is located anteriorly in the lower part of the neck, and the autonomic nervous system primarily innervates the thyroid.  Both the SNS and PNS supply the thyroid gland, and the vagus nerve is the main nerve from the PNS that supplies the thyroid gland.  However, these nerves don’t control the production or secretion of thyroid hormone, but mostly influence the vasculature of the thyroid gland (1).

How Does The Vagus Nerve Affect The Immune System?

As for how the vagus nerve affects the immune system, there are a few different ways.  First of all, it innervates the immune organs, including the spleen, thymus, and the gut.  There is actually a good amount of research on the gut-brain axis, and the vagus nerve plays an important role in this communication.  Low vagal tone has been associated with numerous conditions involving the gut, including irritable bowel syndrome, inflammatory bowel disease, and SIBO (2).

Keep in mind that the vagus nerve plays a role in stomach acid secretion, and so if you have low stomach acid, vagus nerve dysfunction can be one potential cause.  And low stomach acid alone can cause a lot of problems, including intestinal dysbiosis/small intestinal bacterial overgrowth.  When I suspect low stomach acid in my patients there are times when I recommend for them to take betaine HCL, but of course the goal is to address the cause of the problem.

How Chronic Stress Affects The Vagus Nerve

So now that you know some of the consequences of dysfunction of the vagus nerve, it probably would be a good idea to discuss how chronic stress can have a negative effect on vagus nerve function.  Without question chronic stress is the main factor that can have a negative effect on vagus nerve function.  This is one of the reasons why chronic stress is pro-inflammatory, as the vagus nerve is also involved in something called the cholinergic anti-inflammatory pathway (3).

It’s also important to mention that stress stimulates the sympathetic nervous system while inhibiting the parasympathetic nervous system.  Stress causes a release of corticotrophin-releasing factor, and this can cause an increase in intestinal permeability (a leaky gut) and intestinal dysbiosis (4).  So hopefully you understand how chronic stress can lead to inflammation and affect the health of the gut.

I’ve mentioned the Triad of Autoimmunity in the past, as this involves three factors that are necessary for an autoimmune condition to develop.  These three factors are 1) a genetic predisposition, 2) an environmental trigger, and 3) a leaky gut.  So vagus nerve dysfunction can set the stage for autoimmunity not just by causing an inflammatory environment, but by causing a leaky gut and gut dysbiosis.

How To Improve The Health of Your Vagus Nerve

One of the best ways to improve the health of the vagus nerve is by incorporating mind body medicine.  This includes techniques such as meditation, yoga, qigong, biofeedback, etc.  Dr. Datis Kharrazian is the author of the amazing book “Why Isn’t My Brain Working”, and he wrote a blog post that discusses four vagus exercises you can incorporate:

1. Gargle (2 minutes of vigorous gargling).  Gargling with water a few times per day can activate the vagus nerve.  Dr. Kharrazian recommends to drink several large glasses of water per day and to gargle each sip until you finish the glass of water.

2. Stimulate your gag reflex.  Dr. Kharrazian mentions that he has his patients purchase a box of tongue blades so they can stimulate their gag reflex throughout the day.  You would just lay the tongue blade on the back of your tongue and push down to activate a gag reflex.

3. Sing loud in the shower.  Dr. Kharrazian recommends to sing as loudly as you can when you are in the car or at home.  I usually do this while taking a cold shower, which also can activate the vagus nerve!

4. Coffee enemas.  Although many people use coffee enemas as a form of detoxification, I was surprised to learn that coffee enemas can help to activate the vagus nerve.

One thing that isn’t on this list is to see a doctor of chiropractic.  Of course I’m going to be biased since I’m a chiropractor, but while many people perceive chiropractors as being neck and back pain doctors, the truth is that they can greatly help to improve the health of people’s nervous systems.  In fact, one study I came across showed that spinal adjustments of the cervical spine can affect the parasympathetic nervous system (5).  On the other hand, the study also mentioned that spinal adjustments of the thoracic spine resulted in a sympathetic response. Acupuncture is also something to consider.

While I do recommend nutritional supplements and herbs to my patients, you might have noticed that nothing I just mentioned involves taking supplements!  So even someone who is on a budget can do things to improve the function of their vagus nerve.

Vagus Nerve Activation Schedule

Dr. Eva Detko has put together a guide, which includes a weekly schedule consisting of things you can do to activate your vagus nerve.  And so if you’re looking to start a daily routine that only takes a few minutes today Click Here.  Upon clicking on this link you will be taken to another page where you will be asked to enter your email address, and besides receiving the free guide where she lists her weekly schedule, you will also be registered for the upcoming vagus nerve summit I mentioned earlier.

How Heart Rate Variability Affects The Vagus Nerve

Dr. Eva mentions heart rate variability in her guide too, but I also wanted to bring this up here, as I’ve written about heart rate variability in the past.  In the article I wrote I mentioned how I use a device by the company HeartMath to help improve heart rate variability, which is a way of measuring vagal nerve tone.  An elevated heart rate isn’t a good thing, but we do want a high heart rate variability.

So hopefully you have a better appreciation of the importance of the vagus nerve, and how chronic stress can have a negative effect on the gut and immune system.  Chronic stress is a big factor in many people, especially in 2020 with everything going on.  And while in past articles and blog posts I’ve mentioned the importance of blocking out time for stress management, and it’s something I also encourage my patients to do, for many people it would also be a good idea to incorporate one or more of the vagus nerve exercises I listed earlier.

If you have Graves’ disease, toxic multinodular goiter, or a different type of hyperthyroid condition, and if you’re sick and tired of your endocrinologist pressuring you to receive radioactive iodine or thyroid surgery, then you might be interested in joining our 21-Day Overcoming Hyperthyroidism Challenge (starts June 8th!):

The 21-day challenge will include the following…

Component #1: Daily Overcoming Hyperthyroidism Video Lesson

During this daily 20-45 minute recorded lesson I will focus on a different topic that is essential to overcoming your hyperthyroid condition. There will be one lesson every day for 21 consecutive days (although a few lessons include multiple videos). If you’re interested in the specific topics that will be presented please check out the video below where I discuss the 21-day challenge calendar.

Component #2: Daily (M-F) 30-45 minute live group coaching session

The live group coaching calls will take place on Zoom, which is very easy to use on computers, mobile phones, and tablets. And if you are unable to attend live you’ll have the opportunity to email your questions during the separate Q & A sessions (discussed below). For those who choose to join live, the way it works is that I’ll send you a link to join the call, and if you are using a mobile phone or tablet you’ll need to install the free app. I will record every coaching session and post the recordings in a private membership area for those who are unable to attend live. As for the time of the coaching sessions, I will rotate them to accommodate those in different time zones. They will take place either 1pm or 9pm Eastern time (New York time zone).

Component #3: Recording of each coaching call for those who are unable to attend live

I already mentioned this, and of course I hope most people will be able to attend at least 2 or 3 live sessions per week, although I’ll add that when I had my last challenge in April I had some participants who didn’t attend the live calls, but simply watched the recordings and emailed their questions.

Component #4: Daily priority action step

I want people to take action, but I want the action steps to be attainable, which is why there will be a single priority action step each day, although at times there will be one or two additional action steps that aren’t as urgent.

Component #5: Access to a private members-only group

We want you to build relationships with one another and enjoy this challenge together. One way we accomplished this in April was through the live coaching calls, but another way was through the private members-only group we had. Since not everyone wants to be on Facebook we hosted this on a platform called Kajabi, and while we did have a lot of people participate, we realized that there are some limitations to Kajabi. So as crazy as this may sound, for this challenge I’m going to have two private members-only groups…one in Kajabi, and one in Facebook. And so you can join either one of these groups, or both if you’d like! In April we had over 130 participants, and so if we have a similar turnout this time I think there will be enough engagement in both groups. I’ll pop in these groups every now and then, but I plan on having my nutritional health coaches moderate the groups.

Component #6: Weekly 90 minute live Q & A session

Although I’ll be answering some questions during the daily coaching calls, these will only be around 45 minutes, and I will be focusing on answering live questions. But there will also be three separate live Q & A sessions (one per week) during the 21-day challenge hosted by yours truly. These will be at least 90 minutes long, although in April I exceeded two hours with each of the Q & A sessions, as my goal is to answer ALL questions! I’ll once again rotate the day and times to accommodate those in different time zones, and so they will either be at 1pm ET or 8pm ET. However, unlike the daily coaching calls, if you are unable to attend any of the Q & A sessions live you can email your questions ahead of time.

You Get All of This For A Single Payment of $49

If you watch the video on top of the registration page (the link is below) you’ll see dozens of people rave about the last challenge I had in April, and I think it’s safe to say that every single one of them easily got back their investment.

Optional Upgrade: 45-minute one-on-one diet and lifestyle call with a certified nutritional health coach

Both of my nutritional health coaches are excellent, and I thought it was important to include an option for affordable one-on-one support with all of the stress everyone is dealing with, although I’m confident the daily group coaching calls will also help with this. You have the option of doing this over the phone or through Skype/Zoom. If you listen to some of the video testimonials on this page from members of the past challenge you’ll hear some rave reviews about the diet and lifestyle call! And so if it’s in your budget I’d highly recommend taking advantage of it for the discounted rate of $50. But if not you still will receive a ton of value from the rest of the challenge.

For more information on the 21-day challenge check out the link below:

www.OvercomingHyperthyroidism.com

Most of the hyperthyroid patients I see in my practice have Graves’ disease, with toxic multinodular goiter the next most common form of hyperthyroidism.  However, not everyone with hyperthyroidism truly understands their diagnosis, and so I wanted to put together a blog post that differentiates toxic multinodular goiter from Graves’ disease.  In this post I will also discuss the conventional and natural treatment options for toxic multinodular goiter (also known as Plummer’s disease).

What Is Toxic Multinodular Goiter?

Multinodular goiter is the most common of all the disorders of the thyroid gland (1).  As the name implies, this involves a goiter (swelling of the thyroid gland) in the presence of multiple thyroid nodules.  “Toxic” multinodular goiter involves multinodular goiter in the presence of hyperthyroidism, and while many people have a non-toxic multinodular goiter, a large proportion of those with multinodular goiter will eventually develop hyperthyroidism, although this might not occur for a few decades (1).

How Is Toxic Multinodular Goiter Diagnosed?

As for how toxic multinodular goiter is diagnosed, once again, the “toxic” part indicates that the person has hyperthyroidism.  Sometimes the person has a noticeable goiter, while other times the practitioner will need to rely on palpation and/or a thyroid ultrasound.  If the goiter is large enough this can result in symptoms such as dysphagia (difficulty swallowing), cough, and hoarseness.  Similarly, large nodules might be detected through palpation, but a thyroid ultrasound might be indicated.

How Is Graves’ Disease Diagnosed?

I’ve discussed this in great detail in other articles and posts, but essentially Graves’ disease is diagnosed when someone has hyperthyroidism in the presence of either 1) elevated TSH receptor antibodies/thyroid stimulating immunoglobulins, 2) an elevated radioactive iodine uptake test, and/or 3) thyroid eye disease.  A small percentage of people have subclinical Graves’ disease, which is when their thyroid hormone levels are normal, but they have a depressed TSH in the presence of one of the three factors I listed here.

What Causes a Multinodular Goiter?

There are a few different factors that can lead to the development of a multinodular goiter.  Two primary factors are genetics and gender, as there does seem to be a genetic predisposition for this condition, and it’s more common in women.  But there are also some secondary factors, including the following (1):

• Elevated TSH (induced by iodine deficiency, goitrogens, inborn errors of thyroid hormone synthesis). It’s important to understand that having a goiter and/or nodules is common with both hypothyroidism and hyperthyroidism.  An elevated TSH is usually indicative of low or depressed thyroid hormone levels, which can be caused by an iodine deficiency, goitrogenic substances (which can inhibit thyroid function), and/or other factors that can disrupt thyroid hormone production.  Many people with an elevated TSH have Hashimoto’s thyroiditis, which is an autoimmune thyroid condition.  In fact, this is the most common reason why someone has an elevated TSH.
• Smoking, stress, certain drugs. Although one of the studies listed “smoking, stress, and certain drugs” as potential causes, there isn’t a lot of evidence in the research showing that cigarette smoking causes a multinodular goiter, and I couldn’t find a single study showing a correlation between stress and multinodular goiter.
• IGF-1 and other thyroid stimulating factors. In April 2018 I wrote a blog post entitled “Can Insulin Resistance Cause Thyroid Nodules?“, and the answer to this question is “yes!”  Numerous studies show that high amounts of insulin can result in an enlargement of various tissues and organs, including the thyroid gland.  So high insulin levels can be a factor with both a goiter and thyroid nodules.  The insulin-like growth factor (IGF) system plays an important role in regulating normal development and growth of the thyroid and appears to be involved in thyroid cell hyperplasia (2).
• Estrogen dominance/problems with estrogen metabolism. It is well known that estrogen can promote the growth of certain types of cancer cells, but there is evidence that it can also be a potent growth factor for benign and malignant thyroid cells (3) (4).  While having high estrogen levels is an obvious sign of estrogen dominance, normal estrogen levels don’t necessarily rule out estrogen dominance.  First of all, when evaluating blood work, I’ve seen a number of patients have normal, or even low estradiol/estrone levels, but high total estrogens.  Second, if estrogen is normal but progesterone is low, then this is also considered to be a form of estrogen dominance.  Finally, someone can have normal estrogen levels but an unequal distribution of the estrogen metabolites due to problems with phase 2 detoxification (specifically methylation, sulfation, and/or glutathione).

So what happens is that as a result of one of the above reasons someone develops a multinodular goiter, which is initially non-toxic.  But over a period of years there is a greater risk of the person with multinodular goiter developing hyperthyroidism.  Toxic multinodular goiter can be associated with hyperfunctioning thyroid nodules (also known as toxic thyroid adenomas), which means that the nodules autonomously produces thyroid hormone.  In fact, some sources consider ALL cases of toxic multinodular goiter to have nodules that produce thyroid hormone.  Just in case this is confusing, there are a few different scenarios when someone has multinodular goiter in the presence of hyperthyroidism:

Scenario #1: Multinodular goiter with hyperthyroidism caused by nodules that produce thyroid hormone.  Pretty much all sources consider this to be toxic multinodular goiter, while some label the other two scenarios below as multinodular goiter in the presence of hyperthyroidism.

Scenario #2: Multinodular goiter with hyperthyroidism that isn’t caused by nodules that produce thyroid hormone.  Once again, some sources don’t consider this to be toxic multinodular goiter, while other sources do.

Scenario #3: Multinodular goiter with hyperthyroidism caused by elevated thyroid stimulating immunoglobulins.  This of course describes someone who has both multinodular goiter and Graves’ disease.

The truth is that it really doesn’t matter what the condition is called, as either way, the goal should be to address the cause of the condition.  So for example, if someone has multinodular goiter with nodules that produce thyroid hormone, the goal should be to address the cause of the goiter and thyroid nodules.  Similarly, if someone has multinodular goiter with nodules that do not produce thyroid hormone, then we still want to address the cause of the problem.  And of course if someone has multinodular goiter and Graves’ disease, then the goal still should be to address the cause of the problem, although it might be more complex since in this scenario there is an autoimmune component to deal with.

What Causes Graves’ Disease?

According to the triad of autoimmunity, in order for Graves’ disease to develop you need 1) a genetic predisposition, 2) exposure to an environmental trigger, and 3) an increase in intestinal permeability (a leaky gut).  Different people can have different triggers, as for some people the trigger can be a food allergen (i.e. gluten), whereas other people can have their condition triggered through an infection (i.e. H. pylori), and even stress can be a trigger.

Signs and Symptoms of Toxic Multinodular Goiter

The signs and symptoms of toxic multinodular goiter are similar to the signs and symptoms of Graves’ disease, which include the following:

• Increased heart rate
• Palpitations
• Tremor
• Weight loss
• Heat intolerance
• Anxiety
• Loose stools
• Hair loss

Because of the goiter, the person might also experience other symptoms such as neck discomfort, difficulty swallowing (dysphagia), and/or difficulty breathing (dyspnea).  Hoarseness is rare, but it does happen at times.  Other possible signs/symptoms include tracheal deviation, external jugular vein engorgement, and rarely a large substernal goiter may result in facial and cervical plethora and edema (5).

Having Toxic Multinodular Goiter AND Graves’ Disease

I have worked with patients who had toxic multinodular goiter, and also had elevated thyroid antibodies.  There are three main types of thyroid antibodies, which include thyroid peroxidase (TPO) antibodies, thyroglobulin antibodies, and thyroid stimulating immunoglobulins.  As I mentioned earlier, one of the ways of diagnosing Graves’ disease is through the presence of thyroid stimulating immunoglobulins.  And I have had some patients with toxic multinodular goiter who had elevated TSI levels.  I’ve also had some patients with toxic multinodular goiter who had negative TSI levels, but had elevated thyroid peroxidase and/or thyroglobulin antibodies.

When someone has toxic multinodular goiter and also has an autoimmune component, you need to do things to improve the person’s immune system health (i.e. find and remove the autoimmune triggers), while also finding and addressing the cause of the multinodular goiter.

Conventional Treatment Options for Toxic Multinodular Goiter

Just as is the case with Graves’ disease, the three main conventional treatment options for toxic multinodular goiter include 1) antithyroid medication, 2) radioactive iodine, and 3) thyroid surgery.  When the goiter is larger most doctors will recommend either radioactive iodine treatment or thyroid surgery.  While removal of the thyroid gland will of course solve the goiter problem, radioactive iodine has been shown to reduce the goiter up to 65% of the original volume (6).  Of course both radioactive iodine and surgery comes with risks, which is why I recommend trying to address the cause of the problem whenever possible.  That being said, there is a time and place for conventional medical treatment.

Although many medical doctors advise their patients with toxic multinodular goiter to receive radioactive iodine or surgery, low dose methimazole treatment might be another option to consider.  A 2019 study looked to compare the effectiveness and safety of long-term methimazole and radioactive iodine in the treatment of toxic multinodular goiter (7).  The results of the study showed that low dose methimazole treatment for 60-100 months is a safe and effective method for the treatment of toxic multinodular goiter, and is not inferior to radioactive iodine treatment.

Three Other Treatment Options Specifically For Thyroid Nodules

Percutaneous ethanol injection

This technique involves injecting ethanol into the toxic nodule under ultrasound guidance.  Studies show that it can be very effective in shrinking benign cystic and mixed thyroid nodules (8) (9).  But what about toxic thyroid nodules?  Well, one study involving twenty autonomously functioning thyroid nodules showed that 17 of 20 patients had significant shrinkage of their thyroid nodules after receiving percutaneous ethanol injection (10).  Another study showed that it can be effective in the treatment of large toxic thyroid nodules (11).  Pain is the most common side effect, but other less common side effects include facial flushing, a drunken sensation, headache, mild dizziness, perithyroidal or perinodal ethanol leakage, intracystic hemorrhage, local hematoma, secondary infection, or vocal cord paralysis, can occur during or after percutaneous ethanol injection for cystic thyroid nodule (12).

Percutaneous laser ablation

This treatment is also done under ultrasound guidance.  The advantage of this is that it is minimally invasive.  A few studies show that laser ablation is safe and effective in reducing nodule volume and neck symptoms (13) (14).  The downside is that it also doesn’t do anything to address the cause of the thyroid nodule, and as a result, regrowth of the thyroid nodule can occur.  But if someone is looking to shrink the thyroid nodule sooner than later they can always choose to do this and still address the underlying cause.  A few studies show that this can help to reduce the size of autonomously functioning thyroid nodules that are associated with toxic multinodular goiter (15) (16).  This treatment might also be an option for malignant thyroid nodules (17).

As for the side effects, one journal article showed complications occurring in 0.5% of cases (8 patients), and all consisted of voice changes due to vocal cord palsy, with complete recovery after 3 months (17). Minor complications were reported in 0.5% of cases (9 patients), including subcapsular or perithyroidal hematoma and skin burn (17).

Percutaneous radiofrequency thermal ablation

This is yet another treatment that is performed under ultrasound guidance, and it involves thermally ablating the thyroid nodules.  Although laser ablation might sound more appealing to some people, the advantage of radiofrequency thermal ablation is that from what I understand a single treatment is usually required, whereas with laser ablation multiple treatments might be necessary, although not always.  And this treatment can be used for autonomously functioning thyroid nodules (18).  That being said, for someone who is facing thyroid surgery or radioactive iodine, I think that either percutaneous laser ablation or radiofrequency thermal ablation are options to consider. Some of the potential side effects include a transient voice change, hyperthyroidism, hematoma, skin burn, edema, coughing, and nausea/vomiting (19).

When Should You Consider These Procedures?

You might be wondering when these three other treatment options should be considered.  Ultimately this is your decision, and I definitely would consider these over a thyroidectomy or radioactive iodine whenever possible.  You just need to keep in mind that none of these procedures do anything to address the underlying cause of the condition.  So for example, if you have problems with estrogen metabolism or insulin resistance, you ideally would want to address these problems first and see if the thyroid nodules decrease.

Even if you choose to get one of these alternative treatment options for your thyroid nodules, it might be challenging to find a clinic that will perform these procedures.  I did have a patient who got percutaneous radiofrequency thermal ablation through the University of Virginia in 2019.  But I’m sure there are other clinics and practitioners that perform these procedures.

Also, remember that these three alternative methods focus on thyroid nodules, but not the goiter.  Some of the factors I described in this blog post can cause the development of both a goiter and thyroid nodules, but there can be other causes of a goiter.  When I was dealing with Graves’ disease I had a small goiter that resolved after treatment, and many people with overt hypothyroidism develop a goiter.  Very large goiters usually won’t get back to their normal size when following a natural treatment approach, and surgery or radioactive iodine might be considered in some of these cases.

Natural Treatment Options for Toxic Multinodular Goiter

As I mentioned earlier, genetics and gender are both factors with the development of multinodular goiter, and so of course these can’t be modified.  However, other factors can be addressed, such as doing things to decrease insulin resistance, supporting estrogen metabolism and detoxification, and correcting an iodine deficiency.  I’ve discussed these in separate articles and blog posts on my website, and recently I created a video on estrogen metabolism you might want to check out.

The three main factors I would focus on are 1) balancing blood sugar/correcting insulin resistance, 2) supporting estrogen metabolism, and 3) supporting the phase 2 detoxification pathways.  There is overlap between #2 and #3, as healthy estrogen metabolism is dependent on healthy methylation, healthy sulfation, and healthy glutathione.  I discuss the six different pathways of phase two detoxification in a blog post I wrote entitled “How To Optimize Detoxification Part 2”.

Is the approach the same if someone has toxic multinodular goiter?  I bring this up because a lot of the research focuses on non-toxic multinodular goiter.  With my toxic multinodular goiter patients I still address the factors I discussed in this blog post (estrogen metabolism, insulin resistance, etc.), although if someone tests positive for an iodine deficiency you do want to make sure to be cautious with iodine supplementation.  While an iodine deficiency can be a factor in the development of a multinodular goiter, in some cases of toxic multinodular goiter with hyperfunctioning nodules, supplementing with iodine can exacerbate the hyperthyroidism.

What’s Your Experience With Toxic Multinodular Goiter?

If you have toxic multinodular goiter I’d love to hear what treatments you have gone through, and so please share your experience in the comments section below.  Have you done anything to address the cause of your condition, such as address estrogen metabolism or insulin resistance?  And if so, did this help?  I’d especially be interested in hearing from anyone who has thoroughly researched or actually received percutaneous ethanol injection, laser ablation, or radiofrequency thermal ablation.

 

For those with thyroid and autoimmune thyroid conditions, in order to achieve a state of optimal health you need to detect and remove your triggers.   While signs/symptoms and a comprehensive health history can be helpful, testing is the main way I find triggers in my practice.  So I’ve decided to put together a post that discusses seven tests that can help identify your triggers.  These are not listed in the order of importance, although towards the end of this post I’ll give you an idea as to how I prioritize these tests.

Test #1: Adrenal testing.  Chronic stress is something that affects just about everyone…especially during this time with everything going on with covid-19.  Of course most conventional medical doctors don’t do anything to help improve their patient’s adrenal health, including endocrinologists, and many refuse to do any adrenal testing unless if they suspect conditions such as Addison’s disease or Cushing’s syndrome.  While many natural healthcare practitioners do test the adrenals of their patients, some just recommend general adrenal support to all of their patients.

Obviously there are things you can do to improve the health of your adrenals without testing.  Eating well and improving stress handling are two things everyone can and should do regardless of what their adrenals look like.  Similarly, if someone is intentionally getting less than 7 hours sleep on a regular basis then this is something they can work on without doing adrenal testing.

But some people do need additional support in the form of nutrients and herbs, and different people will have different adrenal patterns.  And symptoms alone can’t always predict the adrenal pattern.  For example, when I was dealing with Graves’ disease my energy levels were fine, yet my adrenal saliva test results showed what some would refer to as an “adrenal fatigue pattern”, as my cortisol levels were depressed, my DHEA was low, and a few other markers were also low.  I ended up taking nutritional supplements to support cortisol, including licorice root, which extends the life of cortisol, and you therefore wouldn’t want to take this herb if you had high cortisol levels (or high blood pressure, as it’s contraindicated for those with hypertension).  If someone has elevated cortisol levels they might choose to take something such as phosphatidylserine, but probably wouldn’t want to take this if their cortisol was low.

Sure, you can just take adaptogenic herbs while addressing diet and lifestyle factors, and this alone might help to restore the health of the adrenals.  But there is a reason why many companies offer adrenal testing and why many natural healthcare practitioners like myself recommend adrenal testing to most of their patients.  Simply put, healthy adrenals are very important for a healthy immune system, healthy sex hormones, etc.  And while I mentioned earlier that those who are intentionally neglecting their sleep can modify their sleep habits, there are many people who have problems falling and/or staying asleep, and many times testing the adrenals can reveal why this is the case (i.e. high nighttime cortisol).

What Type of Adrenal Testing Should You Do?

When I was diagnosed with Graves’ disease I used saliva testing to evaluate the health of my adrenals.  I used a company called Diagnos-Techs, although there are some other good labs that offer saliva testing.  I still frequently recommend saliva testing to my patients, although for some of my patients I recommend the DUTCH test, which involves dried urine testing.  If someone is just testing their adrenals then saliva testing is fine, but if someone is looking to test the sex hormones then I commonly recommend the DUTCH test.

Click here to watch a video tutorial I created entitled “What’s the Best Test For Adrenal Fatigue?”

Click here for more information on the Adrenal Stress Index test.

Click here for more information on the DUTCH test.

Test #2: Blood tests for stealth infections.  As of writing this blog post the world is dealing with a new type of coronavirus (covid-19), but what really opened up my eyes to viruses and other stealth infections was my Lyme disease diagnosis in the summer of 2018.  Before then I did some testing for viruses such as Epstein-Barr, and I did some research and wrote a few articles on viruses, along with Lyme disease and coinfections.  I don’t have all of my patients test for Lyme disease, and one of the reasons for this is because the standard tests for Lyme disease performed at conventional labs (i.e. western blot) aren’t too accurate.

When I was diagnosed with Lyme disease I used a lab called Medical Diagnostic Laboratories.  Although they did an IgM/IgG Western blot test, they also did another test called Lyme disease C6 peptide, along with testing for certain coinfections (i.e. Bartonella, Babesia, Mycoplasma).  They also tested for Epstein-Barr, cytomegalovirus, and human herpesvirus-6 (HHV-6).  That being said, while I wouldn’t rely on a Western blot from a lab such as Labcorp or Quest Diagnostics, I think it’s fine to use these labs for Epstein-Barr and other viruses.

I realize that currently many people are staying away from labs out of fear of getting covid-19, but if you’re dealing with a thyroid or autoimmune thyroid condition and haven’t at least done a test for Epstein-Barr then you might want to consider doing so in the future, as there is a lot of research showing a relationship between Epstein-Barr and thyroid/autoimmune thyroid conditions.  While it’s true that Epstein-Barr can’t be completely eradicated from the body, if it reactivates it can be put back in an inactive state.  Following a specific anti-viral protocol is sometimes necessary, although with any stealth infection the number one focus should be to improve the health of your immune system.

Click here to watch a video tutorial I created entitled “7 Blood Tests People With Autoimmune Conditions Should Get”

Test #3: Comprehensive stool panel.  Gut infections such as H. pylori, Yersinia enterocolitica, and parasites can all be potential triggers of Graves’ disease and Hashimoto’s.  Although I don’t currently recommend a comprehensive stool panel to all of my patients, there is a good argument that everyone with an autoimmune condition should get one when trying to look for triggers.  The argument against having everyone do such a test is that many people have achieved a state of remission without spending hundreds of dollars on a comprehensive stool panel, and this includes myself.

However, I’ve also had patients who didn’t get a comprehensive stool panel initially but had to get one later because they weren’t improving.  And some of these patients had positive findings…even though they didn’t have symptoms which would indicate that they had a gut infection.  Once again, I commonly recommend conservative testing, but if someone has it in their budget to do more comprehensive testing upfront then they might want to consider doing a comprehensive stool panel.

Which Comprehensive Stool Panel Do I Recommend?

Over the last few years I’ve been recommending the GI-MAP to my patients, as this uses quantitative PCR to detect bacteria, viruses, and parasites.  Genova Diagnostics also has a very good comprehensive stool panel called the GI Effects.

Click here to watch a video tutorial I created entitled “GI MAP Overview With Treatment Suggestions”

Click here for more information on the GI MAP and GI Effects.

Test #4: Tests for heavy metals.  Environmental toxins can be a trigger, and while the focus here will be on heavy metals, it’s important to mention that other chemicals can trigger thyroid and autoimmune thyroid conditions.  For example, xenoestrogens can directly affect the thyroid gland, and it might be a factor in thyroid autoimmunity.  One problem is that there are tens of thousands of environmental toxins, and we are unable to test for most of these.

Based on what I just said, one can make the argument that it’s a waste of money to test for heavy metals.  After all, can’t you just assume you’re toxic and do things to support detoxification?  Without question you can and should do things to reduce your toxic load.  But since heavy metals such as mercury have been proven to negatively affect the thyroid gland, and can also be an autoimmune trigger, I think it’s wise to start off with a baseline reading.  Plus, depending on what method you use, testing for heavy metals is relatively affordable.

Most healthcare practitioners will test for the levels of heavy metals, and there are four ways to do this.  You can test for heavy metals in the hair, urine, blood, and stool.  Rarely do I see practitioners test for heavy metals using stool testing, and blood testing is mainly used to determine if someone has an acute exposure to one or more heavy metals.  In my practice I utilize hair mineral analysis testing, while other practitioners will utilize urine testing.  It’s important to understand that heavy metals can be deeply embedded in the tissues, and therefore might not show up on either a hair or urine test.

For this reason, some practitioners will utilize “provoked” urine testing, where the person does a baseline urine test, takes an oral chelating agent to mobilize the metals from the tissues, and then does a second urine test, which usually shows very high levels of heavy metals.  Some question the safety of using oral chelators, which can be a concern if you have low glutathione levels.  But there have been many doctors who have successfully used provoked urine testing in their practice.

What Lab Do I Recommend?

For hair mineral analysis testing I recommend Analytical Research Labs, as their specialty is hair testing, and they don’t wash the hair before being analyzed, which is important.  For urine testing many healthcare practitioners use Doctor’s Data.

Click here for more information on the hair mineral analysis.

Test #5: Food sensitivity testing.  I don’t commonly recommend food sensitivity testing to my patients, as I usually recommend an elimination/reintroduction diet as a way of identifying food triggers.  The main reason for this is because false results are common.  That being said, the elimination/reintroduction diet isn’t perfect, and many people would prefer to spend the money to try to identify their food triggers.  And there is no shortage of companies that offer food sensitivity testing.

If you do choose to order a food sensitivity panel I would make sure of a few things.  First of all, make sure you test for most of the foods you eat.  Some companies will offer a panel where they test either 90 or 180 foods, and while the 90-food panel option will be less expensive, if you eat a good amount of foods that are included on the 180-food panel but not the 90-food panel then it makes sense to go with the more comprehensive test.  Also, you need to be eating the foods that you are testing for.  As an example, if you have been gluten and dairy free for a few months, and you do a food sensitivity panel that includes gluten and dairy, we wouldn’t expect your body to produce antibodies towards gluten and dairy (since you’ve been avoiding them for awhile), and as a result, we would expect the results to come back negative, even if you had a sensitivity to one or both of these.  And this applies to other foods as well.

What Company Do I Recommend For Food Sensitivity Testing?

As I mentioned, I don’t recommend food sensitivity testing to most of my patients, but when I do there are two main companies I have used in the past…Alletess and Cyrex Labs.  Of these two, I prefer Cyrex Labs for a few different reasons.  First of all, Cyrex Labs runs all of their tests through twice and then compares the results, and a correlation between the two tests must be met before reporting the results.  This of course decreases the chances of getting a false result.  Second, their Array #10 panel tests some foods raw and others cooked, which makes sense, as some foods people consume cooked while others are eaten raw, and it’s possible to be sensitive to a specific food when it’s eaten raw, but not be sensitive to the same food when it’s cooked.  Third, Cyrex Labs uses advanced purification techniques to ensure that it assesses reactivity to the unadulterated food antigen, resulting in greater specificity.

Click here to watch a video tutorial I created entitled “What’s The Best Gluten Sensitivity Test?”

Click here for more information on food sensitivity testing.

Test #6: Organic acids test.  Organic acids testing involves collecting a urine specimen, and offers a comprehensive metabolic snapshot of a patient’s overall health with over 70 markers.  In my opinion, organic acids testing is the best test for determining if someone has a yeast overgrowth.  It also looks at certain bacterial markers, oxalates, markers related to mitochondrial health, neurotransmitters, ketone and fatty acid oxidation, nutrients, and indicators of detoxification.  For more information I’d read an article I wrote entitled “Can Those With Graves’ Disease and Hashimoto’s Benefit From Organic Acids Testing?”

I love organic acids testing.  In 2009 (the year I got into remission) I wasn’t familiar with organic acids testing, but I think I started learning about this test in 2015, and in 2016 I attended an organic acids workshop in New Jersey and decided to run an organic acids test on myself.   Overall the results of my test looked pretty good, although I tested high for oxalates, which are a risk factor for kidney stones, and can deposit in other areas of the body, including the thyroid gland, bone, brain, skin, and nervous tissue.  I can’t say that organic acids testing played a role in myself getting into remission, and while I don’t have all of my patients do this test, since I started utilizing organic acids testing in my practice I’ve found significant markers in some of my patients who ordered this test.

What Company Do I Recommend For Organic Acids Testing?

I usually recommend the organic acids test from Great Plains Laboratory, although Genova Diagnostics has a good one called the Organix.  As of writing this blog post, the organic acids test from Great Plains Laboratory is the only one that tests for oxalates.

Click here to watch a video tutorial I created entitled “Organic Acids Test Interpretation with Treatment Suggestions”

Click here for more information on the OAT from Great Plains Laboratory and the Organix from Genova Diagnostics

Test #7: Testing for mycotoxins.  Many people have mold problems, and in 2017 I wrote a comprehensive article entitled “Mycotoxins, CIRS, and Thyroid Health“.  When talking about mold testing, many people think about testing their home for mold, and this certainly is something to consider if you suspect a mold problem.  However, the reason why people experience symptoms is due to mycotoxins produced from mold, and this can also be tested for.  Quite frankly, most people don’t need to do this test, but I’m bringing it up because many people aren’t even aware that you can test for mycotoxins, and sometimes this test can be valuable.  Just remember that if toxic mold is a problem, while you can do things to eliminate mycotoxins from your body, the number one priority is to remove the source of the mold.

It’s also worth mentioning that the organic acids test from Great Plains Laboratory looks at a few markers that relate to mold, which if positive can suggest a toxic mold problem.  However, if these markers are negative this does not rule out a mold toxicity issue.

What Company Do I Recommend For Myotoxins Testing?

I like the MycoTOX test from Great Plains Laboratory, as it’s a urine test that screens for eleven different mycotoxins, from 40 species of mold.  Real Time Labs is another good option for mycotoxins testing.

Click here to watch a video tutorial I created entitled “Mold Markers on the Organic Acids Test”

Click here for more information on the MycoTox test from Great Plains Laboratory and the Organix from Genova Diagnostics

Are There Other Tests Worth Ordering?

Without question there are other tests to consider.  For example, Great Plains Laboratory has a GPL-TOX test, which is a toxic non-metal chemical profile that screens for the presence of 170+ different toxic chemicals using 18 different metabolites.  While the GPL-TOX, hair mineral analysis, and urine test for heavy metals all measure the levels of environmental toxins, there are tests that measure the immune system response to these chemicals.  An example is the Chemical Immune Reactivity Screen by Cyrex Labs, which measures an expanded range of environmental chemical toxins that bind to human tissues and as a result cause an immune response.

Another test I didn’t mention that can play a role in one’s thyroid or autoimmune thyroid condition is the small intestinal bacterial overgrowth (SIBO) breath test.  SIBO isn’t a direct trigger, but it can increase the permeability of the gut, which is part of the triad of autoimmunity.  Testing for nutrient deficiencies can also be helpful, although there isn’t a single test that does this perfectly.  I use a combination of the hair mineral analysis and blood testing to determine nutrient deficiencies.  The NutrEval test by Genova Diagnostics and Micronutrient panel by Spectracell are other options to consider.

Which Do I Consider To Be The Most Important Tests?

Of course I don’t expect you to order all of these tests I mentioned.  With regards to my patients, I most commonly recommend either the adrenal saliva test or DUTCH test, along with a hair mineral analysis, and certain blood tests.  Sometimes I’ll recommend the GI-MAP and/or organic acids test.  While after the initial consultation I send a follow-up email to my patients listing the most important tests and usually an optional test or two, the truth is that all of the tests are optional.  In other words, ultimately the patient decides which tests he or she wants to order.

For example, sometimes a patient I work with can only afford a single test (i.e. adrenal saliva test), and so they might just start with this, and then we’ll see what imbalances are present.  On the other hand, sometimes a patient will have certain tests in mind that I didn’t recommend (i.e. food sensitivity testing), and of course I have no problem with someone ordering additional tests, although if I don’t think they’re necessary I’ll let the person know.

How To Better Understand Your Test Results…For FREE!

Although I do think it’s wise to discuss your test results one-on-one with a healthcare practitioner so that you can receive specific recommendations, I realize that not everyone can afford to do this.  As a result, in the fall of 2019 I started creating video tutorials to help people with autoimmune conditions such as Graves’ disease and Hashimoto’s better understand their test results.  You probably noticed that I included some links to these tutorials throughout this blog post.  If you have a non-autoimmune thyroid condition I’m confident that you’ll still find the information in these video tutorials to be beneficial.  To watch some of these tutorials visit https://understandyourtests.com/videos.

Have You Used Tests To Find YOUR Triggers?

I’m sure many people reading this have ordered one or more of the tests I mentioned in this blog post. Perhaps you even ordered a test that I didn’t mention. Either way, I’d love to hear what tests you have ordered, and so please feel free to share this in the comments below, and also let me know if they were helpful in finding your triggers.

Recently I found out that a patient of mine was misdiagnosed with Hashimoto’s thyroiditis by her medical doctor.  Most of my patients with Hashimoto’s and Graves’ disease who see me for the first time have already been diagnosed with an autoimmune thyroid condition.  And both conditions usually aren’t too difficult to diagnose.  But I’m sure there are some people who don’t understand how both of these autoimmune thyroid conditions are diagnosed, and they simply take the word of their endocrinologist or primary care physician.  And so I figured I’d put together a post that discusses how both of these conditions are diagnosed.

What’s disturbing is that the person who was misdiagnosed with Hashimoto’s wasn’t even hypothyroid at the time of her diagnosis, yet she was put on thyroid hormone replacement.  Now to be fair, many people with Hashimoto’s thyroiditis have subclinical hypothyroidism, where their TSH is elevated and their thyroid hormone levels are within the lab reference range.  But in this person’s case, her TSH was 1.18 uIU/mL at the time of her diagnosis.  In addition, she didn’t have any thyroid antibodies tested.  Yet she was told she had Hashimoto’s and was put on thyroid hormone replacement, which she was taking since 2014.

Although it’s upsetting that this person was misdiagnosed with Hashimoto’s, I think it’s safe to say that most people who were told they have an autoimmune thyroid condition have received the appropriate diagnosis.  But it’s also safe to say that this person isn’t the only one who has been misdiagnosed with an autoimmune thyroid condition.  And even if only a small percentage of people are misdiagnosed every year, I want to try to reduce the incidence of this, which is why I’m putting together this post.

Diagnosing Hashimoto’s Thyroiditis

According to the American Thyroid Association, this is how Hashimoto’s thyroiditis is diagnosed (1):

“The diagnosis of Hashimoto’s thyroiditis may be made when patients present with symptoms of hypothyroidism, often accompanied by a goiter (an enlarged thyroid gland) on physical examination, and laboratory testing of hypothyroidism, which is an elevated thyroid stimulating hormone (TSH) with or without low thyroid hormone (free T4) levels. TPO antibody, when measured, is usually elevated.  Occasionally, the disease may be diagnosed early, especially in people with a strong family history of thyroid disease. TPO antibody may be positive, but thyroid hormone levels may be normal or there may only be isolated mild elevation of serum TSH. Symptoms of hypothyroidism may be absent.”

So let’s break down their diagnosis:

• Patient presents with symptoms of hypothyroidism, often accompanied by an enlarged thyroid gland (goiter)
• Laboratory testing shows an elevated TSH, with or without low thyroid hormone levels
• TPO antibodies are usually elevated

They also mention that when diagnosed early, TPO antibodies may be positive, but thyroid hormone levels might be normal or there may only be a mild elevation of serum TSH, and that symptoms of hypothyroidism might be absent.  So you don’t need to have symptoms of hypothyroidism to be diagnosed, and the TSH might be slightly elevated, but TPO antibodies usually are positive.  Unfortunately they didn’t mention anti-thyroglobulin antibodies, which are also associated with Hashimoto’s, as there are cases when TPO antibodies are negative but someone has positive anti-thyroglobulin antibodies.

Is a Thyroid Ultrasound Necessary?

Some sources will also mention the value of doing a thyroid ultrasound in coming up with a diagnosis.  One study showed that reduced thyroid echogenicity was a valid predictor of thyroid autoimmunity (2).  However, one can argue that positive ultrasound findings aren’t necessary to diagnosis Hashimoto’s if someone has an elevated TSH and either elevated TPO and/or thyroglobulin antibodies.

Summary of Hashimoto’s Thyroiditis Diagnosis

So when putting everything together that I mentioned above, it should be clear how Hashimoto’s thyroiditis is diagnosed, as the following two factors both need to be present:

• Elevated TSH
• Elevated thyroid peroxidase antibodies and/or anti-thyroglobulin antibodies

Normal TSH In the Presence of Elevated Thyroid Antibodies

But what if someone has elevated thyroid antibodies but their TSH is perfectly fine?  Or if their TSH is within the laboratory reference range, but higher than optimal, yet the person has one or more elevated thyroid antibodies?  Well, from a medical standpoint neither of these patients will probably be diagnosed with Hashimoto’s, although they do have the antibodies associated with Hashimoto’s.  In this situation most medical doctors won’t give thyroid hormone replacement, but even if the person doesn’t need to take thyroid hormone replacement, it doesn’t mean that the immune system should be ignored.

In fact, for those who have read my book “Hashimoto’s Triggers”, the very first chapter discusses the timeline of Hashimoto’s.  In this chapter I discuss the following four stages of Hashimoto’s.  I’ll list the stages below, but you can actually access the first chapter of my book for free by visiting Amazon.com and searching for my book on Hashimoto’s (or you can click here), and on the left side of the page click on “Look Inside”, and you’ll be able to check out the first chapter of my book.

The Autoimmunity Timeline

Stage #1: Pre-autoimmunity. This is the most critical time to prevent an autoimmune condition from developing.  The pre-autoimmune stage is essentially when, over time, a person’s body becomes more susceptible to developing autoimmunity.

Stage #2: Silent autoimmunity. In this stage, the autoimmune process has already started. However, there has been very little or no tissue damage (i.e., to the thyroid gland), and, therefore, no symptoms are present, and the basic thyroid panel results are negative at this point (i.e., normal TSH and thyroid hormone levels).  The person is usually in the silent stage for many years.

Stage #3. Symptoms are present with some tissue damage. Although stage #2 might involve some tissue damage, it’s minimal, but stage #3 is when this damage reaches the point where the person begins to experience symptoms. Once again, it can take many years for this to happen.

Stage #4. Symptoms are present and there is greater tissue loss. This is the “final” stage of autoimmunity, as it’s when the person’s symptoms will usually worsen, there is greater tissue loss, and the thyroid blood tests are positive. Although some people might be diagnosed with an autoimmune thyroid condition in stage #3, many people with Hashimoto’s won’t be diagnosed until they reach stage #4.

So when someone has a normal TSH and elevated thyroid antibodies, this is considered to be stage #2, which is silent autoimmunity.  Some may say that there is no concern because the person might never progress to stage #3.  While this may be true, many people WILL progress to stage #3, and eventually stage #4.  As a result, I think it’s crazy to ignore the immune system if someone has elevated thyroid antibodies, even if the TSH and thyroid hormones are within the optimal range.

By the way, if you want to learn more about the optimal reference ranges of the TSH and thyroid hormone levels, last month I released a video entitled “How To Read Your Thyroid Panel Results”, where I discuss the optimal reference ranges.  I also created separate videos you might want to check out on the three main types of thyroid antibodies.

Diagnosing Graves’ Disease

So let’s take a look at how the American Thyroid Association says that Graves’ disease is diagnosed (3):

“The diagnosis of hyperthyroidism is made on the basis of your symptoms and findings during a physical exam and it is confirmed by laboratory tests that measure the amount of thyroid hormones (thyroxine, or T4, and triiodothyronine, or T3) and thyroid-stimulating hormone in your blood. Clues that your hyperthyroidism is caused by Graves’ disease are the presence of Graves’ eye disease and/or dermopathy, a symmetrically enlarged thyroid gland and a history of other family members with thyroid or other autoimmune problems, including type 1 diabetes, rheumatoid arthritis, pernicious anemia, or painless white patches on the skin known as vitiligo.

The choice of initial diagnostic testing depends on cost, availability and local expertise. Measurement of antibodies, such as thyrotropin receptor antibodies (TRAb) or thyroid stimulating immunoglobulins (TSI), is cost effective and if positive, confirms the diagnosis of Graves’ disease without further testing needed. If this test is negative (which can also occur in some patients with Graves’ disease), or if this test is not available, then your doctor should refer you to have a radioactive iodine uptake test (RAIU) to confirm the diagnosis.”

Their diagnosis explanation is a bit lengthy, as they start out by explaining how hyperthyroidism is diagnosed, and then they give “clues” on how your hyperthyroidism is caused by Graves’ disease (i.e. thyroid eye disease, dermopathy), before finally mentioning that Graves’ disease is either diagnosed by positive TRAB or TSI, or by a radioactive iodine uptake test (if the thyroid antibodies are negative).  One thing I’m happy that they mentioned is that the radioactive iodine uptake test should be done only if the thyroid antibodies are negative.  Unfortunately many endocrinologists recommend this test to all of their Graves’ disease patients.

About the Radioactive Iodine Uptake Test

As I just mentioned, the radioactive iodine uptake test is commonly recommended by endocrinologists to aid in the diagnosis of Graves’ disease.  This test involves taking a very small amount of radioactive iodine, and the scan shows how much of the radioactive iodine is absorbed by the thyroid gland. A high uptake reading is usually present in Graves’ disease, although it can also be high in toxic multinodular goiter.

So what’s the problem with having everyone with Graves’ disease do this test?  Well, the good news is that the amount of radioactive iodine is so small that it won’t cause significant damage to the thyroid gland.  However, if the person has hyperthyroidism and also tests positive for TRAB and/or TSI, then this confirms that the person has Graves’ disease.  Some endocrinologists will argue that the RAI uptake test is still necessary to see if there are hot or cold nodules.  Thyroid nodules that absorb the radioactive iodine (hot nodules) are usually not malignant, while thyroid nodules that do not absorb the radioactive iodine (cold nodules) have a 5% chance of being malignant (4).

So the radioactive iodine uptake test can’t reveal if someone has cancerous thyroid nodules.  If someone has hot nodules they probably are benign, and if someone has cold nodules there is a slightly higher risk of the thyroid nodule being cancerous, but still only 5%.  So to me it makes sense to pass on this test and do a thyroid ultrasound, which also won’t confirm if thyroid nodules are malignant or benign, although sometimes you can get a good idea by the characteristics of the nodule on an ultrasound.

What If Graves’ Disease Antibodies and The RAI Uptake Test are Both Negative?

If antibodies associated with Graves’ disease are negative and the RAI uptake test isn’t elevated then the person probably doesn’t Graves’ disease.  If they have overt hyperthyroidism then they might have toxic multinodular goiter or subacute hyperthyroidism.  For those who have been diagnosed with toxic multinodular goiter, in the near future I’m going to be creating an updated blog post on this topic.

But one thing I didn’t mention was the role of eye symptoms in diagnosing Graves’ disease.  Of course there are many different types of eye symptoms one can have, and just because someone has hyperthyroidism in the presence of certain eye symptoms doesn’t confirm that they have Graves’ disease.  For example, many people have dry eyes.  However, if someone has hyperthyroidism in the presence of eye bulging, eye swelling, or other more extreme symptoms, this probably means the person has Graves’ disease, even without testing the thyroid antibodies or doing an RAI uptake test.

So let’s take an example of someone who has hyperthyroidism, along with the symptoms of thyroid eye disease, yet the antibodies associated with Graves’ disease are negative.  Should this person get the RAI uptake test to confirm the presence of Graves’ disease?  It admittedly is a tougher call in this situation, but in my opinion I’d still say “no”, as if the person has hyperthyroidism AND the symptoms of thyroid eye disease then they probably have Graves’ disease.

Graves’ Disease vs. Hashitoxicosis

One other thing I should mention is that every now and then I’ll come across someone with hyperthyroidism and their thyroid stimulating immunoglobulins are negative, yet they have positive TPO and/or thyroglobulin antibodies.  If this person has thyroid eye disease then they probably have Graves’ disease, as it’s very common for people with Graves’ disease to also have TPO antibodies, and many also have thyroglobulin antibodies.  But one also has to rule out hashitoxicosis, which I discussed in a 2019 blog post.  I won’t get into detail about hashitoxicosis here, as you can read the blog post for more information, but I will say that people with hashitoxicosis will typically have hyperthyroidism with elevated TPO and/or thyroglobulin antibodies, and they will have a normal TRAB and TSI.  If they do a radioactive iodine uptake test this will be negative.

Summary of Graves’ Disease Diagnosis

So in order for Graves’ disease to be diagnosed, the following need to be present:

• Depressed TSH
• Elevated TSH receptor antibodies and/or thyroid stimulating immunoglobulins

However, Graves’ disease is also is commonly diagnosed by hyperthyroidism and an elevated radioactive iodine uptake test.  And as I also mentioned, if someone has hyperthyroidism and thyroid eye disease, there is a pretty good chance they have Graves’ disease, even without testing the thyroid antibodies or doing the RAI uptake test.

Subclinical vs. Overt Hyperthyroidism

You may have noticed that I didn’t include elevated thyroid hormone levels in my summary.  And the reason for this is because some people have “subclinical Graves’ disease” (5), where they have a depressed TSH, an elevated TRAB or TSI, but their thyroid hormones are normal.  This isn’t too common, although I’ve had some patients with subclinical Graves’ Disease.  But once again, regardless of whether someone has subclinical Graves’ disease or subclinical Hashimoto’s thyroiditis, you want to address the autoimmune component.  I also should mention that some people have subclinical hyperthyroidism without positive thyroid autoantibodies.

How Long Have You Been Diagnosed With An Autoimmune Thyroid Condition?

I’d like to know how long you have been diagnosed with an autoimmune thyroid condition for, and so please let me know in the comments below.  And while I’m hoping that nobody reading this has been misdiagnosed, if you were and would like to share your story please feel free to post it below so that others can learn from your experience.  Thank you!