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Interviewer: Your primary care doctor told you that you have thyroid nodules. What should you do now? Dr. Dev Abraham is a Medical Director at the Utah Diabetes and Endocrinology Center.

A lot of times, Dr. Abraham, from what I understand, people find out about these thyroid nodules while the doctor was looking for something else and then they're told, "You have thyroid nodules." Should that person worry at that point?

Dr. Abraham: They shouldn't worry, but at the same time, they should have a very careful and judicious evaluation. What do I mean by that? Almost a third to half of US population can have thyroid nodules. And fortunately, the vast majority of thyroid nodules are benign thyroid nodules. So if one looks at how common thyroid cancers are in nodules, it is about 4-8% on an average. So 4 to 8 out of 100 nodules turn out to be thyroid cancer.

Interviewer: So if somebody had one of these incidental findings of a thyroid nodule, they should make an appointment with somebody such as yourself, an endocrinologist?

Dr. Abraham: Yes. Most endocrinologists are capable of evaluating patients for thyroid nodules.

Interviewer: And then, when they come into your office, what types of things will you do to evaluate to see if it's cancerous or not?

Dr. Abraham: We look at their clinical risk profile. Patients who have been exposed to external beam radiation, typical external beam radiation exposure occurs in some cancers, such as Hodgkin's Disease and leukemias for children. Or disasters such as Chernobyl and recently the Fukushima Daiichi Plant disaster in Japan. All of these radiation exposures can increase patient's risk for developing thyroid nodules. Also, if there is a strong family history of thyroid cancer, that is also a risk factor for careful evaluation.

So we look at the risk factors in patients and also the size and features of the nodule. And we perform what is called fine needle aspiration biopsy during the same visit.

Interviewer: And is there a time when you might just watch to see if they continue to grow?

Dr. Abraham: Yes. Very small nodules, we generally don't do biopsies or nodules with the certain benign characteristics on ultrasound.

Interviewer: And then what about those nodules that turn out to be not cancerous? Is there any other harm to leaving them there?

Dr. Abraham: There is really no harm, but we do recommend some surveillance over duration of time simply because in patients who have developed one nodule in a thyroid gland, they are at risk of developing other nodules. And some of the nodules that come about in the future may not start in an innocent manner. So we do recommend some surveillance. The frequency you'll have to discuss with your physician on a case-by-case basis. They would tailor it to your risk factor profile.

Interviewer: Are there any questions, common questions or concerns people have that I haven't addressed?

Dr. Abraham: Recently, it came to recognition of the frequency of thyroid cancer in general population. This is following a study that came out of South Korea, where they were actively screening for other cancers such as breast and colon and stomach, etc., and lungs. They also added thyroid cancer as a part of added screening or a value added screening. What they found out was, they diagnosed a whole bunch of sub-clinical, minute thyroid cancer in general population and they subjected a vast amount of Korean population to surgery. When in fact they came to harm by actually going through the surgery than from the cancer itself.

So now we know that what we call this microscopic, or sub-clinical, thyroid cancer is literally common in general population that we cannot even use sometimes an ultrasound to diagnose. And these cancers coexist with us and we die of something else. And simply diagnosing these causes more harm is what came out of that study.

So increasingly in the US, there is a view that is coming that even if there is a small thyroid cancer that was diagnosed by biopsy or a small nodule, we choose not to even do the biopsy and we watch these patients because surgery is not a completely safe procedure, even in the best surgical hands. There is a certain percentage of a chance things can go bad. So that's an important thing that should be discussed with patients.

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updated: February 27, 2019
originally published: April 13, 2016

Interviewer: Could it be a thyroid problem that's sabotaging your diet and weight loss plan? We'll find out next on The Scope.

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Interviewer: You've been trying to lose weight but you're just not seeing the results that you would like to see and you've been at it for a little while. Now, you're starting to wonder if there's something else in play like maybe it's a thyroid problem that's sabotaging your weight loss. Dr. Dev Abraham is the Medical Director of the Utah Diabetes and Endocrinology Center. So could a thyroid problem sabotage my diet and weight loss plan?

Dr. Abraham: There's a little misconception with regards to thyroid and weight connection. If you look at the older textbooks, it is very categorically stated that it is the cause of weight gain. So in another words, if someone gains weight, they must have thyroid problem. It's not necessarily true in modern times for several reasons.

The number one reason is in olden days they didn't have an accurate way of testing thyroid dysfunction with blood tests, let alone reliable, reproducible blood tests. In the last 15, 20 years duration, we have super accurate thyroid blood tests so it's very easy to determine whether weight change a person may experience is due to thyroid or not.

If you look at how much weight patients gain when you don't take thyroid hormones for months, it's really a small amount on an average of few pounds. If someone gains 50 pounds, 100 pounds over a span of a year or two years, it's uncharacteristic for a thyroid hormone imbalance to do that.

Interviewer: It's something else at that point.

Dr. Abraham: It is usually something else. But thyroid is often the first test that's often done because it's a very simple and easily available test. And it's also very, very treatable. So even if that much weight gain cannot be attributed to thyroid, if these patients have mild abnormality of the thyroid we still try to treat it first because it's a simple remedy.

Interviewer: So in the instance of somebody trying to lose weight and we're taking them at their word that their diet is on, their exercise is on, but they're not losing weight, could it be a thyroid problem that's causing that?

Dr. Abraham: It should definitely be tested, but if the test comes negative for thyroid dysfunction, that virtually rules out thyroid as a cause for the weight fluctuations.

Interviewer: And as a physician, how often have you seen thyroid being responsible for somebody not being able to lose weight or putting on weight unexpectedly?

Dr. Abraham: A very, very small percent.

Interviewer: Oh, really?

Dr. Abraham: Yes.

Interviewer: So it's a whole different kind of thinking than it was?

Dr. Abraham: It is, absolutely. If you look at the amount of weight gain that the society is experiencing, which is stated to get worse, it's quite astronomical. If only thyroid is the problem for this weight gain, we literally would be able to cure obesity.

Interviewer: With a pill.

Dr. Abraham: With a pill.

Interviewer: And that's what we want.

Dr. Abraham: And that hasn't occurred because the thyroid is usually not the single main cause.

Interviewer: So it sounds like, unfortunately, if I've been trying to lose weight and I'm not losing weight and I think everything else is right, it's probably not going to be my thyroid.

Dr. Abraham: That is a fair statement to make with a few exceptions. If there is a strong family history of thyroid dysfunction, in particularly female members of the family, or if there has been unexpected thyroid abnormality after childbirth, in those subjects, at least a test should be done before making that determination whether it is the thyroid or not. But it is accurate, in most patients if there is weight fluctuations, that's independent of thyroid. At least in the current day situation.

Interviewer: So look someplace else? Maybe I just need to exercise a little harder.

Dr. Abraham: Well, exercise is extremely important to lose weight but if you, for example, walk on a flat surface, you expend the equivalent of a slice of breads worth of calories. So one extra pound weight gain during Christmas, for example, can have the equivalent calories of about 3,500 calories. Which is about walking on a steady pace for about 35 miles.

So to expect weight loss purely by exercise is a very difficult process. But a combination of caloric restriction and adding some exercise has a multiplying effect with regards to weight loss. So most of the programs that are offered through the Utah Diabetes and Endocrinology Center focus on a whole health improvement with regards to dietary modification, exercise and caloric restriction without becoming deficient in micronutrients.

Interviewer: And sometimes it just takes time?

Dr. Abraham: It does take a longer time than most patients anticipate with weight loss and they give up sometimes. And that's what we try to encourage, any small loss is still a step in the right direction.

Interviewer: What about those individuals that they have been really religious but they're not losing anything? They're not gaining but they're not losing.

Dr. Abraham: It's a very complicated mechanism of why an individual gains weight. What we're beginning to understand is that there is a reset mechanism of how much calories does one need to feel full. In other words, these are probably mechanisms and centers in the brain that reset and we always feel hungry when there are enough calories that are retained in our system that we haven't burned yet. So researchers are still working on it. So it appears to be multiple factors that are involved.

Interviewer: And your piece of advice to that person still trying to lose that weight?

Dr. Abraham: A multi-pronged or multi-disciplinary approach works the best. You cannot change your genetics, it's too late to choose your parents, but at the same time, you can work with what you have if you have a plan about it. Sometimes, it does involve including professionals who are skilled in those fields to guide patients to decide the right thing. Not one cap fits all in this situation. So we try to modify what works best for each patient.

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