When Should you Treat a Benign Thyroid Nodule? (and How?)

Did you know that up to 80% of Americans will have a thyroid nodule in their life? So what are we supposed to do about them?

The good news is that most people don't need to do anything. In fact, the majority of patients with a thyroid nodule will never even know that they have it. For a sizable percentage, however, they will find a thyroid nodule while doing a scan for something else. We call those incidental thyroid nodules. Others will have them noted by their doctor or will find their nodule themselves

No matter how your thyroid nodule is identified, the first step in the management is to check your thyroid labs. If those labs show that your thyroid is working normally, or if it is underactive, those patients should have an ultrasound. On the other hand, if your thyroid is overactive, you should have a thyroid scan.

For those who have an ultrasound, the nodule will be characterized and the radiologist or surgeon will tell you if it is suspicious. If the nodule is suspicious, it needs a biopsy. If the biopsy says it's cancer, then you should (usually) have surgery. But there are options!

But most people will find that they have a low risk nodule or they will have a benign thyroid nodule. When should you treat a benign thyroid nodule? And how should you treat it.

We used to say that you should treat a benign thyroid nodule when it is bigger than 4cm. Doctors used to believe that there was a higher risk of cancer in these bigger nodules. Newer research does not support that idea very much, but the idea persists. For many people, therefore, the 4cm cutoff is a marker of when they should have treatment. Those same doctors usually recommend surgery as the only treatment option. That might mean that you need to take thyroid hormone for the rest of your life.

I don't usually use that 4cm cutoff. Instead, I ask 2 questions when a patient asks about when to treat their thyroid nodule?

1- Does it bother you?

2- Is your thyroid nodule growing?

3- How old are you? (I mean, usually I know the answer to this question, but still, it's relevant)

Why do I ask each of these questions? First, because if your benign thyroid nodule doesn't bother you, then it may not need to be treated no matter how big it is.

Next, if your thyroid nodule is growing, and it has been growing over time, then you might want to treat it before it becomes too big. This is especially important if you are trying to save your thyroid with a non-surgical thyroid treatment such as RFA, or if you are trying to avoid letting other people know that you had any treatment at all (such as with scarless thyroid surgery). These treatments are both either easier, safer, or have better outcomes with smaller nodules.

Finally, if you are younger, we tend to treat thyroid nodules sooner, even if they are smaller or not causing problems. That is because most nodules will grow over time.

So when should you treat your benign thyroid nodule? If it's bothering you, if it's growing, or if you are young. (or if you are worried about cancer or it's overactive, but that's a different topic for another day!)

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