The brain is always a piece of the Hashimoto’s puzzle

One thing I have learned from my readers is they are largely on their own. Rarely do conventional or alternative practitioners understand the depth of Hashimoto’s, a complex web that involves the neurological, hormone, and immune systems (we call it the neuroendocrine-immune axis). If you have Hashimoto’s you must think outside of the “thyroid box.” I am in the process of updating the tremendous amount of information I have learned about the thyroid since publishing Why Do I Still Have Thyroid Symptoms? in 2009. I am also writing other books that supply additional pieces to the Hashimoto’s puzzle.

My recent book Why Isn’t My Brain Working? discusses a big puzzle piece—the brain is always a part of the Hashimoto’s puzzle. My primary goal with the thyroid book was to let readers know most cases of hypothyroidism are autoimmune and to offer some basic solutions. My goal with the new brain book is to educate Hashimoto’s patients that their persistent fatigue, depression, and poor digestion may be brain-based as Hashimoto’s devastates brain health. If you have Hashimoto’s I encourage you to read the following chapters in the brain book:

Chapter 8: Gluten Sensitivity and Beyond

Chapter 9: Brain-Gut Axis

Chapter 10: Brain Inflammation

Chapter 11: What is Neurological Autoimmunity

Chapter 17: Hormone-Brain Connection

Thyroid education for the patient

I appreciate the amazing support from my readers and now understand the only way to raise the bar for thyroid care is to create accurate and referenced information not just health care providers but for patients. I like to think my first thyroid book helped evolve thyroid care beyond iodine supplements and natural thyroid hormones to a more complex but well rounded approach. I admit at times it is hard to see others repackage my years of hard work into their own blog articles and thyroid books with no acknowledgement, but at the end of the day what matters most is the information gets to people who are suffering. I will continue to work very hard the next few years to update and share directly with patients new pieces to the thyroid puzzle.

In this newsletter, however, I would like to clarify the concept of goiter and goitrogens.

thyroid enlargement

Goiter and goitrogens: Another tale in thyroid misunderstanding

Many people assume any enlargement of the thyroid gland is a goiter and indicates an iodine deficiency. Nothing is further from the truth and I would like to clarify the information. I also want to address the outdated concept of the food goitrogens still embraced by many doctors and patients despite lack of clinical evidence. But first let’s start with thyroid gland enlargement.

Thyroid enlargement from thyroiditis

Enlargement of the thyroid gland is classified as diffuse if the entire thyroid gland is enlarged or solitary if only a small section of the thyroid is enlarged. The most common causes of solitary enlargements are benign cysts and nodules. However, a nodule should always be evaluated to make sure it is not a malignant growth found with thyroid cancer.

Now let’s talk about diffuse enlargement. This means the entire gland has become enlarged. The two main causes of diffuse enlargement are goiter or swelling from thyroiditis (inflammation of thyroid gland). Diffuse enlargements are rarely found with thyroid cancer

One of the key ways to differentiate thyroiditis from goiter is to look at whether the size of the thyroid changes. With thyroiditis, the thyroid gland constantly changes size as it goes through various stages of inflammation and swelling. Painless thyroiditis (the thyroid gland is not sensitive to touch) is the hallmark of autoimmune thyroiditis. Painful thyroiditis, on the other hand, is usually associated with viral infection in the thyroid gland and accompanied by fever and signs of infection (bacterial infections are rare due to the thyroid gland’s iodine-rich, anti-bacterial environment).

If you have Hashimoto’s and have noticed painless swelling of your thyroid gland you do not have goiter but instead painless thyroiditis. Factors that may trigger swelling and autoimmunity include iodine, gluten, stress or anything else that activates the immune system. Unfortunately, many people with Hashimoto’s are misdiagnosed with goiter when in fact they have swelling from autoimmune thyroiditis. Remember, the key to diagnosing autoimmune thyroidits (inflammation of the thyroid gland) is painless swelling of thyroid that comes and goes.

Thyroid enlargement from goiter

Now let’s talk about goiter. Goiter is not swelling but instead thick tissue growth of the thyroid that does not change size. The most common cause of goiter in the United States is not iodine deficiency or overconsumption of goitrogenic foods. I know this is widely believed in the natural medicine community, but anyone who tells you this does not know how to read the scientific literature or perform a proper thyroid clinical work-up. The single most common cause of goiter in the United States is from chronically undiagnosed autoimmune Hashimoto’s completely unrelated to iodine deficiency.

Let’s talk about what actually causes a goiter. Goiter is excessive tissue growth of the thyroid and occurs when the thyroid gland has been exposed to too much thyroid-stimulating hormone (TSH) or human chorionic gonadotropin (HCG). And yes, HCG shots for weight loss can cause goiter, but it typically occurs due to pregnancy. Please understand thyroid tissue does not magically grow in the absence of sufficient iodine. It grows when thyroid cells are stimulated by chronic or aggressive thyroid-stimulating hormone (TSH) exposure. This may occur from iodine deficiency, but more often results from chronic undiagnosed Hashimoto’s or pregnancy. Goiter due to iodine deficiency is rare in the United States. Unfortunately, however, many naïve and unskilled educators, doctors, thyroid book authors, and health care practitioners still make the claim.

What do you do if you have goiter?

So what do you do if you have goiter? First you objectively confirm the diagnosis with a thyroid ultrasound. Second, you must find out if you still have an ongoing goiter mechanism as evidenced by an elevated TSH or HCG level. If those are not elevated, chances are you developed the goiter in the past and it is no longer being stimulated to grow. Most people don’t even know they have a goiter until a doctor examines them, at which point TSH needs to be checked to see if it’s still an ongoing mechanism. If TSH is elevated, the possibilities are Hashimoto’s (most common and confirmed with elevated thyroid antibodies), iodine deficiency, or a goitrogenic compound that blocks iodine uptake of the thyroid gland. If it’s iodine-based then taking iodine supplements should immediately correct all thyroid symptoms and normalize TSH.

If that doesn’t happen then it’s due to either a goitrogen or Hashimoto’s. You can identify Hashimoto’s through elevated serum thyroid peroxidase (TPO) or thyroglobulin (TGB) antibodies. You need to check both. Also, sometimes the test will come back negative despite having Hashimoto’s, so if that happens it’s important to repeat the test.

Goitrogens in foods, drugs, and chemicals

Although the most common cause of goiter is Hashimoto’s, let’s talk about goitrogens.

Goitrogens are substances (whether in drugs, chemicals, or foods) that disrupt the production of thyroid hormones by interfering with iodine uptake in the thyroid gland. This triggers the pituitary to release TSH, which then promotes the growth of thyroid tissue, eventually leading to goiter. Although iodine is important for thyroid function, it only takes a pinhead of iodine a day and a teaspoon of iodine over a lifetime to avoid thyroid goiter.

Let’s shatter another myth about the thyroid. Normal consumption of goitrogenic foods do NOT cause goiter (consuming large amounts of juiced goitrogens, such as cabbage juice, would not be considered normal consumption). Examples of goitrogenic foods include broccoli, cabbage, kale, cauliflower, Brussels sprouts, soy, and a variety of other fruits and vegetables. The fear of goitrogenic foods is another example of how people have taken in vitro (test tube) studies using unbelievably excessive amounts of a dietary goitrogens and concluded eating any small amount of these foods can cause a goiter. For those who don’t believe me, please go on a goitrogen diet loaded with strawberries, kale, peaches, broccoli, cauliflower, and spinach and see if you develop a goiter. I promise you will not. As a matter of fact, these phytochemical-rich foods are essential for health when you have autoimmunity, except for soy, which is immune reactive for many Hashimoto’s patients. I have seen several patients develop thyroiditis swelling with soy and conclude the soy caused a goiter. In those cases the thyroid swelling reduced when they removed the soy from their diet, confirming that the swelling was due to an inflammatory response and not goiter.

Although dietary goitrogens are not clinically relevant there is not doubt that environmental compounds and medications may cause goiter. Listed below is list of commonly known goitrogens.

Medications that may promote goiter

  • Anti-thyroid medications (methimasole, Tapazol, propylthiouracil): used for hyperthyroid patients
  • Sulfonamides: used to prevent the growth of bacteria in the body
  • Amiodarone (cardarone): used as an anti-arrhythmic agent
  • Ethionamide (Trecator): used as an antibiotic for the treatment of tuberculosis
  • Aminosalicylate Sodium (Tubasal): used an anti-infective for the treatment of tuberculosis
  • Lithium: used for bipolar disorders, depression, anxiety , cluster headaches and migraines
  • Aminoglutethimide: used for the treatment of Cushing’s syndrome and other endocrine disorders that produce excess hormones (glucocorticoids, mineralcorticoids, estrogen, androgens)
  • Salofalk: used for the treatment of ulcerative colitis

Environmental compounds that may promote goiter

  • Mercury, Arsenic and potentially other heavy metals
  • Nitrates
  • Pesticide compounds

Unfortunately, the only accurate and objective way to know whether a goitrogenic compound is causing goiter is to do a radioactive uptake test. Unfortunately, this test can trigger a flare-up in those who suffer from autoimmunity. However, if a person with a goiter is being exposed to any of the known goitrogenic compounds, removing exposure to those compounds is vital.

I hope this information helps clarify the issue for you. I know many of you who have Hashimoto’s have had your painless thyroiditis swelling misdiagnosed as goiter or have had your goiter incorrectly blamed on iodine deficiency.

Points to consider when you have an enlarged thyroid gland

I encourage thyroid patients with an enlarged thyroid gland to consider the following points:

  1. If you have been diagnosed with goiter make sure you ask for an ultrasound. Many doctors misdiagnose painless autoimmune thyroiditis as goiter. A thyroid ultrasound delivers a clear and proper diagnosis.
  2. If you have an actual goiter, please test your TSH test to see whether the goitrogenic mechanism is still active. If TSH is elevated please test TPO and TGB thyroid antibodies to rule out Hashimoto’s, the most common cause of goiter. If your TSH is normal, then something in the past caused your goiter.
  3. Be cautious of health care providers who immediately assume iodine deficiency when you have a goiter. They will place you on iodine and be shocked to see your goiter size not change. Remember, goiter tissue is permanent tissue enlargement. It can only be reduced with excess thyroid hormones to induce atrophy or surgery, not iodine.
  4. If you have painless autoimmune thyroiditis, pay careful attention to any mechanisms that cause it to swell, which can indicate exacerbation of autoimmunity. The most common triggers are food intolerances, stress, overtraining, overworking, and lack of sleep. You can use topical glutathione cream directly into your thyroid gland and see if it reduces your swelling.

Body Ecology radio interview with Donna Gates648_large

Please check out my recent radio interview with the Donna Gates, the author of the body ecology diet at


  • Susan S. May 2, 2014 at 6:22 pm

    Dear Guri Dr. K,

    Hearing about you on Mark Ryan’s website got me to immeditely stop gluten and improve so thank you both. <3

    I'm almost done reading your awesome book, "Why do I still have…" and it as well as everything I've read here never addresses the odd one like me who is suppose to have Hashimoto's but NEVER had one hypo symptom. I'm super hyper and since childhood diagnosed with ADHD and today have classic Hyperactive symptoms (not graves, no palpatating, just fast metabolism and energetic) and heard always "slightly overactive thyroid". Now I have a disease that usually affects Hyperthyroidistic patients ! ? ! ?

    From what I've learned from you, I suppose I caused my own Hashi's by years of abusing sugar and overeating then ignoring my gut issues..until I yanked Gluten from the diet. Luckly I've stayed somewhat slim and now even slimmer but I am definitaly NOT a hypo patient like everybody keeps mentioning. How unusal is it for a hyper human to get Hashi's??

    I'm told I have a thyroid (cold) nodule which oddly started to grow once I was put on thyroid meds..could it be the wrong drug messing with my TSH levels and stimulating this? NOBODY has tested my nodule only given me 2 Thyroid Uptake tests here in Germany which do not indicate status of a cold nodule.. BOY am I in the dark and getting ripped off.

    Wish I could fly to SanDiego and see you.

    Thanks for your passion and work you are doing to help us.

    • Susan S. May 2, 2014 at 6:25 pm

      Dr. K,

      In my salutation above, I meant to write “Dear Guru Dr. K.”

      I hope you realize what I meant.
      All the best, Susan

    • Thyroid Book May 5, 2014 at 8:27 pm

      This is complicated and requires a practitioner to weigh in. If it’s possible, you may want to work with a practitioner in the US via email or Skype, some of them do that and can better guide you.

  • Susan May 12, 2014 at 10:45 am

    Thank you so much for your answer..I needed to hear just that.
    I’m going to call Dr.Noseworthy in Florida…also found a link to him from Marc Ryan’s
    website; it’s meant to be!

    Honored to hear from you… Thank you again Dr. K for getting me off gluten & on my way!!

  • Genine September 28, 2014 at 7:04 pm

    Hi Doctor K thank you for the information on thyroid health I was diagnosed with hyper-/with a goiter the treatment I choose was radioactive iodine treatment. I am am hypo-with a goiter w nodules do have any suggestions

  • Jason September 30, 2014 at 7:09 pm

    Is it alright to juice 1 glass of cabbage juice a day?

    • Thyroid Book October 5, 2014 at 10:30 pm

      He does not recommend juicing goitrogenic vegetables, just eating them normally.

  • dolly October 18, 2014 at 12:23 pm

    can I do something to get off my medication levothyroxcin, everybody sas we have to be on it for life.

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