Introduction to Hashimoto’s Disease

Hashimoto’s disease, or Hashimoto’s thyroiditis, is a chronic inflammatory condition of the thyroid gland. This is the most common cause of hypothyroidism, or underactive thyroid, in the United States and many other countries. We also know that Hashimoto’s disease is caused by an immune malfunction where your own immune system attacks your thyroid gland, causing inflammation and fibrosis/scarring of the gland. Hashimoto’s disease affects roughly 4 out of 1000 women and 1 out of 1000 men each year. Overall, 10-12% of the general population will develop Hashimoto’s at some point in their life. Most women are diagnosed between the age of 30-50 years old.

Below I will discuss the top 3 things to know about Hashimoto’s disease, including the cause, treatment, and why thyroid surgery is curative.

Learn more about all types of thyroid disease, thyroid cancer, and expert thyroid care.

Top 3 Things to Know about Hashimoto’s Disease

Top Things to Know About Hashimoto’s Disease #1: This is a disease caused by your own immune system

Hashimoto’s thyroiditis is an autoimmune disease where the immune system malfunctions (autoimmune disease). We do not know exactly why it occurs, but we think multiple factors may play a role. Excessive iodine may trigger thyroid disease. There is likely a hormonal component because women are affected much more commonly than men. Lastly, there is likely a genetic factor as well because Hashimoto’s thyroiditis is seen in families where multiple people have thyroid disease or autoimmune disease. 

Hashimoto’s disease involves your immune system causing inflammation and scarring in the thyroid gland. This process is often cyclical and causes repeated damage to the thyroid gland itself. This ultimately leads to decreased thyroid hormone production (hypothyroidism) and subsequent symptoms. Many patients with Hashimoto’s disease also have other autoimmune diseases (i.e. Lupus, Sjogren’s, Rheumatoid Arthritis, etc.).

While a skilled, thorough ultrasound in the best way to image the thyroid and lymph nodes in the neck, Hashimoto’s can make this test very challenging. Hashimoto's disease can confuse the diagnosis of a thyroid nodule or lump on ultrasound, particularly to providers who are untrained and not experts in thyroid disease.  There is no question that patients with Hashimoto's can develop real thyroid nodules/growths and real cancer. Hashimoto’s thyroiditis, however, may also be associated with thyroid pseudo-nodule formation. These pseudo-nodules are not true, discrete thyroid nodules, but they can be hard to distinguish from thyroid nodules/cancer, especially if a thyroid expert is not interpreting the ultrasound images.  Pseudo-nodules found on ultrasound in Hashimoto’s patients will come and go or change based upon unknown clinical and pathophysiologic factors. Finally, enlarged lymph nodes are also frequently observed due to the inflammatory process and are not able to be differentiated from metastatic cancerous lymph nodes on ultrasound.

Learn more about Hashimoto’s disease, including symptoms and diagnosis.

Top Things to Know About Hashimoto’s Disease #2: Many patients will need medical treatment

Patients with symptomatic Hashimoto’s disease need expert endocrinology care and monitoring. Due to the scarring, inflammation, and fibrosis caused by the immune system attacking the thyroid tissue, Hashimoto’s thyroiditis frequently requires treatment. Many individuals develop a diseased thyroid gland (see Figure 1 below) that is not able to function well enough to meet the physiologic needs of the body with respect to thyroid hormone production (hypothyroidism). Common symptoms include fatigue, weight gain, memory problems or brain fog, depression, neck/thyroid discomfort, thinning hair or hair loss, heat/cold intolerance, skin and nail changes, joint and muscle pain, constipation, difficulty sleeping, and changes in appetite. Once this occurs, patients are started on thyroid hormone medication and are monitored for the rest of their life. The vast majority of patients do very well on thyroid medication as long as they take the medication as directed, live a healthy lifestyle, and have their thyroid levels checked regularly (typically 1-2 times per year).

Occasionally, a small percentage of patients need additional treatment for Hashimoto’s disease and the symptoms. In the short-term, some patients need anti-inflammatory medications and/or steroids to alleviate symptoms from the inflammation, particularly the pain and swelling. Additionally, some anecdotal evidence suggests that dietary changes, such as removing gluten and increasing anti-oxidant intake, may improve some symptoms.

Despite multiple treatments and optimal thyroid hormone replacement, there is a small portion of patients who still do not feel well overall. Although we are unsure exactly why this occurs, the general consensus is that a broader, systemic component of the immune system malfunction is the cause. These patients, along with patients who have trouble regulating the ideal dosage of thyroid medication or who have other thyroid disease (i.e. nodules, thyroid cancer, etc.) are candidates for definitive cure of Hashimoto’s disease with expert thyroid surgery.

Figure 1: Hashimoto’s disease on ultrasound. Note the irregular, moth-eaten, scalloped appearance of the thyroid tissue outlined in orange.

Figure 2: Normal thyroid tissue on ultrasound

Top Things to Know About Hashimoto’s Disease #3: Thyroid surgery is the definitive cure

Many patients with Hashimoto’s disease have thyroid surgery for a number of reasons. Patients with Hashimoto’s can have large or suspicious nodules/tumors in the gland, thyroid cancer, and/or an enlarged thyroid gland (goiter) that require thyroid surgery. A small percentage of patients with Hashimoto’s disease, however, benefit from surgery to cure this illness itself.

As noted above, some patients with Hashimoto’s disease are symptomatic despite having normal or optimal thyroid hormone labs while taking a consistent dose of thyroid hormone medication. Additionally, a small number of patients are not able to remain on a consistent dose of thyroid medication and continue to have fluctuating symptoms and medication dosages over a long period of time. These clinical situations can be frustrating, exhausting, and overwhelming for patients and their endocrinologists. Fortunately, thyroid surgery to remove the entire gland is curative.

You cannot have Hashimoto’s disease, or its symptoms, if you do not have a thyroid gland! More and more studies are showing that expert thyroid surgery done at the right center with very low complication rates is very effective at curing Hashimoto’s disease and resolving many, if not all of, the symptoms associated with the illness. Some of our patients have felt noticeably better within 24 hours of thyroid surgery.

Due to the scarring and inflammation from Hashimoto’s thyroiditis, surgery can be very challenging. The entire thyroid gland must be removed to cure Hashimoto’s disease. Complete thyroid removal is even riskier than thyroid surgery for half the thyroid. This is because both sides of the neck are worked on, exposing all 4 parathyroid glands (calcium control glands) as well as all the nerves to the voice box to potential damage. Thus, total thyroid removal for Hashimoto’s disease should only be done by high-volume, experienced surgeons at busy centers such as ours.

Summary

Hashimoto’s disease is very common, and affects women more often than men. Most patients with Hashimoto’s thyroiditis will end up needing medical treatment at some point. This almost always involves taking thyroid hormone medication to meet their physiologic needs since the diseased thyroid gland is not functioning adequately. A small percentage of patients, however, have persistent symptoms, poor quality of life, and are not able to be improved and treated with a consistent dose of thyroid medication. These patients can be cured of Hashimoto’s disease and have a vastly improved quality of life with expert thyroid surgery.

Our team of thyroid cancer experts is here to help and guide you every step along the way and will be there for you after your thyroid surgery for Hashimoto’s disease. To learn more and become a patient, please see our resources below.

Additional Resources

• Become our patient by filling out the form at this link. 
• Learn more  The Clayman Thyroid Center here. 
• Learn more about our sister surgeons at the Scarless Thyroid Surgery Center, Norman Parathyroid Center, and Carling Adrenal Center
• Learn more about the Hospital for Endocrine Surgery.