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 HERE.


  • Sue November 12, 2013 at 5:52 pm

    I love your work. I love your books. I just wonder why you never mention Graves Disease. I know it is a cause of thyroid enlargement, as well as goiter. It is a disease of the thyroid along with Hashimoto’s–and yet I never see you mention it anywhere. Where I live (upstate NY) it is actually a common diagnosis.

    • Elaine February 9, 2014 at 6:30 pm

      He mentions it a little in relation to autoimmunity as all autoimmune diseases require addressing the immune health.

  • Kim Rader November 12, 2013 at 6:17 pm

    I just wanted to say I have been supplementing with iodine 12.5mg per day sometimes more (feeling under the weather) with great success! I’m hypothyroid and I have been able to lower my dose of desicated Nature-Throid. The key with iodine is providing the co-factors so it functions properly. Therefore I also supplement with Selenium, Zinc, B complex and a protein shake for tyrosine. I also have yet to remove my almalgam mercury poisoning fillings…so I eat cilantro frequently and supplement with Chlorella to help detox the heavy metals.

  • Julie November 13, 2013 at 12:08 am

    Love the books & newsletter… I have several issues, some are car accident related and I have done a lot of the suggested treatments Dr. K goes over. I am improving but wanted to bring up the fact that X-rays seem to effect my thyroid, latest example was a full mouth xray at a dentist who did not have the DIGITAL machine. Within 2 weeks, my symptoms got so much worse and I gained over 30 pounds by 3 months and now have leveled off but not loosing at 9 months. I am getting all metal crowns replaced with non-metal crowns… another factor. Hope this helps.

  • Heather Burkhardt November 13, 2013 at 10:09 am

    Thank you Dr. Kharrazian. I am really grateful for your work. I read your first thyroid book, immediately found a doctor from your website, and he has helped me tremendously. I participate in the Hashimoto\’s 411 forum on FB which I found via your blog. I really appreciate the direction you are going with patient centered education, and am always eager to read your blogs. Thanks again, you have helped me.

  • Jason November 13, 2013 at 11:32 am

    Fantastic article Dr. K! Curious of your thoughts/insight into the potential cause(s) of thyroid nodules. If biopsy shows negative for malignancy and TPO, TBG are both negative, what might be the mechanism for multi-nodular thyroid? Arsenic or other heavy metals/chemical and environmental toxins?Can\’t wait to pick up the new brain book – heard your interview on Underground Wellness and was fascinated by your insights. Thanks for all the work you do!

    • Kate November 19, 2014 at 11:37 am

      Hi Jason –
      Your question is right on in what I need to understand. I am not seeing lots of replies and hope you could direct me to a better source for a response to your question. I am still mind blown by discovering and seeing him in interviews. Just an hour ago was trying to figure out if he means Goiter and nodules are the same thing and I don’t think so. Also my brother and Sister both had their thyroid removed after diagnosis of cancer. I am being led to believe by endocrinologist ( Upstate NY) that it’s only a matter of time and I should just have my thyroid removed…. my gut is saying hold on a minute… so this information is fantastic but I need to understand his relationship when he talks about goiter, swelling and nodules.
      Please reply!!
      Thank you so much!

  • Mickey Trescott December 8, 2013 at 9:06 am

    Dr. Kharrazian,
    Thank you for this informative article and for clearing up the confusion regarding goitrogens. I am asked constantly about them by those who want to try an elimination diet but have been scared into thinking they need to be avoided religiously by their alternative health practitioner. In my own personal recovery from Hashimoto’s, I never noticed a difference when I ate them or not. In fact, I craved the leafy greens like kale and spinach when I was avoiding them.

    I will be referencing your article on a blog post I have coming up in the next couple of weeks. Thanks again!


  • travelingthrough January 10, 2014 at 10:34 am

    So is my “hyperemic” thyroid (i.e. – more numerous blood vessels & a little swelling) *not the same thing as a goiter?) I would love to find this answer.

    Also, in your article about iodine & Hashimoto’s, could you please add an update with regard to your opinion considering the use of selenium in connection with this? Because people disregard you and Kessler because you didn’t mention selenium, and I’ve been trying to get to the bottom of understanding this.

    I need you to throw selenium into the discussion for iodine & Hashimoto’s. Thanks much!

  • Peacefullbliss February 6, 2014 at 12:39 pm

    I had a mutinodulnar goitre for about 15-20 years. I had regular thin needle aspirations to check it before I had my thyroid removed in 2012. The goitre had become too large. I had my thyroid levels tested regularly and was always informed the levels were “normal”. I was never prescribed thyroid replacement. For the first time ever in 2013 I had my antibodies levels tested. The lab results simply said my antibodies levels were “normal” no figures given. My mother has two autoimmune diseases. Could I possibly have Hashimotos despite an apparent negative antibodies result? Should I have my antibodies retested? I would like to know where I stand.

    • Elaine February 9, 2014 at 6:33 pm

      Did they test TPO and TBG? Also, sometimes the tests come back negative if overall immunity is depressed. When people boost their health and address leaky gut immunity improves and the tests will come back positive even though they feel better.

    • J. Kenney December 11, 2014 at 8:11 pm

      This for Peacefullbliss: Obviously I am only seeing this in Dec ’14. If you no longer have a thyroid gland, then you must have replacement thyroid hormone, natural desiccated thyroid. Get the thyroid essential book, Hypothyroidism: The Unsuspected Illness, by Broda O. Barnes, M.D., Ph.D. Access this web page:

      Use the basal temperature test, ingeniously developed by Dr. Barnes, described there to assess your thyroid state. (That needs a known accurate thermometer.) I don’t have the URL before me right now, so you can find the Broda Barnes Foundation with a little googling. They maintain a physician list although it is somewhat dated.

      Good luck!

  • Lucy May 5, 2014 at 10:25 pm

    I have been recently diagnosed with low thyroid and a borderline case of Hashimoto’s. I have been reading recently that it’s not healthy to eat goitrogens raw…that they can suppress thyroid function. I was just starting to juice kale etc… but now am unsure if I should continue that with Hashimoto’s. Should the goitrogens be cooked instead? I want to continue juicing as a supplement to my diet but don’t want to do something detrimental to my thyroid as a result.

  • Elaine May 6, 2014 at 10:34 am

    Although Dr. Kharrazian does not discourage people from eating kale, cabbage, etc cooked and in normal amounts, he does say juicing large amounts raw can be overly goitrogenic. Also, not sure if there is such a thing as borderline Hashimoto’s. If your antibodies are positive then you have an autoimmune reaction to the thyroid gland.

  • Jane May 29, 2014 at 6:01 pm

    Thank you Dr Kharrazian, for clearing up the confusion and writing this article. I just had my 1st thyroid ultrasound and because of your work, I know where I stand, especially on iodine. Someone needs to write a book called ‘Stop the Iodine Madness’, it’s so 1980’s!

  • Robin White July 22, 2014 at 12:02 pm

    Great information. I have Hashimotos and have never had an ultrasound done. Is it possible that an enlarged thyroid can cause tinnitus? I have had this for 10 years when I went into perimenopause. I do believe they are all related somehow. Thank you!

  • Cindi August 29, 2014 at 12:46 pm

    Yours is the only reference I have found that lists food intolerances as a trigger. I haven’t been able to track down another cause for my painless enlarged thyroid which comes and goes for several years. Can you elaborate at all on food intolerances?

    I am not positive but it seems like one thing that causes this for me is putting coconut oil on my body. But coconut oil allergies are supposed to be extremely rare, and eating coconut oil and milk don’t seem to bother me.

  • Mandeep September 23, 2014 at 11:13 pm

    Hello. I am having goitre problem. for how much time we have to apply topical glutathione cream and how many times a day to see result

  • Sonia December 13, 2014 at 4:09 am

    Hi, is Natural L-Glutathione cream with Setria the same as Topical glutathione cream?
    Thanks for your reply. Sonia

  • Angy May 4, 2015 at 3:43 pm

    So what can I do with TSH 15 but all t3 t4 rev t3 and t4 all in normal ranges? What blood tests should I run?

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