CLINICAL APPLICATIONS

* Hyperthyroidism 

¡± with low-grade fever, tachycardia (90 to 120 heartbeats per minute), tremors of the tongue and fingers, enlarged thyroid gland, unilateral or bilateral swollen and bulging eyes

¡± with palpitations or tachycardia, fatigue, weight loss, fidgeting, irritability, bad temper, aversion to heat, perspiration, hunger and increased appetite, and increased blood pressure

 

WESTERN THERAPEUTIC ACTIONS

* Lowers the level of thyroid hormone in the blood

* Reduces enlargement of the thyroid gland

* Treats the unwanted ¡§sympathetic excess¡¨ signs and symptoms of hyperthyroidism

 

CHINESE THERAPEUTIC ACTIONS

* Softens hardness, resolves nodules, and eliminates phlegm

* Clears toxic heat and drains Liver fire

* Tranquilizes the shen (spirit)

* Tonifies qi and yin

 

DOSAGE

Take 3 to 4 capsules three times daily. However, the dosage may need to be adjusted based on age, body weight, severity of condition, and response to the treatment. Patients with hyperthyroidism (other than thyrotoxicosis) should notice dramatic improvement within one to one-and-a-half months of herbal treatment.

 

INGREDIENTS

Bie Jia (Carapax Trionycis)

Chuan Niu Xi (Radix Cyathulae)

Fang Feng (Radix Saposhnikoviae)

Gan Cao (Radix et Rhizoma Glycyrrhizae)

Huang Qi (Radix Astragali)

Mu Li (Concha Ostreae)

Xia Ku Cao (Spica Prunellae)

Xuan Shen (Radix Scrophulariae)

Yuan Zhi (Radix Polygalae)

Zhe Bei Mu (Bulbus Fritillariae Thunbergii)

Zhi Huang Qi (Radix Astragali Praeparata cum Melle)

Zhi Mu (Rhizoma Anemarrhenae)

Zhi Zi (Fructus Gardeniae)

 

BACKGROUND

Hyperthyroidism is thyroid hormone excess with clinical manifestations such tachycardia, fatigue, weight loss, nervousness, tremor, heat intolerance, increased appetite and hunger, and in some cases, unilateral or bilateral swollen and bulging eyes. Hyperthyroidism may be caused by autoimmune disorder (Grave¡¦s disease), iodine excess, and hyperfunctioning (toxic adenoma, toxic multinodular goiter) or inflammation (thyroiditis) of the thyroid glands. Optimal management requires treatment of the cause and balancing of the thyroid hormones.

 

FORMULA EXPLANATION

According to traditional Chinese medicine, hyperthyroidism is a combination of qi and yin deficiencies, Liver fire rising, and phlegm stagnation. The fundamental causes are qi and yin deficiencies while the symptoms and signs show Liver fire and phlegm stagnation. Treatment, therefore, must address both the cause and the symptoms simultaneously.

        Bie Jia (Carapax Trionycis) nourishes yin and resolves hard lumps. Xuan Shen (Radix Scrophulariae) and Zhi Mu (Rhizoma Anemarrhenae) have three important functions: replenishing the jing (essence), clearing heat and resolving hard lumps in the body. Zhi Zi (Fructus Gardeniae) and Xia Ku Cao (Spica Prunellae) clear heat and purge Liver fire. They reduce the ¡§sympathetic excess¡¨ signs and symptoms commonly associated with hyperthyroidism, such as increased heart rate, increased blood pressure, and tremor. Zhe Bei Mu (Bulbus Fritillariae Thunbergii) resolves phlegm and further assists Xia Ku Cao (Spica Prunellae) to disperse lumps and hardenings. Clinically, Zhe Bei Mu (Bulbus Fritillariae Thunbergii) and Mu Li (Concha Ostreae) are commonly used to treat goiter. Chuan Niu Xi (Radix Cyathulae) stimulates blood circulation and enhances the overall effectiveness of the formula. Yuan Zhi (Radix Polygalae) calms the shen (spirit) and relieves nervousness and anxiety. Gan Cao (Radix et Rhizoma Glycyrrhizae) harmonizes all the herbs of the formula. Fang Feng (Radix Saposhnikoviae) and Huang Qi (Radix Astragali), two principle herbs in the formula Yu Ping Feng San (Jade Windscreen Powder), have excellent effects to strengthen wei (defensive) qi and stop perspiration.

        Together, herbs in Thyrodex effectively treat hyperthyroidism by clearing heat and fire, eliminate phlegm accumulation, and nourish qi and yin.

 

CAUTIONS & CONTRAINDICATIONS

* This formula is contraindicated during pregnancy and nursing.

* Patients with thyrotoxicosis or thyroid storm require emergency medical treatment. Warning signs and symptoms of thyroid storm or thyrotoxicosis include high fever, tachycardia, fidgeting, irritability, nausea, vomiting, obvious weight loss, profuse perspiration, delirium, and possible loss of unconsciousness.

* The etiology of Grave¡¦s disease is the excessive stimulation by the immune system of the thyroid gland to produce thyroid hormone. Therefore, during the acute inflammatory phase of the disease when the immune system is activated by the presence of pathogens, qi tonics that boost the immune system, such as Huang Qi (Radix Astragali) in this formula, should not be used since this herb may further stimulate the immune system. During this acute inflammatory phase, Gardenia Complex is a more suitable formula as it has herbs that clear heat and fire to suppress the immune system and reduce inflammation throughout the entire body.

 

CLINICAL NOTES

* Patients with hyperthyroidism (other than thyrotoxicosis) should notice dramatic improvement within one to one-and-a-half months of herbal treatment. Most symptoms should completely subside within three to six months of treatment. Protrusion of the eye(s) may persist despite herbal treatment.

* Patients with hyperthyroidism can be treated with drugs, herbs, or both. However, if both drugs and herbs are used, it is important to monitor the patient's condition frequently to ensure proper control of the signs and symptoms. Over-dosage with drugs and/or herbs may cause "hypothyroid-like" signs and symptoms, and under-dosage may contribute to "hyperthyroid-like" signs and symptoms.

* Practitioners should suspect hyperthyroidism when the following manifestations are present:

¡± Young adults (especially female) who have a bad temper, hunger with excessive appetite, palpitations, and profuse perspiration.

¡± Young adults (especially female) who are fidgety and irritable, have early menses with a light flow, amenorrhea, and significant weight loss.

¡± Young adults with sudden onset of difficulty with physical movement, numbness of legs, or possible collapse of leg muscles while walking.

* Thyrodex is an herbal formula developed by Professor Xiao-Ping Zhang of Anhui Hospital of Traditional Chinese Medicine. It is an empirical formula designed to treat patients with hyperthyroidism. It has been used for over 30 years in China and has helped several thousand patients with hyperthyroidism.

 

Pulse Diagnosis by Dr. Jimmy Wei-Yen Chang:

* Hyperthyroidism caused by pituitary gland problem: floating, rapid, weak pulse on the cun positions.

* Hyperthyroidism related to stress: floating, rapid, weak pulse on the left guan.

 

SUPPLEMENTARY FORMULAS

* For high blood pressure and fast heart rate due to excess fire, add Gardenia Complex.

* For anxiety and nervousness, add Calm (ES).

* For insomnia, add Schisandra ZZZ or Calm ZZZ.

* For hypertension, use Gastrodia Complex or Gentiana Complex.

* For enlarged thyroid, use with Resolve (AI).

* For thirst with dry mouth and throat, add Nourish (Fluids).

* With Kidney yin deficiency, add Nourish or Kidney Tonic (Yin).

* With blood stagnation, add Circulation (SJ))

* For dysmenorrhea, use Mense-Ease.

 

ACUPUNCTURE TREATMENT

Traditional Points:

* Huatoujiaji points (Extra 15), Jianshi (PC 5), Sanyinjiao (SP 6), Yinxi (HT 6), Fuliu (KI 7), Taixi (KI 3), Neiguan (PC 6)

* Xingjian (LR 2), Quchi (LI 11)

 

Classic Master Tung's Points:

* Hyperthyroidism: Sanzhong (T 77.07), Tongguan (T 88.01), Simashang (T 88.18), Simazhong (T 88.17), Simaxia (T 88.19), Xinling (T 33.17)*, Sihuashang (T 77.08), Yizhong (T 77.05), Erzhong (T 77.06). Bleed the Helix on the earlobe. Bleed before needling for best result.

* With bulging eyes: Sanzhong (T 77.07), Tongguan (T 88.01), Simashang (T 88.18), Simazhong (T 88.17), Simaxia (T 88.19), Xinling (T 33.17)*, Sihuashang (T 77.08), Yizhong (T 77.05), Erzhong (T 77.06). Bleed the Helix on the earlobe. Bleed before needling for best result.

 

Master Tung¡¦s Points by Dr. Chuan-Min Wang:

* Hyperthyroid: Yizhong (T 77.05), Erzhong (T 77.06), Sanzhong (T 77.07)

 

Balance Method by Dr. Richard Tan:

* Left side: Guanchong (TH 1), Yangchi (TH 4), Taichong (LR 3), Ququan (LR 8)

* Right side: Neiguan (PC 6), Zhongchong (PC 9), Chongyang (ST 42), Lidui (ST 45), Yanglingquan (GB 34), Zulinqi (GB 41)

* Yintang, bilateral ear Shenmen and Anmian

* Left and right sides can be alternated from treatment to treatment.

 

Auricular Medicine by Dr. Li-Chun Huang:

* Hyperthyroidism: Thyroid, Pituitary, Endocrine, Thalamus, Nervous Subcortex, Kidney, Liver, Heart, Occiput, Shenmen. Bleed Ear Apex.

* Simple goiter: Thyroid, Endocrine, Pituitary, Thalamus, San Jiao, Kidney, Liver

 

NUTRITION

* Consume plenty of the following foods: broccoli, brussel sprouts, cabbage, cauliflower, kale, mustard greens, peaches, pears, soybeans, spinach, and turnips. These foods may help to suppress thyroid hormone production.[1]

* Short-term consumption of foods rich in iodine will provide temporary relief of hyperthyroidism due to a negative feedback mechanism. Long-term consumption, however, is not recommended because foods rich in iodine will facilitate the production of thyroid hormone. Foods rich in iodine include sea salt, iodized salt, kelp, and sargassum.

* Eat a variety of fresh, organic fruits and vegetables of all colors. 

* Incorporate more high-fiber whole grains and nuts into the diet.

* Drink warm or hot liquids with meals. Putting cold and ice on any part of the body will immediately constrict the flow of blood to that region. Similarly, drinking cold or iced drinks with meals will hinder the natural peristaltic movements of the digestive system.

* Foods with antioxidant effects, such as vitamin A, C and E are beneficial as they neutralize the free radicals and minimize damage to cells. Beneficial foods include citrus fruits, carrots, green leaf vegetables, and green tea.

* Chew food completely and thoroughly. The digestive tract can process and absorb smaller pieces of food much better than food that is incompletely chewed. Larger pieces of food can lead to incomplete digestion and digestive discomfort.

* Always eat breakfast. According to the TCM clock, the most optimal time for the digestive system is in the morning from 8 to 10 a.m.

* Give the body two to three hours between the last meal of the day and bedtime. During sleep, the digestive system slows down as well. Make sure the body has adequate time to digest the food before going into sleep mode.

* If the patient is allergic to any food or feels uncomfortable after eating certain foods, then they should avoid eating these foods.

* Avoid fast food, processed foods, junk food, artificial sugars, and carbonated drinks. Stay away from meat, greasy food, alcohol, caffeine, tap water, iron supplements, and vegetables and fruits with pesticides.

* The Spleen is responsible for generating post-natal qi and good Spleen function also contributes to a healthy immune system. Foods that damage the Spleen should be avoided:

¡± Avoid any and all foods that contain sugar, such as cake, dessert, candy, chocolate, canned juice, soft drinks, caffeinated drinks, stevia, sugar substitutes, agave, xylitol, and corn syrup.

¡± Avoid raw or uncooked meats, such as sashimi, sushi, steak tartar, and seared meat. Minimize consumption of foods that are cooling in nature, including tofu, tomato, celery, asparagus, bamboo, seaweed, kelp, bitter melon, cucumber, gourd, luffa, eggplant, winter melon, watermelon, honeydew, citrus, oranges, guava, grapefruit, pineapple, plums, pear, banana, papaya, white radish, mustard leaf, potherb mustard, Chinese kale, napa, and bamboo sprout. Do not eat foods straight from the refrigerator. Long-term intake of cold fruits and vegetables like the ones listed above may be damaging to the Spleen. The cooling property of foods can be neutralized by cooking or adding 20 pieces of Gou Qi Zi (Fructus Lycii).

¡± Avoid carbohydrates like white rice or bread as they may produce dampness.

¡± No seafood especially shellfish like crabs, oyster, scallops, clams, lobster and shrimp (they enter the yangming Stomach channel).

¡± Avoid fermented foods like cheese or fermented tofu.

¡± Do not eat dairy products, such as milk, cream, yogurt (except for unsweetened low-fat yogurt), cheese, and ice cream.

¡± No lamb, beef, goose or duck.

¡± Avoid deep-fried or greasy foods.

* Warm and hot natured foods that damage qi and yin should be avoided, such as:

¡± certain fruits like mango and durian that produce heat.

¡± stimulants like coffee, alcohol, and energy drinks.

¡± spicy/pungent/aromatic vegetables such as pepper, garlic, onions, basil, rosemary, cumin, funnel, anise, leeks, chives, scallions, thyme, saffron, wormwood, mustard, chili pepper, and wasabi.

* Avoid food and drinks with artificial coloring.

*  Consume as few meat products as possible. Do not eat processed meats, such as lunch meats, hot dogs and sausages, as they contain nitrites that are associated with inflammation and chronic disease.

 

The Tao of Nutrition by Dr. Maoshing Ni and Cathy McNease:

* Goiter

¡± Make soup from dried (preferably green) orange peel, carrots, and seaweed.

¡± Soak cherry pits in vinegar until they disintegrate, then apply locally.

 

LIFESTYLE INSTRUCTIONS

* Eliminate all stimulants, such as cigarette smoking, secondhand smoke, and caffeine from tea, coffee or soft drinks.

* Avoid vigorous exercise, hot tubs, and saunas.

* Advise the patients to engage in relaxing exercises, such as walking, qi gong or tai chi chuan [tai ji chuan].

* Sleep by 10 p.m. In TCM, 11 p.m. to 1 a.m. is when the yin shifts to yang. It is crucial for the body to be at rest during this time for optimal health.

 

CASE STUDIES

* M.D., a 52-year-old female, presented with a nodule on the left thyroid, palpitation, agitation, shortness of breath with chest pressure, nausea, frequent urination, restless sleep and soft bowel movements. Her blood pressure was 110/70 mmHg and her heart rate was from 90 to 120 beats per minute. The Western diagnosis was hyperthyroidism. Her TCM diagnosis was Liver fire with Liver and Kidney yin deficiencies with phlegm stagnation. Thyrodex was prescribed. Within one week of acupuncture and herbs, the patients started to feel better. Listed below is her lab report showing great improvement over a four-month period. All her symptoms continued to steadily and gradually improve. This is a great formula. Her medical doctor does not understand how her condition improved but had canceled her scheduled radiation treatment. She was very happy. Submitted by M.N., Knoxville, Tennessee.

* A 39-year-old female with hyperthyroidism had been diagnosed with Grave¡¦s disease. Subjective and objective signs and symptoms included goiter, exophthalmus, and insomnia. Objective laboratory analysis indicated elevation of thyroid hormone (T4) and decreased TSH. Conventional pharmaceutical and alternative medical treatments failed to improve her condition. When she sought Chinese medicine as a last measure prior to possible surgical intervention, she was instructed to take Thyrodex (4 capsules three times daily). After a short period of taking Thyrodex, she noticed significant improvements in sleep habits and energy levels. The patient felt less irritable and anxious. Her eye discomfort also resolved. Furthermore, there were no side effects from the herbs whatsoever. The practitioner concluded an overall positive outcome and diminishing signs and symptoms of Grave¡¦s disease using Thyrodex. Upon follow-ups visits, the lab results for thyroid hormones were within normal limits. Submitted by D. S., San Diego, California.

* A 46-year-old female with hyperthyroidism presented with the following symptoms: feelings of warmth and thirst, perspiration, fast metabolism, difficulty sleeping, chronic sore throat (worse at night), migraines, poor appetite in the morning, and frequent diarrhea. The pulse was thin and deep on the left side, and full on the right side. The tongue was pale and scalloped with a slightly thick white coat. The diagnosis was Kidney yin deficiency with Liver yang rising, accompanied by Spleen qi deficiency with dampness. The patient was instructed to take Thyrodex (4 capsules three times daily). After six months of treatment using Thyrodex, the lab results showed normal levels of T4 and TSH (T3 was not tested). The patient¡¦s attitude and overall demeanor was quite upbeat. She continued to take Thyrodex (2 capsules three times daily). Both the medical doctor and the acupuncturist closely monitored her condition. Submitted by R.H., Ft. Collins, Colorado.

* M.C., a 55-year-old female, presented with trouble sleeping. Lab results showed hyperthyroidism, goiter and hypertension. Her blood pressure was 166/98 mmHg and her heart rate was 90 beats per minute. The diagnosis was Liver fire rising. Thyrodex was prescribed at 4 capsules three times a day. Thyroid hormones dropped from 10.34 to 4.88 in two months. Swelling in the neck was also better. Submitted by W.F., Bloomfield, New Jersey.

* D.E., a 49-year-old woman with a history of hyperthyroidism, presented with heart palpitations, sweating easily (especially at night), hunger, weight loss, and becoming easily agitated. Her blood pressure was 120/88 mmHg, with heart rate of 98 beats per minute. The Western diagnosis was hyperthyroidism; the TCM diagnosis was Stomach fire, Heart yin deficiency, and wei (defensive) qi deficiency. The patient was taking Tapazole at 2.5 to 5 mg per day. The practitioner prescribed Thyrodex at 3 to 4 capsules, three times daily, and acupuncture treatments. After commencing herbal treatment, the patient gradually reduced her Tapazole from 5.0 mg to 2.5 mg per day. In the course of two months of herbal treatment, the patient showed significant improvement with no more palpitations, sweating, or excessive hunger. Even with drug therapy reduced by 50%, TSH levels remained approximately the same while under herbal treatment. The patient continues to receive both herbal and acupuncture treatments. Submitted by D.L., Doylestown, Pennsylvania.

* L.S., a 45-year-old female, presented with hyperthyroidism, which she had been previously diagnosed with but was not interested in receiving Western treatment. Her symptoms consisted of rapid heart beat, weight loss, hair loss, and exhaustion. Blood tests had also confirmed the indication of her hyperthyroidism as well. The patient had noted she had a tendency to always feel stressed at work. After diagnosing this condition as Kidney yin deficiency with Liver qi stagnation, the patient was prescribed both Kidney Tonic (Yin) and Thyrodex. With taking the herbs the patient reported that most of her symptoms had stabilized; however, the hair loss was still present. She continued to take the herbs for additional improvement. Submitted by B.L., Fort Myers, Florida.

* A 39-year-old female presented with elevated blood pressure, palpitations, hot flashes, anxiety, and swelling in her neck, with a heart rate of 92 beats per minute. The Western diagnosis was hyperthyroidism; the TCM diagnosis was Liver and Kidney yin deficiencies. After she began taking Thyrodex, the patient experienced diminished hot flashes and anxiety. Her blood pressure remained unchanged but the goiter diminished in size. After Gastrodia Complex was added to the herbal treatment, the patient noticed improvement in her blood pressure after just one bottle. Submitted by P.W., Paulet, Vermont.

 

PHARMACOLOGICAL AND CLINICAL RESEARCH

Thyrodex is formulated to treat hyperthyroidism with increased thyroid hormone in the blood leading to many signs and symptoms similar to ¡§sympathetic excess,¡¨ such as increased blood pressure, tachycardia, and weight loss. Treatment should focus on reducing the amount of thyroid hormone, decreasing the enlargement of the thyroid gland, and relieving the signs and symptoms of hyperthyroidism.

        Hyperthyroidism is characterized in part by the inflammation of the thyroid gland, such as thyroiditis. Therefore, herbs with anti-inflammatory effects are used in this formula to reduce the inflammation. Fang Feng (Radix Saposhnikoviae) has a marked effect to suppress inflammation via the inhibition of nitrite production by inducible nitric oxide synthase.[2] Xia Ku Cao (Spica Prunellae) shows anti-inflammatory activity by inhibiting lipopolysaccharide-induced prostaglandin E2 and nitric oxide in mouse macrophages.[3] Zhi Zi (Fructus Gardeniae) illustrates a dose-dependent effect to suppress vascular inflammation via inhibition of tumor necrosis factor-alpha (TNF-£\).[4] Zhi Mu (Rhizoma Anemarrhenae) exhibits significant anti-inflammatory action by inhibiting cyclo-oxygenase-2, inducible nitric oxide synthase and 5-lipoxygenase.[5] Lastly, glycyrrhizin and glycyrrhetinic acid from Gan Cao (Radix et Rhizoma Glycyrrhizae) have demonstrated marked anti-inflammatory effects. The proposed mechanism of anti-inflammatory action includes decreased permeability of the blood vessels, antihistamine functions, and decreased sensitivity to stimuli. The anti-inflammatory influence of glycyrrhizin and glycyrrhetinic acid is approximately 1/10^th that of cortisone.[6]

        Though the causes vary, the clinical signs and symptoms of hyperthyroidism are essentially the same: low-grade fever, heat intolerance, increased blood pressure, palpitations or tachycardia (90 to 120 heartbeats per minute), fidgeting, irritability, bad temper, fatigue, and enlarged thyroid gland. Thyrodex utilizes many herbs to specifically manage these symptoms of ¡§sympathetic excess.¡¨ Fang Feng (Radix Saposhnikoviae) and Zhi Mu (Rhizoma Anemarrhenae) have antipyretic effects to reduce fever.[7],[8] Xia Ku Cao (Spica Prunellae) and Xuan Shen (Radix Scrophulariae) both have antihypertensive effects to reduce blood pressure. The mechanism of this antihypertensive effect is generally attributed to vasodilation.[9]^,[10],[11] Zhi Zi (Fructus Gardeniae) has a hypotensive effect. It stimulates the parasympathetic nervous system and decreases cardiac contractility and cardiac output.[12] Yuan Zhi (Radix Polygalae) and Zhi Zi (Fructus Gardeniae) have a suppressant effect on the central nervous system to treat anxiety, restlessness, insomnia, and other symptoms of hyperactivity.[13]^,[14]^,[15] Huang Qi (Radix Astragali) and Gan Cao (Radix et Rhizoma Glycyrrhizae) restore the digestive functions to improve energy and relieve fatigue.[16] Lastly, Zhe Bei Mu (Bulbus Fritillariae Thunbergii), Mu Li (Concha Ostreae), Xuan Shen (Radix Scrophulariae) and Zhi Mu (Rhizoma Anemarrhenae) are Chinese herbs historically prescribed to dissolve lumps and hardenings. Clinically, they have been used with great results for treating goiter and hyperthyroidism.[17]^,[18]

        In summary, Thyrodex is a great formula to treat hyperthyroidism with signs and symptoms of ¡§sympathetic excess,¡¨ such as increased blood pressure, tachycardia, heat intolerance, weight loss, and restlessness.

 

COMPARATIVE ANALYSIS

Hyperthyroidism is a common disorder that is well understood, but it only has limited treatment options: drugs or surgery. In most cases, patients prefer non-invasion drug therapy first. Unfortunately, these drugs [such as tapazole and propylthiouracil] are ineffective and cannot consistently control thyroid hormones within an optimal range. Fluctuation of thyroid hormone levels contributes to the presentation of hyperthyroidism or hypothyroidism, depending on whether the drug is under- or over-dosed, respectively. Eventually, most patients receive either surgery or radioactive iodine treatments. These treatments are invasive and irreversible, as they literally remove or destroy the thyroid gland to reduce its production of thyroid hormones. After these invasive treatments, many patients develop hypothyroidism, and must take synthetic thyroid hormone for the rest of their life.

        Hyperthyroidism is a disorder characterized by Liver fire rising with underlying qi and yin deficiencies. Hyperthyroidism has been treated in China for thousands of years successfully by using herbs that suppress the sympathetic excess to control the symptoms, and herbs that nourish underlying deficiencies to regulate the endocrine system. By targeting both the symptoms and the cause, herbs exert immediate and long-term effectiveness for the management of hyperthyroidism. However, herbal therapy in this case has certain limitations. Patients in thyroid storm crisis must be referred to Western medicine for urgent treatment. Furthermore, use of herbs will not reverse protrusion of the eyes, no matter the dose or duration.

        Hyperthyroidism can be treated with both Western medicine and traditional Chinese medicine. Ideally, all options should be explored (including drugs, herbs, and others), as many cases of mild to moderate hyperthyroidism respond well to such treatment. If these treatments are effective, they spare the patients emotional grief, financial burden, and unnecessary exposure to risks associated with surgery and radioactive iodine treatments. If all other options fail, then surgery or radioactive iodine treatments can be considered as last alternatives, as these treatments are invasive and irreversible. It is important that practitioners and patients are informed and educated to understand all available options so that they may decide together on the most appropriate therapy.