After Surgery: Life with No Thyroid
What life is like after your thyroid surgery — known as thyroidectomy — depends in part on the reason for and extent of your surgery.
You may have a total thyroidectomy — removal of your entire thyroid gland — for several reasons:
To treat thyroid cancer
To remove a thyroid with multiple nodules, to remove an enlarged thyroid (goiter), or when nodules or a goiter are affecting your breathing and/or swallowing, or is visible and cosmetically unsightly
To treat hyperthyroidism when you can’t tolerate antithyroid drugs, aren’t responding to them, or won’t take them and radioactive iodine (RAI) is not an option, such as during pregnancy
Because your entire thyroid is removed in a total thyroidectomy, you become hypothyroid. As a result, you will require life-long thyroid hormone replacement medication — such as a levothyroxine drug like Synthroid or Levoxyl, or a natural desiccated thyroid (NDT) drug like Nature-throid or Armour — to replace your needed thyroid hormone.
Sub-total/partial thyroidectomy or lobectomy
A sub-total/partial thyroidectomy (removal of part of your thyroid) or lobectomy (removal of one side or lobe of your thyroid) is performed for several reasons:
To remove a single thyroid nodule
To remove part of the thyroid when you have some one-sided thyroid enlargement
Less commonly, to remove a very small, non-aggressive thyroid cancer
In some cases, after a sub-total/partial thyroidectomy or lobectomy, your remaining thyroid tissue will be capable of producing enough thyroid hormone to prevent you from becoming hypothyroid. But the majority of patients do end up requiring thyroid hormone replacement medication over time.
After surgery: starting thyroid hormone replacement medication
Total thyroidectomy: If you have had a total thyroidectomy you will eventually end up taking thyroid hormone replacement medication. When will you typically start on this medication?
If you had your total thyroidectomy to treat thyroid cancer, your doctor will evaluate the pathology, stage your cancer, and recommend a follow-up treatment plan. If radioactive iodine (RAI) is required to ablate any thyroid tissue remaining after surgery, you will not be started on your thyroid medication until that treatment is completed.
If you had a total thyroidectomy due to goiter or nodules and were not hyperthyroid prior to surgery, your doctor will likely start you on thyroid hormone replacement medication right after your surgery.
If you had a total thyroidectomy as a treatment for hyperthyroidism, your doctor will likely evaluate your thyroid levels frequently after surgery. Levels of circulating thyroid hormone can remain elevated for weeks after surgery, and treatment will begin once your levels have dropped to a point where it’s safe and necessary for you to take thyroid hormone medication.
Sub-total/partial thyroidectomy/lobectomy: If you had a sub-total/partial thyroidectomy or lobectomy, it is likely that you will eventually need thyroid hormone replacement medication. Doctors will typically allow for enough time to evaluate whether your remaining thyroid tissue is producing enough thyroid hormone. TSH — and possibly free T4 and Free T3 — will be tested to determine if you have become hypothyroid after surgery. If your levels fall outside the reference range, your doctor will prescribe a thyroid medication.
Note: In some cases, your doctor may not make it clear to you after surgery that you are at risk of becoming hypothyroid. If, after a sub-total/partial thyroidectomy or lobectomy you begin to notice hypothyroid symptoms, see your doctor right away to have thyroid testing performed. Common symptoms you might experience include fatigue, weight gain, depression, hair loss, bloating and puffiness, and constipation.
About thyroid hormone replacement medication
While your thyroid surgery may have been to treat cancer, goiter, nodules, or hyperthyroidism, going forward, you usually become hypothyroid. Your missing thyroid gland is unable to produce enough necessary thyroid hormone, and you will need to get that hormone via a prescription medication.
The most commonly prescribed thyroid hormone replacement medication is a synthetic version of the thyroid hormone known as thyroxine (T4). Known generically as levothyroxine — some common brand names are Synthroid, Levoxyl, and Tirosint — this category of thyroid drug is the treatment preferred by conventional endocrinologists and physicians.
There is a synthetic version of the thyroid hormone triiodothyronine (T3) called liothyronine. The brand name in the United States is Cytomel. Liothyronine is also available by prescription in sustained-release formulations from compounding pharmacies. In some cases, liothyronine is prescribed along with levothyroxine, as part of T4/T3 combination therapy.
There is also a category of prescription thyroid hormone replacement drugs known as natural desiccated thyroid or NDT. The most well-known NDT drugs include Armour Thyroid and Nature-throid. These are drugs, produced from the dried thyroid glands of pigs, that natural forms of both the T4 and T3 hormones. T4/T3 combination therapy and NDT drugs are not commonly prescribed by conventional endocrinologists and practitioners but are increasingly popular with holistic and integrative physicians.
Starting your thyroid hormone medication
Typically, you will be prescribed an initial dose of thyroid hormone medication that is based on your body weight. You should be rechecked in six to 12 weeks after you start medication or change your dose to determine if additional adjustments need to be made to your dosage. Once your thyroid levels have stabilized at your physician’s target test levels, your doctor may wait longer periods — such as 3, 6, or 12 months — between follow-up checks.
A few pointers on taking your medication:
Don’t forget to take your thyroid medication daily, ideally at the same time each day.
Take your thyroid medication in the morning — or at bedtime — on an empty stomach, at least an hour before or after eating.
Wait at least an hour after taking your thyroid medication before drinking coffee, including decaffeinated coffee.
Avoid taking foods and supplements high in calcium — such as calcium supplements, antacids, milk, and calcium-fortified juice — within four hours of taking your thyroid medication.
Avoid taking iron supplements within four hours of taking your thyroid medication.
Your TSH target
If you had your thyroidectomy due to thyroid cancer, in some cases, your doctor will recommend that you take what's known as a "suppressive" dose of thyroid hormone replacement. This means that your TSH should be kept either at the low end of the reference range or below the range, to help prevent a recurrence of your thyroid cancer.
If you did not have thyroid cancer, it’s likely that your physician will target a TSH level for you that falls within the laboratory reference range. Note that while the reference range at most labs runs from around 0.5 mIU/L to 5.0 mIU/L, many people on thyroid hormone replacement feel best when TSH is below 2.5 mIU/L.
Optimizing your thyroid treatment
While some physicians feel that hypothyroidism treatment is complete once your TSH is in the reference range, there are practitioners who recognize that safe relief of your symptoms — what is referred to as “optimization” — is the goal.
If you are taking levothyroxine, have a TSH in the reference range (or suppressed, if you had thyroid cancer), you may want to discuss other treatment options with your practitioner, including:
Changing your dose to lower your TSH level. As noted, some practitioners feel that the target TSH level should be 2.5 mIU/L or less in order to relieve symptoms.
Switching brands of levothyroxine. Synthroid, for example, contains two allergens: acacia and lactose. Other brands are free of those fillers. And the liquid, gel-cap Tirosint is designed for maximum absorption for people with allergies, digestive problems, and absorption issues.
Changing to T4/T3 combination therapy, by adding a T3 drug such as liothyronine, Cytomel, or compounded, sustained-release T3.
Switching to — or adding — a T4/T3 natural desiccated thyroid drug such as Nature-throid or Armour.
If you are interested in pursuing T3 or natural desiccated thyroid treatment, you may need to consult with an integrative or holistic physician, as conventional endocrinologists and physicians tend to limit hypothyroidism treatment to levothyroxine drugs.
What about goitrogenic foods and soy?
Some experts caution those with thyroid conditions to be careful about overconsuming raw goitrogenic foods. Goitrogens are foods — including cruciferous vegetables like kale, spinach, broccoli, and Brussels sprouts — that when eaten raw and in large quantities can slow down your thyroid gland.
After a thyroidectomy, however, you are safe to eat goitrogenic foods — raw or cooked — without concern for any impact on your thyroid function.
You should, however, be careful about overconsumption of soy foods. When overconsumed, soy can impair your ability to absorb your thyroid medication.