Why Do I Still Have Thyroid Symptoms When My Lab Tests Are Normal?
By Datis Kharrazian, DHSc, DC, MS
Morgan James Publishing, 2010
“In the U.S., autoimmune disease accounts for approximately 90 percent of adult hypothyroidism, mostly due to Hashimoto’s” (page 23).
“Although iodine deficiency is the most common cause of hypothyroidism for most of the world’s population, in the United States and other westernized countries, Hashimoto’s accounts for the majority of cases of hypothyroidism” (page 27).
Datis Kharrazian clearly establishes the fact that Hashimoto’s disease is not a thyroid issue per se but rather an autoimmune disease and therefore, like other autoimmune disorders, can only be treated by balancing the immune system. If there are 27 million Americans with malfunctioning thyroids, as some experts estimate, then there must also be a huge number of undiagnosed Hashimoto’s patients in the U.S. Most practitioners fail to test for Hashimoto’s in a hypothyroid patient because they do not change their treatment plan for Hashimoto’s. Instead of treating the immune system, conventional practitioners will treat the thyroid gland in a Hashimoto’s patient.
People suffering from hypothyroidism will greatly benefit from reading Why Do I Still Have Thyroid Symptoms When My Lab Tests Are Normal? In the first part of the book, Kharrazian explains the relationship between Hashimoto’s disease, the immune system, the thyroid gland, and gluten. Sadly, for people with Hashimoto’s, gluten must be avoided for life. The gliadin portion of the gluten causes the immune system to flare up and attack not only the gluten in the blood stream but also the thyroid gland, due to the similarity of gliadin and peptide fragments associated with the thyroid gland. A leaky gut is to blame for gluten getting in the bloodstream in the first place, but once the gluten-sensitive genes are turned on, they cannot be turned off, and therefore gluten must be avoided for life. Amazingly, “the immune response to gluten can last up to six months each time it is ingested.” Each time a person with Hashimoto’s consumes gluten, he risks a possible six-month attack on his thyroid gland.
Using emulsified vitamin D, glutathione cream and S.O.D. (superoxide dismutase), Kharrazian has had much success in the first step of bringing balance to the immune system. Not only is vitamin D a powerful immune modulator, but “90 percent of people with an autoimmune thyroid disease have a genetic defect that affects their ability to process vitamin D.” Although their blood tests may show adequate levels of D, the vitamin D deficiency is at the cellular level. Therefore, in his practice Kharrazian likes to see autoimmune thyroid patients in the high normal end of vitamin D status.
Vitamin D also supports the T-regulatory cells, which begin to malfunction in an autoimmune attack. As their name suggests, when T-regulatory cells malfunction, the regulation of the immune attack goes awry. Tissue damage occurs when the incorrect amounts of T-helper and T-suppressor cells are called for by the weary T-regulatory cells. Using emulsified vitamin D, Kharrazian reestablishes proper function of the T-regulatory cells.
Taming the dominant side of the immune system is the second step in balancing the immune system. The two major parts of the immune system are the TH-1 pathway, which produces an immediate response and the TH-2 pathway, which produces a delayed response. Using a lab test, Kharrazian measures the percentages of each type of cytokine to determine which side of the immune system is dominant. He lists in his book nutritional compounds that will stimulate each side (TH-1 or TH-2) of the immune system.
Kharrazian tames the dominant side by giving supplements that will strengthen the weaker side. For instance, if a person is TH-1 dominant, as 90 percent of those with Hashimoto’s are, then they would consume herbs such as astragalus and echinacea, which stimulate the TH-2 pathway. Since not all autoimmune responses are due to an imbalance of the two sides, Kharrazian also gives direction on how to treat an immune response when caused by an antigen or hapten, such as those created by chronic infection, pesticides or heavy metals.
The second half of the book concisely covers the six patterns of hypothyroidism that are not caused by Hashimoto’s, how to discover them from a blood test, and why only one can be remedied with thyroid medication. Kharrazian devotes a chapter to each of the following cofactors of thyroid health: blood sugar, digestion, adrenal glands, use of hormone pills that destroy thyroid health, and the brain. At the end of each chapter, the reader will find recommended supplements that can strengthen or stabilize each possible problem area.
Kharrazian has put together a very comprehensive guide to understanding the complicated and varied path toward reestablishing thyroid health including improving adrenal, blood sugar and hormonal health. I give this a hearty thumbs up as an excellent reference book with two small caveats. The first is that Kharrazian promotes using emulsified D and fish oil (for EPA and DHA) instead of cod liver oil, which he says, would not supply enough vitamin D without too much EPA and DHA. My opinion is that one could work with a practitioner and use cod liver oil in conjunction with emulsified D to obtain therapeutic levels of D. Kharrazian notes that vitamin A is a modulator to both sides of the immune system as well as “a critical nutrient for thyroid activity,” but fails to make the connection that cod liver oil is an excellent source of vitamin A. Finally he points out strong anecdotal evidence that people with Hashimoto’s do best on a casein free (dairy free) diet. The issue I find with advice to avoid all dairy is that rarely is any distinction made between raw, cultured, and pasteurized dairy; therefore, I feel that the dairy free recommendation may need to be explored on an individual basis.
This article appeared in Wise Traditions in Food, Farming and the Healing Arts, the quarterly magazine of the Weston A. Price Foundation, Summer 2010.
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Elaine says
Corrections
Hi, one error here: “For instance, if a person is TH-1 dominant, as 90 percent of those with Hashimoto’s are, then they would consume herbs such as astragalus and echinacea, which stimulate the TH-2 pathway.”
Astragalus and echinacea stimulate TH-1, not TH-2.
Also I know he uses emulsified vitamin D in a cod liver oil base to get the therapeutic doses of D often needed, so he still uses CLO, just with a D boost.
John says
Good summary
I like your write up and would add that goat dairy may be another overlooked option. I don’t recall it being mentioned in the book.
I would add this book is intended for the health care professional. Dr.K is now on a campaign to train health care providers in his approach to Hashimotos and thyroid related issues. Some of the areas covered do get technical and complicated. He often leaves out certain dosing details for many of the recommended supplements as they need to be individualized case by case.
Nonetheless this is still an excellent book for the patient who wants to be better informed and can find a knowledgeable practitioner to work with. Unfortunately most MD’s have not embraced this or similar approaches and will leave you untreated or worse, give an incorrect diagnosis.
cath hannaford says
Root Canal Dangers
Shocking! Probably the most informative and detailed article on root canals that I have ever read. Thank you.
Meghan Kinney says
I’m wondering what to do if the doc recommends root canal. Extraction is better as long as the ligament is taken too? What’s the answer? Right now I have amalgams and plan to get them replaced but don’t have the money. I do currently have a broken tooth that will probably need a cap. Is this an ok option?
FrankX says
If Huggins lost his license in Colorado
can he still claim to be a DDS? The report at http://www.quackwatch.org/01Qu…ggins.html makes him sound like he wanted to have the hearing go against him. Example:
40. It is highly probably that had additional studies lent credence to Respondent’s practices, he would have supplied them or at least been able to identify them in substantially greater detail, particularly in light of the fact that he knew the scientific bases of his practices were being questioned and his dental license was at stake.
Lowell says
Dental Work Dangers
15 years ago I had all amlagam fillings replaced with composite, and it was the best thing I have ever done, health wise. The differance was amazing. I had previously as well sores all across my scalp, that had not healed in over a year. One would heal slightly and another form. Mercury retention toxicity. After the first and largest quadrant of amalgam was removed, the sores disappeared, as the body then was able to handle it and dump the mercury. All of it was done by the Huggins protocol, at a Huggins trained dentist.
I also had previous bouts with the yeast syndrome, some severe; and that also has not since been a problem. Prior to that I had to stay on a not to low sugar diet etc.
I had 5 cavitations also cleaned, with that procedure. The word is that you have to do it right, and all I can tell you is that the Huggins protocol obviously was.
My website is http://www.lowellsfacts.com There are two amalgam related truth pages there.
D. says
QUACKWATCH??
Never believe anything from quackwatch. Stephen Barrett is not even a licensed physician, yet he promotes himself as the Lord of all that is right and good. Leave him,and his proclamations,in the gutter where he belongs.
Jason says
Yep just a Big Pharma paid shill
Laura A says
So what are the alternatives to a root canal? I got one a year or so before I was diagnosed with MS. Is it worth having it removed? What is involved with that and what would go in it’s place? Is there a healthy alternative? particularly for a front tooth?
darleng says
A vicum of Root Canals…
I was diagnosed with FULL BLOWN aids some 21 years ago- with 6 months to live. I researched and did alternative treatments and educated myself* I read much about the dangers of root canals but 7 years ago had 3.( then 45 looking 35 and feeling great) Devistating effects- the virus that was never evident shouted through outmyy entire body and my face was shrinking! What I can tell anyone is that you have to educate yourself and believe that you have the power to say no to a Dr. who is only what he has been taught by the pharmaceitical companies that write their bible. I am now 50 and always looking for the healthier answers … it is an adventure and always feeling better is a great destination! 🙂
Eileen says
incorrect example of stimulators for TH1/TH2 dominance
I believe you may have mixed up the recommended stimulants for the TH1 vs. TH2 dominance according to the info in Dr. K’s book.
“It is well documented in clinical research that Th1 stimulants are Echinacea, maitake mushrooms and golden seal to name a few. Th2 stimulators are caffeine, green tea, and grape seed extract. So in the example I gave in the previous slide, if a patient with an under functioning thyroid is TH1 dominant, then I would prescribe supplements containing caffeine, green tea, and grape seed extract to stimulate the TH2 side to regain balance. If they were TH2 dominant, then Echinacea, mushrooms, and golden seal would balance out their immune system.” (http://www.medhelp.org/user_jo…2-dominant)
The example you gave in your review says the opposite.
kelly says
Like Meghan Kinney,I myself have a broken tooth and don’t know what’s the best option? Also I have about 4 root canals I plan to have something done but not sure due to my area of limited dentist qualified for removal of them. I don’t want to get even sicker from having them removed improperly. Oh what to do because money is a problem as well but first thing is first and that is a treatment plan with a qualified dentist how to do this?
marissa says
root canal alternative
oil-pulling is an auyrvedic practice that restores mouth health almost entirely. i recommend google-ing it and read the thousands of amazing stories.
Meg says
The article states that “Dentists are generally taught to remove a tooth and leave the periodontal ligament in the socket, a procedure which would be like delivering a baby and leaving the placenta in the uterus.” Except that this isn’t true. I’ve been a professor at 2 dental schools and a student at 1 and this statement would be considered completely crazy. No one today advocates leaving the periodontal ligament in the socket and it is certainly not what “dentists are generally taught”. It isn’t even something that is controversial. This statement is just wrong. It isn’t even a matter of philosophy or opinion. This isn’t what dentists are taught. I know. I’m teaching them!
WAPF- please do some fact checking!
Lori Lamb says
To all of you who beleive quackwatch!
I recently did some of my own research on quackwatch and found that when I googled to the name of the Dr. arguing against this protocol, he didn’t even exist. The ADA has ghost writers that do nothing but post faulse, faulty stories about obvious truths. I don’t trust the ADA, FDA, USDA or any government organization that tells me something is safe. They are Liars! It’s all about covering the butts of the industry to avoid class action lawsuits if they were to admit the truth. I for one with 15 silver fillings removed that my insurance would not cover because the ADA still insists that silver fillings are safe are full of ____!
balance says
root canal options
Read this for a more balanced practical view on root canals:
http://www.mgoldmandds.com/rct.htm
Ainsley Apirana says
what about gum disease – can it be related to root canal fillings
Nancy says
Where do the majority of people go for root canal teeth removal and cavitation cleaning. Who is considered to be the expert, most skilled and reasonably priced (outside US, if necessary)? Thanks.
Janet says
where is the science. what do the charts depicting the rise of certain diseases and the simultaneous rise of amalgams have to do with each other? Did the people affected by the disease have this dental work, and did those receiving it all, or a significant sample get the disease? I reject mercury in my mouth, but i am not that thrilled with the plastic crap alternative either. Sewing teeth into a rabbit does not produce such a conclusion. I am appalled at the rumor and innuendo and non convincing psuedo science, even though i refuse amalgams myself. I would like to see some research, some studies. They can be based on past dental records and the health of those individuals. Some critical reading and thinking is needed here.
Ronald says
Squirming is to be expected.
Amazing all of the attacks on Dr. Price and Dr. Huggins and the simultaneous trust and belief in all things mainstream dentistry. The ‘Quackwatchers’ love attacking things that they don’t know or understand – usually due to their own narrow-mindedness. The research is there. As a matter of fact, you just read a nice summation of it. Or did you actually read it?
I have seen the clinical reality of these facts for years. Patients who get better after having a rotten root canal or mercury amalgam fillings removed. I’ve seen the sacs of infection that are commonly at the tips of the roots when removed even though they didn’t show on the x-rays.
I find mainstream dentistry one of the most dangerous and archaic medical practices still alive today. Shame for the people being subjected to it.
Teri says
Egomania. A word of wisdom. When only a very small portion of the accomplished professional body agrees to a idea that was put into place by ONE–the idea is probably wrong. Remember “three heads are better than one”–this article is the case of ONE. You can always find some truth to convince others of your idea. This is ALWAYS the case. It does not mean this is overall truth. This article has a little evidence and rationalizations to back up an idea that is really not true. I think a million dentist, the dental and medical association as a whole are a little smarter than a few guys with no science to back them up.
Laura says
Root canal dangers
I had a root canal — my only one — on the left side of my mouth 5 years ago. Then last year I was diagnosed with degenerative disc disease and herniated discs in both the cervical and lumbar regions. The herniated discs were on the left side and affected my left side, including sciatica and left arm numbness.
Could there be any connection between cervical arthritis and root canals? I had never had any back problems before and since reading that root canals tend to affect the side of the body that they were performed…well, it appears to be quite a coincidence there, at the very least.
concerned says
Kharrazian’s vitamin D with cod liver oil contains Genistein from soy which has gotten a lot of bad press by the WPF website for being damaging to thyroid health which makes me wonder why its in there. Also the Apex Oxi-cell cream he formulated for Hashi patients contains Fluoride as Fluoric Acid which is also known to suppress the thyroid. The no dairy, egg, gluten, soy, high glycemic fruit, lectin (including nuts and beans), nightshade, alcohol, and caffeine diet in the book seems to leave someone with almost nothing to eat besides meat and veggies and low carb fruits. A low carb diet high in muscle meats suppresses thyroid function and stresses the adrenals. I find the whole immune system imbalance thing fascinating and think that it would be great if taking herbs to balance the immune system work to fix autoimmune issues which are so prevalent now. What a simple fix if it really works! I do think its weird that the products he created for his protocol contain substances that inhibit thyroid function as well as the “healing diet” he recommends. Also, I tried the Oxi-cell cream and got a horrible rash from it. Tried supplementing with an emulsified D(just D no Genistein) along with my cod liver oil with no benefits. Also took his glutathione recycler supplement and noticed no change. Also followed the diet with no positive changes which is frustrating because the food was so monotonous. My digestion also felt much worse on this strict diet and my teeth began to decay. I have not had my immune system tested and have not tried the herbs to boost the weaker immune branch yet, I don’t know if I will after my experience with the other products. I just think there are a great deal of expensive tests and supplements and very strict diets, and a lot of of it is pointless or overkill. I have had better luck following Ray Peat’s guidelines with sugar, gelatin, dairy, coconut oil, coffee and fruit and avoidance of PUFAs and its far more enjoyable to eat this way. On Datis’ diet and protocol I had lower temperatures and pulse and felt more and more lethargic until I was pretty much bedridden, severe brain fog and forgetfulness, exhausted, dizzy, depressed and horrible PMS. With the Peat diet without supplements I continue to feel better and better. Check out Josh Rubin’s youtube on Hashimoto’s for another perspective http://www.youtube.com/watch?v…ature=plcp
Nicole o says
Owmer
Need dental work done and don’t want to gt a root canal. What are my options????
Linda says
Alternatives to root canal???
I keep seeing questions about alternatives to root canals. I have pain in the site of a crowned tooth. I’m fairly certain the dentist will advise root canal. If I just have the tooth extracted, there is danger of a cavitation, and my other teeth will shift out of place. I can’t afford an implant, and I’ve heard they are not safe either. I appreciate all this information about the dangers of root canals, but it appears that MANY of us need to know about alternatives. Thank you.
marshan says
Have always believed this all to be truth..
Ara says
11 root canals and 3 implants
This is topic is so complex, so confusing. I’m supposed to take out my 11 root canals? Wouldn’t that be more traumatic to my jaw? Is there any alternative? I feel hopeless
Veda says
no body
Dear sir I am interested to have a look at my tooth ( and many feelings and root canal ) by a dentist that is aware of Dr Price research can you send me a list of such a dentist in the US and abroad I am living in India thanks veda:D;)
Larry Huddleston says
Root Canal Dangers
Mi Wife had a root canal Oct 1st 2010 this did not go very well it was a prefereted root canals with in six months she had lost over 50 lbs she has a small cyst in the rt cheek were the first crown was placed in her mouth. She has dry mouth, dry eyes, her mouth cracks in the corners. Frequent mouth sores, joint pain. She has been on three different types of medications 1st was metholtrexate her liver enzymes were very high so the put her on cellcept and had very bad on set of shingles so the tried her on eovace and her pancreous started to shut down now she starts a new drug at the U of M August6 for infused chemo to supress her immune system even more. She still has the crowns. Would like you input on this Thank You.
Karen says
revision of root canal
I had a root canal 20 years ago and the tooth became hot again. I was told to have a revision of the root canal. I had a revision. The infection did not go away, it got worse despite antibiotics. The end result is an extraction of the tooth, loss of bone in my face where the infection was, and a whole lot of pain. My other root canals are fine.
So I don’t know what to think about this article but can share what the oral surgeon told me– NEVER agree to redo a root canal that has already been done. Always in that case have the tooth removed.
Good luck everyone.
Rose says
Reading this information for many of us is after the fact of having many root canals and other dental procedures. Its extremely scary to know this stuff and not really have any way to rectify it. I have had 6 root canals and believe there is truth to them being infested with bacteria. My root canals are part of several bridges, If I was to get all these teeth extracted I would have massive holes in my mouth and all the troubles associated with missing teeth. Unable to eat, face caving in, other teeth falling over, etc. Not to mention the fact that many of us are not rich, And lets face it, you have to be practically rich to get almost any procedure done by dentists. The costs alone make it impossible for anyone to do anything about it anyway. Problem now is information is empowering but also very frightening when one cant do anything about it.
What to do now is a huge problem, you have opened a can of worms without giving anyone answers as to what to do if they have tons of root canals already?
OK, I read zirconium implants, they cost anywhere from 3-6 thousand dollars, most people cant even afford one implant, let alone 1/2 dozen or so.
This information while I embrace it for the most part has got me paranoid as to my health issues and future health issues.
What a quandry!!!!
Renee says
Thanks for the informative article. However, I have YET to see any articles or suggestions on what to do now? I had a root canal where they saved the tooth and filled it with composite. 5 years later the tooth broke beyond repair and was extracted. I now have a gap in my teeth. The gums have completely healed over, but I am wondering if I can/should consider an implant or other thing to replace or fill the gap to avoid tooth movement and bone loss. Help? Anyone answering these queries?
Dental Student says
Actually, after proper root canal treatment of a periapical infection with bone loss and lesions, filling the canal and even the side dentin canals, you get a stable result with regrowth of the lost bone tissue and no symptoms in the following years. How can you state of the chronic infection within the dentin, that’s why there are several techniques to properly clean the canal before the obscuration, if the end result is bone generation in the years following the treatment?
Extracting teeth is the prosthetic dentist’s dream because he can sell you expensive restorations that last 7 years average (20 even) and nothing is as stable and efficient as your own tooth, even a “dead one”.
However a root canal treatment should be prognosed for it’s success considering the thickness of the dentin roots, paradont level and overall health, etc.
madison elkhorn says
My conventional dentist said they never leave the PDL. He said he never heard of anyone- conventional or holistic leaving the PDL.
CU4DK says
Answers to : Alternatives to root canals
So, let me get this straight. A dead tooth that is treated is bad in your mouth, but an artificial implant (metal) is ok? Double standard? To people wanting an alternative to root canals or to expensive implants your answer is DENTURES. Non invasive, reasonably priced and you can add to is as you age and lose more of your teeth. There is nothing else besides that. Implants too expensive, bridges – you cut into otherwise healthy teeth to make them into anchors, so the only other option is dentures. Yes, the esthetics are missing, and some people have allergic reactions to the dye in the acrylic, but you asked for alternatives. There you go. I would still get a root canal to save my own tooth than just lose it. I have silver fillings and a root canal, and am alive and well. Good luck.
MInx says
check this out..
http://www.curetoothdecay.com/…m The health of the teeth comes from within. Clean the diet, and remineralize the dentin. =)
Dental Decepticon says
I’ve had a root canal for about two decades due to a childhood accident that had my a milk tooth knocked out, which subsequently resulted in the root dying. Over a decade later the tooth began to discolour, as such, I had a crown done.
In the past twelve months I’ve felt an odd, intermittent, mild pain in my right side, near the kidney (*same side as the root canal). X-Rays, ultrasounds and blood tests have shown nothing. Yet, the ‘irritation’ still persists.
I’m beginning to think the dead tooth might have something to do with it, as otherwise I’m in perfect health; with a good diet, regular exercise and no family history of any kidney related issues.
Reading all this new ‘anti root canal’ stuff is fast goading me to part with a hefty chunk of my hard earned just so as to eliminate even the mere possibility of some arcane bacteria harbouring in my face… 🙁
F*** dentistry. >:(
Lorraine Harris says
Practitioner of Oriental Medicine and Licensed Acupuncturist
I prescribe strong Chinese herbal anti-microbials (kill bacteria)and a good probiotic before and after dental procedures. Have also done that for myself for a root canal, low grade infection (dentist first missed), tooth abscess. Finally, I’m pain free!
Regina Geiselman says
What is the medicine you use? I have to get 4 molar implants in 2 weeks. Thank you,
marie says
I just had a broken root canal tooth removed on Tuesday. I can already see an improvement in my health. I know this is the best thing to do for my health. It was not expensive compared to how much it was hurting my health. Fatigue has been reduced. I have 3 more to remove next month. I will let you know how I am then. Our health is our wealth. The 700.dollars to remove under anesthesia and remove the necessary tissue and treat the socket was worth every dollar.
Val says
Root canal
What is the safest way to have my root canal removed? I have read that you can get really sick after removal.
Jana Irvin says
I am elderly, broke and struggling. I have been blessed with good health so far and am terrified after learning that due to numerous “leaking” root canals and teeth that apparantly are infecsted underneath the many fillings I have, all my teeth have to go and be replaced with plates. I had a second opinion which was exactly the same as the first….done in another city. I am willing to have them all removed, my life is more important than the teeth. PROBLEM: I don’t have the $3590. to get the teeth removed and replaced with plates. I was denied financing as my income is very low now. For many months now I have been consistantly waking up every morning with severe headaches and feel some increasing pain in both the upper teeth and the jawline on the left and right lower quadrants. Is there any way to get help to finance this desperately needed dental work? Thank you for your consideration.
Jana Irvin
Digger says
Milk tolerance & benefits may be related to whether you are drinking milk that has A1 or A2 beta-caseins. All goat, sheep and human milk is A2. Guernseys are almost all A2. Jerseys are about 70% A2. Brown Swiss 50% A2. Most Holsteins, the predominant breed in US is almost all A1. DNA testing for this is available from UC Davis.
Best intro to this subject may be the AcresUSA interview with the author of The Devil in the Milk. See http://www.acresusa.com/toolbo…odford.pdf
natalie wright says
dental fillings
I wrote last week, i had the composite resin filling changed, with a glass inomer, with no resins, a few days later it was sensitive again , filling area sore to touch, reacting to it again, had it extracted on Friday, now I have no fillings in mouth, I believe I reject all dental fillings, root canals,
Nicole says
Mssmartypants
Oh wow. I have had a gut feeling about this horrid thing I’ve had in my mouth since an accident age 9. After years of fighting candida and subsequent ca cervix, things have been sooo much better with vigilant WAPF diet and GAPS. But there has still been something nigggling and this is it. Funnily enough the tooth has recently finally broken apart and the stuff that came out was disgusting. Despite reassurances from my dentist that it was fine – no infection- the periodontist says it is, with accompanying bone loss and gingivitis. So I figure zirconia implant and ceramic crown is the way to go? I feel fortunate to be able to afford it, but its my front tooth I’m young and I’d rather sell my car for a good tooth (I love cycling anyway!) thanks for a great summation of the pathophysiology – better late than never
Bill says
Wow, so many things to consider here. I had been to 5 doctors since a routine chest scan after surgery revealed an enlarged thyroid glad. No of the countless hours of time spent in their practices led to any kind of discussions that mentions the things that your short article does. Think i need to postpone sugery for a while, until I look it these differences of what causes enlarged thyroid gland.