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Hyperthyroidism: what choices do you have ?

Updated: Jan 24, 2021

Drugs, RAI or Surgery?


Your doctor can suggest you two drugs: Methimazole or Propylthiouracil.

They both act by preventing iodine form binding to the thyroid. In doing so, the thyroid will not produce T4 and T3.

There is a tiny difference between the two drugs:

  • Methimazole prevents the thyroid from using iodine.

  • Propylthiouracil does the same but in addition, it blocks the conversion of T4 into T3. Moreover, differently from Methimazole, it works faster as it has a shorter half-life and decreases T3 levels. People will experience a decrease in symptoms faster than with Methimazole. This makes Propylthiouracil the best candidate to treat more severe state of hyperthyroidism.


Divided into two phases:

  1. Initial dose (aka loading dose): Your doctor will start by giving you a high dose. This is until you are brought to the euthyroid stage. There could be a possibility that this high dosage will make you hypothyroid. Doctors will rather have you hypothyroid than the opposite, due to the severe and life-threatening hyperthyroidism symptoms.

  2. Maintenance dose: once you are euthyroid the dosage is subsequently decreased.

--> NOTE: after the loading dose, Methimazole is taken once, max twice a day. Whereas, Propylthiouracil three times a day.

Do anti hyperthyroidism drugs interact with other medications? Yes

These drugs can interact with other medications: you MUST assess it with your doctor before starting the treatment.

Can they be taken during Pregnancy? Better NO

Methimazole especially can pass the placenta and cause severe problems to the unborn baby.


  • Mild: rash, musculoskeletal and gastrointestinal.

  • Severe: agranulocytosis (usually low white blood cells count) and liver toxicity.

Do Propylthiouracil and Methimazole can cause hyperthyroidism and Graves to go into remission?

Chances are pretty low. About 20% to 30% can go in remission. However, people suffering from large goiters or severe hyperthyroidism highly unlikely will go into remission just with drugs.

This brings us to the next option: Radioactive Iodine Treatment (RAI)

This method is based on the idea that in the body only thyroid takes and uses iodine.

Radioactive iodine is up-taken by the thyroid, and when this occurs it will destroy your thyroid cells.

When is it used?

Three main reasons to use RAI are:

  1. To destroy or ablate hyperactive thyroid cells (such as Graves' disease)

  2. To destroy or ablate remaining normal thyroid tissue and thyroid cancer cells after thyroidectomy

  3. To destroy or ablate thyroid cancer recurrences

How to take it?

One pill is taken orally in outpatient settings. This means doctors will give you a pill that you can easily take and go home.

However, there are some precautions you must take:

  • For a week you must avoid any contact with pregnant women and children for a week after pill intake

  • Again for a week limit contact with non-pregnant adults

  • Radiation is also in secretions (saliva and bathroom), thus precaution must be taken

About 6 months are needed to see the effects of the treatment. For this reason, you will have to perform blood tests frequently.

--> After treatment patients can feel worse before feeling better. These patients will need to take hyperthyroid drugs plus beta-blockers to treat the symptoms which can be severe

--> Iodine ablation is also associated with increase Graves' ophthalmopathy

--> Radiation can also inflame the thyroid (thyroiditis) which requires glucocorticoids (you may know it as cortisone)

Treatment failure and 'side effects':

10% of people will not respond to therapy and will have to redo RAI.

Side effects: on 1st July 2019 an article was published saying that RAI increases the risk of solid cancers, including breast cancer. It is related to how many times you underwent RAI and on dosage.

To cite the article:

In RAI-treated patients with hyperthyroidism, greater organ-absorbed doses appeared to be modestly positively associated with risk of death from solid cancer, including breast cancer. Additional studies are needed of the risks and advantages of all major treatment options available to patients with hyperthyroidism.

What to do if you already had RAI?

Remember that cancer is multifactorial. You can act by modifying your lifestyle. Take care of your diet, physical activity and cut smoking (if you are a smoker) as well as avoiding passive smoking.

When to do surgery?

Surgery is usually only indicated if the patient:

  • develops severe side effects to drugs, or

  • contraindications to RAI

Surgery refers to either total thyroidectomy or subtotal (only half is removed) thyroidectomy.

The choice is based upon the severity of hyperthyroidism (usually Graves) and cancer staging.

It could be also a choice for pregnant women with uncontrolled hyperthyroidism. Surgery, in this case, is done around the second trimester (the safest period during pregnancy).

When drugs and iodine treatments fail they can worsen Graves'ophthalmopathy. In this case the only, curative treatment is surgery.

Thyromegaly (extremely large thyroid) can compress the trachea and block breathing. Surgery is the only option.

Subtotal or Total Thyroidectomy?

Complications related to both procedures are permanent hypocalcemia and recurrent laryngeal palsy (weakened voice or loss of voice, and cause problems in the respiratory tract).

Both procedures carry the same risk percentage, thus the choice between them is based on your condition. It's a careful choice that must be assessed with your surgeon and endocrinologist. In the case of cancer, you must add your oncologist.

What happens after Thyroidectomy?

Usually, following cancer, you could be given the choice to undergo RAI ablation to make sure all thyroid cancer cells are destroyed. Again, this must be assessed by your doctors.

Hypothyroidism is now a consequence of surgery. After thyroidectomy, you will produce less thyroid hormones. For this reason, doctors will prescribe you levothyroxine.

In the case of cancer: remember, depending on the type and stage treatments change. Generally, you must keep your TSH as low as possible to prevent recurrences.

Follow us. In the next article, we will talk about natural ways to treat your Hyperthyroidism.

Let us know about you:

Which treatment did you opt for?

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