Back to Search Results


Management of a Thyroid Nodule

Author: Nanette F. Santoro, MD

Editor: Brett Worly, MD

Registered users can also download a PDF or listen to a podcast of this Pearl.
Log in now, or create a free account to access bonus Pearls features.

The prevalence of thyroid nodules varies with the level of iodine sufficiency. Because iodine deficiency is relatively rare in the United States, only about 5% of US women will have a palpable thyroid nodule. In contrast, as many as 67% of women will have a detectable nodule when high resolution ultrasound is randomly used to examine the thyroid gland.

The clinical concern with detecting a thyroid nodule is the possibility of thyroid cancer, which may occur in up to 15% of cases. Even though most thyroid cancers are well differentiated, slow growing, and have an overall good prognosis, it is incumbent on the clinician to rule out a thyroid cancer when a palpable nodule is present.

Nodules greater than 1 cm in size, whether detected by palpation or incidentally found by imaging, merit a diagnostic evaluation. Regardless of how detected, the risk of cancer is the same. It is also appropriate to investigate nodules smaller than 1cm in patients when such nodules are associated with suspicious symptoms, lymphadenopathy, or clinical risk factors for cancer.

Risk factors for thyroid cancer include:

  • Childhood head and neck irradiation
  • Whole body irradiation for bone marrow transplant
  • First-degree relative with thyroid cancer

Clinical findings concerning for cancer include:

  • Rapid growth of a nodule
  • Hoarseness
  • Vocal cord paralysis
  • Cervical lymphadenopathy
  • Fixation to surrounding tissues

After initial history and physical exam, a TSH (thyroid stimulating hormone) and thyroid ultrasound should be obtained.

If the TSH level is low, a radionuclide thyroid scan should also be obtained to help determine whether the nodule is producing excess thyroid hormone, which in turn suppresses serum TSH (a “hot nodule”). Hyperfunctioning nodules are unlikely to be malignant, so fine needle aspiration for cytology is unnecessary. The ultrasound serves to confirm that the nodules of hyperfunctioning are concordant with the nodules demonstrated anatomically. Referral to an endocrinologist for further management of the hyperthyroid state may be appropriate.

When the TSH is normal or elevated, ultrasound of the thyroid is used to confirm the presence of the nodule, determine its location, character, and assess for the presence of any suspicious cervical lymph nodes. FNA (fine needle aspiration) with ultrasound guidance is the procedure of choice for confirming the diagnosis based on ultrasound patterns of suspicion.

Presence of multiple nodules, such as might be found in a woman with a multinodular goiter, does not rule out malignancy. Sampling each nodule with an FNA is not practical, but ultrasound features of the nodules such as size, hypoechogenicity, micro calcifications and hypervascularity can be used to help predict the likelihood for malignancy and target nodules for biopsy.

Further Reading:

Haugen BR, Alexander EK, Bible KC, et al., 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016 Jan;26(1):1-133. doi: 10.1089/thy.2015.0020.

Initial Approval January 2010. Revised September 2016. Reaffirmed January 2018. Reaffirmed July 2019. Reaffirmed March 202. Revised September 2022


********** Notice Regarding Use ************

The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. (“SASGOG”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. SASGOG reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. SASGOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither SASGOG nor its respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

Copyright 2022 The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. All rights reserved. No re-print, duplication or posting allowed without prior written consent.


Visit us at:




Back to Search Results