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Graves Disease

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About Graves Disease

Graves’ Disease is an autoimmune disorder that leads to overactivity of the thyroid gland – Hyperthyroidism. Hyperthyroidism occurs when the thyroid makes too much thyroid hormone. Graves’ disease is the most common cause of hyperthyroidism and typically causes thyroid symptoms, eye symptoms and skin symptoms. It is caused by an abnormal immune system response that causes the thyroid gland to produce too much thyroid hormones. Graves’ disease is most common in women over age 20 – however, the disorder may occur at any age and may affect men as well.

What is Graves Disease?

  • Graves’ disease is an autoimmune disorder, in which the body produces antibodies to the receptor for thyroid-stimulating hormone (TSHR). Antibodies to thyroglobulin and to the thyroid hormones T3 and T4 may also be produced
  • These antibodies (TSHR-Ab) bind to the TSH receptors, which are located on the cells that produce thyroid hormone in the thyroid gland (follicular cells), and chronically stimulate them, resulting in an abnormally high production of T3 and T4. This causes the clinical symptoms of hyperthyroidism, and the enlargement of the thyroid gland (visible as goitre)
  • The infiltrative exophthalmos (eye symptoms) that is frequently encountered, has been explained by postulating that the thyroid gland and the extraocular muscles share a common antigen that is recognized by the antibodies
  • Antibodies binding to the extraocular muscles would cause swelling behind the eyeball. This swelling has also been postulated to be the consequence of mucopolysacharide deposition posterior to the eyes, a symptom tangentially related to Graves’ Disease
  • The “orange peel” skin (skin symptoms) has been explained by the infiltration of antibodies under the skin, causing an inflammatory reaction and subsequent fibrous plaques

Graves Disease Symptoms

  • Eyeballs that stick out (exophthalmos)
  • Anxiety
  • Difficulty concentrating
  • Double vision
  • Eye irritation and tearing
  • Fatigue
  • Frequent bowel movements
  • Goitre
  • Heat intolerance
  • Increased appetite
  • Increased sweating
  • Insomnia
  • Menstrual irregularities
  • Muscle weakness
  • Nervousness
  • Rapid or irregular heartbeat (palpitations or arrhythmia)
  • Restlessness and difficulty sleeping
  • Shortness of breath with exertion
  • Tremor
  • Weight loss

Graves Disease Diagnosis

  • The onset of Graves’ disease symptoms is often slow and the intensity of symptoms can increase gradually for a long time before the correct diagnosis is made and may take months or years
  • A highly suggestive symptom of hyperthyroidism and Graves’ Disease, is a change in tolerance to external temperature. A hyperthyroid person will usually develop a preference for cold weather, a desire for less clothing and less bed covering, and a decreased ability to tolerate hot weather
  • Other nearly pathognomonic signs of hyperthyroidism are excessive sweating, high pulse during sleep, and a pattern of weight loss with increased appetite
  • Hyperthyroidism in Graves’ disease is confirmed, as with any other cause of hyperthyroidism, by a blood test – elevated blood levels of the principal thyroid hormones (i.e. free T3 and T4), and a suppressed thyroid-stimulating hormone (low due to negative feedback from the elevated T3 and T4), point to hyperthyroidism
  • Graves’ Disease can run in the family – studies of twins suggest that the genetic factors account for 79% of the liability for Graves’ disease
  • Differentiating Graves’ hyperthyroidism from the other causes of hyperthyroidism (thyroiditis, toxic multinodular goiter, toxic thyroid nodule, and excess thyroid hormone supplementation) is important to determine proper treatment. So, when hyperthyroidism is confirmed, or when blood results are inconclusive, thyroid antibodies should be measured because almost all patients with Graves’ hyperthyroidism have detectable TSHR-Ab
  • Measurement of thyroid-stimulating immunoglobulin (TSI) is the most accurate measure of thyroid antibodies and they will be positive in 60 to 90% of people with Graves’ disease. If TSI is not elevated, then a radioactive iodine uptake should be performed; an elevated result with a diffuse pattern is typical of Graves’ disease. Biopsy to obtain histological testing is not normally required but may be obtained if thyroidectomy is performed

Graves Disease Signs and Tests

  • Physical examination may show an increased heart rate, goitre and other signs of hyperthyroidism
  • Examination of the neck may show that the thyroid gland is enlarged
  • Tests including blood tests and thyroid imaging may be needed to confirm the diagnosis

Tests used to help find out if you have Graves Disease include:

Thyroid function tests

  • A blood sample is sent to a lab to see if your body has the right amount of thyroid hormone (T4) and TSH
  • A high level of thyroid hormone in the blood plus a low level of TSH is a sign of overactive thyroid
  • Sometimes, routine screening of thyroid function reveals mild overactive thyroid in a person without symptoms
  • In such cases, doctors might suggest treatment or watchful waiting to see if levels return to normal

Antibody tests

  • A blood sample is sent to a lab to look for antibodies that suggest Graves’ disease

Thyroid imaging – radioactive iodine uptake (RAIU)

  • An RAIU scan tells how much iodine the thyroid takes up
  • A high uptake suggests Graves’ disease
  • This test can be helpful in ruling out other possible causes of overactive thyroid

Eye Disease

  • Some of the eye problems related to Graves’ Disease usually improve when Hyperthyroidism is treated – with a better response often seen after total thyroidectomy
  • Radioactive iodine can sometimes make eye problems worse
  • Eye problems are worse in people who smoke, even after the hyperthyroidism is cured
  • Sometimes prednisone (a steroid medication that suppresses the immune system) is needed to reduce eye irritation and swelling
  • You may need to tape your eyes closed at night to prevent drying
  • Sunglasses and eyedrops may reduce eye irritation
  • Endoscopic orbital decompression surgery may be needed to return the eyes to their normal position 
  • Click here for more information about thyroid eye disease

Treatment of Graves Disease

  • The purpose of treatment is to control the overactivity of the thyroid gland
  • Beta-blockers such as propranolol are often used to treat symptoms of rapid heart rate, sweating, and anxiety until the hyperthyroidism is controlled

Hyperthyroidism (Graves’ Disease) is treated with one or more of the following

  • Antithyroid medications
  • Radioactive iodine
  • Thyroid surgery

Candidates for surgery may include:

  • Pregnant hyperthyroid patients who cannot take antithyroid drugs
  • Patients who do not want to use radioactive iodine
  • Patients with thyroid eye disease
  • Children
  • Patients with very large or multinodular goitres

Eye symptoms may be a reason to recommend surgical treatment and if you have radiation or surgery, you will need to take replacement thyroid hormones for the rest of your life – because these treatments destroy or remove the gland.

If you have any concerns or problems regarding Graves Disease or thyroid symptoms, speak to your Local Doctor, who will arrange to contact your thyroid surgeon.