Learn about the symptoms, causes and treatment of this immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism).
Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism). Although a number of disorders may result in hyperthyroidism, Graves' disease is a common cause.
Thyroid hormones affect many body systems, so signs and symptoms of Graves' disease can be wide ranging. Although Graves' disease may affect anyone, it's more common among women and in people younger than age 40.
The primary treatment goals are to reduce the amount of thyroid hormones that the body produces and lessen the severity of symptoms.
The thyroid gland is located at the base of the neck, just below the Adam's apple.
Common signs and symptoms of Graves' disease include:
About 30% of people with Graves' disease show some signs and symptoms of Graves' ophthalmopathy. In Graves' ophthalmopathy, inflammation and other immune system events affect muscles and other tissues around your eyes. Signs and symptoms may include:
An uncommon manifestation of Graves' disease, called Graves' dermopathy, is the reddening and thickening of the skin, most often on your shins or the tops of your feet.
A number of medical conditions can cause the signs and symptoms associated with Graves' disease. See your doctor if you experience any potential problems related to Graves' disease to get a prompt and accurate diagnosis.
Seek emergency care if you're experiencing heart-related signs and symptoms, such as a rapid or irregular heartbeat, or if you develop vision loss.
Widespread enlargement of the thyroid can expand the gland well beyond its typical size (left) and cause a noticeable bulge in the neck (right).
Graves' disease is caused by a malfunction in the body's disease-fighting immune system. It's unknown why this happens.
The immune system normally produces antibodies designed to target a specific virus, bacterium or other foreign substance. In Graves' disease — for reasons that aren't well understood — the immune system produces an antibody to one part of the cells in the hormone-producing gland in the neck (thyroid gland).
Normally, thyroid function is regulated by a hormone released by a tiny gland at the base of the brain (pituitary gland). The antibody associated with Graves' disease — thyrotropin receptor antibody (TRAb) — acts like the regulatory pituitary hormone. That means that TRAb overrides the normal regulation of the thyroid, causing an overproduction of thyroid hormones (hyperthyroidism).
Graves' ophthalmopathy results from a buildup of certain carbohydrates in the muscles and tissues behind the eyes — the cause of which also isn't known. It appears that the same antibody that can cause thyroid dysfunction may also have an "attraction" to tissues surrounding the eyes.
Graves' ophthalmopathy often appears at the same time as hyperthyroidism or several months later. But signs and symptoms of ophthalmopathy may appear years before or after the onset of hyperthyroidism. Graves' ophthalmopathy can also occur even if there's no hyperthyroidism.
Although anyone can develop Graves' disease, many factors can increase the risk of disease, including:
Complications of Graves' disease can include:
Thyroid storm. A rare but life-threatening complication of Graves' disease is thyroid storm, also known as accelerated hyperthyroidism or thyrotoxic crisis. It's more likely when severe hyperthyroidism is untreated or treated inadequately.
The sudden and drastic increase in thyroid hormones can produce many effects, including fever, sweating, vomiting, diarrhea, delirium, severe weakness, seizures, irregular heartbeat, yellow skin and eyes (jaundice), severe low blood pressure, and coma. Thyroid storm requires immediate emergency care.
To diagnose Graves' disease, your doctor may conduct a physical exam and check for signs and symptoms of Graves' disease. He or she may also discuss your medical and family history. Your doctor may also order tests including:
Blood tests. Blood tests can help your doctor determine your levels of thyroid-stimulating hormone (TSH) — the pituitary hormone that normally stimulates the thyroid gland — and your levels of thyroid hormones. People with Graves' disease usually have lower than normal levels of TSH and higher levels of thyroid hormones.
Your doctor may order another lab test to measure the levels of the antibody known to cause Graves' disease. It's usually not needed to diagnose the disease, but results that don't show antibodies might suggest another cause of hyperthyroidism.
The treatment goals for Graves' disease are to stop the production of thyroid hormones and to block the effect of the hormones on the body. Some treatments include:
With this therapy, you take radioactive iodine (radioiodine) by mouth. Because the thyroid needs iodine to produce hormones, the thyroid takes the radioiodine into the thyroid cells and the radiation destroys the overactive thyroid cells over time. This causes your thyroid gland to shrink, and symptoms lessen gradually, usually over several weeks to several months.
Radioiodine therapy may increase your risk of new or worsened symptoms of Graves' ophthalmopathy. This side effect is usually mild and temporary, but the therapy may not be recommended if you already have moderate to severe eye problems.
Other side effects may include tenderness in the neck and a temporary increase in thyroid hormones. Radioiodine therapy isn't used for treating pregnant women or women who are breast-feeding.
Because this treatment causes thyroid activity to decline, you'll likely need treatment later to supply your body with normal amounts of thyroid hormones.
Anti-thyroid medications interfere with the thyroid's use of iodine to produce hormones. These prescription medications include propylthiouracil and methimazole (Tapazole).
Because the risk of liver disease is more common with propylthiouracil, methimazole is considered the first choice when doctors prescribe medication. However, propylthiouracil is the preferred anti-thyroid drug during the first trimester of pregnancy, as methimazole has a slight risk of birth defects. Pregnant women will generally go back to taking methimazole after the first trimester.
When these two drugs are used alone without other treatments, a relapse of hyperthyroidism may occur at a later time. Taking either drug for longer than a year may result in better long-term results. Anti-thyroid drugs may also be used before or after radioiodine therapy as a supplemental treatment.
Side effects of both drugs include rash, joint pain, liver failure or a decrease in disease-fighting white blood cells.
These medications don't inhibit the production of thyroid hormones, but they do block the effect of hormones on the body. They may provide fairly rapid relief of irregular heartbeats, tremors, anxiety or irritability, heat intolerance, sweating, diarrhea, and muscle weakness.
Beta blockers include:
Beta blockers aren't often prescribed for people with asthma because the drugs may trigger an asthma attack. These drugs may also complicate management of diabetes.
Surgery to remove all or part of your thyroid (thyroidectomy or subtotal thyroidectomy) also is an option for the treatment of Graves' disease. After the surgery, you'll likely need treatment to supply your body with normal amounts of thyroid hormones.
Risks of this surgery include potential damage to the nerve that controls your vocal cords and the tiny glands located adjacent to your thyroid gland (parathyroid glands). Your parathyroid glands produce a hormone that controls the level of calcium in your blood. Complications are rare under the care of a surgeon experienced in thyroid surgery. You'll need to take thyroid medication for life after this surgery.
Mild symptoms of Graves' ophthalmopathy may be managed by using over-the-counter artificial tears during the day and lubricating gels at night. If your symptoms are more severe, your doctor may recommend:
Orbital decompression surgery. In this surgery, your doctor removes the bone between your eye socket (orbit) and your sinuses — the air spaces next to the orbit. This gives your eyes room to move back to their original position.
This treatment is usually used if pressure on the optic nerve threatens the loss of vision. Possible complications include double vision.
Graves' ophthalmopathy doesn't always improve with treatment of Graves' disease. Symptoms of Graves' ophthalmopathy may even get worse for three to six months. After that, the signs and symptoms of Graves' ophthalmopathy usually become stable for a year or so and then begin to get better, often on their own.
If you have Graves' disease, make your mental and physical well-being a priority:
These steps may make your eyes feel better if you have Graves' ophthalmopathy:
If the disease affects your skin (Graves' dermopathy), use over-the-counter creams or ointments containing hydrocortisone to relieve swelling and reddening. In addition, using compression wraps on your legs may help.
You'll probably see your primary care doctor first. You may be referred to a specialist in disorders of hormone function and the endocrine system (endocrinologist). If you have Graves' ophthalmopathy, your doctor may also recommend that you see a doctor who has trained in eye disorders (ophthalmologist).
Here's some information to help you get ready for your appointment, and what to expect from your doctor.
Preparing a list of questions can help you make the most of your time with your doctor. For Graves' disease, some basic questions to ask your doctor include:
Your doctor is likely to ask you a number of questions. Be prepared to answer the following: