An Overview of Graves' Disease

Graves' disease is associated with a number of symptoms. The symptoms of hyperthyroidism (due to any cause) include:

• Weight loss
• Heart palpitations
• Fatigue
• Muscle weakness
• Agitation
• Irritability
• Insomnia
• Increased sweating/heat intolerance
• Shaking hands
• Diarrhea or frequent bowel movements
• Increased appetite (sometimes a decrease, instead)
• Thinning hair
• Shortness of breath
• Fertility problems
• Menstrual-cycle changes
• Dizziness
• Hypertension (high blood pressure)

However, additional symptoms commonly occur with Graves' disease but not other types of hyperthyroidism:

• Graves' ophthalmopathy: Also called Graves' orbitopathy, this often causes "bulging eyes." Graves' ophthalmopathy can cause pressure around the eyes, sensitive eyes, and decreased vision. This affects about one-third of people with Graves', and it results from swelling due to the autoimmune process behind the disease.
• Skin lesions: Thyroid dermopathy, also known as Graves' dermopathy, can produce thickening of the skin, swelling, and severe itching. In rare cases, thyroid dermopathy can progress to a condition called acropachy, which is characterized by deformities of the fingers and toes.

Complications

If you have untreated Graves' disease, osteoporosis (thinning of the bones) and heart disease can develop over time.

Thyroid storm is a rare and dangerous complication characterized by a rapid heartbeat, high blood pressure, and high fever. Without immediate emergency medical treatment, this complication can be fatal. General anesthesia for surgery is a common trigger for thyroid storm in people with hyperthyroidism.

The autoimmune process behind Graves' disease is like any other in that the body mistakenly produces antibodies (infection-fighting proteins) against itself.

Several different thyroid antibodies exist, each resulting in a different thyroid condition. TSH receptor antibody (TSHR-Ab) is the antibody associated with Graves' disease.

Thyroid-stimulating hormone (TSH) is released by the pituitary gland in the brain. It binds to TSH receptors on the thyroid gland to trigger production of thyroid hormone. TSHR-Ab acts like TSH, telling the thyroid gland to keep putting out TSH—even when it's not needed.

Risk Factors

Doctors don't understand why some people develop Graves' disease, but there are several risk factors.

Age is one: Graves' is more common in those under age 40. Women are also more likely to develop Grave's disease than men, and there is an increased risk of this condition during pregnancy.

If you have a family history of Graves' disease or if you have another autoimmune condition, such as lupus, you are at an increased risk of developing Grave's disease as well.

Smoking is a strong risk factor for developing this condition. There has been some suggestion that stress could play a role, but the evidence is not consistent and a causative relationship remains uncertain.

If you have symptoms of Graves' disease, your doctor will review your medical history for risk factors and then use a few methods to reach a diagnosis.

Typically, a physical examination and thyroid function blood tests can establish that you have hyperthyroidism, and they may also narrow the cause down to Graves' disease. Other times, an imaging study or a biopsy may also be needed to distinguish Grave's disease from other types of hyperthyroidism.

Physical Examination

Graves' disease shows up in a physical exam as an enlarged thyroid gland, rapid heart rate, agitation, tremor, fast reflexes, and possibly moist, smooth skin. These are all signs of hyperthyroidism, but they do not confirm that you have Graves' disease.

If you have ophthalmopathy or dermopathy, your doctor may have a higher suspicion that you have Graves' disease, but these can occur with other types of hyperthyroidism as well. A goiter, similarly, suggests that you may have Graves' disease, but does not rule out another thyroid condition.

Blood Tests

The most common thyroid tests include TSH, thyroxine (T4) and triiodothyronine (T3). A low TSH with a high T4 and/or high T3 is typical of hyperthyroidism. Your doctor may also request that you have thyroid antibody tests.

Imaging Tests

Graves' disease can produce a change in the appearance of the thyroid gland that may be distinguished from a normal thyroid gland or from other thyroid conditions. Imaging tests used in the evaluation of Graves' disease may include ultrasound, X-ray, a computerized tomography (CT) scan, and magnetic resonance imaging (MRI).

You might also receive radioactive iodine before an imaging test because iodine enters the thyroid and can help improve visualization of the gland.

Biopsy

If there is still uncertainty about your diagnosis, you may have a biopsy, which is when a sample of tissue is removed for examination under a microscope. A biopsy is especially useful if your doctor is concerned about thyroid cancer.

You and your doctor have several different treatment methods to consider, either simultaneously or over time as your condition evolves.

Thyroid Management

Treatments that can help reduce your thyroid gland's overactivity include:

• Anti-thyroid medication: Several anti-thyroid medications are available. They work by preventing the thyroid gland from using iodine to produce thyroid hormones. The most common antithyroid medications include Tapazole(methimazole), carbimazole (which converts to methimazole), and Propylthiouracil (PTU). Methimazole, which is also called thiamazole, is also available in generic form.
• Radioactive iodine: Destruction of all or part of your thyroid gland using radioactive iodine (RAI) can decrease excessive thyroid hormone production. Sometimes, the destruction of the thyroid gland results in hypothyroidism (underactive thyroid).
• Surgery: Removal of all or part of the thyroid gland may be necessary if you cannot be treated with medication or RAI. However, this is not the typical treatment approach for Graves' disease. Removal of the thyroid gland results in hypothyroidism.

Treating Symptoms

If you continue to have hypertension and a rapid heart rate even after taking adequate antithyroid medication, RAI, or surgery, you may need to use medications such as beta blockers, which reduce heart rate and lower blood pressure. Other methods for managing hypertension include exercise, decreasing salt in your diet, weight loss, and relaxation techniques.

Treatment usually isn't needed for ophthalmopathy, but oral steroids or surgery can relieve swelling, if needed.

Thyroid dermopathy is treated with topical (on the surface of the skin) steroids.

You may also need medication to reduce diarrhea, as well as dietary adjustments or calorie supplements to prevent weight loss.

Graves' disease requires modification of some lifestyle issues to help you cope.

Weight Management

Hyperthyroidism may cause weight loss and an increased appetite. To avoid losing too much weight, you may need to increase your caloric intake. It is best to talk your doctor or a dietitian to help you come up with a dietary plan to maintain a healthy weight.

If you increase your food intake, be sure to maintain a balanced diet and to eat foods that are rich in vitamins, minerals, carbohydrates, and protein, rather than consuming processed or deep-fried foods. Hyperthyroidism can reduce your cholesterol, so your dietician may give you permission to eat a higher proportion of fat-containing foods than what is normally recommended in a healthy diet.

Diet

Some foods are known to be goitrogens, which interfere with the body's ability to use iodine. This causes hypothyroidism. If you have Graves' disease, you need to maintain moderation when it comes to goitrogens, as consuming too much of these foods can reduce your thyroid hormone levels, especially if your condition is adequately treated.

Stress

Hyperthyroidism can cause anxiety, irritability, and restlessness. If you experience these issues, be sure to talk with your doctor. Often, antithyroid medications are enough to reduce these symptoms, but sometimes, other coping mechanisms, such as meditation, biofeedback, exercise, and counseling are needed.