Graves’ disease: Causes, symptoms and treatment

10 July 2019 |   Category: Ear Nose Throat
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Graves’ disease is an autoimmune disease causing excessive thyroid hormone release from thyroid gland – hyperthyroidism. As thyroid hormones affect many different body regions, there is a broad range of symptoms of Graves’ disease, and these significantly affect your daily life. It is frequently seen in young adult women. It may cause symptoms such as palpitation, chest pain, shortness of breath, sweating, diarrhea, concentration problems and irritability. If left untreated, it may result in death due to development of certain disorders. The main goal of treatment is to prevent the excessive thyroid hormone production and reduce the severity of symptoms. It can be controlled using anti-thyroid medications. Moreover, it can be cured using radioactive iodine treatment and surgical methods.

What is Graves’ disease?

Graves’ disease (toxic diffuse goiter) is a disease characterized by excessive hormone release from thyroid gland due to immune system cells attacking the body’s own cells. It causes thyroid gland enlargement, i.e. Goiter. It is seen 4- to 5-fold more in women than men. Hyperthyroidism is the most frequent cause. It can be seen at all ages; however, it is most commonly seen between the ages of 20 and 40.

Thyroid gland is a hormone-secreting endocrine gland placed on the anterior-middle part of the neck. It resembles a butterfly. It is a vital organ which ensures a balanced and regular functioning of many important organs and systems such as the heart and the brain. Over- or under-functioning of the thyroid gland leads to many problems in the body. Excessive hormone production by an over-functioning thyroid gland is called ‘hyperthyroidism’.

Hyperthyroidism: Causes, symptoms, diagnosis and treatment

Causes of Graves’ disease

Our immune system protects us against possibly detrimental organisms such as bacteria and viruses. In genetically predisposed individuals, immune system cells attack and damage certain organs as if they are detrimental organisms, and the reason for this is not exactly known. Diseases occurring via this mechanism are called autoimmune diseases. Graves’ disease is also an autoimmune disease seen due to immune cells attacking the thyroid gland.

In this disease, your immune system produces some antibodies called thyroid stimulating immunoglobulins (TSIs). These antibodies lead to excessive thyroid hormone production that is more than the body’s need. This results in hyperthyroidism.

Risk factors for Graves’ disease

  • Genetic: It is more frequent in individuals with familial history of Graves’ disease.
  • Sex: It is more common in women than men.
  • Age: It is frequently seen at younger and middle ages.
  • Presence of another autoimmune disease: It is more common in individuals with autoimmune diseases such as type 1 diabetes or rheumatoid arthritis.
  • Emotional and physical stress: Stressful events or illnesses may trigger the development of Graves’ disease in genetically predisposed individuals.
  • Tobacco: Smoking increases the risk by affecting the immune system. Furthermore, in Graves’ patients who are smokers, the possibility of disease-induced eye involvement is higher.
  • Medications: It may occur due to the use of medications such as amiodarone and alemtuzumab.

What is Hashimoto’s thyroiditis? Causes, symptoms and treatment

Symptoms of Graves’ disease

  • Ophthalmopathy (eye involvement)
  • Chest pain, palpitation
  • Weight loss despite increased appetite
  • Anxiety, restlessness, irritability
  • Sleeplessness, concentration problems
  • Intolerance to heat, excessive sweating
  • Shortness of breath, labored breathing
  • Diarrhea
  • Menstrual irregularity
  • Muscle weakness
  • Hair loss
  • Shaky hands
  • Sexual function disorder

In case of Graves’ disease-induced eye involvement, the eyeball appears like it is placed outwards. Eye dryness, pain, photosensitivity and double vision may be seen. Eye movements become difficulty. Blindness may be seen due to the involvement of optic nerve

Diagnosis of Graves’ disease

The diagnosis is made by medical history, physical examination, laboratory analyses and imaging methods.

  • Medical history: presence of any co-existing condition, medication use, smoking status, and familial history of the disease is questioned.
  • Physical examination: The size of the thyroid gland, the presence of pain and temperature increase is checked by palpation. Additionally, presence of nodule (lump) may be checked. The heart and the abdomen are checked by auscultation using stethoscope. The hands are examined for the presence of shaking. Eyes are also examined in detail.
  • Laboratory tests: Hormone levels indicating thyroid dysfunction including thyroid stimulating hormone (TSH), free T4 and T3 are checked. Moreover, levels of thyroid autoantibodies which may increase in Graves’ disease are also checked.
  • Imaging methods: The structure of the thyroid gland is assessed using thyroid ultrasound, mainly for the presence of nodule. US-guided sampling may be performed when necessary.
  • Radioactive iodine uptake test: It is the radioactive form of the iodine taken with food. It is taken orally in liquid or capsule form. As iodine is used by thyroid gland in the body, it is transferred to thyroid gland via blood. After the iodine is taken, body images are taken using special cameras at certain intervals. Thereby, the amount of iodine uptake by the thyroid gland or the presence of non-thyroid iodine accumulation is checked. The use of certain medications which may affect the test result is interrupted before the procedure. Some foods including seafood should not be consumed. It is used for diagnosis and treatment.

What is goiter? Causes, symptoms and treatment methods

Treatment of Graves’ disease

Graves’ disease can be controlled by a successful treatment using proper methods. The goal is to reduce the excessive thyroid hormone levels and protect the body from the effects. Therapeutic options may vary based on the co-existing conditions and being pregnant. Medical treatment, radioactive iodine treatment and surgical treatment can be used.

Medical treatment of Graves’ disease

  • Beta-blocker medications: They are used for the symptoms including palpitation, high blood pressure, shaky hands and irritability caused by excessive thyroid hormones. The beta-blocker medications in use include propranolol and atenolol. They provide symptom relief until the hormone levels return to normal.
  • Anti-thyroid medications: They show their effect by reducing the thyroid hormone production. Methimazole and propylthiouracil are used for this purpose. They do not provide cure and their effects are not permanent. Due to the presence of previously synthesized hormones, their effects start late. Propylthiouracil is the one with the fastest onset of action and with the least amount crossing placenta. As methimazole is detrimental to the fetus especially in the first trimester, propylthiouracil is used in pregnant and breastfeeding women. The most common side effects include skin rashes and itching. They may cause infection by decreasing the levels of immune cells of the body, and bleeding by decreasing the level of platelets. Therefore, regular blood analysis is required. They may rarely cause liver failure and jaundice.

What is the benefits of iodine? Symptoms of deficiency and treatment

Radioactive iodine treatment

The thyroid gland gets damaged by radioactive iodine via oral route, thereby, excessive hormone release can be reduced. The amount of the iodine used is more than the amount used for diagnosis. It can be used in inoperable patients who are not adequately responding to treatment. It must definitely not be used in pregnant and breastfeeding women. Thyroid gland shrinkage is usually seen a few weeks to a few months after the treatment, and the complaints gradually decrease. The most important side effect is the under-functioning of the thyroid gland due to excessive damage.

Treatment of ophthalmopathy

The first step is to treat Graves’ disease. In addition, cortisone treatment may be initiated. Eye drops can be used and eyes can be closed using dressing to prevent dryness. Sunglasses can be used to reduce photosensitivity. Sleeping with head elevated helps reduce both dryness and swelling. Surgical procedures can be used when necessary.

What is Cortisone? Benefits, Uses, Dosage and Side Effects

Surgical treatment for Graves’ disease

Pregnant women, women who are planning to get pregnant early after treatment, younger individuals, patients with moderate-to-severe ophthalmopathy (especially who are smokers), and patients who cannot tolerate antithyroid medications are treated surgically. In addition, surgical treatment is considered if the thyroid gland enlargement is severe to the extent of damaging the surrounding structures. Thyroid hormone levels are returned to normal using medical treatment before the operation. Based on the hormone levels and the patient’s complaints, total or near-total thyroidectomy may be performed.

Hormone levels are checked at frequent intervals after treatment, and in case of deficiency, external thyroid hormone supplement might be initiated. Bleeding may occur early after the operation. The most important possible side effect is hoarseness.

How long does the treatment of Graves’ disease take?

The risk of recurrence of Graves’ disease is high with treatments shorter than 6 months using antithyroid medications. In this respect, the average treatment duration is 13 months (1- to 2-year). The rate of disease recurrence 1 to 2 years after the medication is discontinued is around 40-80%. The medication is used temporarily (4 to 8 weeks) to prepare the patient for operation. Thyroid hormone levels should be checked at frequent intervals after the medications are discontinued.

Thyroid hormone levels return to normal within 2 months with radioactive iodine treatment. They stay within normal levels for 6 months in 50% of the patients. Over- or under-functioning of thyroid gland may be seen in other patients. The risk of an under-functioning thyroid increases every year.

Beta blocker medications are used until symptom relief.

What is Hashimoto’s thyroiditis? Causes, symptoms and treatment

Herbal treatment of Graves’ disease

As herbal treatment methods may lead to side effects especially in individuals using medications and who have co-existing conditions, you should consult with your doctor before using herbal treatment methods.

Medicinal herbs good for Graves’ disease

In animal studies, certain herbs including Melissa plant (lemon balm), St. John’s wort, throw-wort, club moss have been demonstrated to be effective in hyperthyroidism by reducing the levels of thyroid hormones via various mechanisms. However, human studies on these herbs are lacking, thus, the evidence is insufficient. Moreover, as they affect the thyroid hormone levels, they may cause changes in other hormones related with the thyroid gland. Therefore, they should only be used within a doctor’s knowledge or if recommended by a doctor.

Nutrition in Graves’ disease

Graves’ disease cannot be treated by only dietary changes nor the disease development can be prevented. However, dietary changes may help with the conditions induced by Graves’ disease including weight loss and bone thinning. It should be remembered that the effect of each food is not same for every individual.

  • Vitamin D: Individuals with Graves’ disease should consume foods containing vitamin D, and if necessary, use vitamin D supplements. Foods including eggs, mushroom, salmon may help prevent bone thinning which may be caused by Graves’ disease.
  • Calcium: Dairy products including milk, cheese and yogurt should be consumed for calcium supplementation. They contribute bone strengthening.
  • Magnesium: It is possible to increase calcium absorption by magnesium by consuming foods rich in magnesium such as avocado, dark chocolate, almond and legumes.
  • Selenium: A study performed in regions with mild selenium deficiency has detected that selenium treatment at a dose of 100 microgram given twice a day for six months improves eye manifestations and the quality of life. Therefore, especially patients with eye involvement may prefer foods rich in selenium such as seafood, egg, cereal and dairy products.
  • High-energy foods: As muscle weakness and thinning may be seen due to this disease, foods rich in protein and energy such as chicken, turkey, beans and hazelnut should be consumed.
  • Caffeine restriction: Consumption of foods and beverages containing caffeine such as coffee, tea, coke and chocolate should be restricted. Because caffeine may exacerbate the symptoms of anxiety, irritability, palpitation and weight loss caused by Graves’ disease.
  • Iodine: Iodine is a necessary substance for thyroid hormone synthesis. Adequate dietary iodine intake is necessary. Iodine deficiency may result in thyroid gland enlargement and iodine excess may result in hyperthyroidism. Therefore, you should consult with your doctor about the amount of iodine to be consumed.

Health problems from graves disease

Graves’ disease and hyperthyroidism

Hyperthyroidism develops due to excessive thyroid hormone release in Graves’ disease. One of the most common reasons of hyperthyroidism is Graves’ disease. One goal of the treatment of Graves’ disease is to return the hyperthyroid state to euthyroid state.

Graves’ ophthalmopathy

It is the involvement of the eyes in Graves’ disease. It is mostly seen in Graves’ patient who are also smokers. Patients with Graves’ ophthalmopathy must definitely quit smoking. Symptoms including burning eyes, watering of eyes, photosensitivity, blurred vision, eyelid retraction, swelling and redness, eye inflammation, abnormal eyeball protrusion, being unable to completely close the eyelids during sleep, headache and double vision may be seen. Eye movements become difficulty. Blindness may be seen due to the involvement of optic nerve.

Graves’ dermopathy (pretibial myxedema)

It is seen in approx. 5-15% of the patients. It is characterized with non-pitting swellings on both sides of the extremities and red-orange flaky skin. It may cause itching and pain. Sometimes, it is also possible that there is no sign or symptom. It is mainly seen on tibial area, but also on the dorsum of the foot, back, neck and ankles.

Thyroid storm

It is a rare, however, a life-threatening condition if left untreated. It’s frequently seen in Graves’ disease. It is an emergency seen due to previously-stored thyroid hormones being release into blood. Symptoms include fever, nausea, vomiting, diarrhea, palpitation, heart failure, and mental fog. Beta-blocker medications and anti-thyroid medications are used for symptom alleviation. Cortisone treatment might be necessary in severe cases.

Heart diseases

If left untreated, Graves’ disease may result in cardiac rhythm problems, cardiac muscle functioning and structure problems, and heart failure.

Bone thinning

Excessive thyroid hormone blocks calcium entry into the bones and impairs bone structure. If left untreated, Graves’ disease results in bone fragility and weakness.

Graves’ disease and pregnancy

Graves’ disease is detected in less than 1% of all pregnant women. If a woman with Graves’ disease gets pregnant, it may affect both the pregnancy and the mother’s health. Pregnancy may trigger Graves’ disease in some women. During pregnancy, Graves’ disease increases the risk of abortion, premature delivery, toxemia of pregnancy, heart failure in mother; and the risk of thyroid disease and low birth-weight in baby.

If you are genetically predisposed or if you have Graves’ disease, you should consult with your doctor when planning pregnancy. You should be sure that hyperthyroidism is under control. For medical treatment during pregnancy, propylthiouracil should be used instead of methimazole. Graves’ disease usually tends to improve spontaneously in the 2nd or 3rd trimester. Medications might even be stopped in many patients.

Radioactive iodine treatment cannot be used in pregnant or breast-feeding women. Pregnancy must be planned at least 6 months after radioactive iodine treatment.

Recommendations for Graves’ patients

  • Follow your doctor’s treatment recommendations.
  • Do not miss your follow-up visits as your thyroid hormone levels may change very frequently. As the medications may have significant side effects, return for regular blood tests.
  • As stress may trigger Graves’ disease, try methods to overcome stress. You can get support from your family and friends.
  • As smoking may exacerbate ocular signs, you must absolutely quit smoking.
  • Hormone levels may increase greatly and thyroid storm may occur. In case of sudden-onset mental fog, fever, palpitation and shortness of breath related with this entity, seek emergency medical help.
  • In case of eye involvement, wear sunglasses to protect your eyes from the sun.
  • You can use synthetic tear drops to prevent eye dryness.
  • Sleep with head elevated to decrease the edema around the eyes.

References: 1- What is Graves' disease?, 2- Graves’ disease, 3- What causes Graves’ disease?

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