Graves disease
Diffuse thyrotoxic goiter; Hyperthyroidism - Graves; Thyrotoxicosis - Graves; Exophthalmos - Graves; Ophthalmopathy - Graves; Exophthalmia - Graves; Exorbitism - Graves; Graves' disease
Graves disease is an autoimmune disorder that leads to an overactive thyroid gland (hyperthyroidism). An autoimmune disorder is a condition that occurs when the immune system mistakenly attacks healthy tissue.
Endocrine glands release hormones (chemical messengers) into the bloodstream to be transported to various organs and tissues throughout the body. For instance, the pancreas secretes insulin, which allows the body to regulate levels of sugar in the blood. The thyroid gets instructions from the pituitary to secrete hormones which determine the rate of metabolism in the body (the more hormone in the bloodstream, the faster the chemical activity; the less hormone, the slower the activity).
This image shows the enlargement of the thyroid gland and extension down behind the breastbone (retrosternal space). The image, called a scintiscan, was generated using a radioactive isotope.
Graves disease is an autoimmune disorder that involves overactivity of the thyroid (hyperthyroidism). Hallmarks of the condition are bulging eyes (exophthalmos), heat intolerance, increased energy, difficulty sleeping, diarrhea and anxiety.
The thyroid gland, a part of the endocrine (hormone) system, plays a major role in regulating the body's metabolism.
Causes
The thyroid gland is an important organ of the endocrine system. The gland is located at the front of the neck above where the collarbones meet. This gland releases the hormones thyroxine (T4) and triiodothyronine (T3), which control body metabolism. Controlling metabolism is important for regulating mood, weight, and mental and physical energy levels.
When the body makes too much thyroid hormone, the condition is called hyperthyroidism. (An underactive thyroid leads to hypothyroidism.)
Graves disease is the most common cause of hyperthyroidism. It is due to an abnormal immune system response that causes the thyroid gland to produce too much thyroid hormone. Graves disease is most common in women over age 20. But the disorder can occur at any age and can affect men as well.
You're restless and nervous. You feel hungry all the time, but no matter how much you eat, you keep losing weight. You can't sleep or concentrate, and you feel hot and sweaty. If symptoms like these are putting you on edge, the problem may be an overactive thyroid gland, or hyperthyroidism. This little butterfly-shaped structure in your neck is your thyroid gland. It's job is to release the hormones that help control your body's energy levels, a process known as metabolism. When you have hyperthyroidism, that little gland goes into overdrive, releasing too much of its hormones. Having too much thyroid hormone is like putting your body in fast forward, everything speeds up. That's why you feel shaky, hungry, and your heart feels like it's pounding. So, what causes hyperthyroidism? You can develop an overactive thyroid because you've gotten too much iodine, an element the thyroid uses to make its hormones. Or, you might have a growth on your thyroid that's causing the excess hormone production. But many people with hyperthyroidism have an autoimmune disorder called Graves disease, which also makes their eyes bulge out. During an exam, your doctor may notice that your thyroid is larger than normal, and that you have high blood pressure, tremors, or a fast heart rate. These can all be signs of hypothyroidism. You'll probably have a blood test to check the levels of your thyroid hormones. If you do have an overactive thyroid, you may need to take medicine to slow down the gland and its hormone production. Or, your doctor may suggest having surgery to remove some or all of the thyroid, or taking radioactive iodine to destroy it. If you have surgery or radioactive iodine treatment, you'll probably need to take thyroid hormones for the rest of your life to replace the ones your body can no longer make. You can't prevent hyperthyroidism, but once you have it, it's usually pretty easy to treat. With the right treatment you can finally be free from its symptoms. While you're being treated, watch out for an emergency condition called thyroid crisis, or thyroid storm, which can set in if you've been under a lot of stress or have an infection. If you have a fever, fast and unsteady heartbeat, or you feel less alert than usual, call your emergency services number or go to the ER right away.
Symptoms
Younger people may have these symptoms:
- Anxiety or nervousness, as well as problems sleeping
- Breast enlargement in men (possible)
- Problems concentrating
- Fatigue
- Frequent bowel movements
- Hair loss
- Heat intolerance and increased sweating
- Increased appetite, despite having weight loss
- Irregular menstrual periods in women
- Muscle weakness of the hips and shoulders
- Moodiness, including irritability and anger
- Palpitations (sensation of a strong or unusual heartbeat)
- Rapid or irregular heartbeat
- Shortness of breath with activity
- Tremor (shakiness of the hands)
Many people with Graves disease have problems with their eyes:
- The eyeballs may seem to be bulging out and may be painful.
- Eyes can feel irritated, itchy, or tear more frequently.
- Double vision may be present.
- Decreased vision and damage to the cornea can also occur in severe cases.
Older people may have these symptoms:
- Rapid or irregular heartbeat
- Chest pain
- Memory loss or decreased concentration
- Weakness and fatigue
Exams and Tests
During the physical exam, your health care provider may find:
- You have an increased heart rate
- Your thyroid gland may be enlarged (goiter)
Other tests include:
- Blood tests to measure levels of TSH, T3, and free T4
- Radioactive iodine uptake and scan
This disease may also affect the following test results:
- Orbit CT scan or ultrasound
- Thyroid stimulating immunoglobulin (TSI)
- Thyroid peroxidase (TPO) antibody
- Anti-TSH receptor antibody (TRAb)
Treatment
Treatment is aimed at controlling your overactive thyroid. You may receive one or more types of treatment.
Beta-blocker medicines may help treat:
- Rapid heart rate
- Sweating
- Anxiety
They may be given until the hyperthyroidism is controlled.
Antithyroid medicines:
- Block or change how the thyroid gland uses iodine
- May be used to control the overactive thyroid gland before surgery or radioiodine therapy
- May be used as a long-term treatment
Radioactive iodine is given by mouth. It then concentrates in the overactive thyroid tissue and causes damage.
Surgery may be done to remove the thyroid.
If you have had radioactive iodine treatment or surgery, you will need to take replacement thyroid hormones for the rest of your life. This is because these treatments destroy or remove the gland.
TREATMENT OF THE EYES
Some of the eye problems related to Graves disease often improve after treatment with medicines, radiation, or surgery. Radioiodine therapy can sometimes make eye problems worse. Eye problems are worse in people who smoke, even after the hyperthyroidism is treated.
Sometimes, prednisone is needed to reduce eye irritation and swelling. Prednisone is a steroid medicine that suppresses the immune system.
You may need to tape your eyes closed at night to prevent drying. Sunglasses and eye drops may reduce eye irritation. In rare cases, surgery or radiation therapy (different from radioactive iodine) may be needed to prevent further damage to the eye and loss of vision.
Outlook (Prognosis)
Graves disease often responds well to treatment. Thyroid surgery or radioactive iodine often will cause an underactive thyroid (hypothyroidism). Without getting the correct dosage of thyroid hormone replacement, hypothyroidism can lead to:
- Depression
- Mental and physical sluggishness
- Weight gain
- Dry skin
- Constipation
- Cold intolerance
- Abnormal menstrual periods in women
When to Contact a Medical Professional
Call your provider if you have symptoms of Graves disease. Also call if your eye problems or other symptoms get worse or do not improve with treatment.
Go to the emergency room or call 911 or the local emergency number if you have symptoms of hyperthyroidism with:
- Decrease in consciousness
- Fever
- Rapid, irregular heartbeat
- Sudden shortness of breath
References
Hollenberg A, Wiersinga WM. Hyperthyroid disorders. In: Melmed S, Auchus RJ, Golfine AB, Koenig RJ, Rosen CJ, eds. Williams Textbook of Endocrinology. 14th ed. Philadelphia, PA: Elsevier; 2020:chap 12.
Jonklaas J, Cooper DS. Thyroid. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 213.
Marcdante KJ, Kleigman RM. Thyroid disease. In: Marcdante KJ, Kliegman RM, eds. Nelson Essentials of Pediatrics. 8th ed. Philadelphia, PA: Elsevier; 2019:chap 175.
Marino M, Vitti P, Chiovato L. Graves' disease. In: Jameson JL, De Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 82.
Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016;26(10):1343-1421. PMID: 27521067
Version Info
Last reviewed on: 2/1/2022
Reviewed by: Sandeep K. Dhaliwal, MD, board-certified in Diabetes, Endocrinology, and Metabolism, Springfield, VA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
