Graves Disease

Graves disease may cause a wide range of signs and symptoms. They usually develop slowly, often beginning as mild and going unnoticed at first, and then progressively worsen. Different people may experience a different combination of symptoms at various times.

Graves disease can cause a condition known as exophthalmos or Graves ophthalmopathy. With this condition, tissue can build up behind the eyeballs and the eyelids can retract, leading to a characteristic fixed stare and protruding eyes. This can dry and irritate the eyes, interfere with vision, and in severe cases can cause damage to the cornea, the transparent covering at the front of the eye, and to the optic nerve, the nerve that transmits light images to the brain, resulting in vision loss. This symptom affects about 30% of the people diagnosed with Graves disease.

Some other signs and symptoms may include:

• Difficulty concentrating
• Double vision
• Eye irritation and tearing
• Fatigue
• Frequent bowel movements
• Enlarged thyroid gland (goiter)
• Breast enlargement (gynecomastia) in men (rare)
• Hand tremors
• Heat sensitivity
• Impotence or reduced libido
• Increased appetite
• Increased or irregular heartbeat (palpitations or arrhythmia)
• Insomnia
• Loss of endurance
• Menstrual irregularities
• Muscle weakness
• Nervousness
• Protruding eyes (exophthalmos) and/or fixed stare
• Reddening and thickening of skin on shins
• Restlessness and nervousness
• Sweating
• Unexplained weight loss

Graves disease during pregnancy can cause transient hyperthyroidism in the newborn because thyroid stimulating antibodies can be transferred to the fetus. In children, Graves disease can affect height, rate of development, and puberty.

Long-term exposure to excess thyroid hormones can cause osteoporosis. Sudden acute increases in thyroid hormones can cause a "thyroid storm" or thyrotoxic crisis that can be life-threatening.

Diagnosing Graves disease is a straightforward process when symptoms like goiter or protruding eyes are present. However, 50% of people with Graves disease may not have obvious signs and symptoms and laboratory tests are required for diagnosis. Testing is done to evaluate the health of the thyroid, diagnose Graves disease, and monitor treatment.

Laboratory Tests

To determine whether the thyroid is functioning properly, testing may begin with:

• Thyroid-stimulating hormone (TSH) — typically low in Graves disease
• Free T4 — usually elevated
• Free and Total T3 — often elevated

The above tests may also be ordered periodically to monitor thyroid function and hormone production.

Laboratory tests used to help diagnose Graves disease and distinguish it from other autoimmune conditions may include one or more of the following. These tests detect the presence of thyroid antibodies:

• Thyroid stimulating immunoglobulin (TSI) — presence of this antibody is diagnostic for Graves disease
• Thyroid stimulating hormone receptor antibody (TRAb) — less specific than TSI
• Anti-thyroid peroxidase antibody (anti-TPO) — this autoantibody is found in most people with Graves disease as well as in Hashimoto thyroiditis

Non-laboratory Tests

• Radioactive iodine uptake — For this test, a capsule or "cocktail" containing a measured amount of radioactive iodine is swallowed; iodine is a critical component of thyroid hormones. The iodine accumulates in the thyroid; more accumulates when the gland is overactive, as occurs in Graves disease. After a specified amount of time, a probe similar to a Geiger counter is placed over the thyroid and the amount of radioactivity is compared to the amount that was given. For additional details, visit RadiologyInfo.org.
• Ultrasound may be used for people who can't undergo radioactive iodine uptake to see if the thyroid gland is enlarged.

Treatment of Graves disease is geared to reducing the hormones produced by the thyroid gland and relieving symptoms. Typically, there are three main treatment options:

• Medications are prescribed:
  • Beta-blockers, such as propranolol, may reduce the effects of thyroid hormone on the body. These medications can relieve rapid heart rate, sweating, and anxiety and minimize shaking and nervousness caused by increased hormone activity. Beta-blockers work quickly and provide relief while waiting for long-term treatments to take effect.
  • Anti-thyroid drugs reduce thyroid hormone production. These are usually prescribed for no more than 1 to 2 years. For some people, normal thyroid function will continue after the drugs are stopped. For most people, additional treatment will be required.
• A large dose of radioactive iodine may be given to destroy most or all of the thyroid gland, reducing hormone levels and eliminating the symptoms of hyperthyroidism. In some cases, this therapy is not adequate to cure Graves disease and may need to be repeated. Over time, the thyroid gland may have decreased function and the person may develop hypothyroidism, though this may not develop for many years. Because of this, those who have been treated may need to be monitored.
• Sometimes surgery is performed to remove the thyroid gland. Once the thyroid has been removed or destroyed, the person will need to take thyroid hormone replacement medication.

Most of the eye problems associated with Graves disease decrease as the hormone levels are lowered, but some may require further action. For more about treatment, see the Related Pages section.