Graves’ Disease

Graves’ disease, also known as Basedow’s disease or diffuse toxic goiter, is an autoimmune condition in which a person’s immune system mistakenly stimulates the thyroid gland to produce excess amounts of thyroid hormone, causing hyperthyroidism and sometimes eye problems. It is the most common cause of hyperthyroidism. 1

The thyroid is a small, butterfly-shaped gland in the lower part of the neck, positioned below the voice box. Hormones released by the gland control the body’s metabolism, playing a key role in processes like digestion, temperature, heart rate and growth. If the levels of these hormones go too low or too high and are not corrected, a person can experience a range of unpleasant and potentially dangerous effects and complications. 1 2

Symptoms of Graves’ disease may include: 1

• Nervousness
• Racing heart or palpitations, i.e. pronounced awareness of one’s heartbeat
• Difficulty sleeping
• Intolerance to heat
• Feeling tired and/or weak
• Swelling of the thyroid, i.e. development of a goiter
• Irritation and bulging of the eyes, known as Graves’ ophthalmopathy or thyroid eye disease

Treatment for Graves’ disease depends on the particular person, but may include medication to reduce the amount of thyroid hormone being produced, radioiodine therapy and, in some cases, surgery to remove the thyroid gland. The condition may go into remission and then relapse. Treatment and monitoring is usually lifelong. 1 3 4

With careful management by a doctor who specializes in hormonal conditions, an endocrinologist, the outlook is good and many people with Graves’ disease are able to enjoy a full, healthy life. 5 6

However, untreated or poorly treated Graves’ disease can lead to serious complications, including an increased risk of bone fractures, cardiovascular disease and stroke, as well as thyroid storm. In the case of Graves’ eye disease, vision loss may occur. 3 7 8

Diffuse toxic goiter can affect people of any age, though it tends to be more prevalent in adults, particularly those between the ages of 20 and 50, than children. It is more common in women than men and often runs in families, meaning that several family members may have the same condition. 1 3 9 10 11 12

A person with Graves’, or Basedow’s disease, may develop general signs and symptoms of hyperthyroidism, including: 1 5 13 14

• Anxiety or nervousness
• Irritability, agitation or restlessness
• Rapid or irregular heartbeat or palpitations
• Sleep disturbances, i.e. insomnia
• Increased sweating, body warmth and heat intolerance
• Fatigue and weakness
• Difficulty exercising
• Tremors, i.e. shaky hands
• Having more bowel movements than usual
• Unexplained weight loss or difficulty gaining weight; in some cases there may be weight gain due to increased appetite
• Hair loss
• Erectile dysfunction in men

Symptoms may develop gradually, and may seem to come and go. In some people, there may be swelling of the thyroid gland, called a goiter. This may be noticeable as a bulge in the front of the neck. 1 2 10 Read more about symptoms of hyperthyroidism.

In women, Graves’ disease may also cause menstrual irregularities including: 1 13

• Very light periods
• Infrequent periods
• Absence of periods

An estimated 25 to 50 percent of people with Graves’ disease experience eye symptoms, sometimes without the other symptoms of hyperthyroidism. These eye symptoms are caused by a condition called Graves’ ophthalmopathy, Graves’ orbitopathy or thyroid eye disease; despite the name they can also occur in people without thyroid problems. Eye symptoms may include: 8 13 15

• Irritation, tearing or dryness in the eyes; the eyes may feel gritty
• Redness of the eyes and eyelids
• Swelling of the upper eyelids
• Sensitivity to light
• Bulging of the eyes
• Pain in or behind the eyes, particularly when looking up or to the side

In most cases, the eye symptoms of Graves’ disease are mild and easy to treat. However, in a small number of cases they can be very serious and damage a person’s vision. Some of the more severe symptoms of thyroid eye disease include: 8 13 15

• Inability to move the eyes
• Ulcers on the cornea (the outer layer of the eye)
• Blurred or double vision
• Loss of vision and blindness (rare)

If you are experiencing any eye problems and suspect that you may have thyroid eye disease, it is recommended that you see a doctor without delay.

A small number of people with Graves’ disease develop red, thick, swollen areas of skin, typically on the shins and the top of the feet. This is called pretibial myxedema, thyroid dermopathy or Graves’ dermopathy, and is most often seen in people who also have eye symptoms. 1 16

Graves’ disease is an autoimmune condition, which means that it is caused by the body’s immune system mistakenly targeting healthy tissue, in this case the thyroid gland. Graves’ disease occurs when immune system proteins (antibodies), which normally attack bacteria and viruses, start attacking the thyroid gland. This causes the thyroid gland to secrete more thyroid hormone than is needed by the body, leading to hyperthyroidism. 17

It is not understood exactly what causes the immune system to target the thyroid gland, but hereditary factors are thought to be involved. Certain genes passed down in families seem to make a person more likely to develop Graves’ disease. If a relative has the condition, the risk is increased.

It is thought that other risk factors for the development of the disease may include: 9 18 19 11 20 21

• Being female
• Having been pregnant recently
• Having another autoimmune condition, e.g. type 1 diabetes, Hashimoto’s thyroiditis or rheumatoid arthritis
• Severe stress
• High iodine intake
• Smoking tobacco; this is also associated with worsening of Graves’ eye symptoms
• Certain medications, e.g. Interferon beta-1b
• Certain infections, e.g. Yersinia enterocolitica
• Injury to the thyroid gland, e.g. through surgery

Graves’ ophthalmology is not the result of excess thyroid hormone in the body, but rather inflammation and swelling in the tissues behind the eyes. This swelling pushes the eyeballs forward, causing bulging and other symptoms. The same antibodies that mistakenly stimulate the thyroid gland to produce high levels of thyroid hormone mistakenly target these tissues in some people, though the exact reason for this is not clearly understood. 15 18 22

Smoking tobacco is a risk factor in the development and worsening of thyroid-associated eye disease. 15 22

The first step in the diagnosis of Graves’ disease is typically a visit to a doctor, who will take the person’s medical history and perform a physical examination. If Graves’ disease is suspected, doctors will usually order blood tests to check thyroid hormone levels, as well as levels of thyroid antibodies. An ultrasound scan of the thyroid gland and/or radioactive iodine uptake test may also be needed. These imaging tests can help the doctor to see whether any swelling or nodules, which are small lumps, are present. 1

These are able to measure levels of the following: 1 3 5 11 23 24

Thyroid stimulating hormone (TSH): This varies according to how much thyroid hormone is needed by the body at any given time. TSH levels are usually very low in Graves’ disease and many other conditions that cause hyperthyroidism.

Free thyroxine (FT4): This is a form of thyroid hormone that is converted into the biologically active T3. FT4 levels are usually high when Graves’ disease is present.

Free triiodothyronine (FT3): Not always measured. However, FT3 levels are usually high when Graves’ disease is present.

Good to know: If TSH is low but FT4 and FT3 levels are normal, the person may have what is known as mild or subclinical hyperthyroidism. They will typically need to have follow-up tests in a couple of months to see whether there has been any change. Depending on the results and the particular person, the doctor may recommend treatment based on the initial findings. 1 25

Thyroid antibodies: Graves’ disease is typically characterized by high levels of thyroid antibodies, particularly thyroid stimulating immunoglobulin (TSI), as well as thyroid stimulating hormone receptor antibodies (TSHR Ab), also known as TSH receptor antibodies (TRAbs). High levels of thyroid peroxidase antibodies (TPO) and anti-thyroglobulin antibodies (Tg) are often detected in people affected by Graves’ too.

A non-invasive scan of the throat region, a thyroid ultrasound can help to identify nodules and swelling, thereby helping to identify the cause of the hyperthyroidism. 23

To confirm the diagnosis, a doctor may recommend a test in which the person is given a very small dose of a weakly radioactive substance and then undergoes a special imaging scan. Because the thyroid takes up iodine, this test can provide insights into how the thyroid is functioning and what the cause of the hyperthyroidism may be. It is generally safe for most people, but is not recommended for pregnant women. 1 23 26

It is important to distinguish signs and symptoms of Graves’ disease from other conditions that can sometimes present in similar ways, such as other thyroid problems, an anxiety disorder or bipolar disorder. Blood tests and the other tests detailed above help to ensure an accurate diagnosis. 27

Treatment for Graves’ disease is generally the same as treatment for hyperthyroidism. It typically requires lifelong monitoring and management of thyroid hormone levels, with the help of an endocrinologist and general practitioners, to ensure that they remain in the acceptable range. Depending on the particular person and their circumstances, treatment options may include: 1 5

• Antithyroid medication; this is the term for medicine aimed at reducing thyroid function
• Radioiodine therapy
• Thyroid surgery

Read more about hyperthyroidism treatment »

In many cases, Graves’ orbitopathy clears up on its own, without any specific treatment. However, in other cases treatment may be necessary. This may include: 8

• In mild cases, cool compresses, lubricating eye drops and sunglasses
• Corticosteroid medication
• In severe cases, surgery

A person with thyroid eye disease will be referred to a doctor specializing in the eyes, called an ophthalmologist, for management of the condition.

Good to know: Smoking tobacco increases the risk of developing thyroid eye disease, as well as the risk of complications from thyroid eye disease, and should be avoided. 8 22

The skin lesions that some people with Graves’ disease develop do not generally cause discomfort and are not usually serious. However, they can be unsightly. Treatment for thyroid dermopathy is often not necessary, but where recommended typically involves the application of corticosteroid creams. People with more severe pretibial myxedema may find that wearing compression stockings is also helpful in providing relief. 28 29

Good to know: Almost all people who develop pretibial myxedema also have fairly severe thyroid eye disease. 29

If it is left untreated or medical advice is not adequately followed, Graves’ disease can cause serious complications. These include: 3

• Eye damage and vision loss, in the case of thyroid eye disease 8 22
• Hypothyroidism if thyroid hormone levels are not adequately monitored and managed 11
• Thyroid storm
• Other complications

Read more about thyroid storm and other complications of hyperthyroidism »

Q: Are Graves’ disease and hyperthyroidism the same thing?
A: While the two terms are often used interchangeably, there is a difference. Hyperthyroidism refers to a condition where the thyroid gland is overactive and causes an excess of thyroid hormone in the body, resulting in a range of symptoms. Hyperthyroidism has a number of possible causes; Graves’ disease is the most common of these. Furthermore, a small number of people may have Graves’ disease without symptoms of hyperthyroidism, experiencing only eye problems because of the condition. 30

Q: Is Graves’ disease curable?
A: While the underlying autoimmune condition cannot currently be cured, Graves’ disease can be effectively treated and managed with the help of a doctor and medical therapies. 1

Q: Is there a special Graves’ disease diet?
A: Though some sources claim that various diets may help people with Graves’ disease, no specific diet is recommended by doctors. In general, a balanced and healthy diet is considered sufficient. It is not advisable for a person affected by Graves’ disease to adopt a special diet, stop eating foods they usually eat, or take any nutritional supplements without first consulting a doctor. However, iodine and kelp supplements in particular should be strictly avoided unless recommended by a licensed medical practitioner, as it is thought that they can worsen hyperthyroidism. 31

Q: Is there a natural treatment for Graves’ disease?
A: There are currently no widely-recognized natural treatments for Graves’ disease. If you are concerned that you may have the condition, it is important to consult a doctor without delay. Without proper treatment, Graves’ disease can cause serious complications. Furthermore, taking supplements and natural products not specifically recommended by medical professionals can cause side-effects, and can be dangerous when combined with certain medications. 1

Q: Graves’ disease and pregnancy: what do I need to know?
A: Graves’ disease can cause a number of serious complications for both the mother and baby if it is not adequately managed during pregnancy. Anyone who has been diagnosed with Graves’ disease or suspects that they may have the condition should consult a doctor when planning a pregnancy, if possible, or as soon as they know that they are pregnant.

Q: Graves’ disease vs. Hashimoto’s: what is the difference?
A: Graves’ disease is an autoimmune condition in which the immune system mistakenly stimulates the thyroid gland to produce more thyroid hormone than is needed, leading to hyperthyroidism. Hashimoto’s disease, also known as Hashimoto’s thyroiditis, is also an autoimmune condition, but one in which the immune system mistakenly attacks the thyroid gland, damaging the tissue and typically leading to hypothyroidism. Of the two thyroid disorders, Hashimoto’s is the more common.

• Basedow’s disease
• Toxic diffuse goiter/Diffuse toxic goiter