Graves’ Disease

Graves’ disease is caused by an immune system disorder that makes the thyroid overactive without reason. The exact cause remains unclear, but certain risk factors have been identified:

• Gender: Much more common in women
• Age: Can occur at any age, including children, but most commonly between 20 and 40 years old
• Stress / Psychological Pressure: Intense physical or emotional stress can trigger the disease
• Presence of other autoimmune diseases: People with other autoimmune conditions, e.g., rheumatoid arthritis or type 1 diabetes, are at higher risk
• Smoking: Smoking increases the risk of Graves’ disease up to 2 times
• Genetic predisposition / Heredity: Often occurs in first-degree relatives with the disease
• Infections
• Medications such as interferon
• Pregnancy

Graves’ disease affects the whole body and is not limited to the neck area. 

Its hyperthyroid effects lead to a wide range of symptoms:

• Tachycardia, palpitations, arrhythmias
• High blood pressure
• Fatigue, muscle weakness, weight loss
• Irritability, nervousness, anxiety
• Tremor (shaking) of the limbs
• Excessive sweating, heat intolerance
• Hair thinning or hair loss
• Frequent bowel movements or diarrhea
• Anxiety, mood swings, depression, difficulty concentrating
• Insomnia, sleep disturbances
• Menstrual irregularities
• Reduced libido
• Osteopenia, osteoporosis
• Skin changes (thickened skin on shins and the back of the legs)
• Goiter (neck swelling)

Graves’ ophthalmopathy (thyroid eye disease) affects approximately 50% of patients with Graves’ disease. An autoimmune inflammation in the eye socket can lead to:

• Exophthalmos (protruding eyes)
• Eye irritation and dryness
• Swelling and tearing
• Light sensitivity
• Eye pain
• Foreign body sensation
• Blurred vision
• Double vision (diplopia)
• Reduced visual acuity / vision loss

Graves’ disease, through hyperthyroidism and increased metabolism, negatively affects the following organ systems:

• Cardiovascular system
• Muscular system
• Bones
• Nervous system
• Gastrointestinal system
• Reproductive system and fertility
• Eyes
• Mental health

In hyperthyroidism, TSH (thyroid-stimulating hormone from the pituitary) is significantly reduced, while the thyroid produces excessive amounts of T3 and T4.

Key lab markers include:

• TSH: Low or undetectable
• FT3, FT4 (Free T3 & T4): Usually elevated
• TSI (Thyroid-stimulating immunoglobulin): Elevated

Anti-TPO, Anti-Tg (Thyroid antibodies): Elevated, particularly in autoimmune forms

Diagnosis involves:

• Detailed medical and family history
• Clinical examination of the patient
• Blood tests (as described above)
• Thyroid ultrasound (to detect nodules, lymph nodes, size, and anatomy of the gland)
• Thyroid scintigraphy (to assess thyroid function)

Approximately one-third of patients with Graves’ disease also have thyroid nodules (Plummer’s disease). In such cases, attention is needed not only for hormonal dysfunction but also for nodule-related pressure effects and potential malignancy.

Recent studies show that Graves’ disease can be associated with thyroid cancer more often than previously thought. 

Research indicates that 7% of patients with Graves’ disease also have thyroid cancer. The incidence of cancer rises to 23% in patients with Graves’ disease who also have thyroid nodules.

Smoking negatively affects the thyroid and is directly related to the number of cigarettes smoked daily. 

Studies show that smoking causes:

• Two times the risk of developing Graves’ disease compared to non-smokers
• Eight times the risk of developing Graves’ ophthalmopathy compared to non-smokers

Patients with hyperthyroidism should adjust their diet, avoiding foods and drinks high in iodine:

• Fish and seafood, including sushi
• Salt (high iodine content)
• Milk and dairy products
• Coffee, tea, and other caffeinated drinks
• Alcohol

Beyond dietary sources, avoiding caffeine and iodine intake can be achieved by steering clear of:

• Certain medications, such as cough medicines and antiarrhythmics like amiodarone
• Contrast agents used in CT scans
• Iodine-based antiseptics (e.g., Betadine)

Regarding Graves’ disease and swimming in the sea, patients are advised to rinse their bodies thoroughly with tap water immediately after swimming to minimize iodine absorption.

Hyperthyroidism in women can:

• Affect fertility and the ability to conceive

• Cause miscarriage
• Lead to preeclampsia and maternal heart problems
• Cause premature birth
• Result in low birth weight
• Increase risk of congenital abnormalities in the newborn

Surgical thyroidectomy is often recommended for women with Graves’ disease prior to conception to allow safe pregnancy.

Ι. Antithyroid drugs & Beta-blockers

Antithyroid drugs (propylthiouracil, methimazole) aim to reduce the amount of hormones produced by the thyroid. They help temporarily control the disease but cannot cure it. Moreover, they should not be taken for long periods. Side effects may include rash, nausea, vomiting, loss of taste, joint pain, liver failure, and a decrease in white blood cell count. Lifelong use is contraindicated, and stopping the medication is often followed by relapse in many patients. Antithyroid drugs are often administered as a preparatory treatment prior to surgery.

Beta-blockers (propranolol, atenolol, metoprolol, nadolol) are used to reduce symptoms such as rapid heartbeat, tremors, and anxiety. However, they do not treat the underlying disease; they provide only temporary relief while the disease continues to progress and affect the body.

II. Radioactive Iodine

The administration of radioactive iodine (I-131) is intended to destroy overactive thyroid cells and somewhat shrink the gland. Symptoms gradually improve over weeks or months. However, in many cases, it can have the opposite effect by completely destroying the thyroid, leading to permanent hypothyroidism. Some side effects include the appearance or worsening of ophthalmopathy and neck pain. Its use exposes the patient to a high dose of radiation and is contraindicated in women of reproductive age, pregnant women, and patients with exophthalmos, as it may worsen the existing eye condition. Multiple sessions of radioactive iodine treatment may be required to achieve full control of Graves’ disease.

If the disease is not treated or hyperthyroidism is poorly controlled, it can lead to:

• Heart failure
• Atrial fibrillation
• Severe osteoporosis
• Severe eye disease and vision loss
• Large goiter causing pressure on the trachea or esophagus
• Thyroid storm (life-threatening)
• Growth and puberty delays in children

The likelihood of relapse (reoccurrence) of Graves’ disease after treatment with antithyroid drugs and radioactive iodine is approximately 75% and 20%, respectively. On the other hand, after a radical total thyroidectomy performed by an experienced surgeon, this rate drops to around 2%.

Surgical removal of the thyroid provides a definitive cure for the disease, offering a permanent solution to the problem.

• Aims to completely remove the already functionally damaged thyroid gland.
• Frees the patient from intensive drug therapy with significant side effects.
• Removes the enlarged gland, addressing pressure effects on surrounding organs.
• Allows the removal of any coexisting malignant neoplasm.
• Permanently relieves the patient from bothersome symptoms and the need for continuous, close laboratory monitoring.
• Contributes simultaneously to the therapeutic correction of ophthalmopathy.
• Practically eliminates the risk of disease relapse when performed by an experienced surgeon.
• Ensures fully normal metabolic function and overall health, allowing the patient to enjoy a normal life.

Thyroidectomy is considered the safest and most effective treatment for Graves’ disease when performed by an experienced surgeon.

Dr. Evangelos Karvounis, MD, PhD, FACS, is an award-winning endocrine surgeon, Professor at the Medical School of Athens, and Fellow of the American College of Surgeons. He currently serves as Director of Endocrine Surgery at Euroclinic Athens. The experienced surgeon is available to answer any questions about Graves’ disease and to recommend the most suitable treatment. Contact him today by phone or via the contact form to schedule a consultation for accurate diagnosis and personalized treatment.