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Frequently Asked Questions on Graves' Disease & Hyperthyroidism
Common Questions Patients Ask

by Mary Shomon

If you have been diagnosed as having hyperthyroidism, or suspect that you suffer from this condition, you probably have a number of questions, including:

What is hyperthyroidism?

Hyperthyroidism is an overfunctioning of the thyroid gland. This overfunctioning results in the production of too much thyroid hormone. Because the thyroid hormone controls many bodily functions, this increase in the thyroid hormone level causes these bodily functions, such as heartrate, or in some cases blood pressure, to increase, sometimes to very dangerous levels.

Is it contagious?

No. It's not thought to be contagious. (But one has to wonder, when George and Barbara Bush both came down with Graves' disease at the same time, and then so did their dog Millie.)

What causes hyperthyroidism?

Hyperthyroidism can be caused by:

I thought that hyperthyroidism and Graves' Disease were the same thing? What's the difference?

Graves' Disease is the most common type of hyperthyroidism. In Graves' Disease, the condition is caused by a generalized overactivity of the entire thyroid gland. Graves' disease is named after, Robert Graves, the physician who first described this form of hyperthyroidism.

What's the difference netween Graves' Disease And "diffuse toxic goiter"?

None - they're different names for the same condition. The term "diffuse toxic goiter" just describes the condition (rather than the discoverer) as follows:

I've heard Graves' Disease described as an autoimmune disorder. What does that mean?

It means that the disease is caused by a malfunctioning of the immune system of the body - the very system which also protects us from such unpleasant things as bacteria and cancer cells. The immune system works by producing antibodies (also known as immunoglobulins or lymphocytes) which attack and destroy many bad elements in the body, such as virus, bacteria, etc.. The problem is that sometimes this good defense system gets confused and starts attacking good cells. In Grave's Disease, antibodies are produced that attack some of the proteins on the surface of thyroid cells. In response, the thyroid cells produce too much thyroid hormone, which, in turn, overstimulate the thyroid.

How common is an autoimmune problem that results in some form of hyperthyroidism?

This condition is not common. About 10 percent of the population inherits an immune system that can make problems for the thyroid and only one in ten of these will ever have a problem.

Just what causes this problem in the immune system to occur?

It is believed that the environment somehow makes the immune system go haywire. The disease does seem to run in families, but science does not know why. In general, understanding autoimmune diseases is an issue that researchers focusing on extensively.

How does the environment make the immune system go wrong?

The jury is still out on this one. Severe emotional stress is the most commonly suspected culprit, but it is possible for someone to develop the disease without experiencing this stress. Still, reducing stress in life is always a healthy idea. Other factors the can trigger Grave's disease are smoking, radiation to the neck, medications (such as interleuken-2 and interferon-alpha), and infectious organisms such as viruses.

How can I recognize Graves' Disease?

Even if you have Graves' disease, it can take weeks, or even months, before you suspect you are sick because the symptoms build very gradually. You may think you are just experiencing stress, or feeling extra anxious. Or the disease may actually make you happy in the short term, as one of the side effects of speeding up the thyroid can be weight loss. However, in the longer term, less desirable symptoms, such as muscle weakness, insomnia and trembling can also result. The pulse will likely increase, along with an inability to tolerate heat and abnormally high sweating. You may experience hair loss and diarrhea is common. Women may find that the menstrual flow will lighten and the time between periods grow longer. Depression can also enter the picture. And, as mentioned above, blood pressure and heart rate can increase to dangerous levels. But Graves' Disease often has the most visible impact on the skin and eyes.

How does Graves' Disease affect the eyes?

Graves' disease is associated with inflammation of the eyes, swelling of the tissues around the eyes, and bulging of the eyes. However, 99% of the time, this inflammation will not cause serious or permanent trouble. Early signs of Grave's Disease affecting the eyes include:

It is believed that the swelling is caused by antibodies attacking the tissues of the eye muscles. There may also be a sensitivity to light, and a continual feeling that there is something in the eyes.

Such symptoms usually appear within six months of when the diagnosis of Graves' Disease is made.

How does Graves' Disease affect the skin?

Although it is rare, Graves' Disease patients will sometimes get a lumpy reddish thickening of the skin in front of the shins (pretibial skin). This condition is known as "pretibial myxedema" (also more generically referred to as dermopathy). It's usually painless, not serious and, may not start even when the hyperthyroidism starts. As with the eyes, it is believed that this swelling in the pretibial skin is caused by antibodies attacking these tissues.

What else do I need to know about Graves' Disease?

Now that you know something about hyperthyroidism, the dangers, the causes, and it's most common forms, in the next part of the series, we'll look at how hyperthyroidism is diagnosed.

How can a doctor diagnosis one of the variations of hyperthyroidism?

Initial diagnosis usually simply requires a physical examination for the following:

Other symptoms are:

A family medical history may also hold clues to a diagnosis of hyperthyroidism, specifically if a family member:

A final diagnosis is always made by means of a common blood test which will expose abnormally high thyroid hormone levels and low levels of the thyroid-stimulating hormone (TSH) produced by the pituitary gland. Low blood TSH levels are the most reliable test of most hyperthyroidism. In rare cases, the pituitary gland produces excess amounts of TSH. Then there will be increased levels of both the TSH and thyroid hormones in the blood.

Sometimes, additionally, the thyroid-stimulating antibodies (TSAb) or Thyroid Stimulating Immunoglobulin (TSI) in the blood will also be measured.

And finally, a radioactive picture of the thyroid, made by ingesting radioactive iodine (known as RAI) in the mouth, may also be taken to see if the thyroid gland is overactive. This overactivity of the thyroid gland is a hallmark of Graves' disease, but not of overactive nodules or lumps within the gland.

For more information, see the Graves' Disease/Hyperthyroidism Risk Factors and Symptoms Checklist.

What about some of the other causes of hyperthyroidism, such as toxic nodules or goiters?

Sometimes the thyroid gland also has lumps - also known as nodules. These nodules can be too active and produce too much of the thyroid hormone. Such nodules are called "toxic nodules." When there are many of these, it is referred to as a "toxic multinodular goiter."

Note that not all nodules result in hyperthyroidism.

Can excessive thyroid medication given to hypothyroid sufferers cause hyperthyroidism?

As you know if you have read my other columns, finding the proper dose of medications for hypothyroidism (an underfunctioning thyroid) is not an exact science. In fact, the dosages prescribed may sometimes be so strong that they cause the thyroid to become hyperthyroid. In such a case, your doctor should reduce the dosage of your medication until the thyroid hormone in your system is back at normal levels.

What about iodine as a cause of hyperthyroidism?

Iodine is used by the thyroid gland to make thyroid hormones. Too much iodine can result in hyperthyroidism. Hyperthyroidism caused by an excess of iodine is usually characterized by an abnormal thyroid gland - as in a gland with goiters or a multinodular goiter. Iodine excess can be caused by certain medications that contain larger amounts on iodine. An example is amiodarone - a heart medicine.

What is thyroiditis and how is it a cause of hyperthyroidism?

Thyroiditis is inflammation of the thyroid gland. It generally occurs after a viral illness (which is known as subacute thyroiditis) or a pregnancy (postpartum thyroiditis). No specific virus or bacteria has been identified as causing the condition.

This condition is temporary, but runs through a cycle of about six to three months. First, the thyroid will release too much thyroid hormone, resulting in hyperthyroidism. Then, because the thyroid gland is depleted of the hormone, too little thyroid hormone is released, resulting in hypothyroidism.

Diagnosis of thyroiditis is usually made by means of a thyroid scan, as discussed above. Thyroiditis will reveal itself because the thyroid will take up very little of the RAI.

Thyroiditis is rare as a cause for hyperthyroidism. Because it is largely self-curing, patients are usually only given beta-blocker for relief of symptoms (See Part 3 of the series), rather than any additional treatment. They may also be given anti-inflammatory medicine, such as aspirin to decrease the pain of the inflamed thyroid gland. If the thyroiditis is adequately severe, a corticosteroid may also be used to reduce gland inflammation.

If I ignore my hyperthyroidism, will it go away?

For most forms of hyperthyroid disease, no, they will not go away. Not treating most forms of hyperthyroid can be very dangerous. Initially it can lead to an irregular heat beat, worsening heart failure, and chest pain. Eventually it can lead to high blood pressure, irregular heartbeats, overly strong and fast heartbeats, possible severe emotional disorders, and even heart failure. When the hyperthyroid condition gets this bad, it's called a thyroid crisis or thyroid storm. Stay out of the bad thyroid weather - don't ignore this disease! It can kill you. Get it taken care of.

Is there any way to quickly control the dangerous symptoms of hyperthyroidism?

Regardless of the method of treatment eventually used, a doctor may initially recommend a beta-adrenergic blocking drug - also known as beta blockers - such as atenolol (Tenormin ), nadolol (Corgard ), metoprolol (Lopressor ), or propranolol (Inderal ) to block the action of circulating thyroid hormone on your body tissues, slow your heart rate and reduce your nervousness. These drugs can be useful in rapidly reducing these potentially dangerous symptoms until your treatment has taken effect.

However, they should not be used if you have asthma or heart failure, as they can worsen these conditions. Diabetic patients taking insulin should also take care because the beta-blocking drugs may mask the warning symptoms of low blood sugar.

Finally, these drugs are not a substitute for treatment, but they will normally make you feel better - sometimes in as little as a few hours.

What is the initial treatment for Graves' Disease?

The first course of action - when the disease is mild, or occurs in children or young adults, or needs to be promptly controlled (as with elderly patients whose heart disease puts them at risk from the increased heart rate associated with Grave's Disease) - is a course of antithyroid drugs, such as propylthiouracil (PTU) and methimazole (Tapazole ). These drugs make it more difficult for your thyroid to use the iodine it needs to make the thyroid hormone, resulting in a decrease in thyroid hormone production. Although both drugs can be used during pregnancy, PTU is preferable.

In about 5% of cases, a skin rash will result. In about 0.05% of cases, patients will develop a low white count, thereby increasing the risk of serious infection.

How successful is this drug treatment of Graves' Disease?

It only works for about 20 to 30% of patients. In these patients, antithyroid drug treatment for 12 to 18 months will result in prolonged remission of the disease, particularly if the disease is relatively mild when treatment is begun. This is another reason to see your doctor early if you suspect you have the disease.

Are there any side effects to antithyroid drugs?

In about 5% of cases, antithyroid drugs cause allergic reactions such as skin rashes, hives, and sometimes fever and joint pains. A much more serious potential side effect is a decrease in the white blood cells that are a part of the immune system - thereby resulting in a decrease in your resistance to infection. In very rare cases, these cells may disappear entirely (a condition called agranulocytosis) - which can be potentially fatal if there is a serious infection.

If, while taking these drugs, you experience an infection, stop taking the drug immediately and get a white blood count that same day. If the white count has been lowered and you continue taking the drug, the infection could become fatal. However, a lowered white count will return to normal once you have stopped taking the drug.

Hypothyroidism can result from the use of antithyroid drugs, although it is far less likely to result from this treatment than from surgery or radiation.

If the drugs don't work, what is the next treatment option?

Most hyperthyroid patients wind up being treated with radioactive iodine, otherwise known as RAI. This RAI is administered by mouth, by means of a capsule or a liquid. What happens then is that the RAI goes from the stomach into the bloodstream and eventually into the thyroid gland. The RAI lodges there because the thyroid gland needs iodine to produce the thyroid hormone and therefore the thyroid gland will readily pick up the iodine from the bloodstream. In the thyroid gland, the radiation destroys some of the thyroid cells, thereby reducing production of the thyroid hormone.

What happens to this radiation in my body?

Eventually, the body will pass much of the RAI out through urine. Any remaining RAI will become nonradioactive.

Why do medical personnel run for the door after they give me RAI?

The radiation in RAI can be dangerous with prolonged exposure. Your taking the RAI a time or two will not result in a dangerous exposure to you. However, for medical workers, who are giving this treatment out to patients all day long, day after day, there is a risk of prolonged dangerous exposure. That's why they don't want to stay around the RAI for very long.

Then just how safe is this radiation treatment?

This treatment has been used since 1940, and no serious complications from RAI treatment have become apparent over nearly 50 years of use. However, RAI should not be taken during pregnancy or breast feeding.

How fast does RAI work?

Most patients get relief in three to six months. However, if the initial dose was too small, it may need to be repeated.

Are there any side effects to the radiation?

The main side effect is, that because the damage to the thyroid cannot be controlled, the thyroid of most patients becomes underactive (hypothyroidism) after RAI. This condition is then treated with a thyroid hormone supplement. This may seem silly - trading one thyroid problem for another. But hyperthyroidism is much more dangerous, and difficult to control, than is hypothyroidism. So while becoming hypothyroid may not be a perfect outcome, it is much better than being hyperthyroid.

Are there any alternatives to the drugs or radiation?

Surgery to remove all or part of the thyroid gland (known as a thyroidectomy) will permanently cure hyperthyroidism. However, several things need to happen before surgery takes place.

1. First, surgery can be risky unless the hyperthyroidism is already being controlled by an antithyroid or a beta blocking drug, described below. Therefore, you will take either propylthiouracil or Tapazole to lower your thyroid hormone levels. You should reach normal levels in about six weeks

2. Often , for several days prior to surgery, you will also take some drops of nonradioactive iodine (either Lugol's iodine or supersaturated potassium iodide). This has the effect of reducing the blood supply to the thyroid gland, thereby making surgery easier and safer.

The goal of the surgery is to remove just enough of the gland so that thyroid production is back to normal. As with many things medical, determining how much of the gland to take is part science and part art. If too much is taken, than the patient can become hypothyroid.

There can also be other complications resulting from the surgery. One is vocal cord paralysis. Another, is accidental removal of the parathyroid glands, which are located in the neck in back of the thyroid gland. Because the parathyroid glands regulate the amount of calcium in the body, their removal will result in low calcium levels.

Surgery is now reserved for special cases, including:

How will I be after surgery?

Assuming that enough of your thyroid gland was removed, your hyperthyroidism will be permanently gone. However, you may or may not become hypothyroid, for example, depending again on how much thyroid tissue is left after surgery. The likelihood is that you will become hypothyroid. Therefore, anyone who has been hyperthyroid and been treated by one of the above methods should have a blood test AT LEAST once a year to measure thyroid function. Be sure that these tests include a test of the amount of thyroid-stimulating hormone (TSH) in your blood. If your thyroid is low, your pituitary glad will produce increased amounts of TSH. Therefore, a high TSH blood level is the best indicator of hypothyroidism.

I don't really like the idea of the drugs or surgery or radiation. Are there any alternatives?

There are a variety of alternative options you can explore for your Graves' disease and hyperthyroidism. The best possible resource to explore these is Elaine Moore's book,
Graves' Disease: A Practical Guide.

Sticking Out Our Necks and this website are Copyright Mary Shomon, 1997-2003. All rights reserved. Mary Shomon, Editor/Webmaster
All information is intended for your general knowledge only and is not a substitute for medical advice or treatment for specific medical conditions. You should seek prompt medical care for any specific health issues and consult your physician or health practitioner before starting a new treatment program. Please see our full disclaimer.