Graves’ Disease: Causes, Symptoms, Treatment

Graves' disease is the most common cause of thyroid overactivity (hyperthyroidism) in the United States and is 7-8 times more common in women than men.[1][2][3]

This is a serious condition that requires constant monitoring and impacts how your body works, so it's important to understand what treatment options are available and lifestyle changes to improve your health.

What exactly is Graves’ disease?

Graves’ disease is an autoimmune disorder named after the Irish doctor who first described it in the 1830s.[2] It’s caused by the immune system overstimulating the thyroid, a butterfly-shaped gland in your neck. In response to the immune system’s antibodies, the thyroid gland becomes enlarged and starts producing more thyroid hormones than your body needs.

Thyroid hormones play a critical role in the body by helping the body use energy, stay warm, and keep the brain, heart, and other organs working properly.[2] Graves' disease, which affects one in 200 people, is one of the leading causes of hyperthyroidism.[1]

Like with many other autoimmune disorders, scientists don’t know for sure what puts the cycle of this disease into motion, but they are pretty sure that it has a genetic component, as it runs in families.[4] Graves’ disease is far more common among women than men, and it usually begins between the ages of 30 and 60. However, it can still affect people younger or older than those ages, so keep an eye out for the symptoms, especially if you have a family history of the disease.

People with Graves' disease have an increased risk of developing other autoimmune disorders, such as lupus, rheumatoid arthritis, celiac disease, type 1 diabetes, and vitiligo.[1]

Causes

Being a woman and having a history of Graves' disease in your family are the biggest risk factors for developing the disease yourself. Studies have shown that 20-40% of identical twins share the disease, and 10% of siblings.[3]

A complex of genes called the "human leukocyte antigen" have been studied and are believed to help the immune system distinguish between safe and foreign proteins. However, no specific gene has been identified to date that might be useful for screening family members.[1][2]

Other risk factors are pregnancy, with up to 30% of cases developing within a year after pregnancy. It's believed that fetal cells in the mother after pregnancy might play a role in the immune response.[3] Other triggers include certain medications, and having too much or too little iodine.[1]

Scientists have found a link between viral infections and Graves’ disease, so if you have ever had mononucleosis you are slightly more exposed to the disease.[5]

Food intolerance may also be a trigger of autoimmune diseases in vulnerable patients, with some of the strongest immune reactions being caused by casein, cow milk, and wheat.[6]

How is it different than Hashimoto's?

Graves’ disease and Hashimoto’s thyroiditis are two sides of the same coin. They are both autoimmune disorders, but while the first is causing an excess of thyroid hormones, the second is causing a deficit.

Sometimes (in about 15-20% of patients) the treatment for Graves’ disease can lead to Hashimoto’s thyroiditis. Scientists are still not sure why this happens, but one theory is that it’s due to the immune response to thyroid antigens.[7]

Whatever the cause, it's important to check your thyroid levels at regular intervals. You don’t want to end up getting treated for an excess of thyroid hormones only to find out later you have a deficit.

What are the symptoms of Graves’ disease?

The thyroid is the gland that regulates metabolic processes in your body. If the gland is producing excess hormones (triiodothyronine, or T3, and thyroxine, or T4), all the metabolic processes in the body are accelerated. People suffering from Graves' disease have a wide range of symptoms, and the most common are:

  • Hyperthyroidism – most symptoms are caused by excessive thyroid hormones, such as nervousness, anxiety, fatigue, rapid heartbeat, hand tremors, trouble sleeping, weight loss, and heat intolerance.[1][2]
  • Goiter – the thyroid can become enlarged and cause a bulging of the neck. Nowadays, this isn't common because it's noticeable and people usually get treatment or go to a doctor upon seeing the symptom.
  • Eye diseasean eye condition called Graves’ ophthalmopathy can be detected in 25-50% of people diagnosed with the disease, causing bulging, irritated eyes due to swelling of the tissues around the eyes. Studies have linked smoking to patients' risks of developing the condition. If you are diagnosed with Graves you should quit smoking to avoid this debilitating symptom, even second-hand smoke is dangerous. Graves' ophthalmopathy is treated, depending on its stage, with eye drops, glasses, radiation, or eye surgery.[3]
  • Skin disease in some patients a skin condition called Graves’ dermopathy (pretibial myxedema) can develop, causing thick, lumpy skin on the shins and tops of the feet. It's not usually painful and does not necessarily begin when the hyperthyroidism starts.[1][2]

How is the diagnosis made?

The diagnosis of hyperthyroidism is made on the basis of your medical history, physical exam, and blood or thyroid testing. Clues that your hyperthyroidism is caused by Graves’ disease are the presence of risk factors such as a history of other family members with autoimmune problems.[2]

Lab tests that measure the amount of thyroid hormones (T3 and T4) and thyroid-stimulating hormone (TSH) in your blood can confirm the diagnosis. An ultrasound machine can also be used to produce images of the thyroid and is non-invasive.

Radiation uptake

A radioactive iodine uptake test (RAIU) can also confirm the diagnosis. In this test, you swallow a small amount of radioactive iodine and the doctors see how much collects in your thyroid. A high uptake indicates your thyroid is producing too much thyroxine (T4) hormone.

How to treat Graves disease

The treatment for Graves is prescribed by an endocrinologist and depends on how advanced the condition is. The standard course of treatment is an antithyroid medication that prevents your gland from producing hormones in excess.[8]

The treatment usually alleviates the symptoms within weeks, but it doesn’t solve the problem and doesn’t cure the disease. It’s medication you have to take every day, and you also need to check periodically (once every six months, usually) the level of thyroid hormones in your blood and have your medication adjusted accordingly by your doctor.

Medications

Medications are preferred in patients who have high chances of remission. After 12-18 months if your thyroid levels are back to normal you may be able to discontinue. However, if your hyperthyroidism persists then your doctor may recommend more invasive options.[2]

  • Methimazole – most doctors prefer to prescribe methimazole because it reverses hyperthyroidism faster than propylthiouracil, can be taken every day, and has fewer side-effects.
  • Propylthiouracil – is usually prescribed when methimazole doesn't have the desired effect and has to be taken in two or three daily doses. It's safer for pregnant women, as it causes less severe birth defects, so it's the treatment of choice during pregnancy.[9] However, there have been rare cases of liver damage in people treated with it, and some doctors recommend switching back to methimazole after the first trimester.

Medication side effects

As with all medications, antithyroid drugs come with their side effects. Some of them, such as nausea, loss of taste, and heartburn, disappear after a few weeks once your body gets used with the chemicals. Others, such as skin rashes and hives, can show up at any time during the treatment.[10]

A pretty serious side effect is agranulocytosis, which causes a lowering of your body's white blood cells, the immune system's weapons that fight viruses and bacteria. Treatment involves stopping medication and possibly a course of broad-spectrum antibiotics. It may also lead to a more definitive treatment option such as radioiodine therapy or thyroid surgery.[11]

Invasive options

Another course of action, preferred by some doctors, is radioactive iodine treatment (RAI).[12] The treatment works by killing thyroid tissue cells, thus reducing the size of the gland and the amount of thyroid hormones released in the body. The treatment can be taken in the form of tablets or water-based solutions, and the goal is to reach to a point where the size of the thyroid gland is just right for manufacturing the right quantity of hormones your body needs.

The treatment usually takes weeks to be completed and sometimes it needs to be repeated after a while, but it’s a long-term solution when compared with antithyroid medication. Sometimes, patients end up with too much of their tissue gone and find themselves on the other side of the spectrum. However, it’s not necessarily a bad outcome, because hypothyroidism is a lot easier and safer to treat than hyperthyroidism.

In certain cases, surgery, where the entire gland is taken out, is necessary. This happens when patients can’t tolerate the treatments discussed above, or when the treatments are not working well enough. Pregnant women on antithyroid medication are at risk of miscarriage and stillbirth if the drugs don’t work properly, and doctors recommend surgery for them.[13] Once your thyroid gland is surgically removed, you stop producing thyroid hormones altogether, but it’s simpler to take synthetic replacements than to keep excess production under control.

A healthy diet for Graves’ patients

What you put into your body is vital to your overall health. There are many known endocrine disrupters in the environment, and certain foods known as goitrogens are known to affect thyroid hormone production.

  • Cruciferous vegetables – glucosinolates found in these foods are converted in the body to thiocyanate, which can disrupt the production of thyroid hormones by interfering with iodine uptake. Different vegetables have different amounts of glucosinolates: collards, brussel sprouts, and russian kale contain sufficient amounts to potentially decrease iodine uptake, while broccoli rabe and kale have insufficient amounts.[14] These foods have also been associated with an increased risk of thyroid cancer when accompanied by iodine deficiency.[15] Preparation of the food matters, as cooking brussel sprouts appears to inactivate enzymes that would affect thyroid function in humans.[16]
  • Organic foods – a popular herbicide called glyphosate has known effects on gut bacteria and is theorized to be connected with the growing incidence of Celiac disease and gluten intolerance in the US. It's believed that herbicide residues on foods disrupt gut bacteria, leading to reduced gut bacterium such as Lactobacillus, resulting in autoimmune and thyroid disease.[17][18]
  • Food intolerance – when comparing patients with autoimmune diseases to those without, there is a clear difference in food intolerance. Allergens cause an immune system overreaction and may trigger autoimmune disorders in vulnerable patients. Some of the strongest immune reactions came from casein, cow milk, and wheat. There are reports of gluten avoidance in some patients with beneficial effects.[19][20]
  • Soy – studies suggest that soy foods may inhibit the absorption of synthetic thyroid medication required by hypothyroid patients. However, no problems with soy foods were associated with people who have healthy thyroid glands and adequate iodine intake.[21]
  • Antioxidants – oral antioxidant supplements have been studied for the treatment of Graves' ophthalmopathy and 80% of patients showed improvement.[22]

Other lifestyle changes

You should not be smoking cigarettes for any reason, but especially if you have thyroid issues. Thiocyanate, a chemical in cigarette smoke, can compete with iodine for uptake by the thyroid gland and cause hormone disruption.