Graves‘ disease

What exactly is Graves’ disease?

Graves' disease is an autoimmune disease in which the thyroid gland becomes overactive. In this condition, certain antibodies cause an increase in the production of thyroid hormones, which leads to the typical symptoms of Graves' disease. The disease occurs mostly in people over the age of 30 and more frequently in women.

What are the causes & risk factors for Graves’ disease?

The exact cause of Graves' disease is not known. Various risk factors appear to be involved, but they cannot be named as the sole trigger.

On the one hand, a hereditary, familial predisposition appears to play a role; certain genetic characteristics are known to be more common in patients with Graves' disease. A positive family history therefore presents as a relevant risk factor.

Furthermore, certain viruses, cigarette smoking and stress appear to promote the onset of Graves' disease in certain cases.

With an autoimmune disease like Graves' disease, there is an abnormal reaction from the immune system. The body's own structures are no longer properly recognized, and antibodies are formed.

In Graves' disease, these autoantibodies (TSH receptor autoantibodies (TRAb)) are directed against the TSH receptor (or thyrotropin receptor) on the thyroid cells. Usually, this receptor is activated by thyroid-stimulating hormone (TSH), a hormone from the pituitary gland, which then stimulates the production of the thyroid hormones T3 (triiodothyronine) and T4 (thyroxine).

In turn, the thyroid hormones release TSH in the brain, ensuring that the hormones are always produced and released in a balanced way in a healthy individual, according to their needs. If there is a lack of thyroid hormones, more TSH is released, which stimulates the production in the thyroid gland.

Once there are sufficient hormones again, then less TSH is released into the body and the thyroid gland reduces its activity.

This hormonal regulatory loop is disrupted in patients with Graves' disease. In this condition, the TSH receptor is activated by TSH receptor antibodies (TRAb) without the need for actual TSH. As a result, there is excessive production of thyroid hormones because the body's internal control mechanisms for hormone regulation are no longer functioning.

The TRAb antibodies continuously stimulate the thyroid gland, regardless of whether sufficient hormone levels are already present. Therefore, in Graves' disease, these pathological antibodies lead to hyperthyroidism (overactive thyroid).

What are the symptoms of Graves’ disease? 

Thyroid hormones generally lead to an increase in the body's metabolism. Patients often experience restlessness, palpitations or cardiac arrhythmias. Blood pressure can be raised, excessive sweating and an increased feeling of warmth with a possible increase in body temperature are typical.

Tremors, a movement disorder characterized by trembling of the hands, may also occur. Patients often complain of weight loss despite no change in diet or exercise habits, as well as widespread hair loss. Bowel movements may also become more frequent and diarrhea can occur.

Those affected are often irritable, feel restless and fatigued, and complain of sleep disturbances and reduced performance. In addition, this can lead to metabolic disorders such as abnormal glucose tolerance (similar to diabetes mellitus).

Osteoporosis (bone loss) and muscle pain may also occur. All of these are typical symptoms of hyperthyroidism.

Graves' disease is characterized by a set of specific symptoms, commonly referred to as the Graves’ triad. This triad includes a goiter (visible enlargement of the thyroid gland), tachycardia (an accelerated heart rate), and exophthalmos (protrusion of the eyeballs from their sockets, also known as endocrine orbitopathy).

Approximately 60% of Graves' disease patients display these characteristics. Although the triad is not present in each patient and is also not essential to make a diagnosis, the combination of symptoms is typical and distinctive.

Endocrine orbitopathy can lead to visual disturbances, a feeling of pressure and foreign bodies in the eye and irritation of the conjunctiva.

In severe cases, the goiter can lead to a feeling of pressure on and in the throat and difficulties swallowing. Very rarely it can even lead to shortness of breath.

How is Graves’ disease diagnosed? 

The first step is to do a physical examination, during which the doctor may notice a goiter, exophthalmos, cardiac arrhythmias or very warm, moist skin, for example.

A blood test is particularly important for the diagnosis. This involves analyzing the thyroid hormones (T3 and T4) as well as the TSH pituitary hormone. In the case of hyperthyroidism, T3 and T4 are elevated and TSH is low. However, the thyroid hormones may initially still be within the normal ranges, and this is known as latent hyperthyroidism.

If Graves' disease is suspected, a specific blood test for thyroid antibodies is performed. TSH receptor antibodies (TRAb) are found in over 90% of cases, while other pathological antibodies are less common.

The thyroid gland can also be checked by ultrasound. The size of the organ can be assessed, and the blood flow can be visualized (Doppler sonography), which is usually significantly increased in Graves' disease.

A thyroid scintigraphy may also be performed. In this nuclear medical examination, radioactively labeled medication is used to visualize the anatomy and function of the thyroid gland. A Graves' disease patient usually has an enlarged gland with an overall increased metabolism (corresponds to hyperthyroidism).

How do specialists treat Graves’ disease?

To achieve euthyroidism, i.e. a normal, healthy level of thyroid hormones, treatment with thyreostatics is used.

These are drugs that inhibit the function of the thyroid gland and thus lead to reduced production of the hormones T3 and T4.

Treatment with thyrostatic drugs is carried out over a period of around 12-18 months, but for at least 6 months. During the course of treatment, the symptoms are repeatedly documented, and blood tests are arranged.

After this period, an attempt is often made to discontinue the medication following a consultation with a doctor. If the hyperthyroidism persists or recurs, one of the approaches outlined below is indicated; this affects around 50% of Graves' disease patients.

To treat the cause of Graves' disease, the patient can either undergo surgery or radioiodine therapy.

Surgery, which is mainly used for significantly enlarged thyroid glands, involves the complete removal of the organ in most cases (total thyroidectomy).

In radioiodine therapy, which cannot be used during pregnancy or breastfeeding, the thyroid tissue is non-invasively destroyed by radioactive iodine and its radiation.

Following these treatment methods, it is necessary to take thyroid hormones lifelong, as the body can no longer produce its own.

Additionally, symptoms such as palpitations can be temporarily treated with certain medications, for instance with beta blockers.

What is the life expectancy for Graves’ disease?

If diagnosed early and treated appropriately, Graves' disease is not associated with a reduction in normal life expectancy.

However, if Graves' disease remains untreated, it can lead to various long-term effects and complications. These include, for example, cardiovascular diseases such as cardiac arrhythmia and high blood pressure, as well as osteoporosis.

A rare but dangerous complication of hyperthyroidism is a thyrotoxic crisis. This is life-threatening situation and is fatal in around 20% of patients. A thyrotoxic crisis can be triggered by several serious conditions, such as infections, but also by excessive iodine intake (for example, following the administration of contrast media), the sudden discontinuation of thyroid-inhibiting medication or thyroid surgery without prior medication.

Patients suffer from palpitations and arrhythmia, fever, vomiting and diarrhea. They may also experience muscle tremors, weakness and impaired consciousness. Patients may be disoriented and confused, or drowsy and increasingly lose consciousness. In the final stage of the thyrotoxic crisis, comatose states and circulatory failure may occur. Such a complication requires emergency intensive medical treatment.

What should be considered regarding diet?

For patients with hyperthyroidism that is not adequately treated, it is important to avoid foods high in iodine. This includes many types of fish, seafood, and seaweed. However, the risk of exceeding the recommended iodine intake with a moderate, balanced diet is very low. Patients should be advised on this by their treating physician.

It is particularly important for patients with hyperthyroidism to inform their prescribing doctor about their thyroid condition before taking certain medications (e.g., amiodarone, cold remedies, or dietary supplements). Additionally, Graves' disease should be evaluated before undergoing CT or X-ray examinations with contrast agents to prevent severe complications.

Which specialists & clinics treat Graves’ disease?

Endocrinologists, as specialists, focus on diseases of the various endocrine glands and thus also treat Graves' disease and other thyroid disorders associated with either overactivity or underactivity of the thyroid.

Depending on which treatment methods are used, the attending endocrinologists work closely with general surgeons or nuclear medicine specialists.

Experienced internal medicine specialists or general practitioners can also usually recognize and treat Graves' disease and refer patients to specialist doctors if necessary.

Anyone in need of a doctor would expect the best possible medical care for themselves. Therefore, patients are looking for the most suitable clinic for their needs. Since this is not an objective decision and a respectable doctor would refrain from claiming to be the best, patients must trust the experience of a doctor.

We can help you find an appropriate expert for your condition. All the doctors and clinics listed have undergone extensive review and have been verified by us for their outstanding expertise in the field of Graves’ disease. They are looking forward to and are ready to address your questions and treatment requests.