Graves’ disease, also called Graves’ disease, is an autoimmune disease of the thyroid gland that is usually accompanied by hyperthyroidism. Women are four to five times more likely to be affected by Graves’ disease than men.
What is Graves’ disease?
Graves’ disease is an autoimmune disease of the thyroid gland associated with hyperthyroidism and inflammation of the thyroid gland (thyroiditis). In Graves’ disease, there is an excess of thyroid-stimulating hormone (TSH). As a result of a disorder of the immune system, the body’s own antibodies against the thyroid tissue, so-called TSH receptor antibodies (TRAK), are formed, which dock onto the TSH receptors on the tissue surface of the thyroid, stimulate an overproduction of thyroid hormones uncoupled from the normal hormonal regulatory system, and successively cause hyperthyroidism. Symptomatically, Graves’ disease is usually manifested by a varying degree of goiter (enlarged thyroid gland) often in combination with endocrine orbitopathy (bulging eyeball) and tachycardia (rapid heartbeat); this symptommix in Graves’ disease is also known as the Merseburg triad.
Causes
The causes of Graves’ disease have not been determined to date. However, it is assumed that there is a genetic predisposition (disposition), since the disease occurs more frequently in certain families and in many cases manifests together in identical twins. Furthermore, people affected by Graves’ disease share specific genetic characteristics. In addition, environmental factors, hormonal changes, and stress factors are thought to influence the manifestation and course of Graves’ disease. Pregnancy, for example, is considered to be a definite triggering factor, although it has not yet been conclusively proven that this is causally related to hormonal changes (altered estrogen and progesterone levels) during and after pregnancy. In addition, infections by bacteria (including Yersinia enterocolitica) and viruses (including retroviruses), as well as excessive iodine intake, are also discussed as possible triggers of Graves’ disease.
Symptoms, complaints, and signs
The overproduction of thyroid hormones in Graves’ disease affects many bodily functions and can thus trigger very different symptoms. A disturbed metabolism is noticeable by steady weight loss despite sufficient food intake; sweating, hot flashes, and frequent bowel movements are also typical. Difficulties in falling asleep and sleeping through the night as well as increased irritability indicate involvement of the autonomic nervous system. The heartbeat can accelerate and does not slow down even at night, and this can be accompanied by high blood pressure and shortness of breath. Women often suffer from menstrual disorders, as a result of which menstruation fails to occur – fertility is reduced as a result. In men, Graves’ disease often leads to impotence disorders, and both sexes may experience reduced desire. A disorder of bone metabolism can trigger osteoporosis, which is manifested by reduced bone density and an increased tendency to fractures. Muscle weakness often develops, and muscle pain at rest or with exertion also occurs. Occasionally, increased trembling of the hands is observed. Often, affected persons notice protruding eyes (“Graves’ googly eyes”): In many cases, the eye changes are accompanied by a painful feeling of pressure, visual disturbances, irritation of the conjunctiva and increased sensitivity to light. Other typical signs include enlargement of the thyroid gland (goiter), very warm, dry skin, and excessive hair loss.
Diagnosis and course
The doctor palpates the enlargement of the thyroid gland in Graves’ disease.
Graves’ disease can be palpated by the presence of goiter (enlarged thyroid gland). More than 50 percent of people affected by Graves’ disease have endocrine orbitopathy, in which the eyes bulge out as a result of inflammatory processes in the orbits and in the tissue at the back of the eyes. In addition, sonography (ultrasound) of the thyroid gland reveals hypoechogenic (low echo) tissue structures. Scintigraphy (nuclear imaging) can reveal increased production of thyroid hormones.In addition, a precise blood test to determine the hormone and antibody concentration serves to confirm the diagnosis and is used for differential diagnosis in order to differentiate Graves’ disease from other autoimmune thyroid diseases (e.g. Hashimoto’s thyroiditis). Thus, TRAK levels are usually elevated in Graves’ disease patients. Graves’ disease has a chronic course that can vary greatly from individual to individual and is characterized by spontaneous remissions (spontaneous healing) as well as relapses (recurrence).
Complications
Graves’ disease is a condition that can result in complications. If the condition is not treated medically in the long run, it can threaten heart problems such as cardiac arrhythmias or heart failure (heart failure), among others. One of the most feared effects of Graves’ disease is thyrotoxic crisis, which is a serious metabolic derailment. Although it occurs rarely, it is a life-threatening emergency situation. The risk of a thyrotoxic crisis increases in the event of severe hyperthyroidism or discontinuation of prescribed medication. However, incorrect treatment with iodine-containing agents can also be considered as a possible cause. The thyrotoxic crisis is initially noticeable by rapid heartbeat, constant diarrhea, vomiting, anxiety and restlessness. Furthermore, high fever, disturbances of consciousness and disorientation may set in. In the further course, there is a risk of falling into a coma, circulatory failure, and restriction of kidney functions. Complications due to Graves’ disease are sometimes also possible during pregnancy and can occur even with a sensible therapy. For example, it is conceivable that antibodies against the thyroid gland may form within the mother’s blood, thereby also penetrating the placenta. In such cases, there is a risk that the hormone production of the unborn child will be increased, resulting in overproduction. As a result, the child is at risk of premature birth or insufficient weight at birth. During the first week of life, the baby’s mortality is increased.
When should you go to the doctor?
If an unplanned and unwanted continuous decrease in weight develops, a doctor should be consulted. Weight loss indicates metabolic disorders and is characteristic of Graves’ disease. Sweating, hot flashes or an inner restlessness are signs of an existing irregularity, which should be presented to a doctor to enable a diagnosis to be made. Disturbances of the night sleep, problems with falling asleep as well as a strong tiredness are indications of a health discrepancy. A visit to the doctor is necessary as soon as the complaints persist over several days or weeks or increase in intensity. In case of irritability, behavioral problems or mood swings, a doctor is needed. If the affected person suffers from a disturbance of the heart rhythm, high blood pressure, muscle weakness or problems with mobility, a visit to the doctor is necessary. Hair loss or changes in skin appearance should also be examined and treated. Increasing bone fractures are considered to be of particular concern and should be medically clarified by further tests. If visual disturbances or shortness of breath occur, a visit to the doctor is recommended as soon as possible. There is a risk of further deterioration of the health condition. If sexually mature women experience disturbances or irregularities in their menstrual periods, they should consult a doctor. Decreased libido in both sexes is another indication of impairment that should be followed up.
Treatment and therapy
Because the causes of Graves’ disease are not clear, therapeutic measures are symptomatic and aimed at eliminating or reducing hyperthyroidism with medication. For this purpose, thyrostatic drugs (thiamazole, carbimazole, propylthiouracil) are used, which have an inhibitory effect on hormone synthesis, secretion or iodine incorporation into hormone precursors in the thyroid gland. Long-term drug therapy usually lasts 12 to 18 months, with the dosage decreasing with the duration of therapy. In addition, β-blockers are often used in Graves’ disease to treat associated symptoms (tachycardia, elevated blood pressure). In some cases, this treatment leads to a complete cure (40 to 70 percent).If further drug therapy is unsuccessful after a relapse (about 80 percent of relapse cases), definitive therapeutic measures such as surgery or radioiodine therapy to remove or destroy the thyroid gland may be considered. Radioiodine therapy involves the administration of radioactive iodine, which causes temporary radiation localized to the thyroid gland that causes the thyroid tissue to die. If the thyroid gland is severely enlarged, it is removed during a surgical procedure. As a result of the radioiodine therapy as well as the surgical procedure, there is hypothyroidism that requires hormonal treatment for life.
Outlook and prognosis
The prognosis of Graves’ disease varies greatly from person to person. It may even be in 50 percent of all cases that remission occurs. This means that the symptoms of the disease often subside permanently or temporarily. In such cases, however, the disease may recur even after many years. Conservative therapy in the form of treatment lasting one to one and a half years leads to a successful cure in about 50 percent of those affected. However, this also means that approximately every second person affected develops a so-called relapse, which is the recurrence of the disease. However, after radioiodine therapy or surgical removal of the entire thyroid gland, also known as thyroidectomy, a definitive cure of the existing hyperthyroidism in affected individuals is possible. In both cases, however, patients must subsequently take special thyroid hormones daily for the rest of their lives in order to achieve normal hormone concentrations in the body. Despite this, there is a chance that Graves’ disease will heal on its own in 50 percent of those affected. Nevertheless, treatment is necessary. Because even after healing, the disease can flare up again. A thyrotoxic crisis can also occur in the course of the disease. This is a feared complication because it leads to death in 20 to 30 percent of cases.
Prevention
Because the causes of Graves’ disease are not understood, the disease cannot be prevented. However, all factors that negatively affect the immune system can contribute to the manifestation of Graves’ disease. These include stress and psychological strain, hormonal contraceptive methods, and excessive intake of iodine (X-rays with iodine-containing contrast media, iodized salt). Nicotine use can also trigger Graves’ disease and worsen the course of Graves’ disease.
Follow-up
Graves’ disease may result in lifelong follow-up care. This is independent of the particular treatment method. It is also important to prevent eye symptoms from developing due to endocrine orbitopathy, which is possible in about 50 percent of all patients. In addition, the follow-up treatment of Graves’ disease requires a lot of effort and patience. Thus, therapeutic strategies are medium- to long-term. In the case of conservative drug therapy, the patient receives thyrostatic drugs for one to two years. Depending on the initial situation, the risk of recurrence is 30 to 90 percent. Follow-up examinations must take place every four to eight weeks. Radioiodine therapy and surgery are considered the safest and fastest treatments for Graves’ disease. Following these procedures, however, it is necessary to take thyroid hormones for the rest of one’s life. This is the only way to compensate for the resulting hypothyroidism, i.e. a deficiency of thyroid hormones. If regular check-ups are necessary at the beginning, they are limited to one or two examinations a year as the disease progresses. Immediately after a surgical procedure on the thyroid gland, the patient receives thyroid hormones in a standard amount. How many hormones the patient ultimately needs is determined in the period after surgery and adjusted accordingly on an individual basis. Target levels vary and are determined by the patient’s primary care physician or an endocrinologist.
Here’s what you can do yourself
In the case of Graves’ disease, there are some measures that affected individuals can take themselves to improve their quality of life. At the beginning, there is the certainty after the diagnosis to be physically and emotionally burdened during the treatment period. Self-help groups for those affected by Graves’ disease and other opportunities for discussion are available here.These opportunities for discussion can be particularly valuable if Graves’ disease has already led to visible physical symptoms. The emotional strain and stress can be reduced by creating targeted free spaces as well as by relaxation techniques. Since it is an autoimmune disease, the condition of the affected person has a not insignificant influence on the course of the disease. In order not to put additional strain on the thyroid gland, iodine-containing foods should be avoided. The same applies to food supplements containing iodine. This can slow down the course of the disease and, if necessary, have a favorable effect on therapy. Regarding a possible involvement of the eyes, they should be protected from strong stimuli. This means avoiding strong sunlight, cold wind, drafts and so on as far as possible. Since Graves’ disease can run its course in very different ways and is also quite common, it is also valuable to obtain comprehensive information about the condition. This often enables better management of the disease and its treatment.
