Graves’ disease

Graves’ disease is the most common cause of hyperthyroidism and mainly affects middle-aged people. It is much more common in women than in men. The condition gets its name from Robert Graves, an Irish doctor who first described the condition in the 1800s.

What is Graves’ disease?

Graves’ disease (sometimes called Basedow’s disease) is the second autoimmune disease of the thyroid gland, in addition to Hashimoto’s thyroiditis. In both Graves’ disease and Hashimoto’s thyroiditis, specific antibodies trigger autoimmune-related inflammatory processes in the body. This means that the body’s defence system ‘erroneously’ attacks the thyroid tissue.

In Graves’ disease, the body’s defence cells incorrectly form antibodies, which then bind to the thyroid cells. As a result, the gland begins to produce more thyroid hormones. The result is an overactive thyroid gland (known as hyperthyroidism), where the thyroid gland suddenly works more than it should.

Symptoms

Graves’ disease is mainly characterised by the following three symptoms:

  1. enlargement of the thyroid gland (known medically as a struma or goitre)
  2. protrusion of the eyeballs (exophthalmos or proptosis)
  3. heart palpitations (known medically as tachycardia)

In medicine, the combination of these three symptoms is also referred to as the ‘Merseburg Triad’, and they occur in this form in half of all those affected by Graves’ disease.

Approximately 40 to 60% of all patients suffer from what is known as endocrine orbitopathy, or bulging eyes. The increased fatty tissue in the eye socket and thickening of the eye muscles causes the eyeball to be pushed forward, causing the appearance of bulging eyes. Accompanying symptoms include severe headaches, a feeling of pressure behind the eye, sensitivity to light, inflammation of the conjunctiva and double vision. In addition to these unpleasant side effects, the disfiguring facial changes often cause significant psychological distress.

Other symptoms of hyperthyroidism in Graves’ disease include:

  • weight loss
  • sleep disorders
  • hypersensitivity to heat
  • excessive sweating
  • increased blood pressure
  • hair loss
  • frequent bowel movements
  • For women: menstrual disorders and infertility
  • muscle weakness
  • mental restlessness and irritability, anxiety and poor concentration

In rare cases, patients report swelling in the lower legs, hands and feet.

Causes

It is impossible to predict if and when Graves’ disease will erupt. For example, the onset of the disease may be triggered by a previous viral infection or severe psychological distress. In some cases, however, Graves’ disease occurs in otherwise completely healthy patients. In addition, under certain circumstances Graves’ disease – just like Hashimoto’s thyroiditis – may coincide with other autoimmune diseases such as Addison’s disease (underactive adrenal glands), type 1 diabetes or gluten intolerance (coeliac disease).

Diagnosis

The doctor will begin by conducting an in-depth discussion with the patient, during which the focus is on recording the patient’s medical history. This is followed by a physical examination, during which the patient’s blood pressure is taken and the doctor performs a detailed examination of their eyes, lower legs and hands.

A blood test is essential for diagnosing Graves’ disease, as it allows the doctor to determine the level of the pituitary hormone TSH, which stimulates hormone production in the thyroid gland, as well as the levels of the thyroid hormones T3 and T4. The blood sample is also tested for the antibodies typical of Graves’ disease, and the doctor will examine the thyroid gland using ultrasound (sonography).

Treatment

Initially (and for about a year) patients with Graves’ disease are given thyrostatic drugs to inhibit the production of hormones in the thyroid gland. In addition, drugs known as beta-blockers are administered in the early stages to alleviate the symptoms of hyperthyroidism.

The good news is that in about half of patients with Graves’ disease, the disease is cured after about one year of administration of the medication, and there is no need for them to continue taking thyrostatic drugs.

However, if hyperthyroidism persists for a period of one and a half years, or if symptoms reappear after an initial improvement, it is recommended to that thyroid function is permanently deactivated. This is done either by radioiodine therapy or by surgical removal of the thyroid gland (usually the entire organ). If the patient does undergo surgical removal of the complete thyroid, they will have to take tablets to replace the thyroid hormones for the rest of their life (hormone replacement therapy).

Aftercare

After treatment of benign thyroid disease such as Graves’ disease, regular outpatient lab tests and additional check-ups are essential.

FAQs

How is Graves’ disease treated in pregnant women?

Pregnant women suffering from Graves’ disease are also treated with thyrostatic drugs if their thyroid values are elevated. However, close monitoring of thyroid values is particularly important during pregnancy.

What helps to prevent protrusion of the eyeballs and severe swelling in the eye area?

The primary focus of treatment for Graves’ disease is counteracting the hyperthyroidism. This can be done with medication (radioiodine therapy) or surgery (thyroid reduction). If the eye disorder continues to progress despite the thyroid treatment, high-dose corticosteroids (cortisone) have proven to be an effective treatment. However, this treatment only works within the first year of the disease.

Irradiation of the eye socket offers an additional treatment option. However, the results of treatment vary greatly, and even this treatment is only effective at an early stage. If these treatments are not as successful as expected, surgical intervention may be necessary. Transpalpebral orbital decompression is performed by a plastic surgeon and involves the removal of accumulated fatty tissue from the eye socket. To do this, fine incisions are made in the upper and lower eyelids, which relieves pressure on the eyeball. Often, an upper and lower eyelid correction is performed shortly afterwards to reduce the size of the enlarged gap in the eyelid.

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