Graves’ Disease (Diffuse Toxic Goitre)

Graves' disease is an autoimmune condition in which antibodies stimulate the whole thyroid gland to enlarge and overproduce thyroid hormone. It is the most common cause of hyperthyroidism, and diffuse toxic goitre is its older descriptive name.

About a quarter of patients also develop thyroid eye disease. Graves' disease is very treatable, though each of the three treatment routes involves compromise, and many people eventually need lifelong thyroid hormone replacement.

Symptoms

• Weight loss despite a good appetite
• Palpitations, a fast or irregular pulse
• Tremor, anxiety, irritability and poor sleep
• Heat intolerance and sweating
• Frequent bowel movements
• Muscle weakness in the thighs and upper arms
• A smooth swelling in the front of the neck
• Gritty, bulging or red eyes, double vision
• Light or absent periods

Causes and risk factors

The immune system produces TSH receptor antibodies that act like a permanent 'on' switch for the thyroid. A tendency to autoimmune disease runs in families. It is five to ten times more common in women and often begins between the ages of 20 and 50. Triggers include the months after childbirth, major stress, a high iodine load such as contrast dye or amiodarone, and smoking, which notably increases the risk and severity of eye disease.

How it is diagnosed

• Thyroid function tests: A suppressed TSH with raised free T4 and T3.
• TSH receptor antibodies (TRAb): Confirm Graves' disease and help predict relapse.
• Thyroid ultrasound with Doppler: Shows a diffusely enlarged gland with increased blood flow and checks for nodules.
• Radioisotope uptake scan: Used when the cause is unclear. It is not done in pregnancy.
• Eye assessment: Activity and severity scoring, with orbital imaging if vision is threatened.

Treatment options

• Antithyroid drugs: Carbimazole or methimazole for 12 to 18 months, with propylthiouracil in early pregnancy. About half of patients relapse after stopping. A sore throat or fever on these drugs requires an urgent blood count.
• Beta blockers: Relieve palpitations and tremor while hormone levels fall.
• Radioactive iodine: A single capsule that shrinks the gland over weeks to months. It usually causes permanent hypothyroidism, is avoided with active eye disease, and must not be used in pregnancy.
• Total thyroidectomy: Gives a rapid and definitive cure. Preferred for large goitres, suspicious nodules, significant eye disease or a planned pregnancy in the near future.
• Thyroid eye disease treatment: Stopping smoking, selenium for mild cases, intravenous steroids or newer biologic agents for active disease, and corrective surgery once inactive.

When it is urgent

Thyroid storm, with high fever, a very fast heartbeat, agitation, vomiting or confusion, is a life-threatening emergency. Sudden loss of vision or colour vision, or a sore throat with fever while taking antithyroid tablets, also need same-day hospital assessment where you are.

Travelling to Türkiye for treatment

Medical treatment of Graves' disease needs blood tests every few weeks and belongs with your local doctor. Travel is reasonable for a planned total thyroidectomy by a high-volume thyroid surgeon (about a week, once tablets have brought your hormone levels to normal, which is essential for safe anaesthesia), or for a specialist opinion on thyroid eye disease. Levothyroxine dosing after surgery is adjusted over the following months at home.

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Frequently Asked Questions