Graves' Disease

There are a number of ways that a patient may become hyperthyroid, that is, have an excess amount of thyroid hormone circulating in the body. Some thyroid tumors may produce excessive amounts of hormone. Sometimes inflammation of the entire gland may release increased amounts of thyroid hormone into the blood stream. A state of hyperthyroidism could be caused simply by a patient taking too much thyroid hormone medication. One of the more common forms of hyperthyroidism is called Graves' Disease, where the gland is usually symmetrically enlarged, soft, and very vascular, that is, it may have an increase in the size and number of nourishing blood vessels. There may be an auto immune aspect of Graves' Disease that is shared with one of the forms of thyroiditis. Indeed, Hashimoto's thyroiditis is frequently found simultaneously with active Graves' Disease. When the thyroiditis is the more prominent feature of the changes in the thyroid gland, then the gland may not be large and soft, but rather actually firm and even "rubbery" while still enlarged.

Graves' Disease can affect virtually any person, but females are far more commonly affected, and usually in the younger age groups. We've seen teenage boys and elderly men with this disease however, so again, it is not just limited to younger women.
I like to explain hyperthyroidism using the engine of your car as an example. If your car is supposed to idle at 1000 rpm's and does so, it is the equivalent of having normal thyroid hormone levels in the blood stream. If your car idles at 5000 rpm's, then it is a sick car, hyperthyroid if you will, and this, in time, will put a tremendous strain on your cars' engine and your car as a whole. Similarly, when you are hyperthyroid, you are idling too fast and your body over the long run will pay the price. There is not enough room here to explain every conceivable side effect of Graves' Disease, as this is not meant to be a medical text book for aspiring physicians, but allow me to list a few of the adverse affects of Graves' Disease: a generalized anxiety and emotional lability, the patient my cry very easily and have emotional problems with his or her personal relationships; the ability to concentrate for long periods of time is lost, making work or reading a book quite difficult; the attention span is usually shortened; there may be weight loss in spite of increased appetite; random motion or the inability to sit quietly; fingernails may become brittle and break; the hair may become thinner; there may be chronic fatigue; menstrual periods may be irregular and scant; the patient may feel his or her heart beating in the chest - a symptom called "palpitation"; the pulse may be rapid; the blood pressure may be slightly elevated; the palms of the hands may be moist; sometimes there is a dryness of the eyes or even a "bulging" of the eyes that can be observed. This is called "exophthalmos".


Diagnosing Graves' disease should be quite simple, but the fact that its symptoms mimic so many other diseases, the diagnosis can sometimes be delayed. Although there are some exceptions, the typical Graves' Disease patient will have elevated levels of thyroid hormone in the blood. At the same time, the TSH (or thyroid stimulating hormone, a hormone made in the brain and released into the blood to stimulate the release of thyroid hormone from the thyroid gland) will be markedly suppressed, often almost down to zero. Any patient with physical findings described above, the symptoms described above, and the blood tests mentioned above should certainly be suspected of having Graves' Disease.


There are basically three ways to treat Graves' Disease: medication, radiation, and surgery. Each of these modalities of treatment has it's advantages and disadvantages. First, anti-thyroid medication can be given over an extended length of time. The most commonly used drugs are called Tapazole and Propylthiouracil, or PTU. The plan with these drugs is generally to take them for perhaps a year or more and then stop the medication to see if there has been a spontaneous remission from the hyperthyroid state. This may be a useful way to treat patients who reject the idea of radiation exposure or patients who, for medical reasons, are not candidates for surgery. There are, however, a number of drawbacks with the medication approach to Graves' Disease. First, the recurrence rate of the disease after treatment can be very high, perhaps 30-50% in some series. Also, there are side effects of the medicine which, while rare, can be very serious, such as suppression of the immune system requiring hospitalization and extensive care. This happens in less than 1% of patients - which isn't much unless you are in the 1%. Also, the medical treatment of Graves' Disease requires almost constant supervision by the doctor, necessitating frequent and continuous tests, medical appointments, etc. In today's fast paced world and $30 co-pay for a doctor visit, this is, to some, an unattractive alternative. Radioactive iodine is the second treatment option. It has the advantages of avoiding toxic medication and foregoing an operation, but it, too, has some down side to it. First, it exposes the patient to a significant dose of radiation. In young women of childbearing age, especially those who intend to have children, this raises serious questions. There is concern about the possible relationship between radiation exposure and the formation of cancers in the body. While most studies have failed to show a direct link between birth defects of future children or cancer later in life, there are still enough questions about this that in many centers there is a policy not to treat the young or women of child bearing age with radiation therapy. Too, the first dose of radiation may be insufficient requiring still another dose, and perhaps still another. We have, on occasion, been called upon to operate on some such patients who have failed multiple treatments of radiation. The extensive radiation exposure that their thyroid gland and neck was subjected to made the operation far more difficult and risky than if the thyroid gland had simply been removed in the first place. One of the alleged advantages of radioactive iodine treatment is that by doing so, one may avoid the need to take a thyroid supplement pill on a daily basis. In our experience this has not always been the case.


The third treatment option is surgical removal of the gland. While this does require an operation, it avoids the risks and recurrence rate of the other two forms of therapy. Indeed, with a total thyroidectomy, properly performed by experienced hands, the recurrence rate of Graves' Disease is ZERO, and the complication rate is extremely close to that number. The operation takes about forty minutes complete. This stands in stark contrast to the years of doctors appointments and volumes of tests the patient must endure when treated by other options. Surgery is never without risk, however, and should not be taken lightly. The recurrence rate and complication rate mentioned above is a reflection of OUR work and cannot be universally assumed to apply to anyone else performing these procedures. Perhaps the most important advantage of surgery over the other methods of treatment for Graves' Disease is found in patients who suffer from the eye problem or "exophthalmos" that can sometimes accompany this disease. Total thyroidectomy may increase the chances that the exophthalmos will improve or possibly even disappear following total thyroidectomy.



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