Diagnosis

The diagnosis of Graves' disease may include:

  • Physical exam. Your doctor examines your eyes to see if they're irritated or protruding and looks to see if your thyroid gland is enlarged. Because Graves' disease increases your metabolism, your doctor will check your pulse and blood pressure and look for signs of tremor.
  • Blood sample. Your doctor will order blood tests to determine your levels of thyroid-stimulating hormone (TSH), the pituitary hormone that normally stimulates the thyroid gland, as well as levels of thyroid hormones. People with Graves' disease usually have lower than normal levels of TSH and higher levels of thyroid hormones.

    Another laboratory test measures the levels of the antibody known to cause Graves' disease. This test usually isn't necessary to make a diagnosis, but a negative result might indicate another cause for hyperthyroidism.

  • Radioactive iodine uptake. Your body needs iodine to make thyroid hormones. By giving you a small amount of radioactive iodine and later measuring the amount of it in your thyroid gland with a specialized scanning camera, your doctor can determine the rate at which your thyroid gland takes up iodine. The amount of radioactive iodine taken up by the thyroid gland helps determine if Graves' disease or another condition is the cause of the hyperthyroidism. This test may be combined with a radioactive iodine scan to show a visual image of the uptake pattern.
  • Ultrasound. Ultrasound uses high-frequency sound waves to produce images of structures inside the body. Ultrasound can show if the thyroid gland is enlarged, and is most useful in people who can't undergo radioactive iodine uptake, such as pregnant women.
  • Imaging tests. If the diagnosis of Graves' ophthalmopathy isn't clear from a clinical assessment, your doctor may order an imaging test, such as CT scan, a specialized X-ray technology that produces thin cross-sectional images. Magnetic resonance imaging (MRI), which uses magnetic fields and radio waves to create either cross-sectional or 3-D images, also may be used.

Treatment

The treatment goals for Graves' disease are to inhibit the production of thyroid hormones and to block the effect of the hormones on the body. Some treatments include:

Radioactive iodine therapy

With this therapy, you take radioactive iodine, or radioiodine, by mouth. Because the thyroid needs iodine to produce hormones, the radioiodine goes into the thyroid cells and the radioactivity destroys the overactive thyroid cells over time. This causes your thyroid gland to shrink, and symptoms lessen gradually, usually over several weeks to several months.

Radioiodine therapy may increase your risk of new or worsened symptoms of Graves' ophthalmopathy. This side effect is usually mild and temporary, but the therapy may not be recommended if you already have moderate to severe eye problems.

Other side effects may include tenderness in the neck and a temporary increase in thyroid hormones. Radioiodine therapy isn't used for treating pregnant women or women who are breast-feeding.

Because this treatment causes thyroid activity to decline, you'll likely need treatment later to supply your body with normal amounts of thyroid hormones.

Anti-thyroid medications

Anti-thyroid medications interfere with the thyroid's use of iodine to produce hormones. These prescription medications include propylthiouracil and methimazole (Tapazole).

Because the risk of liver disease is more common with propylthiouracil, methimazole is considered the first choice when doctors prescribe medication.

When these two drugs are used alone, a relapse of hyperthyroidism may occur at a later time. Taking the drug for longer than a year, however, may result in better long-term results. Anti-thyroid drugs may also be used before or after radioiodine therapy as a supplemental treatment.

Side effects of both drugs include rash, joint pain, liver failure or a decrease in disease-fighting white blood cells. Methimazole isn't used to treat pregnant women in the first trimester because of the slight risk of birth defects. Therefore, propylthiouracil is the preferred anti-thyroid drug during the first trimester for pregnant women. After the first trimester, methimazole use is generally resumed and propylthiouracil is no longer prescribed.

Beta blockers

These medications don't inhibit the production of thyroid hormones, but they do block the effect of hormones on the body. They may provide fairly rapid relief of irregular heartbeats, tremors, anxiety or irritability, heat intolerance, sweating, diarrhea, and muscle weakness.

Beta blockers include:

  • Propranolol (Inderal)
  • Atenolol (Tenormin)
  • Metoprolol (Lopressor, Toprol-XL)
  • Nadolol (Corgard)

Beta blockers aren't often prescribed for people with asthma, because the drugs may trigger an asthma attack. These drugs may also complicate management of diabetes.

Surgery

Surgery to remove all or part of your thyroid (thyroidectomy or subtotal thyroidectomy) also is an option for the treatment of Graves' disease. After the surgery, you'll likely need treatment to supply your body with normal amounts of thyroid hormones.

Risks of this surgery include potential damage to the nerve that controls your vocal cords and the tiny glands located adjacent to your thyroid gland (parathyroid glands). Your parathyroid glands produce a hormone that controls the level of calcium in your blood. Complications are rare under the care of a surgeon experienced in thyroid surgery.

Treating Graves' ophthalmopathy

Mild symptoms of Graves' ophthalmopathy may be managed by using over-the-counter artificial tears during the day and lubricating gels at night. If your symptoms are more severe, your doctor may recommend:

  • Corticosteroids. Treatment with prescription corticosteroids, such as prednisone, may diminish swelling behind your eyeballs. Side effects may include fluid retention, weight gain, elevated blood sugar levels, increased blood pressure and mood swings.
  • Prisms. You may have double vision either because of Graves' disease or as a side effect of surgery for Graves' disease. Though they don't work for everyone, prisms in your glasses may correct your double vision.
  • Orbital decompression surgery. In this surgery, your doctor removes the bone between your eye socket (orbit) and your sinuses — the air spaces next to the orbit. This gives your eyes room to move back to their original position.

    This treatment is usually used if pressure on the optic nerve threatens the loss of vision. Possible complications include double vision.

  • Orbital radiotherapy. Orbital radiotherapy was once a common treatment for Graves' ophthalmopathy, but the benefits of the procedure aren't clear. Orbital radiotherapy uses targeted X-rays over the course of several days to destroy some of the tissue behind your eyes. Your doctor may recommend orbital radiotherapy if your eye problems are worsening and prescription corticosteroids alone aren't effective or well-tolerated.

Graves' ophthalmopathy doesn't always improve with treatment for Graves' disease. Symptoms of Graves' ophthalmopathy may even get worse for three to six months. After that, the signs and symptoms of Graves' ophthalmopathy usually stabilize for a year or so and then begin to get better, often on their own.

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this disease.

Lifestyle and home remedies

If you have Graves' disease, make your mental and physical well-being a priority:

  • Eating well and exercising can enhance the improvement in some symptoms while being treated and help you feel better in general. For example, because your thyroid controls your metabolism, you may have a tendency to gain weight when the hyperthyroidism is corrected. Brittle bones also can occur with Graves' disease, and weight-bearing exercises can help maintain bone density.
  • Easing stress as much as you can may be helpful, as stress may trigger or worsen Graves' disease. Listening to music, taking a warm bath or walking can help relax you and put you in a better frame of mind. Partner with your doctor to construct a plan that incorporates good nutrition, exercise and relaxation into your daily routine.

For Graves' ophthalmopathy

These steps may make your eyes feel better if you have Graves' ophthalmopathy:

  • Apply cool compresses to your eyes. The added moisture may soothe your eyes.
  • Wear sunglasses. When your eyes protrude, they're more vulnerable to ultraviolet rays and more sensitive to bright light. Wearing sunglasses that wrap around the sides of your head will also lessen the irritation of your eyes from the wind.
  • Use lubricating eyedrops. Eyedrops may relieve the dry, scratchy sensation on the surface of your eyes. A paraffin-based gel, such as Lacri-Lube, can be applied at night.
  • Elevate the head of your bed. Keeping your head higher than the rest of your body lessens fluid accumulation in the head and may relieve the pressure on your eyes.
  • Don't smoke. Smoking worsens Graves' ophthalmopathy.

For Graves' dermopathy

If the disease affects your skin (Graves' dermopathy), use over-the-counter creams or ointments containing hydrocortisone to relieve swelling and reddening. In addition, using compression wraps on your legs may help.

Preparing for your appointment

You'll probably see your primary care physician first. You may be referred to a specialist in disorders of hormone function and the endocrine system (endocrinologist). If you have Graves' ophthalmopathy, your doctor may also recommend that you see a doctor who specializes in disorders of the eyes (ophthalmologist).

Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

  • Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
  • Write down key personal information, including family medical history, and any major stresses or recent life changes.
  • Make a list of all medications, vitamins or supplements that you're taking. Make note of the dosage of each.
  • Write down questions to ask your doctor.

Preparing a list of questions can help you make the most of your time with your doctor. For Graves' disease, some basic questions to ask your doctor include:

  • What's the most likely cause of my symptoms?
  • What kinds of tests do I need? Do these tests require any special preparation?
  • Is this condition temporary or long-lasting?
  • What treatments are available, and which do you recommend?
  • What types of side effects can I expect from treatment?
  • I have other health conditions. How can I best manage these conditions together?
  • Where can I find more information on Graves' disease?

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Be prepared to answer the following:

  • When did you first notice your symptoms?
  • Do you have symptoms all the time or do they come and go?
  • Have you recently started a new medication?
  • Have you experienced rapid or unintended weight loss? How much have you lost?
  • Have you observed any change in your menstrual cycle?
  • Have you experienced any sexual dysfunction?
  • Are you having trouble sleeping?

Graves' disease care at Mayo Clinic

March 06, 2018
References
  1. Smith TJ, et al. Graves' disease. New England Journal of Medicine. 2016;375:1552.
  2. Graves' disease. U.S. Department of Health and Human Services. https://www.niddk.nih.gov/health-information/health-topics/endocrine/graves-disease/Pages/fact-sheet.aspx. Accessed January 24, 2017.
  3. Longo DL, et al., eds. Disorders of the thyroid gland. In: Harrison's Principles of Internal Medicine. 19th ed. New York, N.Y.: McGraw-Hill Education; 2015. http://accessmedicine.com/. Accessed Jan. 24, 2017.
  4. Papadakis MA, et al., eds. Endocrine disorders. In: Current Medical Diagnosis & Treatment 2017. 56th ed. New York, N.Y.: McGraw-Hill Education; 2017. http://www.accessmedicine.com. Accessed Jan. 24, 2017.
  5. Davies TF. Pathogenesis of Graves' disease. http://www.uptodate.com/home. Accessed Jan. 24, 2017.
  6. Ross DS. Graves' hyperthyroidism in nonpregnant adults: Overview of treatment. http://www.uptodate.com/home. Accessed Jan. 24, 2017.
  7. Ross DS, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016;26:1343.
  8. Mayo CH. The surgical treatment of goiter. The Journal of the American Medical Association. 1904;XLII:1059.
  9. Warner KJ. Allscripts EPSi. Mayo Clinic, Rochester, Minn. Feb. 21, 2017.