Graves' disease: Information & Graves' disease specialists

23.11.2023
Dr. Claus Puhlmann
Medical Author

Graves' disease is an autoimmune disease that affects thyroid function. In German-speaking countries, it is named after the researcher Carl Adolph von Basedow. In the English-speaking world, the disease is known as Graves' disease.

Below you will find more information about this autoimmune disease and selected Graves' disease specialists.

ICD codes for this diseases: E05.0

Selected Graves' disease specialists

Brief overview:

  • What is Graves' disease? An autoimmune disease that leads to hyperthyroidism and particularly affects people in middle age. Women are affected more often than men.
  • Symptoms: In about half of the patients, the Merseburg triad occurs, characterised by a goitre heart palpitations and bulging eyes. Other symptoms include ravenous appetite, frequent bowel movements/diarrhoea, shortness of breath, high blood pressure.
  • Causes: The disease is more common in families with a history of the disease, but environmental factors can also contribute to the onset. 
  • Diagnosis: An ultrasound examination and laboratory tests can diagnose the disease with certainty. If necessary, a thyroid scintigraphy is also used for further clarification.
  • Treatment: Medication and a healthy diet are the most important pillars of treatment. If these measures do not help, radioiodine therapy or, in severe cases, surgery can help.

Article overview

Definition: What is Graves' disease?

The clinical picture of Graves' disease is associated with three characteristic symptoms. This trio, known as the Merseburg Triassic, consists of

  • a goitre (struma),
  • palpitations (tachycardia) and
  • protruding eyes (exophthalmos, “goggle eyes”).

This is accompanied by hyperthyroidism i.e. an excessive production of thyroid hormones.

Graves' disease can occur at any age. Between the ages of 30 and 60, there is an increased risk of the disease developing. The disease often appears for the first time in phases of hormonal restructuring of the body, such as

  • Puberty,
  • Pregnancy or
  • Menopause.

With a ratio of 6 to 1, women are much more often affected by Graves' disease than men. About 3 percent of women and about 0.5 % of men develop Graves' disease during their lifetime.

What are the symptoms of Graves' disease?

The Merseburg Triad occurs in about half of all patients.

An enlargement of the thyroid gland results in a condition called goitre. It can be seen from the outside of the neck when it reaches a certain size.

In the context of hyperthyroidism, the metabolism is accelerated, so that the heart often cannot keep up. It indicates this overload through heart palpitations (tachycardia).

Exophthalmos is an accompanying symptom of Graves' disease. The eyeball (bulbus) visibly emerges from the eye while the eyelids gradually retract behind it. Exophthalmos usually occurs in both eyes. However, it may also be that only one eyeball protrudes.

Exophthalmos, however, is more likely to be a classified as a separate autoimmune disease. Hyperthyroidism only encourages it.

Affected people lose weight faster than other people. But the opposite is also possible. Hyperthyroidism causes constant cravings and increased food intake. In people with a rather weak metabolism, this leads to obesity.

In many cases, hair loss occurs. The muscles are weaker and sufferers sweat more. Those affected are limited in their physical and mental capacity.

Other typical symptoms are:

What are the causes of Graves' disease?

Familial predisposition

Studies on twins have shown that Graves' disease is often genetic. A high percentage of the susceptibility to the disease is inherent in the genetic material, the DNA.

In addition, family trees were analysed. They show that about 30 percent of patients have relatives who also have or have had Graves' disease.

In addition, environmental factors can also be involved in the onset of the disease. Above all,

  • Psychological stress,
  • Nicotine consumption,
  • Excessive iodine intake with food or
  • Pregnancy

increase the risk of developing Graves' disease. In contrast, the use of oral contraceptives seems to reduce the risk.

Disturbance of metabolic control

Graves' disease is an autoimmune disease. This means that the immune system attacks parts of its own body. In Graves' disease, it forms antibodies against the receptor for TSH (thyroid-stimulating hormone, thyrotropin).

As a result, the highly sensitive regulatory cycle for the formation of the thyroid hormones thyroxine (T4) and triiodothyronine (T3) is disturbed.

TSH is produced in the pituitary gland in the Brain secreted. In a healthy person, TSH binds to the TSH receptor of the thyroid cells. As a result, the formation of the thyroid hormones T3 and T4 is stimulated. These in turn have an indirect inhibitory effect on the formation of TSH in the pituitary gland.

Less TSH now means fewer thyroid hormones. However, this reduces the inhibition of TSH formation. Therefore, more TSH and consequently more thyroid hormones are produced in turn.

This finely dosed control circuit is disturbed when antibodies bind to the TSH receptor. Inflammation of the thyroid gland occurs. This means that the TSH receptor is now permanently stimulated and as a result, more of the thyroid hormones T3 and T4 are released. As just described, this leads to an inhibition of TSH formation in the brain.

However, since the regulatory cycle is disturbed by the binding of the antibody to the TSH receptor, more and more T3 and T4 is produced. In addition, the thyroid cells are stimulated to grow. This permanent growth stimulus results in an enlargement of the thyroid gland and the formation of a goitre. The increased release of thyroid hormones then causes the symptoms mentioned above.

However, the antibodies can also cause changes in other parts of the body. In the eye, an endocrine orbitopathy (hormone-related eye socket disease) may develop, which is manifested by the typical "Graves' goggle eyes" (exophthalmos). Inflammation of the connective tissue on the lower leg is known as pretibial myxoedema and is also known to result from excessive production of antibodies against the TSH receptor.

Diagnosis of Graves' disease

The doctor performs a physical examination and checks the thyroid gland with ultrasound. This is followed by laboratory tests.

Some symptoms, such as goitre or exophthalmos, can put the treating doctor on the right track early on.

As part of the laboratory tests, TSH, thyroxine (T4) and triiodothyronine (T3) are usually first determined in the blood serum. Reliable laboratory tests are also available today to detect the antibody against the TSH receptor that triggers the disease.

If the TSH value is normal, Graves' disease is probably not present. If the TSH value is too low and at the same time the T3 and T4 values are too high, hyperthyroidism is present. If the antibody against the TSH receptor is also detected, Graves' disease can be diagnosed.

If larger nodules are seen on ultrasound, the doctor will probably order a thyroid scintigraphy for further clarification.

Ultraschalluntersuchung Schilddrüse
Examination of the thyroid gland using ultrasound © Max Tactic / Fotolia

How is Graves' disease treated?

At the beginning, treatment is with thyrostatic drugs. These drugs inhibit the formation of thyroid hormones by preventing the incorporation of iodine. In this way, they bring the metabolism back into balance.

In addition, beta-blockers are often used to relax the unnaturally high stress on the cardiovascular system. When T3 and T4 levels are reduced to normal, the dose of thyrostatic drugs should be reduced. In order to be able to readjust the dosage individually, it is important to check the progress of the treatment at regular intervals.

Patients can passively promote their healing by

  • abstaining from sporting activities,
  • protecting themselves from stress and mental strain and
  • significantly restricting their iodine intake.

Affected people should completely avoid iodine-containing products. Especially people who are prone to obesity should pay attention to a healthy, balanced diet. In addition, they should suppress frequent cravings (e.g. through sufficient fluid intake or meditation).

On the other hand, sufferers of severe weight loss need to make sure they eat a richly varied diet. This way they can counteract weight loss.

Graves' disease is highly recurrent, which means that it can recur time and again. The drug treatment method works for about half of all patients and the symptoms disappear. Nevertheless, a recurrence of the disease is possible.

Patients in whom

  • the treatment with thyrostatic drugs is not successful or
  • the disease recurs, or
  • who suffer from severe side effects, have

two further options: Radioiodine therapy and the surgical removal of thyroid tissue (thyroidectomy).

Radioiodine therapy requires the patient to take radioactive iodine. In a targeted way, it causes the hormone-producing thyroid cells to die. In cases of

  • an existing pregnancy,
  • desire to have children in the next 6 months or
  • if the patient is breastfeeding,

this form of therapy is not possible.

In particularly severe cases or in a dramatic stage of endocrine orbitopathy, only surgery can help. Nowadays, the complete removal of the thyroid gland is usually the aim (total thyroidectomy). Remaining thyroid tissue could otherwise lead to a recurrence of the hyperthyroidism.

Patients who have had their thyroid gland removed or who have received radioiodine therapy must take thyroid hormones for the rest of their lives. Otherwise they would develop hypothyroidism. However, this treatment is usually well tolerated.

References

  • Deutsche Gesellschaft für Kinderheilkunde und Jugendmedizin; Deutsche Gesellschaft für Endokrinologie (2011) Hyperthyreose. AWMF-Register Nr. 027/041
  • Kahaly GJ et al. (2018) 2018 European Thyroid Association Guideline for the Management of Graves’ Hyperthyroidism. Eur Thyroid J 2018;7:167–186
  • Schott M (2015) Morbus Basedow 2014: Alles wie bisher? Endokrinologie Informationen (Sonderheft): 10-14
  • Stiefelhagen P (2017) Rezidiv bei Morbus Basedow - Op, Radiatio oder Pharmaka? Ärzte Zeitung online vom 01.05.2017
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