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(Thyrotoxicosis, including Graves Disease)


Laura Boucai

, MD, Weill Cornell Medical College

Reviewed/Revised Feb 2024
Topic Resources

Hyperthyroidism is overactivity of the thyroid gland that leads to high levels of thyroid hormones and speeding up of vital body functions.

  • Graves disease is the most common cause of hyperthyroidism.

  • Heart rate and blood pressure may increase, heart rhythms may be abnormal, and people may sweat excessively, feel nervous and anxious, have difficulty sleeping, lose weight without trying, and have an increased frequency of bowel movements.

  • Blood tests can confirm the diagnosis.

  • Usually, methimazole or propylthiouracil can control hyperthyroidism.

The thyroid gland secretes thyroid hormones, which control the speed at which the body’s chemical functions proceed (metabolic rate). Thyroid hormones affect many vital body functions, such as the heart rate, the rate at which calories are burned, skin maintenance, growth, heat production, fertility, and digestion. There are 2 thyroid hormones:

  • T4: Thyroxine (also called tetraiodothyronine)

  • T3: Triiodothyronine

The Thyroid

The pituitary gland produces thyroid-stimulating hormone (TSH), which stimulates the thyroid gland to produce thyroid hormones. The pituitary gland slows or speeds the release of TSH, depending on whether the levels of thyroid hormones circulating in the blood are getting too high or too low.

Hyperthyroidism affects about 1% of people in the United States. It can occur at any age but is more common in women between the ages of 20 and 50 years.

Causes of Hyperthyroidism

The most common causes include

  • Graves disease

  • Toxic (hormone-producing) multinodular goiter

  • Single toxic nodule

  • Thyroiditis

Graves disease, the most common cause of hyperthyroidism, is an autoimmune disorder Autoimmune Disorders An autoimmune disorder is a malfunction of the body's immune system that causes the body to attack its own tissues. What triggers an autoimmune disorder is not known. Symptoms vary depending... read more . In an autoimmune disorder, the person's immune system produces antibodies that attack the body's own tissues. Usually, the antibodies damage cells and worsen their ability to function. However, in Graves disease, the antibodies stimulate the thyroid gland to produce and secrete excess thyroid hormones into the blood. This cause of hyperthyroidism is often hereditary and almost always leads to enlargement of the thyroid.

Toxic multinodular goiter (Plummer disease), in which there are many nodules (small lumps), one or more of which may start to produce and secrete excess thyroid hormone. This disorder is more common with aging and is uncommon in adolescents and young adults.

Thyroiditis is inflammation of the thyroid gland. The inflammation can be caused by a viral infection (subacute thyroiditis Subacute Thyroiditis Subacute thyroiditis is acute inflammation of the thyroid, probably caused by a virus. (See also Overview of the Thyroid Gland.) Subacute thyroiditis usually begins suddenly. In this disorder... read more ), autoimmune thyroid inflammation that occurs after childbirth (silent lymphocytic thyroiditis Silent Lymphocytic Thyroiditis Silent lymphocytic thyroiditis is painless, autoimmune inflammation of the thyroid that typically develops after childbirth and usually goes away on its own. (See also Overview of the Thyroid... read more ), and, much less often, chronic autoimmune inflammation (Hashimoto thyroiditis Hashimoto Thyroiditis Hashimoto thyroiditis is chronic, autoimmune inflammation of the thyroid gland. Hashimoto thyroiditis results when antibodies in the body attack the cells of the thyroid gland—an autoimmune... read more ). At first, the inflammation causes hyperthyroidism as stored hormones are released from the inflamed gland. Later on, hypothyroidism Hypothyroidism Hypothyroidism is underactivity of the thyroid gland that leads to inadequate production of thyroid hormones and a slowing of vital body functions. Facial expressions become dull, the voice... read more Hypothyroidism usually follows because the levels of stored hormones are depleted. However, in people with subacute or silent lymphocytic thyroiditis, the gland usually returns to normal function.

A toxic (overactive) thyroid nodule (a benign tumor, or adenoma) is an area of abnormal local tissue growth within the thyroid gland. This abnormal tissue produces thyroid hormones even without stimulation by thyroid-stimulating hormone (TSH, a hormone produced by the pituitary gland to stimulate the thyroid gland to produce thyroid hormones). Thus, a nodule escapes the mechanisms that normally control the thyroid gland and produces thyroid hormones in large quantities.

Other causes of hyperthyroidism include

  • Some medications, including too much thyroid hormone taken orally

  • Rarely, overstimulation due to an overactive pituitary gland

Medications and iodine can cause hyperthyroidism. Medications include amiodarone, interferon-alpha, programmed death receptor-1 (PD-1) inhibitors (such as nivolumab and pembrolizumab), alemtuzumab, and, rarely, lithium. Excess iodine, as may occur in people taking certain expectorants, or in those given iodine-containing contrast agents for x-ray studies, may cause hyperthyroidism in people with a nodule that has escaped the control of thyroid-stimulating hormone and has the capacity to make large quantities of thyroid hormone when presented with excess iodine, thus becoming a toxic thyroid nodule. Taking too much thyroid hormone orally can also cause hyperthyroidism, and this is one of the most frequent causes of a low TSH level or an elevated T4 level.

An overactive pituitary gland can produce too much thyroid-stimulating hormone, which in turn leads to overproduction of thyroid hormones. However, this is an extremely rare cause of hyperthyroidism.

Other rare causes of hyperthyroidism include certain abnormalities of the placenta that produce excess levels of the hormone human chorionic gonadotropin, which can stimulate the thyroid gland to produce excess thyroid hormone, certain tumors of the ovary that contain thyroid tissue, and thyroid cancer that has spread to other areas of the body.

Symptoms of Hyperthyroidism

Most people with hyperthyroidism have an enlarged thyroid gland (goiter). The entire gland may be enlarged, or nodules may develop within certain areas. If people have subacute thyroiditis Subacute Thyroiditis Subacute thyroiditis is acute inflammation of the thyroid, probably caused by a virus. (See also Overview of the Thyroid Gland.) Subacute thyroiditis usually begins suddenly. In this disorder... read more , the gland may be tender and painful.

Symptoms of hyperthyroidism, regardless of the cause, reflect the speeding up of body functions:

Older adults with hyperthyroidism may not develop these characteristic symptoms but have what is sometimes called apathetic or masked hyperthyroidism, in which they become weak, confused, withdrawn, and depressed.

Hyperthyroidism can cause changes in the eyes. A person with hyperthyroidism may appear to be staring.

Spotlight on Aging: Hyperthyroidism in Older Adults

Hyperthyroidism affects about 1% of people but is more common in older adults. It is often more serious among older adults because they tend to have other disorders as well.

Hyperthyroidism in older adults often results from Graves disease. Almost as often, hyperthyroidism is caused by the gradual growth of many small lumps in the thyroid gland that produce thyroid hormones (toxic thyroid nodules).

Older adults are more likely to be treated with medications that can cause hyperthyroidism. The most common is amiodarone, a medication used to treat heart disease but which may stimulate or damage the thyroid gland.

Hyperthyroidism can cause many vague symptoms that can be attributed to other conditions. Typically, symptoms in older adults differ from those in younger people.

Occasionally, older adults sweat profusely, become nervous and anxious, and have hand tremors and frequent bowel movements or diarrhea.

Graves disease

If the cause of hyperthyroidism is Graves disease, specific eye symptoms (sometimes called thyroid eye disease) and skin symptoms (called infiltrative dermopathy) occur.

Eye symptoms include puffiness around the eyes, increased tear formation, irritation, and unusual sensitivity to light. Two distinctive additional symptoms may occur:

The eyes bulge outward because of inflammation in the eye sockets (orbits). The muscles that move the eyes become inflamed and unable to function properly, making it difficult or impossible to move the eyes normally or to coordinate eye movements, resulting in double vision. The eyelids may not close completely (called eyelid lag), exposing the eyes to injury from foreign particles and dryness. These eye changes may begin before any other symptoms of hyperthyroidism, providing an early clue to Graves disease, but most often eye changes occur when other symptoms of hyperthyroidism are noticed. Eye symptoms may even appear or worsen after the excessive thyroid hormone secretion has been treated and controlled.

Appearance of the Eyes in Graves Disease

When Graves disease affects the eyes, there may also be thickening of the skin, usually over the shins, which has the texture of an orange-peel. The thickened area may be itchy and feels hard when pressed with a finger. As with deposits behind the eyes, this problem may begin before or after other symptoms of hyperthyroidism are noticed.

Thyroid storm

Thyroid storm, which is sudden extreme overactivity of the thyroid gland, is a life-threatening emergency. All body functions are accelerated to dangerously high levels. Severe strain on the heart can lead to a life-threatening irregular heartbeat (arrhythmia), extremely fast pulse, and shock. Thyroid storm may also cause fever, extreme weakness, restlessness, mood swings, confusion, altered consciousness (even coma), and an enlarged liver with mild jaundice Jaundice in Adults In jaundice, the skin and whites of the eyes look yellow. Jaundice occurs when there is too much bilirubin (a yellow pigment) in the blood—a condition called hyperbilirubinemia. (See also Overview... read more Jaundice in Adults (a yellowish discoloration of the skin and the whites of the eyes).

Thyroid storm is generally caused by untreated or inadequately treated hyperthyroidism and can be triggered by infection, injury, surgery, poorly controlled diabetes, pregnancy or labor, or other stresses. Also, thyroid storm can occur when medications being used to treat thyroid problems are stopped. It is rare in children.

Thyroid storm is diagnosed by a person's symptoms and examination findings. People are treated with medications used to treat hyperthyroidism and with measures to treat complications (such as fever or altered consciousness). Typically, people with thyroid storm are treated in an intensive care unit.

Diagnosis of Hyperthyroidism

  • Thyroid function blood tests

Doctors usually suspect hyperthyroidism on the basis of the symptoms and findings on physical examination, including increased heart rate and blood pressure.

Thyroid function blood tests Thyroid function blood tests The thyroid is a small gland, measuring about 2 inches (5 centimeters) across, that is located just under the skin in the neck. The two halves (lobes) of the gland are connected in the middle... read more are used to confirm the diagnosis. Often, testing begins with measurement of thyroid-stimulating hormone (TSH). If the thyroid gland is overactive, the level of TSH is low. However, in rare cases in which the pituitary gland is overactive, the level of TSH is normal or high. If the level of TSH in the blood is low, doctors measure the levels of the thyroid hormones in the blood. If there is a question of whether Graves disease is the cause, doctors check a sample of blood for the presence of antibodies that stimulate the thyroid gland (thyroid-stimulating antibodies).

If a thyroid nodule is suspected as the cause, a thyroid scan Thyroid ultrasound The thyroid is a small gland, measuring about 2 inches (5 centimeters) across, that is located just under the skin in the neck. The two halves (lobes) of the gland are connected in the middle... read more will show whether the nodule is overactive, that is, whether it is producing excess hormones. Such a scan may also help doctors in their evaluation of Graves disease. In a person with Graves disease, the scan shows the entire gland to be overactive, not just one area. In thyroiditis, the scan shows low activity because of the inflammation.

Treatment of Hyperthyroidism

  • Treatment of cause

  • Beta-blockers to block the effects of thyroid hormones

  • Sometimes medications to block the production of thyroid hormones

  • Sometimes radioactive iodine to destroy some or all of the thyroid gland

  • Sometimes surgery to remove all or part of the thyroid

Treatment of hyperthyroidism depends on the cause. In most cases, the problem causing hyperthyroidism can be cured or the symptoms can be eliminated or greatly reduced. Left untreated, however, hyperthyroidism places undue stress on the heart and many other organs.

Treatment with radioactive iodine

Radioactive iodine may be given by mouth to destroy part of the thyroid gland. This is the most common treatment for hyperthyroidism. The radioactivity is mainly delivered to the thyroid gland because the thyroid gland takes up the iodine and concentrates it. Hospitalization is rarely necessary. After treatment, the person should probably not be near infants and young children for 2 to 4 days and should sleep in a separate bed separated at least 6 feet (about 2 meters) from the partner. Pregnancy should be avoided for about 6 to 12 months. People who have had radioactive iodine treatment should stay at least 6 feet away from pregnant women, infants, or small children for 6 to 23 days; the amount of time depends on the dose received. People who have had radioactive iodine treatment may set off radiation alarms at airports and sometimes other places for several weeks after treatment and, therefore, should carry a doctor’s note describing their treatment if they travel on public transportation.

Some doctors try to adjust the dose of radioactive iodine to destroy only enough of the thyroid gland to bring its hormone production back to normal, without reducing thyroid function too much. Other doctors use a larger dose to completely destroy the thyroid. Most of the time, people who undergo this treatment must take thyroid hormone replacement therapy Treatment Hypothyroidism is underactivity of the thyroid gland that leads to inadequate production of thyroid hormones and a slowing of vital body functions. Facial expressions become dull, the voice... read more Treatment for the rest of their life. Although concerns have been raised that radioactive iodine may cause cancer, an increased risk of cancer in people who have had radioactive iodine treatment has never been confirmed. Radioactive iodine is not given to pregnant or nursing women because it crosses the placenta and enters the milk and may destroy the fetus’s or breastfed infant’s thyroid gland.

Did You Know?

  • People who receive radioactive iodine should not go near infants and young children for 2 to 4 days.

Treatment with medications

Beta-blockers such as propranolol or metoprolol help control many of the symptoms of hyperthyroidism. These medications can slow a fast heart rate, reduce tremors, and control anxiety. Doctors therefore find beta-blockers particularly useful to control symptoms of hyperthyroidism until the person responds to other treatments. However, beta-blockers do not reduce excess thyroid hormone production. Therefore, other treatments are added to bring hormone production to normal levels.

Methimazole and propylthiouracil are the medications most commonly used to treat hyperthyroidism. They work by decreasing the gland’s production of thyroid hormones. Carbimazole, a medication that is widely used in Europe, is converted into methimazole in the body. Methimazole is usually preferred because propylthiouracil may damage the liver in young people. Pregnant women who take propylthiouracil or methimazole are closely monitored because these medications cross the placenta and can cause goiter or hypothyroidism in the fetus Hypothyroidism in the Newborn Hypothyroidism is decreased production of thyroid hormone. Hypothyroidism in the newborn may occur if there is a structural problem with the thyroid gland. Symptoms may include delayed growth... read more .

Each medication is taken by mouth, beginning with high doses that are later adjusted according to blood test results. These medications can usually control thyroid function within 2 to 3 months. Larger doses of these medications may work more quickly but increase the risk of side effects.

Iodine, given by mouth, is sometimes used to treat hyperthyroidism. It is reserved for people in whom rapid treatment is needed, such as those with thyroid storm. It may also be used to control hyperthyroidism until the person can have surgery to remove the thyroid. It is not used long-term.


Other treatments

Surgery to remove part or all of the thyroid gland, called thyroidectomy, is a treatment option for people with hyperthyroidism, especially for children and adolescents with Graves disease. Surgery is also an option for people who have a very large goiter as well as for those who are allergic to or who develop severe side effects from the medications used to treat hyperthyroidism or those who do not want radiation exposure. Hyperthyroidism is permanently controlled in more than 90% of people who choose this option. Hypothyroidism often occurs after surgery, and people then have to take replacement thyroid hormone for the rest of their life. Rare complications of surgery include paralysis of the vocal cords and damage to the parathyroid glands (the tiny glands behind the thyroid gland that control calcium levels in the blood).

In Graves disease, additional treatment may be needed for the eye and skin symptoms. Eye symptoms may be helped by elevating the head of the bed, by applying eye drops, by sleeping with the eyelids taped shut, and, occasionally, by taking selenium, teprotumumab, or diuretics (medications that hasten fluid excretion). Double vision may be reduced by using eyeglass prisms. Finally, corticosteroids taken by mouth, x-ray treatment to the orbits, or eye surgery may be needed if the eyes are severely affected. Corticosteroid creams or ointments can help relieve the itching and hardness of the abnormal skin. Often the mild eye symptoms disappear without treatment months or years later.

Drugs Mentioned In This Article

Generic Name Select Brand Names
Northyx, Tapazole
No brand name available
Cordarone, Nexterone, Pacerone
Eskalith, Eskalith CR, Lithobid
HEMANGEOL, Inderal, Inderal LA, Inderal XL, InnoPran XL
KAPSPARGO, Lopressor, Toprol XL, Toprol-XL
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