Thyroid

The thyroid is a small, butterfly-shaped gland just below the Adam’s apple. This gland plays a very important role in controlling the body’s metabolism, that is, how the body functions. It does this by producing thyroid hormones (T₄ and T₃), chemicals that travel through the blood to every part of the body. Thyroid hormones tell the body how fast to work and use energy.

The thyroid gland works like an air conditioner. If there are enough thyroid hormones in the blood, the gland stops making the hormones (just as an air conditioner cycles off when there is enough cool air in a house). When the body needs more thyroid hormones, the gland starts producing again.

The pituitary gland works like a thermostat, telling the thyroid when to start and stop. The pituitary sends thyroid stimulating hormone (TSH) to the thyroid to tell the gland what to do.

About 20 million Americans have some form of thyroid disease. Many are undiagnosed or misdiagnosed. No age, economic group, race, or sex is immune to thyroid disease.

The thyroid gland might produce too much hormone (hyperthyroidism), making the body use energy faster than it should, or too little hormone (hypothyroidism), making the body use energy slower than it should. The gland may also become inflamed (thyroiditis) or enlarged (goiter), or develop one or more lumps (nodules).

Hyperthyroidism makes the body speed up. It occurs when there is too much thyroid hormone in the blood (“hyper” means “too much”). Nearly 10 times more frequent in women, it affects about 2% of all women in the United States.

The most common cause of hyperthyroidism, Graves’ disease, is caused by problems with the immune system and tends to run in families. It affects at least 2.5 million Americans, including Olympic athlete Gail Devers who won a gold medal in track after being diagnosed with and treated for Graves’ disease.

Symptoms include:

• fast heart rate
• nervousness
• increased perspiration
• muscle weakness
• trembling hands
• weight loss
• hair loss
• skin changes
• increased frequency of bowel movements
• decreased menstrual flow and less frequent menstrual flow
• goiter
• eyes that seem to be popping out of their sockets.

The symptoms of hyperthyroidism rarely occur all at once. However, if you have more than one of these symptoms, and they continue for some time, you should see your doctor.

Hypothyroidism causes the body to slow down. It occurs when there is too little thyroid hormone in the blood (“hypo” means “not enough”). Hypothyroidism affects more than 5 million people, many of whom don’t know they have the disease. Women are more likely than men to have hypothyroidism.

Also, one out of every 4,000 infants is born with the condition. If the problem is not corrected, the child will become mentally and physically retarded. Therefore, all newborns in the United States are tested for the disease.

Symptoms in adults include:

• feeling slow or tired
• feeling cold
• drowsy during the day, even after sleeping all night
• slow heart rate
• poor memory
• difficulty concentrating
• muscle cramps
• weight gain
• husky voice
• thinning hair
• dry and coarse skin
• feeling depressed
• heavy menstrual flow
• milky discharge from the breasts
• infertility
• goiter

Many of the symptoms of hypothyroidism can occur normally with aging, so if you have one or two of them, there is probably no reason to worry. However, if you are concerned about any of these symptoms, you should see your doctor.

Thyroiditis is an inflammation of the thyroid gland. Thyroiditis can cause either hyperthyroidism or hypothyroidism, or one followed by the other. It can also cause a goiter, an abnormal swelling in the neck due to an enlarged thyroid. It affects about 12 million people in the United States.

Thyroiditis is the most common cause of hypothyroidism. When patients with thyroiditis have any symptoms, they are usually the symptoms of hypothyroidism. It is also common to have an enlarged thyroid that may shrink over time.

The type of thyroiditis seen most often is Hashimoto’s thyroiditis, a painless disease of the immune system that runs in families. Hashimoto’s thyroiditis affects about 5% of the adult population, increasing particularly in women as they age.

Another form of thyroiditis affects women of childbearing age. Postpartum thyroiditis occurs in 5%-9% of women soon after giving birth and is usually a temporary condition.

Viral and bacterial infections can also cause thyroiditis.

A goiter is an abnormal swelling in the neck caused by an enlarged thyroid gland. It can become quite large. The problem occurs in at least 5% of the population.

Worldwide, the most common cause of a goiter is lack of iodine, a chemical which the thyroid uses to produce its hormones. About 100 million people don’t get enough iodine in their diets, but the problem has been solved in the United States and most developed countries by adding iodine to salt.

Even with the right amount of iodine, the thyroid gland can swell, creating a goiter. This can occur in any type of thyroid disease, including hyperthyroidism, hypothyroidism, thyroiditis, and thyroid cancer. Many goiters develop with normal thyroid hormone levels and do not require treatment.

There are several different causes of hyperthyroidism:

• The entire thyroid gland may be overactive, producing too much hormone. Doctors call this problem diffuse toxic goiter, or Graves’ disease.
• One or more lumps (also called nodules) in the gland may be overactive. One such lump is called a toxic autonomously functioning thyroid nodule, and several lumps are called a toxic multi-nodular goiter.
• The gland may be inflamed, a condition called thyroiditis. It can release the thyroid hormone that was stored in the gland, causing hyperthyroidism that lasts for a few weeks or months.
• Some patients may take more thyroid hormone pills than needed or prescribed.
• Some drugs, such as Quadrinal®, amiodarone (Cordarone®), and Lugol’s solution, contain large amounts of iodine, a chemical the thyroid uses to produce its hormones, and may cause the thyroid to produce too much hormone.

® Quadrinal is a registered trademark of Knoll Pharmaceutical.
® Cordarone is a registered trademark of Wyeth Labs.

There are several different causes of hypothyroidism:

• An inflammation of the thyroid gland called thyroiditis can lower the amount of hormones produced. The number one cause of hypothyroidism is Hashimoto’s thyroiditis, a painless disease of the immune system that runs in families. Another form of thyroiditis, postpartum thyroiditis, occurs in 5%-9% of women soon after giving birth and is usually a temporary condition.
• Thyroid surgery or radioactive iodine treatment may cause hypothyroidism.
• One out of every 4,000 infants is born without a working thyroid gland. If the problem is not corrected, the child will become mentally and physically retarded.
• About 100 million people around the world don’t get enough iodine in their diets. Iodine is a chemical which the thyroid uses to produce its hormones. The problem has been solved in the United States and most developed countries by adding iodine to salt.
• Some other possible causes of hypothyroidism are radiation therapy to the head and neck, birth defects, certain drugs, problems with the pituitary gland, and a gradual wearing out of the thyroid gland.

Graves’ disease is the most common form of hyperthyroidism. It affects many Americans, including Olympic athlete Gail Devers, who won a gold medal in track after being diagnosed with and treated for Graves’ disease.

Graves’ disease is caused by problems with the immune system. Normally, the immune system defends the body against germs and viruses. In autoimmune diseases such as Graves’, the immune system attacks the body’s own tissues. In Graves’ disease, the body produces antibodies which make the thyroid gland produce too much thyroid hormone.

Diseases of the immune system tend to run in families and are about five times more common in women. Graves’ is linked to other autoimmune conditions, such as Hashimoto’s thyroiditis, premature gray hair, diabetes mellitus, arthritis and patchy loss of skin pigment (vitiligo).

Hyperthyroidism from any cause can make the upper eyelids pull back, but Graves’ disease often causes one or both eyes to bulge out of their sockets. This condition, known as exophthalmos, can cause loss of eye muscle control, double vision, and (rarely) loss of vision. Most cases require no treatment, but some patients may need to see an eye doctor (ophthalmologist) for specialized treatment. This may include steroids, radiation, or surgery.

As with any disease, it is important that you watch for the early warning signs of hyperthyroidism. However, only your doctor can tell for sure whether or not you have the disease. Your doctor may examine:

• your history and physical appearance
• the amount of thyroid hormones, thyroid stimulating hormone (TSH), and thyroid stimulating antibodies in your blood
• the structure and function of your thyroid gland, using thyroid imaging, which takes a picture of the gland after you have been given a small amount of radioactive iodine

As with any disease, it is important that you watch for the early warning signs of hypothyroidism. However, only your doctor can tell for sure whether or not you have the disease. Your doctor may examine:

• your history and physical appearance
• the amount of thyroid hormones, thyroid stimulating hormone (TSH), and antithyroid antibodies in your blood.

If you have thyroid disease, your doctor can discuss which treatment is right for you. The two basic goals for treating thyroid disease are to return thyroid hormone levels to normal and to remove potentially cancerous lumps. Treatments include radioactive iodine, antithyroid drugs, beta-blocking drugs, thyroid hormone pills, and surgery. There are several types of treatment:

• Radioactive iodine is used to shrink a thyroid gland that has become enlarged or is producing too much hormone. It may be used on patients with hyperthyroidism, a goiter, or some cases of cancer.
• Surgery is normally used to remove a cancer and may also be used to remove a large goiter.
• Thyroid hormone pills are a common treatment for hypothyroidism, for patients with a goiter, and for patients who have had thyroid surgery. The pills provide the body with the right amount of thyroid hormone.
• Anithyroid drugs and beta-blocking drugs are used to treat hyperthyroid patients.

The basic goal of treatment is to return thyroid hormone levels to normal.

Hyperthyroidism makes the body work too fast because there is too much thyroid hormone in the blood. Graves’ disease is the most common cause of hyperthyroidism. Graves’ disease occurs because of a problem in the body’s immune system: antibodies are produced that overstimulate the thyroid gland.

Patients who are hyperthyroid from taking too much thyroid hormone need only to have their dosage properly adjusted.

Patients whose hyperthyroidism is caused by transient thyroiditis usually do not require any of the treatments described below, since their condition gets better on its own.

Treatment for hyperthyroidism from Graves’ disease, toxic autonomously functioning thyroid nodule, or toxic multi-nodular goiter may include one or more of the following:

Radioactive iodine (I¹³¹)

Radioactive iodine shrinks an enlarged thyroid or toxic nodule or nodules that are making too much thyroid hormone. This treatment is safe and is widely used in adults with hyperthyroidism.

* Radioactive iodine (I¹³¹) is the treatment of choice for the majority of the endocrinologists in this country. It is an effective, simple, safe way to treat patients with Graves’ disease or other forms of hyperthyroidism. Patients often have fears and misconceptions about using radioactive iodine.

* Studies have been done since the 1940’s on patients receiving this treatment. Treated patients, their children, and their grandchildren do not have an increased incidence of cancer, leukemia, etc.

* There are no increased instances of birth defects in children born to mothers who have had this treatment and waited the recommended time before becoming pregnant. (Pregnancy should be avoided for at least six months after the treatment.) As a matter of fact, fertility is often restored to women whose infertility is due to hyperthyroidism. Treating the disease also lessens the chance of miscarriage.

* Pregnant women should not be given radioactive iodine for any reason. If a patient has any doubt as to whether she is pregnant, treatment (and testing) with radioactive iodine should be delayed.

* Hospitalization is not required in order to treat hyperthyroidism with radioactive iodine.

* Radioactive iodine treatment ablates the thyroid gland (turns it into something like a dried-up raisin). Patients wishing to avoid destruction of the gland should know that the thyroid gland frequently “burns out” within 15 years even without treatment.

* Radioactive iodine does not cause a person to gain weight. However, because Graves’ disease increases the metabolism, patients should keep in mind that they cannot continue to eat the way they did while hyperthyroid. Because of changes in the metabolism after hyperthyroidism is treated, many patients will gain weight . This weight can be lost through diet and exercise once the thyroid levels are normalized.

Antithyroid drugs

Propylthiouracil (PTU)
Tapazole®

Antithyroid drugs, such as propylthiouracil (PTU) and methimazole (Tapozole®), are used in patients with Graves’ disease and, less commonly, in other hyperthyroid patients

Surgery (thyroidectomy)

In some cases beta-blocking drugs are prescribed to treat the symptoms of hyperthyroidism while waiting for one of the above treatments to work.

Your doctor will be able to discuss the benefits and risks of each treatment.

Many patients treated for hyperthyroidism become hypothyroid. They will need to take thyroid hormone pills for the rest of their lives. In addition, they will need to see their doctor at least once a year.

® Tapozole is a registered trademark of Jones Medical Industries.

The standard treatment for hypothyroidism is thyroid hormone pills. The pills provide the body with the right amount of thyroid hormone when the gland is not able to produce enough by itself. While the symptoms of hypothyroidism are usually corrected within a few months, most patients need to take the pills for the rest of their lives.

The preferred thyroid hormone for treatment is levothyroxine (T₄). You should use only the brand-name that your doctor prescribes, since generic brands may not be as reliable. Name brand levothyroxine pills include Levothroid®, Synthroid®, Levoxyl®, and Eltroxin®.

Patients sometimes take more pills than they should, trying to speed up the treatment or lose weight. However, this can lead to hyperthyroidism, a disease in which there is too much thyroid hormone in the blood, and to long-term complications, such as osteoporosis. You should take the pills as your doctor prescribes.

At different times in your life, you may need to take different amounts of thyroid hormones. Therefore, you should see your doctor once a year to make sure everything is all right.

® Levothroid is a registered trademark of Forest Pharmaceuticals.
® Synthroid is a registered trademark of Knoll Pharmaceuticals.
® Levoxyl is a registered trademark of Jones Medical Industries.
® Eltroxin is a registered trademark of Roberts Pharmaceuticals.

Signs and symptoms of Hyperthyroidism may include:

• fast heart rate (100-120 beats per minute or higher)
• slightly elevated blood pressure
• nervousness or irritability
• increased perspiration
• muscle weakness (especially in the shoulders, hips, and thighs)
• trembling hands
• weight loss, in spite of a good appetite
• hair loss
• fingernails partially separated from finger-tips (onycholysis)
• swollen fingertips (achropachy or clubbing)
• retracted (pulled back) upper eyelids
• skin changes
• increased frequency of bowel movements
• goiter (an abnormal swelling in the neck caused by an enlarged thyroid gland)
• in women, decreased menstrual flow and less frequent menstrual flow
• in men, slight swelling of the breasts
• in Graves’ disease: thick or swollen skin over the shin bones (pretibial myxedema); eyes that seem to be popping out of their socket (exophthalmos).

Most of these conditions will return to normal after the hyperthyroidism is treated. Certain others may be treated separately.

Possible effects of hypothyroidism are:

• slow heart rate (less than 70 beats per minute)
• elevated blood pressure
• feeling slow or tired
• feeling cold
• drowsy during the day, even after sleeping all night
• poor memory
• difficulty concentrating
• muscle cramps, numb arms and legs
• weight gain
• puffy face, especially under the eyes
• husky voice
• thinning hair
• dry, coarse, flaky, yellowish skin
• in children, short height
• constipation
• heavy menstrual flow
• milky discharge from the breasts
• infertility
• goiter (an abnormal swelling in the neck caused by an enlarged thyroid gland).

Chronic thyroiditis

Called Hashimoto’s thyroiditis, it is by far the most common form. It begins so slowly that most people don’t know anything is wrong. Over time, the disease destroys thyroid tissue until permanent hypothyroidism results. Some patients with Hashimoto’s have normal thyroid functions (euthyroidism) with a goiter.

Subacute thyroiditis

It’s a less common form, with far fewer cases than in chronic thyroiditis. Often caused by a viral infection, the disease lasts for several months. Subacute thyroiditis is painful, causing a tender, swollen thyroid gland with pain throughout the neck. The pain usually responds to treatment with aspirin or other anti-inflammatory drugs. At first, gland destruction causes the release of stored thyroid hormones, inducing temporary hyperthyroidism. A month or two later, the patient may become hypothyroid, because the thyroid has been damaged and its hormone reserves used up. Most patients return to normal within six to nine months, but the hypothyroidism could be permanent.

Painless thyroiditis

It causes a painless swelling of the thyroid gland. When this disease occurs after pregnancy, it is called postpartum thyroiditis. The course of painless thyroiditis is otherwise similiar to painful subacute thyroiditis.

Acute thyroiditis

A rare disease, is caused by an acute infection. Patients with the disease become very sick and have a high fever. The neck is red, hot, and very tender. Acute thyroiditis is a medical emergency and must be treated with antibiotics and surgery.

Hashimoto’s thyroiditis, also called chronic thyroiditis, is named for the Japanese doctor who discovered it. It affects about 5% of the adult population, increasing particularly in women as they age. Hashimoto’s, the most common form of thyroiditis, is the leading cause of hypothyroidism.

Hashimoto’s thyroiditis results from problems with the body’s immune system. Normally, the immune system defends against germs and viruses, but in diseases such as Hashimoto’s, the immune system attacks the body’s own tissues. In patients with Hashimoto’s thyroiditis, the immune system produce antithyroid antibodies, which damage the gland and keep it from producing enough hormones.

Diseases of the immune system tend to run in families and are about five times more common in women than in men. Hashimoto’s is linked to other autoimmune conditions, such as Graves’ disease, premature gray hair, diabetes mellitus, arthritis and patchy loss of pigment of the skin (vitiligo).

As with any disease, it is important that you watch for the early warning signs of thyroiditis. However, only your doctor can tell for sure whether or not you have the disease. Your doctor may examine:

• your history and physical appearance
• the amount of thyroid hormones, thyroid stimulating hormone (TSH), and antithyroid antibodies in your blood
• your sedimentation rate, a blood test useful in diagnosing painful subacute thyroiditis
• the amount of radioactive iodine taken up by your thyroid gland.

Thyroiditis can cause either hyperthyroidism or hypothyroidism, or one followed by the other.

Common signs and symptoms of hyperthyroidism include:

• fast heart rate (100-120 beats per minute, or higher)
• nervousness or irritability
• increased perspiration
• muscle weakness (especially in the shoulders, hips, and thighs)
• trembling hands
• weight loss, in spite of a good appetite.

Common signs and symptoms of hypothyroidism include:

• slow heart rate (less than 70 beats per minute)
• feel slow or tired
• drowsy during the day, even after sleeping all night
• poor memory
• difficulty concentrating
• muscle cramps, numb arms and legs
• weight gain
• constipation
• heavy menstrual flow.

Are all thyroid lumps cancerous? How common is thyroid cancer?

Thyroid lumps (also called nodules) are growths in or on the thyroid gland. They occur in 4%-7% of the population. A thyroid nodule might cause your voice to become hoarse, or it could make breathing or swallowing difficult. However, it usually produces no symptoms and is discovered incidentally by you or your physician

More than 90% of these lumps are benign (not cancerous) and do not need to be removed. Thyroid cancer is found in only about 15,000 people each year and causes about 1,210 deaths per year. The most common form (papillary cancer) moves very slowly, and treatment is almost always successful when the cancer is detected early. A less common form (follicular cancer) also moves relatively slowly. Two less frequent forms of thyroid cancer (undifferentiated, or anaplastic, and medullary) are more serious.

Who can get thyroid cancer?

Anyone can get thyroid cancer. However, one group in particular has a higher risk: people who have had radiation to the head or neck. From the 1920s to the 1960s, x-ray treatments were used for an enlarged thymus gland, inflamed tonsils and adenoids, ringworm, acne, and many other conditions.

At that time, doctors thought the x-rays were safe. About 1 million Americans received the treatment, and some of these people will get thyroid cancer up to 40 or more years after receiving the treatment. We now know that radiation therapy to the head or neck increases the chance of developing thyroid cancer later in life. (Radioactive iodine treatments and x-rays used for testing do not increase the risk of cancer.)

Others at higher risk include a child or elderly person with a lump (nodule) in the thyroid. If a man has a thyroid nodule, it is more likely to be cancerous than if a woman has one.

What are hot and cold nodules?

Thyroid nodules do not function like normal thyroid tissue. A thyroid image (scan) done with a radioactive chemical shows the size, shape, and function of the gland and of thyroid nodules. A nodule that takes up more of the radioactive material than the rest of the gland is called a hot nodule.

A nodule that takes up less radioactive material is a cold nodule. Hot nodules are seldom cancerous, but less than 10% of all nodules are hot. Cold nodules may or may not be cancerous. All lumps should be checked by your doctor.

How do doctors test nodules for cancer?

Your doctor can use several tests to find out whether or not a thyroid lump is cancerous.

• A thyroid image or scan shows the size, shape, and function of the gland. It uses a tiny amount of a radioactive chemical, usually iodine or technetium, which the thyroid absorbs from the blood. A special camera then creates a picture, showing how much iodine was absorbed by each part of the gland.
• In needle aspiration biopsy, a small needle is inserted into the nodule in an effort to suck out (aspirate) cells. If the nodule is a fluid-filled cyst, the aspiration often removes some or all of the fluid. If the nodule is solid, several small samples are removed for examination under the microscope. In over 90% of all cases, this testing tells the doctor whether the lump is benign or malignant.
• Ultrasound uses high-pitch sound waves to find out whether a nodule is solid or filled with fluid. About 10% of lumps are fluid-filled cysts, and they are usually not cancerous. Ultrasound may also detect other nodules that are not easily felt by the doctor. The presence of multiple nodules reduces the likelihood of cancer.

How are nodules treated?

Nodules that are thought to be benign are usually observed at regular intervals. Some patients may be advised to take thyroid hormone pills. In certain instances, the nodule may be surgically removed because of continuing growth, pressure symptoms in the neck, or for cosmetic reasons.

Fluid-filled cysts that come back after several aspirations may need to be removed.

If the testing shows a nodule that is, or might be, malignant (cancerous), your doctor will recommend surgery. (You should discuss special situations, such as pregnancy, with your doctor.) The goal of surgery is to remove as much of the cancerous tissue as possible. If the cancer is found in the early stages when it is still confined to the thyroid gland, the surgery is almost always successful. With papillary cancer, patients usually do well after treatment, even if the cancer has spread to the lymph nodes in the neck.

The surgeon starts by removing one lobe of the thyroid. This specimen is tested during surgery (frozen section) to tell the surgeon whether it is benign or malignant. If it is malignant, most or all of the thyroid is removed. If the cancer has spread, lymph nodes in the neck may also have to be removed. In addition, in patients with either papillary or follicular cancer, radioactive iodine therapy may be needed six weeks after surgery to destroy any remaining cancerous tissue.

What happens after surgery?

After surgery, patients must stay in the hospital for one to three days. They may also need to take some time off from work (one to two weeks for a desk job; three to four weeks for physical labor). Most patients do not have any trouble speaking or swallowing, and they report minimal pain after the surgery. In patients with thyroid cancer, a scan may be done approximately six weeks after surgery to detect any residual thyroid tissue that needs to be treated with radioactive iodine.

Patients with thyroid cancer will need to take thyroid hormone their entire lives. Some patients who have had a noncancerous nodule removed will also be advised to take thyroid hormone pills. These may prevent new nodules from forming in the remaining portion of the thyroid gland.

Why are women more likely to get thyroid disease?

In general, women are much more likely than men to become hyperthyroid or hypothyroid and to get Hashimoto’s thyroiditis. The reason for this is uncertain.

Women are also more vulnerable to autoimmune diseases. Two of the most common thyroid diseases, Hashimoto’s thyroiditis and Graves’ disease, are caused by problems with the body’s immune system. Normally, the immune system defends the body against germs and viruses. In autoimmune diseases, the system attacks the body’s own tissues. Diseases of the immune system tend to run in families.

What about thyroid disease and pregnancy?

Hyperthyroidism or hypothyroidism can affect a woman’s ability to become pregnant. They may also cause a miscarriage if they are not quickly recognized and properly treated.

Women who become pregnant may not notice signs of thyroid disease because similar symptoms can occur in a normal pregnancy. For example, patients may feel warm, tired, nervous, or shaky. In addition, enlargement of the thyroid (goiter) commonly occurs during pregnancy.

A pregnant woman is treated differently than is a non-pregnant woman or a man. For example, radioactive materials commonly used in diagnosing and treating many thyroid diseases are never used in pregnant women. The timing of a biopsy or surgery for a thyroid nodule and the choice of drugs for hyperthyroidism may be different in a pregnant woman. These issues require careful consultation with your doctor.

What is postpartum thyroiditis?

Postpartum thyroiditis is a temporary form of thyroiditis. It occurs in 5%-9% of women soon after giving birth (postpartum period). The effects are usually mild. However, the disease may recur with future pregnancies.

The symptoms usually last for six to nine months. First, the damaged thyroid gland may release its stored thyroid hormones into the blood, causing hyperthyroidism. During this time, you can develop a goiter, have a fast heart rate, and feel warm or anxious. Then, a few months later, you will either return to normal or become hypothyroid. Hypothyroidism occurs because the thyroid has been damaged and its hormone reserves used up. If this happens, you may feel tired, weak, or cold. The hypothyroidism usually lasts a few months until the thyroid gland completely recovers. Occasionally, the hypothyroidism may be permanent.

How do doctors test for thyroid disease during pregnancy?

As with any disease, it is important that you watch for the early warning signs of thyroid disease. However, only your doctor can tell for sure whether or not you have the disease. Your doctor may examine:

• your history and physical appearance
• the amount of thyroid hormones, thyroid stimulating hormone (TSH), and thyroid antibodies in your blood.

How is thyroid disease treated during pregnancy?

Pregnancy places some limits on the treatments which you can receive, because your doctor must also look out for the safety of your child. A common treatment for hyperthyroidism is radioactive iodine, but it must be avoided by women who are pregnant or nursing a baby. Surgery to remove a goiter or cancer may also be delayed until after the pregnancy. However, needle aspiration biopsy of a thyroid nodule may be safely done during pregnancy.

Treatments which may be used for thyroid disease during pregnancy include:

• antithyroid drugs, which block the production of thyroid hormone
• thyroid hormone pills, which provide the body with the right amount of thyroid hormone when the gland is not able to produce enough by itself.

Postpartum thyroiditis may or may not be treated during the hyperthyroid stage, depending upon its severity. If the patient later becomes hypothyroid, her doctor may prescribe thyroid hormone pills.

If you or a blood relative has Hashimoto’s thyroiditis or Graves’ disease, there is a chance that your children will inherit the problem. These diseases are also linked to other autoimmune conditions, such as premature gray hair, diabetes mellitus, arthritis, and patchy loss of skin pigment (vitiligo). You should tell your child’s doctor, so that the appropriate examinations can be performed.

Also, one out of every 4,000 infants is born without a working thyroid gland. If the problem is not corrected, the child will become mentally and physically retarded. Therefore, all newborns in the United States are tested for the disease. Once the problem is discovered and corrected, the child can grow up normally.

How is thyroid disease discovered?

As with any disease, it is important that you watch for the early warning signs. However, only your doctor can tell for sure whether or not you have thyroid disease. He or she can measure the amount of thyroid hormones in your blood, as well as look at the structure and function of your thyroid gland. If a nodule is found, your doctor can test whether or not it is cancerous.

What are the signs and symptoms of thyroid disease?

When your doctor examines you for thyroid disease, he or she should first ask about your symptoms and then check for physical signs. Your doctor will ask questions about your memory, emotions, or menstrual flow, and then check your heart rate, muscles, skin, and thyroid gland.

Which blood tests will my doctor use?

After a physical examination, your doctor may examine certain hormone levels in your blood. The most common tests check the levels of thyroid hormones (T₄ and T₃) and thyroid stimulating hormone (TSH). Your doctor may also perform a test with an injection of thyrotropin releasing hormone (TRH). If your doctor suspects Hashimoto’s thyroiditis or Graves’ disease, he or she will probably test you for antithyroid antibodies or thyroid stimulating antibodies.

What does the radioactive iodine uptake show?

Iodine is an important building-block for thyroid hormones. Your doctor may give you a small amount of radioactive iodine and then measure the amount absorbed by the thyroid gland. If the thyroid absorbs a lot of this iodine, you may be hyperthyroid. Low iodine uptake may signal hypothyroidism or thyroiditis.

Why is the structure of my thyroid important?

Examining the structure of your thyroid gland and the surrounding area tells your doctor about a lump (nodule) which may be cancerous or enlargement of the thyroid (goiter).

Which tests look at the structure of my thyroid?

• A thyroid image (or scan) shows the size, shape, and function of the gland. It uses a radioactive chemical, usually iodine or technetium, which the thyroid absorbs from the blood. A special camera then creates a picture, showing how much chemical was absorbed by each part of the gland. The test shows the size of the thyroid and tells whether lumps are hot (usually benign) or cold (either benign or malignant). The scan is frequently done at the same time as the radioactive iodine uptake.
• In needle aspiration biopsy, a small needle is inserted into the nodule in an effort to suck out (aspirate) cells. If the nodule is a fluid-filled cyst, the needle often removes some or all of the fluid. If the nodule is solid, several small samples are removed for examination under the microscope. Over 90% of the time, this testing tells the doctor whether the nodule is cancerous or not.
• Ultrasound uses high-pitch sound waves to find out whether a nodule is solid or filled with fluid. About 10% of nodules are fluid-filled cysts, and they are usually not cancerous. Ultrasound may also detect other nodules that are not easily felt by the doctor. The presence of multiple nodules reduces the likelihood of cancer.

How does radioactive iodine work?

The thyroid gland absorbs iodine from the blood. When radioactive iodine enters your thyroid, it slowly shrinks the gland over a period of weeks or months.

The treatment is safe, simple, convenient, and inexpensive. It is usually given only once, rarely causes any pain or swelling, and does not increase the risk of cancer. However, it must be avoided during pregnancy or nursing, and patients should not become pregnant for at least six months after treatment.

When is radioactive iodine used?

Radioactive iodine is the most common treatment for hyperthyroidism. It does not require hospitalization. About 90% of patients need only one treatment. They usually start getting better in three to six weeks, and most are cured within six months.

This treatment may also be used after surgery for certain thyroid cancers. Radioactive iodine dissolves any cancerous tissue that could not be removed by surgery. The dose of radioactive iodine is larger in this case, and patients usually stay in the hospital for a day or two.

What can be expected with radioactive iodine treatment for hyperthyroidism?

• It is usually given in liquid form or as a capsule. The dose can range from 4 to 29 millicuries.
• It is tasteless.
• There are almost never any side effects. In some rare cases, there can be an inflammation of the thyroid gland causing a sore throat and discomfort.
• Radioactive iodine not taken up by the thyroid gland is excreted in urine and saliva. There is no evidence that the small amount of I¹³¹ excreted in the urine and saliva is harmful. Nonetheless, prudent nuclear medicine experts have recommended a wide variety of precautions. While these recommendations are sometimes confusing and inconsistent, it may be appropriate to take a few simple measures to avoid unnecessary exposure of infants and children to I¹³¹. Treated patients should rinse out their glasses or cups and eating utensils immediately after drinking and eating. The toilet should be flushed immediately after use, and the rim of the bowl should be wiped dry, if necessary.
• It is advisable to drink two to three extra glasses of water a day during the four- to seven- day period following radioactive treatment so that radioactive material will not collect in the bladder for a long period of time.
• Because radioactive iodine passes into breast milk, breast feeding mothers are asked to wean their babies before treatment.
• It typically takes six weeks before thyroid hormone production is noticeably reduced. The average length of time for the thyroid hormone levels to become normal is about three to four months. If thyroid levels are not considerably reduced six months after treatment, the doctor might suggest repeating the treatment. Ninety percent of the time only one treatment is required; however, it might take as many as three attempts. The patient could be advised to take beta-blocking drugs and other medications the doctor believes are necessary until normal thyroid hormone production is restored.
• Many patients treated with radioactive iodine become hypothyroid. This may happen within weeks, months, or years of treatment. Therefore, patients should be aware of the signs and symptoms of hypothyroidism, and their physicians should monitor their thyroid hormone levels regularly. When the patient becomes hypothyroid, thyroid hormone replacement begins and continues for life-one pill a day.

What do antithyroid drugs do?

Antithyroid drugs block pathways leading to thyroid hormone production.

Antithyroid drugs used in this country are Propylthiouracil (PTU) and Tapazole®. Some physicians will recommend antithyroid medication as a first line of treatment to see if the patient is one of the lucky 30% of patients who go into a remission after taking antithyroid medication for one to two years. (Patients are said to be in remission if their hyperthyroidism does not recur after discontinuing the antithyroid drugs.) If antithyroid drugs do not work for the patient, then physicians usually recommend radioactive iodine.

Antithyroid drugs are also used to treat very young children, older patients with heart conditions, and pregnant women. For severe or complicated cases of hyperthyroidism, especially in older patients, PTU or Tapazole® can be given for four to six weeks to bring the hyperthyroidism under better control prior to administering radioactive iodine treatment.

In cases when women are diagnosed with Graves’ disease while they are pregnant, PTU is prescribed. The smallest dose possible is given because the medication does cross over to the fetus. The mother should be checked every three to four weeks during the pregnancy so that the lowest possible dose can be given. Too much PTU can cause fetal goiter, hypothyroidism, and mental retardation.

® Tapozole is a registered trademark of Jones Medical Industries.

Are there any side effects?

Antithyroid drugs cause side effects in about 10% of patients. Reactions can include:

• skin rash
• swollen, stiff, painful joints
• sore throat and fever
• low white blood count, which can lead to serious infections
• jaundice (yellow coloring of the skin) and, rarely, liver failure.

Most side effects clear up once the drugs are stopped. If you think you are having a reaction to anti-thyroid drugs, call your doctor immediately.

What can be expected with antithyroid drug treatment?

• Several pills are taken from one to four times a day, every day for six to 24 months.
• Some patients complain that the pills have an unpleasant smell and taste.
• There is usually some symptom relief within one to two weeks. In some cases, it can take several months to relieve symptoms.
• Antithyroid drugs have a relatively low success rate. While PTU or Tapazole® may correct the problem temporarily or for a few years, the chances of a permanent remission are about 30% once the drugs are stopped.
• The likelihood of achieving a permanent remission is increased if the patient takes the medication for one to two years.
• There are side effects in 10% of the people treated with Tapazole® or PTU. These are:
  • skin rash over most of the body swollen, stiff, painful joints
  • sore throat and fever — if this happens, the antithyroid drugs should be stopped immediately and the physician contacted
  • jaundice
  • liver damage, which is fatal in rare cases
• Because antithyroid drugs pass into breast milk, only PTU in a dosage less than 200 mg a day is advised if the baby is not weaned.
• Within 15 years, the thyroid gland may burn out, resulting in hypothyroidism, and the patient will need thyroid hormone replacement.

When are beta-blocking drugs used?

Beta-blocking drugs, also called beta blockers, treat the symptoms of hyperthyroidism. They do not significantly affect the gland or the levels of thyroid hormones in the blood. Instead, they “block” the effects of thyroid hormones.

Beta blockers are most useful for patients whose hyperthyroidism makes them uncomfortable. High hormone levels can cause a faster heart rate and trembling. Beta-blocking drugs help control these symptoms.

Beta-blocking drugs should not be used by patients with asthma.

When are thyroid hormone pills used?

Thyroid hormone pills provide the body with the right amount of thyroid hormone when the gland is not able to produce enough by itself. The pills are frequently needed after surgery or radioactive iodine therapy.

Thyroid hormone tablets are the standard treatment for hypothyroidism. While symptoms usually get better within a few months, most patients must take the pills for the rest of their lives. This is especially true for hypothyroidism caused by Hashimoto’s thyroiditis or radioactive iodine treatment.

If the entire thyroid gland has been surgically removed, thyroid hormone tablets replace the body’s own source of the hormone. If only a part of the gland has been removed, the pills may keep the remaining gland from working too hard. This decreases the chance that the thyroid gland will grow back.

How much hormone do I need?

The preferred hormone for treatment is levothyroxine (T₄). You should use only the brand-name that your doctor prescribes, since generic brands may not be as reliable. Name-brand levothyroxine pills include Synthroid®, Levoxyl®, Levothroid®, Euthyrox®, and Eltroxin®.

Patients sometimes take more pills than they should, trying to speed up the treatment or lose weight. However, this can lead to hyperthyroidism and long term complications, such as osteoporosis. You should take the pills as your doctor prescribes.

At different times in your life, you may need to take different amounts of thyroid hormone. Therefore, you should see your doctor at least once a year to make sure everything is all right.

® Synthroid is a registered trademark of Knoll Pharmaceuticals.
® Levoxyl is a registered trademark of Jones Medical Industries.
® Levothroid is a registered trademark of Forest Pharmaceuticals.
® Euthyrox is a registered trademark of EM Pharma.
® Eltroxin is a registered trademark of Roberts Pharmaceuticals.

Are thyroid hormone pills needed after treatment for hyperthyroidism?
Many patients treated for hyperthyroidism become hypothyroid. They will need to take thyroid hormone pills for the rest of their lives. In addition, they will need to see their doctor at least once a year.

When is surgery performed?

Surgery (thyroidectomy) is the primary treatment for suspected thyroid cancer and can be used to treat hyperthyroidism. Surgery is used to remove large goiters that make breathing or swallowing difficult. Occasionally, a goiter may be removed for cosmetic reasons.Can you tell me more about cancer surgery?

If thyroid cancer is suspected, your doctor will recommend surgery. The surgeon usually removes only one lobe of the thyroid, unless cancer is confirmed at surgery. A section of the gland is tested during surgery (frozen section) to tell the surgeon whether it is cancerous (malignant) or not cancerous (benign). If it is malignant, all or most of the thyroid is removed. If the cancer has spread outside of the thyroid, lymph nodes in the neck may also have to be removed. In addition, radioactive iodine therapy may be needed six weeks after surgery to destroy any remaining cancer tissue.

How is the cancer surgery operation done?

The operation is usually performed under general anesthesia and takes about two hours. After surgery, patients may stay in the hospital for up to three days. They may also need to take some time off from work (a week or two for a desk job and three to four weeks for physical labor).

Are there any risks to thyroid surgery?

Thyroid surgery is a safe treatment. However, as with any surgery, there are risks. About 1% of patients develop problems with normal speech caused by damage to nerves leading to the voice box, which lies very close to the thyroid. Occasionally, there may be damage to the parathyroid glands, which control the level of calcium in the blood. If this happens, the patient will need to take calcium and other medicines to prevent future problems. Minor risks of surgery include infection, bleeding, and a scar. The chance of death is very small.

What can be expected with thyroid surgery?

• Patients will be in the hospital for one to three days.
• Surgery is usually done under general anesthesia and lasts about two hours.
• A small cut approximately three to four inches long is made along the natural crease of the neck.
• After going to the recovery room for a few hours, patients are returned to their rooms. Patients can usually get out of bed, eat, and have visitors the evening of the surgery.
• It can take up to a year for the scar to heal and the redness to disappear.
• Because most of the thyroid gland is removed, some patients will have to begin lifelong thyroid hormone replacement.

What are the possible complications of thyroid surgery?

• The four parathyroid glands located around the thyroid gland can be accidentally damaged causing low calcium levels that can lead to muscle spasms, convulsions, and the formation of cataracts, if untreated.
• Minor voice changes are not uncommon, but only 1% of those operated on have major voice problems. The nerves from the larynx (voice box) are very near the thyroid gland and sometimes pass through the gland. It is sometimes unavoidable that they are damaged during surgery.
• As with any surgery, there is the risk of surgical death, bleeding, and infection.

Hyperthyroidism

• means too much thyroid hormone
• affects 2.5 million people in the United States
• affects 2% of all women in the United States
• affects women 5 to 10 times more than men
• can cause infertility and miscarriage

Graves’ disease

• is the leading cause of hyperthyroidism
• is an autoimmune disease*

Hypothyroidism

• means too little thyroid hormone
• affects 5 million Americans
• affects women 10 times more than men
• affects 1 out of every 4,000 infants born
• can cause infertility and miscarriage

Hashimoto’s thyroiditis

• is the leading cause of hypothyroidism
• affects 1 out of 5 women over the age of 75
• is an autoimmune disease*
• is associated with a higher rate of miscarriage

Postpartum thyroiditis

• occurs in 5% – 9% of women after giving birth
• is usually temporary but can recur with future pregnancies

Thyroid nodules

• affect 4% – 7% of the population
• are benign 90% of the time
• are less likely to be cancerous in women

*Autoimmune diseases run in families and are 5 times more common in women than men.

Between one and two million Americans received radiation treatments in childhood or adolescence between 1920 and 1960. The most common reasons for these treatments were:

• enlarged thymus gland
• acne
• ringworm
• enlarged tonsils and adenoids
• various chest conditions

The risk factor for developing thyroid cancer if you had childhood radiation treatments is between 2% and 7% as compared to .004% in the general population.

There have been cases of side effects from radiation treatments (not radioactive iodine treatments) reported as long as 45 years after treatment.

Most physicians agree that the thyroid gland of these patients should be checked annually.

Some physicians rely solely on physical (manual) examination of patients treated as children with radiation. Others prefer to perform scans or ultrasounds for nodules too small to detect manually that might be cancerous.

A person treated as a child with radiation can request that their medical records be sent to them by writing the hospital or clinic where they had the treatments. Ask for a record of how much each dose of radiation was as well as how often and over what period of time treatments were given.

One of the more psychologically unpleasant and frustrating side effects that can occur with either hyperthyroidism or hypothyroidism is hair loss. There is no way to predict which patients will experience hair loss and which will not. Similarly, there is no way to predict who will be severely affected and who will have only minimal hair loss.

Because each person is unique, responses to thyroid disease and treatment will vary. This can be disturbing to patients who have lost a great deal of hair and want to know exactly when this will stop and when their hair will be normal again.

Here are a few facts to remember if you experience hair loss because of hyperthyroidism or hypothyroidism:

• Hair loss from thyroid disease is usually reversible with proper treatment of the thyroid condition.
• Typically hair loss does not immediately stop when the blood work becomes normal. Most people stop losing their hair and begin replacing lost hair a few months after the thyroid hormone levels become normal. In some cases, it can take longer.
• Stress can contribute to hair loss. Because of the nature of thyroid disease, it can have a direct impact on the psychological well-being of patients, particularly on the coping mechanisms that deal with stress. Unfortunately, as patients become more and more concerned about their hair loss, their stress levels increase, making the situation worse.
• It is advisable to take caution when considering chemical treatments of the hair-for example, coloring or permanent waves. If at all possible, avoid such treatments until the hair loss has stopped.
• Cutting the hair shorter, using moisturizing and conditioning hair products, and avoiding back combing are other methods to decrease stress on the hair.

The most important things you can do to minimize further hair loss are to faithfully take prescribed thyroid medications and to be calm and patient.

How does thyroid disease affect my cholesterol level?

One of the observed side effects of hypothyroidism is an elevation of LDL cholesterol, the “bad cholesterol.” Elevated LDL levels have been associated with heart disease, particularly coronary artery disease, and peripheral vascular disease. Elevated triglycerides also pose a serious medical problem. However, only in the most severe cases of hypothyroidism does the disease cause a marked elevation in triglyceride levels.

The “good cholesterol” is called HDL cholesterol. Scientific studies are inconclusive about the effects of hypothyroidism on HDL levels. Some have shown a decrease; others have shown no change; and a few have shown a minimal increase.

All patients with hypercholesterolemia (high cholesterol) should have tests of their thyroid function since a small percentage of these patients will have hypothyroidism contributing to their cholesterol problem. Treatment with thyroid hormone will lower cholesterol levels in those patients with an abnormal cholesterol from hypothyroidism.

The overall effect of hypothyroidism is a significant increase in the bad cholesterol. Long-standing, untreated hypothyroidism can lead to permanent damage to the coronary arteries and other blood vessels. Therefore, it is important to treat hypothyroidism and monitor cholesterol levels closely.

Most patients with hypothyroidism have some degree of associated depression, ranging from mild to severe. 10% – 15% of the patients with a diagnosis of depression may have thyroid hormone deficiency. Patients with depression should be tested to determine if they have a thyroid disorder.

• Several research studies have been done and continue to be done on the association between depression and thyroid disease. Although all forms of depression, including bipolar disorders like manic depression, can be found in either hypothyroidism or hyperthyroidism, depression is more often associated with hypothyroidism. Many patients with hypothyroidism have some degree of associated depression, ranging from mild to severe.
• If a large population of depressed patients was screened, a significant percentage, perhaps 10% – 15%, would be found to have thyroid hormone deficiency. For this reason, patients with a diagnosis of depression should be tested to determine if they have too little thyroid hormone. If they do, thyroid medication should be prescribed.
• Thyroid hormone is sometimes prescribed for depressed patients with normal thyroid function because it magnifies the beneficial effects of certain antidepressants.
• Lithium, a commonly prescribed drug for certain types of depression, has profound effects on the size and function of the thyroid gland. Patients taking lithium need periodic examinations of their thyroid gland and thyroid function.

The leading cause of hyperthyroidism is an autoimmune disease called Graves’ Disease.

The leading cause of hypothyroidism is an autoimmune disease called Hashimoto’s thyroiditis.

Autoimmune diseases in general

Autoimmune diseases tend to run in families. In other words, there is a strong genetic predisposition to develop one or more autoimmune diseases. Females are affected five times more than men by autoimmune disease. Patients with other autoimmune diseases are more likely to develop autoimmune thyroid diseases.

Researchers are trying to unlock the mysteries of autoimmune diseases, but there are still many unanswered questions. Basically an autoimmune disease occurs when the immune system produces antibodies that attack healthy tissues. In Graves’ disease, the immune system produces anti-thyroid antibodies that cause the thyroid gland to make too much thyroid hormone. In Hashimoto’s thyroiditis, antithyroid antibodies damage the thyroid gland and prevent it from producing enough thyroid hormone.

Autoimmune diseases associated with a higher than normal rate of thyroid autoimmune diseases

• vitiligo (patchy loss of skin coloration)
• alopecia areata (sudden, circular hair loss)
• premature gray hair
• pernicious anemia (inability to absorb B₁₂)
• rheumatoid arthritis
• myasthenia gravis (episodic muscle weakness that can affect vision, speech, swallowing, and breathing )
• Lupus erythematosus ( connective tissue disorder)
• insulin-dependent diabetes
• Addison’s disease (adrenal insufficiency)
• premature ovarian failure

Tests for antibodies present in autoimmune thyroid disease

• TPOab (thyroperoxidase antibodies)
• TGab (thyroglobulin antibodies)

One of these two types of antibodies is found in nearly all patients with Hashimoto’s thyroiditis and in approximately 50% of patients with Graves’ disease.

• TRab (thyrotropin receptor antibodies; also called thyroid stimulating immunoglobulins or thyroid stimulating antibodies.)

The eye changes associated with Graves’ disease can be called either Graves’ ophthalmopathy, Graves’ orbitopathy, or Graves’ eye disease. Approximately 50% of the patients with Graves’ disease develop some eye disease, but the eye changes may be so subtle that patients are unaware of them. For most patients with Graves’ disease, eye involvement is minimal. Severe orbitopathy occurs in less than 5% of patients with Graves’ disease.

Graves’ eye disease is not caused by thyroid dysfunction. Graves’ disease is an autoimmune disease that affects the eyes and the thyroid gland independently of each other. Thus, the hyperthyroidism may improve with therapy, while the eye disease stays the same or gets worse. Even though the thyroid disease and the eye disease run independent courses, it is important to treat the hyperthyroidism associated with Graves’ disease.

An ophthalmologist is usually involved in the treatment of Graves’ eye disease. Most thyroidologists and endocrinologists should be able to recommend an ophthalmologist experienced in the treatment of Graves’ eye disease. In addition, The Thyroid Society maintains a list of such ophthalmologists throughout the country.

Symptoms of Graves’ eye disease may include a feeling of irritation or sand in the eyes, double vision (diplopia), and excessive tearing. Inflammation and swelling behind the eye may cause actual protrusion of the eyeball from the orbit. When this protrusion occurs, it is called exophthalmos or proptosis.

When the eye changes are severe, there may be marked swelling of the eye, inability to move an eye, corneal ulceration, and in extreme cases, loss of vision. Fortunately, these severe changes occur infrequently, but when they do occur, consultation with an ophthalmologist is essential. Graves’ eye disease usually affects both eyes, although each eye may be affected to a different degree. In some cases, only one eye is affected.

The course of Graves’ eye disease is unpredictable. The initial, or active, phase of Graves’ eye disease may last for eighteen to twenty-four months. During this time period, the eye signs and symptoms may change considerably. For this reason, physicians are reluctant to use certain treatments, such as surgery, during this phase, fearing that ongoing inflammation will cause the eyes to change again after surgery. Thus, most physicians advise patients to defer treatments such as surgery until the eye disease goes into an inactive phase. Of course, if a patient’s symptoms are severe or if loss of vision is threatened, then all available treatments will be used at any time, even during the active phase.

Most patients will receive only symptomatic treatment during the active phase of Graves’ eye disease (see list below). Most importantly, it should be stressed that smoking aggravates Graves’ eye disease.

Physicians may advise the following to relieve symptoms associated with Graves’ eye disease:

• discontinue smoking
• avoid smoke-filled rooms
• use lubricating eye drops
• cover eyes while sleeping
• wear wrap-around dark glasses outdoors during the day
• elevate the head of the bed to reduce overnight eye swelling
• wear prism glasses, or cover one eye with a patch, to relieve double vision
• turn ceiling fans off before going to bed
• avoid exposure to strong sunlight
• avoid or limit wearing contact lenses
• take diuretics temporarily to relieve swelling around the eyes

When symptoms of inflammation are severe, either steroids in large doses or radiation therapy may be advised. Surgery (orbital decompression) is sometimes recommended when the inflammation is so severe that loss of vision is threatened. The choice of therapy among steroids, radiation, and surgery (used individually or in combination) and the timing of therapy require a great deal of thought on the part of the team caring for the patient with Graves’ eye disease.

Once the inflammation in the eyes has stabilized, or entered the inactive phase, patients may then have surgery to relieve signs and symptoms, such as lid retraction, swelling around the eyes, or double vision. Ophthalmologists specializing in plastic surgery of the eye perform the surgery to relieve lid retraction and swelling around the eyes. Sometimes other ophthalmologists who specialize in diseases of the muscles of the eye perform the operation(s) to relieve double vision.

Medical and Surgical Treatment Options for Graves’ Eye Disease

• steroids
• radiation therapy
• surgical adjustment of eyelid placement
• plastic surgery for swelling around the eye(s)
• eye muscle surgery for realignment of the eye(s)
• orbital decompression