Graves' Disease: Symptoms, Causes, and Treatments

Introduction

Graves' disease is an autoimmune disorder that primarily targets the thyroid gland, leading to an overproduction of thyroid hormones, a condition known as hyperthyroidism. This condition holds significant importance in endocrine health, as it stands as the most common cause of hyperthyroidism. Its prevalence is notable, affecting nearly 1 in 100 Americans and exhibiting a higher incidence in women and individuals between the ages of 20 and 50. Understanding Graves' disease is essential for overall health awareness, particularly given the potential for serious complications if left unmanaged. The fact that a significant portion of the population can be affected, coupled with the risk of severe health issues like thyroid storm or cardiac complications, underscores the importance of public knowledge about this condition. Furthermore, the peak incidence of Graves' disease during women's reproductive years suggests a potential interplay between hormonal factors and the onset of the disease, warranting closer examination.

What is Graves' Disease?: An Autoimmune Attack on the Thyroid

Graves' disease is a detailed autoimmune condition where the body's defense system mistakenly identifies and attacks the thyroid gland. This immune system malfunction results in the overproduction of thyroid hormones, leading to hyperthyroidism. This overproduction is primarily driven by thyroid-stimulating immunoglobulins (TSIs), antibodies that mimic the action of thyroid-stimulating hormone (TSH). The thyroid gland, a small butterfly-shaped organ in the neck, plays a crucial role in regulating the body's metabolism, controlling body temperature, and influencing the function of various organs. Graves' disease can have systemic manifestations, affecting not only the thyroid but also other organs such as the heart, skeletal muscles, eyes, skin, bones, and liver. The autoimmune nature of Graves' disease, where the body's own defenses turn against it, points to a fundamental issue within the immune system, raising questions about possible triggers and the likelihood of other autoimmune disorders co-occurring. The specific mechanism of TSIs mimicking TSH highlights a precise point of failure in immune regulation, suggesting potential targets for future treatments aimed at directly addressing this antibody activity rather than just managing hormone levels.

Causes and Risk Factors

Genetic Factors: The Inherited Predisposition

Family history and genetic predisposition play a significant role in the development of Graves' disease, with hereditary factors estimated to account for a substantial 75% to 80% of an individual's risk. Individuals with a family member who has Graves' disease or another autoimmune disorder have an increased likelihood of developing the condition. Several specific genes have been linked to Graves' disease, including those within the human leukocyte antigen (HLA) complex, as well as genes like CD25, CD40, CTLA-4, FOXP3, TSHR (thyroid stimulating hormone receptor), and TG (thyroglobulin). It's important to note that Graves' disease is not caused by a single gene but rather by a combination of multiple genes and genetic variants. This strong genetic component suggests that individuals with a family history of thyroid issues or other autoimmune conditions should be particularly attentive to any potential symptoms of Graves' disease. The involvement of numerous genes, especially those that regulate the immune system, underscores the intricate role of the immune system in the development of this condition and may explain the diverse ways in which the disease can manifest and progress.

Environmental Triggers: External Influences on Disease Onset

Various environmental factors are believed to potentially trigger or worsen Graves' disease in individuals who are genetically susceptible. These include stress, infections (both viral and bacterial), exposure to iodine, smoking, and pregnancy, particularly in the postpartum period. These triggers might activate genes that increase susceptibility to the disease. Notably, smoking is a significant risk factor for Graves' disease and can also worsen associated eye problems. The identification and management of modifiable environmental triggers, such as stress and smoking, could be a valuable strategy in reducing the risk or severity of Graves' disease, especially for those with a family history. The potential link between viral infections and Graves' disease, possibly through a mechanism called molecular mimicry where viral proteins resemble thyroid proteins , warrants further investigation into preventative measures or early interventions following specific infections in susceptible individuals.

Associated Autoimmune Disorders: Clustering of Immune System Issues

Graves' disease often occurs alongside other autoimmune disorders, indicating a broader tendency for the immune system to target the body's own tissues. Some of the conditions associated with Graves' disease include rheumatoid arthritis, lupus, type 1 diabetes, vitiligo, autoimmune gastritis, celiac disease, pernicious anemia, Addison's disease, ankylosing spondylitis, ulcerative colitis, Crohn's disease, myasthenia gravis, and Sjögren syndrome. This phenomenon, where having one autoimmune disease increases the risk of developing another, is known as polyautoimmunity. The frequent co-occurrence of Graves' disease with these other conditions suggests a shared underlying susceptibility or common pathways involved in the development of autoimmunity. Therefore, individuals diagnosed with Graves' disease should be monitored for the potential development of other autoimmune conditions, and vice versa, to ensure comprehensive management and early detection of any related health issues.

Symptoms of Graves' Disease: Recognizing the Body's Signals

Graves' disease manifests through a variety of symptoms, which can be broadly categorized into primary and secondary indicators.

Key Indicators: Primary Symptoms

• Goiter: An enlargement of the thyroid gland, often noticeable as a swelling in the neck.
• Heat Intolerance and Increased Sweating: Feeling unusually hot and sweating more than normal.
• Unexplained Weight Loss: Losing weight despite having a normal or increased appetite.
• Increased Irritability or Anxiety, Nervousness: Feeling more anxious, irritable, or on edge than usual.
• Bulging Eyes (Graves' Ophthalmopathy): Protrusion of one or both eyeballs, sometimes accompanied by early signs like eye protrusion, eyelid retraction (where the eyelids pull back, making the white of the eye more visible), dry eye, and puffy eyes.
• Rapid or Irregular Heartbeat (Palpitations): Feeling like the heart is racing, pounding, or skipping beats.
• Fatigue: Feeling unusually tired or weak.
• Tremors: Shaking or trembling, often in the hands.
• Difficulty Sleeping: Trouble falling asleep or staying asleep.

The wide array of primary symptoms, impacting various systems throughout the body, highlights the far-reaching effects of thyroid hormone imbalance in Graves' disease. Recognizing the early signs of Graves' ophthalmopathy, such as dry eyes and eyelid retraction, even before more pronounced symptoms like bulging eyes appear, is crucial for timely intervention in at-risk individuals.

Additional Clues: Secondary Symptoms

• Menstrual Irregularities: Changes in the menstrual cycle, such as lighter or less frequent periods (oligomenorrhea or amenorrhea) in women.
• Skin Changes (Graves’ Dermopathy): A condition also known as pretibial myxedema, characterized by a lumpy, reddish thickening of the skin, often on the shins, with a texture resembling an orange peel (peau d'orange).
• Hair Loss: Noticeable thinning or shedding of hair.
• Muscle Weakness: Feeling weak or having difficulty with physical activities.
• Frequent Bowel Movements or Diarrhea: Having more frequent bowel movements than usual.
• Changes in Libido: Increased or decreased sexual desire.

These secondary symptoms, while less common, can provide valuable additional information for diagnosing Graves' disease, particularly when they occur in conjunction with the primary symptoms. The specific description of Graves' dermopathy's appearance offers a distinct visual clue that can aid in clinical recognition.

Diagnosis: Identifying Graves' Disease

Diagnosing Graves' disease typically involves a combination of several methods. A healthcare professional will conduct a physical examination, which includes assessing the thyroid gland for enlargement (goiter) and looking for other characteristic signs such as a rapid heartbeat (tachycardia), tremors, and changes in the eyes. Blood tests are crucial for measuring the levels of thyroid hormones. These tests usually reveal a low level of thyroid-stimulating hormone (TSH) and elevated levels of free thyroxine (free T4) and triiodothyronine (T3). Additionally, blood tests can detect the presence of thyroid-stimulating immunoglobulins (TSIs) or thyrotropin receptor antibodies (TRAb), which are specific to Graves' disease. Imaging studies may also be used to further evaluate the thyroid gland. A thyroid scan, which involves measuring the uptake of a small amount of radioactive iodine (RAIU), typically shows increased and diffuse uptake throughout the thyroid gland in individuals with Graves' disease. Thyroid ultrasounds can provide detailed images of the thyroid gland, helping to assess its size and identify any nodules or increased blood flow. Early detection of Graves' disease is crucial as it allows for timely intervention and helps prevent potential complications such as thyroid storm, heart disease, and vision problems. The combination of clinical findings, biochemical markers in blood tests, and functional imaging provides a comprehensive approach to diagnosing Graves' disease and distinguishing it from other causes of hyperthyroidism. While RAIU scans are valuable, the improved availability and quality of thyroid ultrasounds may reduce the need for RAIU in all cases. Prompt diagnosis, facilitated by awareness of symptoms, is essential in reducing the risk of severe complications.

Treatment Options for Graves' Disease: Managing the Overactive Thyroid

Various treatment options are available for managing Graves' disease, each with its own mechanisms, benefits, and considerations.

Medication Management

Medications play a key role in controlling the symptoms and hormone levels associated with Graves' disease. Antithyroid drugs, such as methimazole and propylthiouracil, work by reducing the production of thyroid hormones in the thyroid gland by interfering with its ability to use iodine. These medications are often used for a period of 12 to 18 months to induce remission. Beta-blockers, such as propranolol, atenolol, metoprolol, and nadolol, do not affect thyroid hormone levels but help to manage many of the symptoms of hyperthyroidism, including rapid heart rate, tremors, anxiety, and heat intolerance. It's important to understand that while medications can effectively manage symptoms, they may not always provide a permanent cure for Graves' disease. Both antithyroid drugs and beta-blockers can have potential side effects that need to be monitored. The choice between methimazole and propylthiouracil can depend on individual factors, such as the stage of pregnancy, due to differing risks to the fetus.

Radioactive Iodine Therapy Explained

Radioactive iodine therapy is a common and effective treatment that involves taking a single dose of radioactive iodine (iodine-131) orally, either as a pill or liquid. The radioactive iodine is absorbed by the overactive thyroid cells, and the radiation gradually destroys these cells over several weeks or months, leading to a decrease in thyroid hormone production and often resulting in hypothyroidism. As a consequence, most individuals who undergo radioactive iodine therapy will need to take thyroid hormone replacement medication (levothyroxine) for the rest of their lives. This therapy is not used for women who are pregnant or breastfeeding as it can harm the fetus's thyroid and can be passed through breast milk. It's also worth noting that radioactive iodine therapy may temporarily worsen the symptoms of Graves' ophthalmopathy in some individuals.

Considering Surgical Options

Surgery, specifically a thyroidectomy (the removal of part or all of the thyroid gland), is another treatment option for Graves' disease. This might be recommended in certain situations, such as when the goiter is very large and causing compression symptoms (difficulty swallowing or breathing), if there is suspicion of thyroid cancer, or when other treatment options are not suitable or effective, such as during pregnancy. If the entire thyroid gland is removed (total thyroidectomy), the individual will require lifelong thyroid hormone replacement. Potential risks associated with thyroid surgery include temporary or permanent injury to the recurrent laryngeal nerve, which can affect the voice.

The ultimate choice of treatment for Graves' disease depends on a variety of individual factors, including the patient's age, the severity of their condition, the presence of other health issues, their pregnancy status, and their personal preferences.

Understanding the Stakes: Complications of Untreated Graves' Disease

If Graves' disease is left untreated, it can lead to several serious complications. One of the most severe is thyroid storm, also known as a thyrotoxic crisis, which is a sudden and life-threatening exacerbation of hyperthyroidism. Symptoms of thyroid storm can include a high fever, rapid heartbeat, agitation, delirium, and even loss of consciousness. Untreated hyperthyroidism due to Graves' disease can also lead to various cardiovascular complications, such as heart disease, irregular heart rhythms like atrial fibrillation, heart failure, and an increased risk of stroke. Vision problems are another significant concern, particularly those associated with severe Graves' ophthalmopathy, which can cause double vision and, in some cases, vision loss due to pressure on the optic nerve. Other potential complications of untreated Graves' disease include brittle bones (osteoporosis) and various complications during pregnancy. Given these potential risks, long-term management of Graves' disease is crucial to prevent these serious health issues. The severity of these potential complications highlights the importance of early diagnosis and consistent treatment. The chronic nature of Graves' disease and the risk of complications even with treatment underscore the need for ongoing medical supervision.

Living with Graves' Disease: Practical Management Tips

Managing Graves' disease effectively involves a combination of medical treatment and lifestyle adjustments. Stress reduction techniques such as yoga, meditation, journaling, and ensuring adequate sleep can help manage symptoms like anxiety and irritability. Maintaining a balanced diet is also important. While there isn't a specific diet for Graves' disease, some individuals may need to consider their iodine intake and ensure they are getting enough calcium and selenium. Avoiding highly processed foods and excessive caffeine may also be beneficial. Regular medical check-ups are essential for monitoring thyroid hormone levels and adjusting treatment plans as needed. Seeking support from healthcare providers such as endocrinologists and ophthalmologists, as well as connecting with patient communities and support groups, can provide valuable shared experiences and advice. Empowering oneself with knowledge about the condition and adopting healthy lifestyle habits can significantly improve the quality of life for individuals living with Graves' disease. Given the varied dietary advice, it's best for patients to consult with healthcare professionals or registered dietitians to create personalized plans. Connecting with others who understand the challenges of Graves' disease through support groups can provide invaluable emotional and practical assistance.

Conclusion

In summary, Graves' disease is a chronic autoimmune disorder that leads to the overproduction of thyroid hormones (hyperthyroidism). It is a significant condition in endocrine health due to its prevalence and potential for serious complications if left untreated. While Graves' disease is a long-term condition, it can be effectively managed through a combination of medical care, treatment options such as medications, radioactive iodine therapy, or surgery, and supportive lifestyle adjustments. It is crucial for individuals to consult their doctor if they suspect any symptoms of hyperthyroidism or Graves' disease to ensure timely diagnosis and appropriate management. Consistent long-term follow-up and adherence to prescribed treatment plans are essential for maintaining good health and preventing complications associated with this condition.

Works cited

1. Graves' Disease - NIDDK, accessed April 4, 2025, https://www.niddk.nih.gov/health-information/endocrine-diseases/graves-disease
2. Graves' Disease: What It Is, Causes, Symptoms & Treatment - Cleveland Clinic, accessed April 4, 2025, https://my.clevelandclinic.org/health/diseases/15244-graves-disease
3. Graves disease: MedlinePlus Medical Encyclopedia, accessed April 4, 2025, https://medlineplus.gov/ency/article/000358.htm
4. Graves' Disease | Endocrinology & Diabetes - UC Davis Health, accessed April 4, 2025, https://health.ucdavis.edu/conditions/endocrinology-diabetes/thyroid-disorders/graves-disease
5. Graves' disease - Symptoms and causes - Mayo Clinic, accessed April 4, 2025, https://www.mayoclinic.org/diseases-conditions/graves-disease/symptoms-causes/syc-20356240
6. Mayo Clinic Minute: Graves' disease - when the thyroid is overactive, accessed April 4, 2025, https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-minute-graves-disease-when-the-thyroid-is-overactive/
7. Graves Disease - StatPearls - NCBI Bookshelf, accessed April 4, 2025, https://www.ncbi.nlm.nih.gov/books/NBK448195/
8. Graves' disease - Wikipedia, accessed April 4, 2025, https://en.wikipedia.org/wiki/Graves%27_disease
9. Graves' Disease - American Thyroid Association, accessed April 4, 2025, https://www.thyroid.org/graves-disease/
10. Long term outcomes of patients with Graves' Disease - American Thyroid Association, accessed April 4, 2025, https://www.thyroid.org/patient-thyroid-information/ct-for-patients/february-2024/vol-17-issue-2-p-7-8/
11. Graves' disease - Genetics - MedlinePlus, accessed April 4, 2025, https://medlineplus.gov/genetics/condition/graves-disease/
12. Graves' Disease: A Practical Guide, accessed April 4, 2025, https://gertitashkomd.com/services-graves-disease/
13. Causes and Risk Factors of Graves' Disease - Verywell Health, accessed April 4, 2025, https://www.verywellhealth.com/graves-disease-hereditary-6499993
14. Graves' Disease Causes | Genetic and Environmental Risk Factors, accessed April 4, 2025, https://www.thyroideyes.com/what-is-graves-disease/causes
15. Is Graves disease hereditary? Genes, risk factors, and more - Medical News Today, accessed April 4, 2025, https://www.medicalnewstoday.com/articles/is-graves-disease-hereditary
16. Outcome of Graves' Disease and Associated Genetic Predisposition: A Systematic Review of Literature | medRxiv, accessed April 4, 2025, https://www.medrxiv.org/content/10.1101/2024.09.27.24314519v1.full-text
17. Graves Disease: Practice Essentials, Pathophysiology, Epidemiology, accessed April 4, 2025, https://emedicine.medscape.com/article/120619-overview
18. Dissecting the Genetic Susceptibility to Graves' Disease in a Cohort of Patients of Italian Origin - Frontiers, accessed April 4, 2025, https://www.frontiersin.org/journals/endocrinology/articles/10.3389/fendo.2016.00021/full
19. The genetics of Graves' disease - PMC - PubMed Central, accessed April 4, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10808215/
20. Recurrence of Graves' Disease: What Genetics of HLA and PTPN22 Can Tell Us - PMC, accessed April 4, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC8650699/
21. Actual Associations between HLA Haplotype and Graves' Disease Development - PMC, accessed April 4, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC9099647/
22. Significance of HLA in Graves' disease and Graves' orbitopathy in ..., accessed April 4, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC10568027/
23. What Causes Graves Disease? Key Triggers Explained - BuzzRx, accessed April 4, 2025, https://www.buzzrx.com/blog/what-causes-graves-disease
24. Causes of Graves' disease - News-Medical, accessed April 4, 2025, https://www.news-medical.net/health/Causes-of-Graves-disease.aspx
25. Graves' disease - Women's Health.gov, accessed April 4, 2025, https://womenshealth.gov/a-z-topics/graves-disease
26. Hyperthyroidism: Graves' Ophthalmopathy - MyHealth Alberta, accessed April 4, 2025, https://myhealth.alberta.ca/Health/pages/conditions.aspx?hwid=hw148045
27. Hyperthyroidism: Graves' Ophthalmopathy Information & Treatment - Columbia Doctors, accessed April 4, 2025, https://www.columbiadoctors.org/health-library/condition/hyperthyroidism-graves-ophthalmopathy/
28. Thyroid Eye Disease (Graves' Eye Disease): Symptoms & Causes - Cleveland Clinic, accessed April 4, 2025, https://my.clevelandclinic.org/health/diseases/17558-thyroid-eye-disease
29. Viruses that May Trigger Hashimoto's - Dr. Izabella Wentz, accessed April 4, 2025, https://thyroidpharmacist.com/articles/viruses-may-trigger-hashimotos/
30. What Are Common Symptoms of Autoimmune Disease? | Johns Hopkins Medicine, accessed April 4, 2025, https://www.hopkinsmedicine.org/health/wellness-and-prevention/what-are-common-symptoms-of-autoimmune-disease
31. Autoimmune disorders Information | Mount Sinai - New York, accessed April 4, 2025, https://www.mountsinai.org/health-library/diseases-conditions/autoimmune-disorders
32. One in six patients with Graves' disease will develop another autoimmune disease— why knowing about polyautoimmunity is important - American Thyroid Association, accessed April 4, 2025, https://www.thyroid.org/patient-thyroid-information/ct-for-patients/december-2024/vol-17-issue-12-p-14-15/
33. Graves' Disease Testing, accessed April 4, 2025, https://www.testing.com/graves-disease-testing/
34. Graves Disease - Symptoms and Causes - Penn Medicine, accessed April 4, 2025, https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/graves-disease
35. Overactive thyroid (hyperthyroidism) - NHS, accessed April 4, 2025, https://www.nhs.uk/conditions/overactive-thyroid-hyperthyroidism/
36. Graves' disease physical examination - wikidoc, accessed April 4, 2025, https://www.wikidoc.org/index.php/Graves%27_disease_physical_examination
37. Diffuse Toxic Goiter (Graves Disease) Clinical Presentation: History, Physical Examination, accessed April 4, 2025, https://emedicine.medscape.com/article/120140-clinical
38. Graves' Disease: Overview, Causes, and Symptoms - Healthline, accessed April 4, 2025, https://www.healthline.com/health/graves-disease
39. What Is Thyroid Eye Disease (TED) or Graves' eye disease ..., accessed April 4, 2025, https://www.aao.org/eye-health/diseases/graves-disease-symptoms
40. Hyperthyroidism - DermNet, accessed April 4, 2025, https://dermnetnz.org/topics/hyperthyroidism
41. Graves' disease - Diagnosis and treatment - Mayo Clinic, accessed April 4, 2025, https://www.mayoclinic.org/diseases-conditions/graves-disease/diagnosis-treatment/drc-20356245
42. Thyroid nodules - Diagnosis & treatment - Mayo Clinic, accessed April 4, 2025, https://www.mayoclinic.org/diseases-conditions/thyroid-nodules/diagnosis-treatment/drc-20355266
43. Graves' Disease - Clayman Thyroid Center, accessed April 4, 2025, https://www.thyroidcancer.com/graves-disease
44. Thyroid Tests: Purpose, Procedure & Preparation - Cleveland Clinic, accessed April 4, 2025, https://my.clevelandclinic.org/health/diagnostics/17556-thyroid-blood-tests
45. Thyroid Function Tests, accessed April 4, 2025, https://www.thyroid.org/thyroid-function-tests/
46. Imaging In Graves' Disease - Advanced ENT & Allergy - Keith Forwith, accessed April 4, 2025, https://thyroid.doctor/imaging-in-graves-disease/
47. Thyroid Scan and Uptake - Radiologyinfo.org, accessed April 4, 2025, https://www.radiologyinfo.org/en/info/thyroiduptake
48. Graves' Disease > Fact Sheets > Yale Medicine, accessed April 4, 2025, https://www.yalemedicine.org/conditions/graves-disease
49. Graves' Disease Causes, Symptoms, Diagnosis, and Treatment - Exon Publications, accessed April 4, 2025, https://exonpublications.com/index.php/exon/article/view/graves-disease-public-education
50. Graves' disease | healthdirect, accessed April 4, 2025, https://www.healthdirect.gov.au/graves-disease
51. Your Annual Check-Up Could Prevent Thyroid Disease from Ruling Your Life, accessed April 4, 2025, https://www.mytpmg.com/blog/your-annual-check-up-could-prevent-thyroid-disease-from-ruling-your-life/
52. Graves' disease: Medications, other treatments, and more, accessed April 4, 2025, https://www.medicalnewstoday.com/articles/graves-disease-medication
53. Medications for Graves' Disease - Advanced ENT & Allergy - Keith Forwith, accessed April 4, 2025, https://thyroid.doctor/medications-for-graves-disease/
54. Approach to the Patient Considering Long-term Antithyroid Drug Therapy for Graves' Disease - Oxford Academic, accessed April 4, 2025, https://academic.oup.com/jcem/article/109/10/e1881/7709985?rss=1
55. Graves' Disease Update - MedCentral, accessed April 4, 2025, https://www.medcentral.com/endocrinology/thyroid/hyperthyroidism/graves-disease-update
56. Beta Blockers in Graves' Disease, accessed April 4, 2025, https://gdatf.org/bulletins/beta-blockers-in-graves-disease/
57. Radioiodine therapy: MedlinePlus Medical Encyclopedia, accessed April 4, 2025, https://medlineplus.gov/ency/article/007702.htm
58. Radioactive Iodine (I-131) Therapy for Hyperthyroidism - Radiologyinfo.org, accessed April 4, 2025, https://www.radiologyinfo.org/en/info/radioiodine
59. Radioactive Iodine Therapy: What It Is, Benefits & Side Effects - Cleveland Clinic, accessed April 4, 2025, https://my.clevelandclinic.org/health/procedures/radioactive-iodine-therapy
60. 8 Questions to Ask Your Doctor Before Thyroid Surgery | Duke Health, accessed April 4, 2025, https://www.dukehealth.org/blog/8-questions-ask-your-doctor-thyroid-surgery
61. Thyroidectomy: What It Is, Complications & Recovery - Cleveland Clinic, accessed April 4, 2025, https://my.clevelandclinic.org/health/treatments/7016-thyroidectomy
62. Surgical Management of Graves' Disease - American Thyroid Association, accessed April 4, 2025, https://www.thyroid.org/surgical-management-graves-disease/
63. Thyroidectomy - Mayo Clinic, accessed April 4, 2025, https://www.mayoclinic.org/tests-procedures/thyroidectomy/about/pac-20385195
64. When Do I Need Thyroid Surgery? - CU Anschutz newsroom, accessed April 4, 2025, https://news.cuanschutz.edu/department-of-surgery/when-do-i-need-thyroid-surgery
65. Thyroid Storm - StatPearls - NCBI Bookshelf, accessed April 4, 2025, https://www.ncbi.nlm.nih.gov/books/NBK448095/
66. Thyroid Storm: Causes, Symptoms, Diagnosis & Treatment - Cleveland Clinic, accessed April 4, 2025, https://my.clevelandclinic.org/health/diseases/23203-thyroid-storm
67. Thyrotoxicosis: What It Is, Causes, Symptoms & Treatment - Cleveland Clinic, accessed April 4, 2025, https://my.clevelandclinic.org/health/diseases/21741-thyrotoxicosis
68. 7 Complications of Graves' Disease - Healthline, accessed April 4, 2025, https://www.healthline.com/health/eye-health/complications-graves-disease
69. Overactive thyroid (hyperthyroidism) - Complications - NHS, accessed April 4, 2025, https://www.nhs.uk/conditions/overactive-thyroid-hyperthyroidism/complications/
70. The long-term effects of Graves' disease - Medical News Today, accessed April 4, 2025, https://www.medicalnewstoday.com/articles/long-term-effects-of-graves-disease
71. accessed December 31, 1969, https://www.thyroid.org/thyroid-storm/
72. Cardiovascular Complications Secondary to Graves' Disease: A Prospective Study from Ukraine - PMC, accessed April 4, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC4372210/
73. Significant cardiac disease complicating Graves' disease in previously healthy young adults, accessed April 4, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC6993248/
74. Does Hyperthyroidism Affect the Heart? - Healthline, accessed April 4, 2025, https://www.healthline.com/health/hyperthyroid-heart-disease
75. accessed December 31, 1969, https://www.heart.org/en/health-topics/heart-failure/causes-of-heart-failure/thyroid-disease-and-heart-failure
76. Sight-Threatening Graves' Ophthalmopathy - Endotext - NCBI Bookshelf, accessed April 4, 2025, https://www.ncbi.nlm.nih.gov/books/NBK279098/
77. Long-term management of Graves disease: a narrative review - PMC - PubMed Central, accessed April 4, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC9946914/
78. Long-term management of Graves disease: a narrative review, accessed April 4, 2025, https://www.e-jyms.org/journal/view.php?doi=10.12701/jyms.2022.00444
79. 5 Ways to Protect Your Mental Health When You Have Graves' Disease, accessed April 4, 2025, https://www.everydayhealth.com/hormones-metabolic-disorders/protect-mental-health-when-you-have-graves-disease/
80. Healthy Living With Graves' Disease - Everyday Health, accessed April 4, 2025, https://www.everydayhealth.com/graves-disease/healthy-living-with-graves-disease/
81. Taking Care of Yourself When You Have Graves' Disease - Healthline, accessed April 4, 2025, https://www.healthline.com/health/eye-health/self-care-graves-disease
82. Managing Stress to Be in Control of Your Autoimmune Thyroid Disease - HealthCentral, accessed April 4, 2025, https://www.healthcentral.com/condition/thyroid/how-manage-stress-if-you-have-autoimmune-thyroid-disease
83. How to Manage Stress If You Have Autoimmune Thyroid Disease - True Health Initiative, accessed April 4, 2025, https://www.truehealthinitiative.org/news/how-to-manage-stress-if-you-have-autoimmune-thyroid-disease/
84. accessed December 31, 1969, https://www.hopkinsmedicine.org/health/wellness-and-prevention/5-stress-management-techniques
85. Graves' disease and nutrition recommendations - MSU Extension, accessed April 4, 2025, https://www.canr.msu.edu/news/graves_disease_and_nutrition_recommendations
86. Diet for Graves' Disease: Foods to Eat and Avoid - Healthgrades Health Library, accessed April 4, 2025, https://resources.healthgrades.com/right-care/thyroid-disorders/how-diet-may-affect-graves-disease
87. Graves' disease diet: Foods to eat and avoid - Medical News Today, accessed April 4, 2025, https://www.medicalnewstoday.com/articles/graves-disease-diet
88. Graves' Disease Diet: Foods to Eat and Foods to Avoid - Healthline, accessed April 4, 2025, https://www.healthline.com/health/graves-disease-diet
89. What Can You Not Eat With Graves' Disease? - MedicineNet, accessed April 4, 2025, https://www.medicinenet.com/what_can_you_not_eat_with_graves_disease/article.htm
90. accessed December 31, 1969, https://www.thyroid.org/diet-and-thyroid/
91. The Importance of Check-Ups with Your Endocrinologist | Blog - Upstate Medical University, accessed April 4, 2025, https://www.upstatemedicine.com/2024/10/11/why-regular-endocrinology-check-ups-are-essential-for-health-maintenance/
92. Thyroid Eye Disease Support and Advocacy Organizations, accessed April 4, 2025, https://www.thyroideyes.com/thyroid-eye-disease-support/ted-and-vision-support-groups
93. Resources to Treat Graves' Disease - Everyday Health, accessed April 4, 2025, https://www.everydayhealth.com/graves-disease/resources/
94. Patient Journey Thyroid - Support groups | American Association of Clinical Endocrinology, accessed April 4, 2025, https://www.aace.com/patient-journey/thyroid/support-groups
95. ATA Alliance for Thyroid Patient Education, accessed April 4, 2025, https://www.thyroid.org/patient-thyroid-information/alliance-physicians-thyroid/
96. Graves' Disease and Thyroid Foundation, accessed April 4, 2025, https://gdatf.org/