Hyperthyroidism
Definition & classification
Hyperthyroidism is a common endocrine condition
caused by an overactive thyroid gland causing an excess
of thyroid hormone.
Hyperthyroidism affects around 1-2% of the population.
It is important to first define the terminology:
Hyperthyroidism: overactive thyroid gland (i.e.
increased thyroid hormone production) causing an
excess of thyroid hormone and thyrotoxicosis.
Thyrotoxicosis: refers to an excess of thyroid hormone,
having an overactive thyroid gland is not a prerequisite
(e.g. ingestion of excess thyroid hormone).
Hyperthyroidism more commonly affects women than
men (5-10 times more common) and may be associated
with a number of autoimmune and endocrine
conditions.
In this note, we focus predominantly on
hyperthyroidism (thyrotoxicosis with hyperthyroidism)
in adults, though we will briefly discuss thyrotoxicosis
without hyperthyroidism.
Thyrotoxicosis with hyperthyroidism.
Thyrotoxicosis with hyperthyroidism is an excess
of thyroid hormone caused by overactivity of the
thyroid gland.
Graves’ disease
Graves’ disease is a common autoimmune condition and
is the most common cause of hyperthyroidism (60-
80% of cases) in the UK.
It is caused by IgG antibodies to the TSH receptors
found within the thyroid. Termed thyroid-stimulating
hormone receptor antibodies (TSHR-Ab), these
antibodies mimic the action of TSH causing excessive
stimulation of the gland.
Graves’ ophthalmopathy affects up to 30% of patients.
Toxic multinodular goitre
Toxic multinodular goitre is the second most
common cause of hyperthyroidism in the UK.
In this condition, multiple autonomous nodules
develop that are capable of producing and
secreting thyroid hormones.
Solitary toxic adenoma
In this condition, a single adenoma develops and
produces and releases excess thyroid hormones.
Amiodarone-induced thyrotoxicosis type 1
Amiodarone is a lipophilic class III anti-arrhythmic
drug with a high iodine content. Its effects on the
thyroid can be alarming and may cause both
hypothyroidism and hyperthyroidism.
In type 1 the Jod-Basedow phenomenon, in which
excess iodine intake causes excess thyroid hormone
synthesis, occurs. It is seen in patients with pre-existing
thyroid disease.
Follicular thyroid cancer
In metastatic follicular thyroid cancer, malignant
tissue may remain functional. The increased
amounts of tissue can lead to an overproduction
of thyroid hormone.
Struma ovarii
This is a rare but interesting condition. Hyperthyroidism
is caused by thyroid hormone release from ectopic
thyroid tissue related to:
• Ovarian teratomas
• Dermoid tumours
The majority of these tumours are benign.
Beta-HCG related
Beta-HCG is thought to mimic the action of TSH causing thyroid
hormone synthesis and release. It occurs in states of elevated Beta-
HCG:
• Pregnancy
• Hydatidiform mole
• Choriocarcinoma
• Testicular germ cell tumour
Secondary hyperthyroidism
Secondary hyperthyroidism is characterized by
excess TSH production stimulating increased
T3/T4 to be produced and released. It is very rare
and typically caused by a TSH-secreting pituitary
adenoma.
Thyrotoxicosis without hyperthyroidism.
Thyrotoxicosis may occur without
hyperthyroidism (i.e. an overactive thyroid gland),
these conditions are described as thyrotoxicosis
without hyperthyroidism.
These conditions do not feature overactivity of the
thyroid gland. This may be demonstrated by reduced
or absent radioiodine uptake. It can result from:
• Thyroiditis: inflammation of the thyroid gland
resulting in the release of stored thyroid hormone.
• Exogenous ingestion: a person ingests thyroid
hormone.
Anti-thyroid drugs will have little effect in the majority
of these conditions as increased synthesis of thyroid
hormone is not always part of the aetiology.
Levothyroxine
When taken at supra-therapeutic doses levothyroxine may
cause thyrotoxicosis without hyperthyroidism. Patients may
abuse levothyroxine for weight-loss purposes.
De Quervain’s (subacute granulomatous)
thyroiditis
This is a self-limiting condition, thought to be
viral in origin. It results in inflammation of the
thyroid gland and release of thyroid hormone.
It features three phases (though does not always follow
this pattern):
• Thyrotoxicosis
• Hypothyroidism
• Resolution
CLINICAL FEATURES OF HYPERTHYROIDISM
• Weight loss (often accompanied by an increased
appetite)
• Anxiety
• Heat intolerance
• Tremor
• Palpitations
• Increased heart rate
• Muscle weakness
• Fatigue
• Increased bowel movements
• Shortness of breath
• Goiter (commonly found on physical
examination)
DIAGNOSIS OF HYPERTHYROIDSIM
Thyroid panel. This blood test measures the levels of
thyroid hormone and thyroid-stimulating
hormone (TSH).
Thyroid scan. A technician injects a small amount of
radioactive iodine into your bloodstream. Your thyroid
absorbs it, and a special camera takes pictures of the
gland to look for nodules or other issues.
• Ultrasound. A device called a transducer uses sound
waves to create images of your thyroid.
Radioactive iodine uptake test. You swallow a
tiny, safe amount of radioactive iodine. Then, a
device called a gamma probe measures how
much of the iodine collects in your thyroid. If
this uptake is high, you probably have Graves’
disease or thyroid nodules.
MANAGEMENT OF HYPERTHYROIDISM
Radioactive iodine. This is the most common way to
treat hyperthyroidism. You swallow a tiny, safe amount
of radioactive iodine. Your overactive thyroid cells
absorb it and die. This makes your thyroid shrink,
lowering your thyroid hormone levels, although your
symptoms may not improve for several months.
• Surgery. If medications aren’t a good option,
removal of thyroid will be prefered. This is
called a thyroidectomy.
• Beta-blockers. These medications are usually
used to treat high blood pressure. They can
reduce high levels of thyroid hormone
