Symptoma

Hyperthyroidism

Thyrotoxicosis

Hyperthyroidism is a group of disorders characterized overproduction and secretion of thyroid hormones by the thyroid gland.

Hyperthyroidism is characterized by the activation of sympathetic nervous system [3]. The common symptoms of hyperthyroidism include:

Older adults usually either have no symptoms, or have only subtle ones such as increased heart rate, easy fatigability and heat intolerance.

  • Goiter

    In the patients with goiter, hyperthyroidism and symptoms of exophthalmos, and the patients with goiter, hyperthyroidism without symptoms of exophthalmos, IL-2 and TGF-β expression level were not different (p 0.05). [ncbi.nlm.nih.gov]

    Toxic multinodular goiter: 60% of the cases of toxic multinodular goiter are caused by defects in the TSH (thyroid stimulating hormone) receptor gene. In 40% of the cases, the cause is unknown. [symptoma.com]

    Toxic multinodular goiter Toxic multinodular goiter (Plummer disease) accounts for 15-20% of thyrotoxicosis cases (see the image below). It occurs more commonly in elderly individuals, especially those with a long-standing goiter. [emedicine.medscape.com]

    A goiter or nodule may be present. [merck.com]

  • Weight Loss

    A 28-year-old woman presented with weight loss and tiredness. Investigations revealed hyperthyroidism. She was commenced on treatment and later became pregnant. [ncbi.nlm.nih.gov]

    When the thyroid gland is overactive ( hyper thyroidism) the body’s processes speed up and you may experience nervousness, anxiety, rapid heartbeat, hand tremor, excessive sweating, weight loss, and sleep problems, among other symptoms. [endocrineweb.com]

    If you have been diagnosed with hyperthyroidism, then you may have noticed some changes in your body, from unexplained weight loss to fatigue and tremors. [healthhub.sg]

  • Weakness

    Neurological examination showed weakness in the muscles of the bilateral upper and lower limbs. Muscle weakness was more severe in the proximal site than in the distal site. [ncbi.nlm.nih.gov]

    Molar pregnancy, choriocarcinoma, and hyperemesis gravidarum produce high levels of serum human chorionic gonadotropin (hCG), a weak thyroid stimulator. [merck.com]

  • Fatigue

    It is the largest study to date of this population and will help mental health ... read more Chronic Fatigue Syndrome Possibly Explained by Lower Levels of Key Thyroid Hormones Mar. 20, 2018 — A new study reveals that chronic fatigue syndrome, a debilitating [sciencedaily.com]

    We report the case of a 33-year-old euthyroid woman who presented to our hospital with palpitation, hand tremor, fatigue, and excessive sweating after HSG. [ncbi.nlm.nih.gov]

    If you have been diagnosed with hyperthyroidism, then you may have noticed some changes in your body, from unexplained weight loss to fatigue and tremors. [healthhub.sg]

  • Fever

    Familial Mediterranean fever (FMF) is a genetic autoinflammatory disorder characterized by serositis and recurrent fever. [ncbi.nlm.nih.gov]

    Patients typically appear markedly hypermetabolic with high fevers, tachycardia, nausea and vomiting, tremulousness, agitation, and psychosis. Late in the progression of disease, patients may become stuporous or comatose with hypotension. [web.archive.org]

  • Polydipsia

    Clinical features Early symptoms : anxiety, palpitations, rapid pulse, fatigue, muscle weakness, weight loss, diarrhea, hyperactive reflexes, increased sweating, heat intolerance, warm skin, excessive perspiration, menstrual changes, hand tremor, polydipsia [pathologyoutlines.com]

    Overdosage of any thyroid drug may produce the signs and symptoms of thyrotoxicosis including, but not limited to: polydipsia, polyuria, polyphagia, reduced heat tolerance and hyperactivity or personality change. [web.archive.org]

    The most common presenting symptoms are: rapid weight loss, tachycardia (rapid heart rate), vomiting, diarrhea, increased consumption of fluids (polydipsia), polyphasia, and increased urine production (polyuria). [en.wikipedia.org]

  • Failure to Thrive

    Congenital hyperthyroidism can be a cause of failure to thrive, hyperactivity, developmental delay, and craniosynostosis during infancy. Most commonly, the condition occurs in the setting of maternal autoimmune thyroid disease. [ncbi.nlm.nih.gov]

    The main signs are failure to thrive and gain weight, even though the baby has an enormous appetite. Untreated hyperthyroidism can lead to heart problems, including rhythm disturbances. If it isn’t detected for a long time, it can weaken the bones. [luriechildrens.org]

  • Palpitations

    A 22-year-old lactating mother presented with symptoms of uneasiness, palpitation, tachycardia and exophthalmos. She had an abdominal lump suggestive of 26 weeks uterine size but her urine pregnancy test was negative. [ncbi.nlm.nih.gov]

    Any time someone experiences strange sensations they run the risk of developing nervousness and anxiety as a result, especially if some of those symptoms,like heart palpitations, are frightening. [calmclinic.com]

  • Heart Failure

    Excess thyroid hormone affects cardiovascular hemodynamics, leading to high-output heart failure and, in late stages, dilated cardiomyopathy. [ncbi.nlm.nih.gov]

    Heart failure. By forcing the heart to work harder and faster, an overactive thyroid can overtax it and cause heart failure, a condition in which the heart can't pump enough blood to meet the body's needs. [health.harvard.edu]

  • Tachycardia

    Fetal tachycardia was followed by intrauterine death at 30 wk in the second pregnancy and macerated stillbirth at 26 wk in the third pregnancy. Fetal tachycardia was detected at 17 wk in the fourth pregnancy. [ncbi.nlm.nih.gov]

  • Hypertension

    KEYWORDS: Hashimoto's thyroiditis; hyperthyroidism; pregnancy; systolic arterial hypertension [ncbi.nlm.nih.gov]

  • Heart Murmur

    Children's Health Inside Children's Health: Adult & Child ADHD Autism Developmental Milestones Learning Disabilities Nutrition Nutrition for children Parenting Issues Physical Activity Vaccinations Featured Content: Different types of heart murmurs » [health.harvard.edu]

    Heart murmurs and a gallop rhythm can develop due to secondary hypertrophic cardiomyopathy. [en.wikipedia.org]

  • Diplopia

    […] problems such as proptosis, conjunctival oedema, or ophthalmoplegia—and the dreaded complication of optic nerve compression is mercifully rare. 1 When it does occur, however, severe thyroid eye disease is difficult to treat and may result in disfigurement, diplopia [doi.org]

    They may also notice diplopia or double vision. This is due to entrapment of the muscles. The eyes may become irritated and red: conjunctivitis. There may be periorbital edema, upper lid retraction, or lower lid retraction. [web.archive.org]

    […] diarrhea Lower leg swelling Sudden paralysis Shortness of breath with exertion Decreased menstrual flow Impaired fertility Sleep disturbances (including insomnia ) Changes in vision Photophobia, or light sensitivity Eye irritation with excess tears Diplopia [emedicinehealth.com]

    In severe cases, blurred vision, diplopia, or reduced color perception may develop. 16 Smoking increases the risk of developing Graves orbitopathy (odds ratio 3.7). 17 Pretibial myxedema, a less common finding, develops from fibroblast activation and [aafp.org]

  • Muscle Weakness

    She presented with muscle weakness, nausea, vomiting, and diarrhea since one week. The initial diagnosis was TPP. However, biochemistry tests showed hypokalemia with metabolic alkalosis and renal potassium wasting. [ncbi.nlm.nih.gov]

    However, in the longer term, less desirable symptoms, such as muscle weakness, insomnia and trembling can also result. The pulse will likely increase, along with an inability to tolerate heat and abnormally high sweating. [thyroid-info.com]

    These include: Increased heart rate Hand tremor Brisk response to tapping with a reflex hammer Excessive sweating Muscle weakness Protruding eyes If your doctor suspects hyperthyroidism, he or she will order blood tests. [drugs.com]

  • Muscle Cramp

    cramps Dry skin Goiter (swelling of thyroid gland) Brittle nails Slow heart rate Irregular period Sensitivity to cold Constipation Carpal tunnel syndrome Treatment for hypothyroidism Levothyroxine sodium tablets (aka Synthroid) can be taken once a day [piedmont.org]

  • Sweating

    After tracheal extubation, the patient exhibited abnormal tachycardia, agitation, sweating, and hyperpyrexia. The clinical manifestation and the following thyroid function test indicate a high index of suspicion for impending thyroid storm. [ncbi.nlm.nih.gov]

    This leads to a wide range of symptoms including weight loss, increased appetite, increased sweating, intolerance to heat, anxiety and irritability. Hyperthyroidism can be treated by drugs, surgery or radiation. [symptoma.com]

    While you’re pregnant, it’s tough to tell if your thyroid is acting up or if the excessive sweating and vomiting are just from being pregnant. [thebump.com]

    Heart rate and blood pressure may increase, heart rhythms may be abnormal, and people may sweat excessively, feel nervous and anxious, have difficulty sleeping, and lose weight without trying. Blood tests can confirm the diagnosis. [msdmanuals.com]

  • Increased Sweating

    This leads to a wide range of symptoms including weight loss, increased appetite, increased sweating, intolerance to heat, anxiety and irritability. Hyperthyroidism can be treated by drugs, surgery or radiation. [symptoma.com]

    Typical symptoms of the condition include: Nervousness and irritability Increased resting heart rate, which causes heart palpitations Heat intolerance and increased sweating Tremors Weight loss with increase in appetite Frequent bowel movements Thyroid [ucsfhealth.org]

    Feeling too hot Increased sweating Muscle weakness Trembling hands Rapid heartbeat Tiredness/fatigue Weight loss Diarrhea or frequent bowel movements Irritability and anxiety Eye problems, such as irritation or discomfort Menstrual irregularities Infertility [hormone.org]

  • Flushing

    For 3 days after treatment with RAI, patient should double flush his toilet and wash his hands often. One should also avoid contact with young children and pregnant women during this time, to avoid harmful effects by radioactivity. [flexikon.doccheck.com]

    […] symptoms that can occur with this disease: Breast development in men Clammy skin Diarrhea Feeling faint when you raise your hands High blood pressure Itchy or irritated eyes Itchy skin Nausea and vomiting Protruding eyes (exophthalmos) Skin blushing or flushing [pennmedicine.org]

    Iodine-containing medications need to be discontinued several weeks before therapy. 21 Safety Precautions Most of the radioactive iodine is eliminated from the body in urine, saliva, and feces within 48 hours; however, double flushing of the toilet and [aafp.org]

  • Dry Skin

    skin Gaining weight too quickly Low energy / activity level Abnormal menstrual cycles Never change a medication dose on your own. [cincinnatichildrens.org]

    skin Goiter (swelling of thyroid gland) Brittle nails Slow heart rate Irregular period Sensitivity to cold Constipation Carpal tunnel syndrome Treatment for hypothyroidism Levothyroxine sodium tablets (aka Synthroid) can be taken once a day as a replacement [piedmont.org]

    Other symptoms may include a lighter flow during menstrual periods, dry skin and brittle nails. Grave's disease can also affect the muscles that lift the eyelids. When the eyes seem to protrude, this is called exophthalmos. [massagetoday.com]

    Symptoms of hypothyroidism include weight gain, feeling the cold, dry skin and hair, pins and needles in the fingers, lack of energy, and puffiness of the face. [btf-thyroid.org]

  • Alopecia

    Hyperthyroidism classic high & hot signs and symptoms: constipation, weight gain, cold intolerance, hair loss (alopecia). [youtube.com]

    […] increased appetite increased bowel movements and urination infertility and a loss of interest in sex itchy skin with raised itchy swellings (urticaria) nails become loose menstrual problems in women, especially lighter periods or absence of periods alopecia [medicalnewstoday.com]

    Hair thinning or diffuse alopecia. Urticaria, pruritus. Brisk reflexes. Goitre. Proximal myopathy (muscle weakness wasting). Gynaecomastia. Lid lag (may be present in any cause of hyperthyroidism). [patient.info]

  • Neck Swelling

    swelling heavy menstruation slow or stopped menstruation joint pain and muscle aches depression night sweats difficulty concentrating sleep paralysis nightmares altered vision like afterglow blurry vision The First Signs of Hyperthyroid An overactive [healdove.com]

  • Anxiety Disorder

    She consulted a psychologist who told her that she suffered from an anxiety disorder and recommended psychotherapy, which was not helpful. [currentpsychiatry.com]

    These findings provide a ... read more Thyroid Screening May Not Be Needed in All Youth With Psychiatric Disorders Aug. 6, 2019 — A new study looks at the prevalence of abnormal thyroid function in youth with severe mood and anxiety disorder. [sciencedaily.com]

    disorder And more There’s hope! [holtorfmed.com]

  • Loss of Libido

    Loss of libido. Oligomenorrhoea or amenorrhoea. Palmar erythema. Sweaty and warm palms. Fine tremor. Tachycardia - may be atrial fibrillation and/or heart failure (common in the elderly). Hair thinning or diffuse alopecia. Urticaria, pruritus. [patient.info]

    […] of libido, amenorrhea, nausea, vomiting, diarrhea, gynecomastia and feminization.[8] Long term untreated hyperthyroidism can lead to osteoporosis. [en.wikipedia.org]

  • Amenorrhea

    Stenosis, Regurgitation Aortic Stenosis, Regurgitation Cardiomyopathies Myocarditides Constrictive Pericarditis Atrial Fibrillation Infective Endocarditis Aortic Aneurysm Atherosclerosis Hypertension Urinary Tract Infection Pyelonephritis Meningitis Amenorrhea [play.google.com]

    […] state is established.[7] In addition, those with hyperthyroidism may present with a variety of physical symptoms such as palpitations and abnormal heart rhythms (the notable ones being atrial fibrillation), shortness of breath (dyspnea), loss of libido, amenorrhea [en.wikipedia.org]

  • Polyuria

    Overdosage of any thyroid drug may produce the signs and symptoms of thyrotoxicosis including, but not limited to: polydipsia, polyuria, polyphagia, reduced heat tolerance and hyperactivity or personality change. [web.archive.org]

    The most common presenting symptoms are: rapid weight loss, tachycardia (rapid heart rate), vomiting, diarrhea, increased consumption of fluids (polydipsia), polyphasia, and increased urine production (polyuria). [en.wikipedia.org]

  • Irritability

    Typical symptoms of the condition include: Nervousness and irritability Increased resting heart rate, which causes heart palpitations Heat intolerance and increased sweating Tremors Weight loss with increase in appetite Frequent bowel movements Thyroid [ucsfhealth.org]

    This leads to a wide range of symptoms including weight loss, increased appetite, increased sweating, intolerance to heat, anxiety and irritability. Hyperthyroidism can be treated by drugs, surgery or radiation. [symptoma.com]

    Abstract Patients with hyperthyroidism frequently have neuropsychiatric complaints such as lack of concentration, poor memory, depression, anxiety, nervousness, and irritability, suggesting brain dysfunction. [ncbi.nlm.nih.gov]

    It occurs when the thyroid becomes irritated. It temporarily causes the thyroid to be overactive. The thyroid then often becomes underactive. Hyperthyroidism may occur for other reasons. [hopkinsmedicine.org]

  • Tremor

    For example, beta-blockers help slow down a rapid heart rate and reduce hand tremors. Updated on: 05/07/19 Hyperthyroidism Symptoms [endocrineweb.com]

    We report the case of a 33-year-old euthyroid woman who presented to our hospital with palpitation, hand tremor, fatigue, and excessive sweating after HSG. [ncbi.nlm.nih.gov]

  • Hyperactivity

    […] or a toxic nodule (when just one nodule is hyperactive). [columbiasurgery.org]

    Congenital hyperthyroidism can be a cause of failure to thrive, hyperactivity, developmental delay, and craniosynostosis during infancy. Most commonly, the condition occurs in the setting of maternal autoimmune thyroid disease. [ncbi.nlm.nih.gov]

    Increased energy (hyperactivity) Fatigue Unexplained weight loss Trouble sleeping Inability to tolerate heat Trouble concentrating in school Diarrhea Fast, pounding heartbeat Bulging eyes Irregular periods Shaking Hyperthyroidism can be treated by taking [cincinnatichildrens.org]

    The ingestion of radioactive iodine shows how quickly the thyroid absorbs iodine (a primary component of thyroxine), along with which parts of the thyroid appear to be hyperactive. [massagetoday.com]

    Beta-blockers: Propranolol 2 mg/kg/d divided in three to four doses/day or atenolol 1-2 mg/kg once daily is the quickest method to control cardiovascular and neuromuscular hyperactivity. [clinicaladvisor.com]

  • Insomnia

    […] which causes a thick redness on the front of legs and typically occurs with Graves' disease Thin, delicate skin and irregular fingernail and hair growth Menstrual disturbance, such as decreased flow Mental disturbances Sleep disturbances, including insomnia [ucsfhealth.org]

    However, in the longer term, less desirable symptoms, such as muscle weakness, insomnia and trembling can also result. The pulse will likely increase, along with an inability to tolerate heat and abnormally high sweating. [thyroid-info.com]

    A also developed insomnia, depressed mood, and intrusive ego-dystonic thoughts. These symptoms emerged 10 years after a subtotal thyroidectomy for hyperthyroidism (Graves’ disease). [currentpsychiatry.com]

    Hyperthyroid patients typically experience symptoms such as anxiety, insomnia, weight loss, rapid heartbeat, sweating, diarrhea, and eye or vision changes. [holtorfmed.com]

  • Agitation

    After tracheal extubation, the patient exhibited abnormal tachycardia, agitation, sweating, and hyperpyrexia. The clinical manifestation and the following thyroid function test indicate a high index of suspicion for impending thyroid storm. [ncbi.nlm.nih.gov]

    Patients typically appear markedly hypermetabolic with high fevers, tachycardia, nausea and vomiting, tremulousness, agitation, and psychosis. Late in the progression of disease, patients may become stuporous or comatose with hypotension. [web.archive.org]

    […] excessive ingestion of thyroid hormone ("factitious hyperthyroidism") Includes a wide range of symptoms, such as ophtalmopathy, dermatopathy, fever, marked tachycardia, heart failure, tremor, nausea, vomiting, diarrhea, dehydration, restlessness, extreme agitation [pathologyoutlines.com]

    Psychiatric symptoms seen with hyperthyroidism Anxiety Apathy (more often seen in older patients) Cognitive impairment Delirium Depression Emotional lability Fatigue Hypomania or mania Impaired concentration Insomnia Irritability Mood swings Psychomotor agitation [currentpsychiatry.com]

In addition to complete history, examination and base-line investigations, the following specific set of investigations are helpful in establishing the diagnosis of any thyroid disease [4].

  • Serum T3 an T4 levels
  • Serum TSH levels
  • Iodine uptake
  • Thyroid scan
  • Ultrasonography

In case of auto-immune thyroiditis, the most specific auto-antibody test is an ELISA (Enzyme Linked Immunosorbent Assay) test for anti-thyroid peroxidase antibody. The titres are significantly increased in case of Grave’s hyperthyroidism, but are very low or absent in case of toxic adenoma or toxic multi-nodular goiter.

Hyperthyroidism is managed by providing symptomatic relief and anti-thyroid therapy, which includes anti-thyroid drugs, radio-active iodine-131 or thyroidectomy.

Anti-thyroid drugs

The drugs commonly used are carbimazole, and propylthiouracil. Both of these drugs interfere with the oxidation of iodides and binding of iodine to tyrosine [5] [6]. 

Advantages:

  • No surgery required
  • No use of radioactive iodine

Disadvantages:

  • Treatment is prolonged (6-24 months)
  • Failure rate is 50% and relapses may occur [7]
  • Very dangerous side-effect such as agranulocytosis, aplastic anemia and oropharyngeal bacterial infection can occur and may require discontinuation of the drug

Surgery

In toxic and nodular goiter surgery, subtotal or total thyroidectomy cures the disease by reducing the mass of overactive tissue [8]. 

Advantages:

  • Cure is rapid
  • Cure rate is high

Disadvantages:

Radioactive iodine (RAI)

Radioiodine destroys the thyroid cells without surgery. In this treatment, radioactive iodine is given orally which is taken up by the follicles. In the thyroid follicles, beta and gamma rays are emitted from the radioactive iodine which destroys the follicles [10].

Advantages:

  • No surgery
  • No prolonged drug treatment

Disadvantages:

Contraindications:

Hyperthyroidism resulting from toxic multi-nodular goiter and toxic adenoma mostly occurs in adults and remains throughout life. Long term high-dose anti-thyroid drugs are not recommended after the person becomes euthyroid. Instead, radio-active iodine ablation is recommended. Increased thyroid hormone causes left ventricular thickening that results in an increased risk of cardiac death and other cardiac problems. Eye problems usually improve after proper treatment.

Hyperthyroidism can result from several different causes that are listed below [1].

  • Graves disease: It has an autoimmune etiology and is characterized by the presence of auto-antibodies that are capable of stimulating the thyroid gland.
  • Toxic multinodular goiter: 60% of the cases of toxic multinodular goiter are caused by defects in the TSH (thyroid stimulating hormone) receptor gene. In 40% of the cases, the cause is unknown.
  • Toxic adenoma: Toxic adenoma of the thyroid gland is caused by a point mutation in the TSH (thyroid stimulating hormone) receptor gene.
  • Thyroiditis: Different types of thyroiditis have their own etiologies. Hashimoto's thyroiditis has an autoimmune basis whereas De Quervian thyroiditis has a genetic predisposition in specific human leukocyte antigens (HLAs). Suppurative thyroiditis is caused by infections. Drugs such as lithium, amiodarone and interferon-alpha can also cause the development of thyroiditis.

In the United States, the most commonly occurring form of hyperthyroidism is Grave’s disease. It constitutes around 60 to 80% of the total cases. The peak occurrence is in people with ages 20 to 40.

In iodine-deficient areas, the most common type is toxic multi-nodular goiter, comprising up to 15 to 20% of total cases. It typically presents in people older than 50 years of age.

Thyroid hormone secretion is controlled by a complex feed-back mechanism which involves stimulatory and inhibitory factors. The hypothalamus releases thyrotropin-releasing hormone (TRH) which stimulates the pituitary gland to release thyroid stimulating hormone (TSH). Thyroid stimulating hormone in turn causes the release of T3 and T4 from the thyroid gland. Increased levels of T3 and T4 decrease the production of TSH by negative feed-back mechanism.

Any pathology involving the pituitary gland, thyroid or in the periphery leading to increased levels of circulating thyroid hormone results in thyrotoxicosis. Regardless of where the pathology lies, the result is an increase in the transcription of the cellular proteins which then leads to the increased basal metabolic rate [2].

There are no current guidelines on the prevention of hyperthyroidism. Hyperthyroidism caused by Grave’s disease cannot be prevented as it is genetically mediated. However, people residing in iodine deficient areas must introduce iodine in their diets to prevent the occurrence of toxic multi-nodular goiter which is most likely to occur in such areas. This might greatly affect the over-all incidence of hyperthyroidism in these areas.

Also, people with a positive family history of hyperthyroidism or those residing in iodine deficient areas should get themselves periodically checked up for early diagnosis and treatment.

Hyperthyroidism is a term reserved for disorders that result in the overproduction of the thyroid hormone by the thyroid gland. Thyrotoxicosis is a term used to describe a state of thyroid hormone excess resulting from any source. The most common cause of thyroid hormone excess is Graves disease. Toxic multinodular goiter is the second most common cause.

Hyperthyroidism refers to the condition in which the levels of thyroid hormone in the body are high. This leads to a wide range of symptoms including weight loss, increased appetite, increased sweating, intolerance to heat, anxiety and irritability. Hyperthyroidism can be treated by drugs, surgery or radiation.

  1. Lacka K, Fraczek MM. [Classification and etiology of hyperthyroidism]. Polski merkuriusz lekarski : organ Polskiego Towarzystwa Lekarskiego. Mar 2014;36(213):206-211.
  2. Benker G, Breuer N, Muller R, Wehr M. [Pathophysiology of various forms of hyperthyroidism]. Klinische Wochenschrift. Jun 19 1990;68(12):631-634.
  3. Chen JL CH, Tseng YJ, Chu WC. Hyperthyroidism is characterized by both increased sympathetic and decreased vagal modulation of heart rate: evidence from spectral analysis of heart rate variability. Clin Endocrinol (Oxf). 2006;64(6):611-616.
  4. Bernier MO, Aurengo A, Leenhardt L. [Hyperthyroidism. Etiology, physiopathology, diagnosis, evolution, treatment]. La Revue du praticien. May 15 2001;51(9):1023-1031.
  5. Gupta SK, Mithal A, Godbole MM. Single daily dose of carbimazole in the treatment of hyperthyroidism. The National medical journal of India. Sep-Oct 1992;5(5):214-216.
  6. Rubbens P. [Propylthiouracil therapy of hyperthyroidism]. Belgisch tijdschrift voor geneeskunde. Apr 15 1953;9(8):367-375.
  7. Jonas M, Ambroziak U, Bednarczuk T, Nauman J. Predicting a relapse of Graves' hyperthyroidism in adults during the early phase of treatment with anti-thyroid drugs. Endokrynologia Polska. Nov-Dec 2006;57(6):596-604.
  8. Snyder S, Govednik C, Lairmore T, Jiang DS, Song J. Total thyroidectomy as primary definitive treatment for Graves' hyperthyroidism. The American surgeon. Dec 2013;79(12):1283-1288.
  9. Boger MS, Perrier ND. Advantages and disadvantages of surgical therapy and optimal extent of thyroidectomy for the treatment of hyperthyroidism. The Surgical clinics of North America. Jun 2004;84(3):849-874.
  10. Chakrabarti B. Radio-iodine (NaI131) therapy in hyperthyroidism. Journal of the Indian Medical Association. Nov 2001;99(11):642-645.

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