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How is Graves’ Disease Diagnosed?

In this week’s episode of Thyroid Thursday, Dr. Douglas is joined by endocrinologist, Dr. Pejman Cohan, to discuss the topic – How is Graves’ disease diagnosed?

Dr. Douglas:

Hi, I’m Dr. Raymond Douglas, and I’m an oculoplastic and orbit specialist here in Beverly Hills, California. And today, we’re talking about Graves’ Disease and we’re talking to Dr. Pejman Cohan who’s an endocrinologist here in Beverly Hills, and is an amazing physician who takes care of patients with the autoimmune disease, Grave’s disease, all the time. And since we’re talking about Graves’, many patients ask us, “How do I know that I have a diagnosis of Graves’ and where does someone who even thinks that they may have some symptoms of a thyroid abnormality go to get diagnosed?”

Dr. Cohan:

So how is Graves’ disease diagnosed? Well, patients with Graves’ disease will usually get some pretty strong clues. For example, they may be losing weight despite eating a lot of food, they may have diarrhea, they may get a racy heart or palpitations, they can get a tremor, and women can experience menstrual irregularities. These are just some of the general body symptoms that alert a person that something is not right. And usually, these symptoms lead them to their primary care doctor who then may do some primary screening with blood work and document that the thyroid may be off, and then refer them to a specialist.

Dr. Douglas:

Now that we have talked a bit about the symptoms, let’s now discuss what type of testing might be involved to know whether or not a patient has Graves’ disease. I know many people post their laboratory results online or have questions about their laboratory results and the interpretation, but also they hear about scans and other things like that for the thyroid. Maybe you could tell us a little about what to expect and what your patients experience.

Dr. Cohan:

The laboratory part of diagnosing Graves’ can sometimes be confusing for patients and sometimes confusing for, even, some physicians. This is because one of the laboratory tests that we put a lot of weight on is a test called TSH, thyroid stimulating hormone. And this hormone is actually made by the pituitary gland and in people who have an overactive thyroid, the TSH number goes down. And so, in the presence of high levels of thyroid hormone, this marker that we’re measuring in the blood called TSH is actually suppressed or low. And oftentimes, this number can be undetectable in people who have Graves’ disease. So that’s one of the things that sometimes can be a little bit difficult to understand is this TSH number. The thyroid hormone levels, which are abbreviated as T4 and T3, are often elevated. Now sometimes, we have milder cases of Graves’ disease where the T4 and T3 may be still in a normal range, and sometimes one may be elevated and not the other. But, in general, the TSH is going to be low, and the T4 and T3 will either be normal or high in people who have hyperthyroidism. And so, this is the first clue that they have an overactive thyroid. Before doing any tests, and as you know very well as an oculoplastic surgeon, just looking at the patient can give us a clue as to whether they have Graves’ disease, and examining their eyes and if you look closely, as I think you would agree, that probably a quarter or maybe 20 percent of patients with Graves’ disease will have some eye manifestations. Even though that they may not be symptomatic, per say, but they have some manifestation of the eye disease when you examine them closely. So the history, some of the laboratory tests with the TSH, T3, T4, the physical examination, and then, we can start to do more detailed tests and actually look for markers of the autoimmune process in the blood. And these are termed thyroid stimulating immunoglobulin, sometimes it’s called thyroid binding inhibiting immunoglobulin. So we just abbreviate these as TSI or TBII. These are the markers that the overactive thyroid is immune-mediated.

Dr. Douglas:

It can get quite complex. Many of the early signs that we see in the eyes, as you know, are redness of the eyes, irritation because the autoimmune disease attacks the tear-producing glands, so the eyes can get very red, very irritated, and often, that’s one of the first signs that people will notice as they begin to think about everything else that’s been going on in their lives. One short question: what many people ask, and have asked me, well, I had a nodule diagnosed in my thyroid. Is that something I need to be worried about as, you know, this Graves’ disease process was developing?

Dr. Cohan:

Yes, nodules refer to growths or lumps within the thyroid gland. They’re very common in the population, and so, depending on which study you look at, approximately 20 to 30 percent of normal people can have nodules, or lumps, in their thyroid gland. And in people who have Graves’ disease, they can have those nodules, too. So it could be a coexisting condition on top of the background of Graves’ disease. And, depending on the size and the features of those nodules, some of them require a biopsy to make sure that they’re not cancerous. Now, fortunately, 95 percent of nodules in the thyroid are benign, but those that have some features on ultrasound will usually be further tested by a fine-needle biopsy, which is a pretty easy office-based procedure.

Dr. Douglas: 

In patients who notice any of the symptoms that we’ve chatted about, close collaboration with their endocrinologist, really working through not just the diagnostic tests, but examining the patients, and really taking an interest in their history and all the symptoms that they’ve been through are always the most important thing.

Now that we have answered the question, “how is Graves’ disease diagnosed,” if you think you may have Graves’ disease or if you have already been diagnosed with Graves’ disease, please contact our office for more information about our customized treatment options – 310.657.4302.

Posted in: Thyroid Eye Disease

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