Graves Disease / Overactive Thyroid: Autoimmune Disorder Explained by Chief Physician Katharina von Schenk

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00:00:27: Expertly scrutinized clearly explained.

00:00:35: It sits like a small butterfly in the throat, just below the larynx.

00:00:39: Inside it acts like command centre for energy, mood and growth.

00:00:45: When the thyroid becomes unbalanced ,it can lead to various diseases.

00:00:50: Today we'll be discussing hyperthyroidism in Graves' disease, a medical condition of the thyroid gland where the immune system essentially mistakenly activates the gland causing it to continuously produce an excessive amount of hormones.

00:01:06: Each year approximately forty out every one hundred thousand people are diagnosed with Grave's disease.

00:01:13: I'm joined today by Thyroid expert Katharina von Schenck who is from Neuss.

00:01:18: She is the Chief Physician of The Clinic for Endocrine Surgery at the Rhineland Clinicum Lukas Krankenhaus in Neus.

00:01:26: It's lovely to have you here, Ms Von Schenk.

00:01:29: Good day!

00:01:30: I am very much looking forward to the interview.

00:01:33: Mrs von Schenk Would You Be Able To Provide a Brief Explanation Of What Precisely We Should Understand When we refer to the condition of hyperthyroidism as it relates to Graves' disease?

00:01:45: Grave's Disease with its associated hyperthyroidism, is an autoimmune condition of the thyroid gland.

00:01:52: This means that the immune system mistakenly stimulates the thyroid to produce an excessive amount of thyroid hormones.

00:02:00: These are then released systemically and can lead to typical symptoms of overactive function such as excessive sweating heart palpitations with a noticeably rapid pulse rate perhaps also elevation in blood pressure And overall a general boost to the entire metabolism, which is therefore often accompanied by weight reduction.

00:02:21: How does this all come about?

00:02:24: The precise causes are not yet fully understood.

00:02:28: there are certainly disturbances within the immune system for example triggered by viral infections or also genetic predisposition what means that these conditions tend to run in families.

00:02:41: preferentially as with almost all thyroid diseases, it's us women.

00:02:46: Especially when metabolic changes occur for example during puberty pregnancy or also then in menopause.

00:02:54: but generally is it possible for every person to get this disease?

00:02:58: Every single person at practically any stage of life and of course this includes men too.

00:03:05: It's not exclusively limited to us women But also children and adolescents can be affected by.

00:03:12: And how does that manifest itself?

00:03:15: Well, the initial symptoms are typically those of an overactive thyroid function.

00:03:20: Of course you only really know that for sure once you've had the appropriate blood tests performed but patients often complain about sweating restlessness nervousness sleep disturbances and perhaps even hair loss.

00:03:34: It's very unpleasant.

00:03:36: The increased heart rate can also lead to tremors especially in the fingers a fine, rapid trembling of the fingers.

00:03:44: When the family doctor has performed the laboratory examination and an overactive thyroid function has been diagnosed he will also typically measure the antibodies against the so-called TSH receptor.

00:03:57: The TSH Receptor essentially controls thyroid function And this gets completely out of balance when this receptor is stimulated even though there are already plenty of hormones present.

00:04:13: What that means is, the cause isn't even located within the thyroid gland itself but rather the thyroid glands primarily target organ.

00:04:31: If a family doctor has diagnosed hyperthyroidism and has already determined the TSH receptor which With this, the presence of graves' disease is already confirmed and subsequently as with all other thyroid conditions an ultrasound should definitely be performed.

00:04:50: This means we examine the thyroid gland using ultrasound.

00:04:54: The thyroid can be enlarged but it doesn't necessarily have to be.

00:04:58: nodules may be present But they don't have to Be And typically one generally finds a somewhat loosened tissue but with a significantly increased blood flow to the thyroid gland.

00:05:10: And that's quite typical and also diagnostic, so on ultrasound we can already suspect Graves' disease even if patients came to us without lab results –and only did the ultrasound!

00:05:23: However…the lab results including these TSH receptor antibodies are diagnostic.

00:05:29: What role do imaging procedures play?

00:05:32: A scintigraphy can prove very useful especially when we also happen to find, and this is by no means an uncommon occurrence, nodules within the thyroid gland itself.

00:05:43: To properly assess this if we were to also find what's known as a warm nodule then we would be looking at specific variant of Graves' disease presenting with a marine-Lenard syndrome.

00:05:56: This essentially means a classic form of Grave's disease further complicated.

00:06:05: Or do we have what are called cold nodules, or perhaps suspicious nodules?

00:06:10: This is also assessed using ultrasound in combination with scintigraphy.

00:06:15: However for a normal grave's thyroid gland without any nodules... ...a scintigraphy is not necessary!

00:06:21: And does cold and warm refer to whether it might possibly be cancer?

00:06:26: Cold-or-warm nodules don't tell us anything at all about the benign or malignant nature of thyroid nodules which are also very rare overall.

00:06:35: But if we have a suspicious nodule, it's then more cold than warm in the syntergram.

00:06:41: What this means is that in this nodule no thyroid hormones are being synthesized.

00:06:46: In warm nodules they're synthesised and warm nodule can appear suspicious on ultrasound but almost never malignant.

00:07:03: Basically, there are three forms of therapy.

00:07:06: First of all once an overactive thyroid has been diagnosed a so-called thyrostatic therapy should be initiated.

00:07:14: This means the patient receives medication that should suppress thyroid function and restore it to a normal balanced metabolic state.

00:07:22: That's the first step.

00:07:24: And if the thyroid antibodies or If the TSH receptor antibodies are not particularly elevated This also represents a very promising therapeutic approach.

00:07:35: This treatment is primarily administered relatively long-term, for at least eighteen months and patients have good prospect of achieving complete cure with it When the antibody load is quite high.

00:07:47: we are referring to these TSH receptor antibodies which we abbreviate as TRAB.

00:07:54: if they're above ten Then the risk that after tapering off thyrostatic therapy, there will be a renewed flare-up of hypothyroidism is quite high.

00:08:06: And then one should also at an early stage consider definitive treatment for thyroid gland and we essentially have two forms of therapy available to us.

00:08:16: One is radioiodine therapy which has very low complications.

00:08:21: All the operative risks, which we will be discussing in more detail later on are completely eliminated.

00:08:28: And patients have a very high prospect of success without having to suffer any post-operative complications.

00:08:35: This doesn't work one hundred percent effectively and is also not advisable for every single patient.

00:08:41: For example if someone has a very large thyroid gland say sixty or eighty millilitres When the normal size would typically be around eighteen to twenty millilitres, then a significantly higher radiation dose will required so-to speak irradiate the thyroid gland from inside out.

00:09:01: And it's also possible that single application of radioiodine therapy might not achieve desired outcome.

00:09:08: It may need repeated and doesn't work overnight but rather requires several weeks up to maximum four months before the final result can truly be assessed.

00:09:20: Under what circumstances is surgical intervention recommended, and what specific procedures do you typically perform in endocrine surgery?

00:09:29: If an operation is deemed necessary then the thyroid gland should also be completely removed because even tiny remnants weighing just a few grams are capable of causing a new outbreak of the disease.

00:09:42: therefore a complete thyroidectomy.

00:09:46: When patients have nodules, especially if we're unsure whether it could be a malignant one then in any case the inclination should rather be towards surgical removal than radioiodine therapy even if the thyroid glands are very large or if time is irrelevant factor.

00:10:04: This means its usually the patient's who were women.

00:10:08: they have strong desire to have children and after for example a Radioiodine Therapy They should not become pregnant for half to three-quarters of a year.

00:10:18: And then you have to wait about three or four months, For the therapy to be successful.

00:10:22: That means it takes almost A year until patients can try To get pregnant.

00:10:27: This is not The case with surgery There It's faster at best But we also naturally Have to consider some particular risks.

00:10:37: Which ones would that Be?

00:10:39: The problems even a layperson Is familiar With are that the removal of thyroid gland can lead to injury, or at least a significant functional impairment of vocal cord nerves resulting in subsequent voice changes, hoarseness and furthermore swallowing.

00:10:55: difficulties also arise.

00:10:58: They're mostly temporary but naturally very unpleasant.

00:11:04: Fortunately, this is a rare complication that we try to minimize even with technical aids like continuous nerve monitoring during an operation but it will not be zero.

00:11:15: The more frequent and significant problem that we often encounter Is the disruption in body's overall calcium balance which typically occurs after complete surgical removal of entire thyroid gland.

00:11:28: This due to impairment function of parathyroid glands.

00:11:33: The parathyroid glands are small glands that are arranged in pairs, meaning two on the right and two on left.

00:11:40: Situated on the thyroid gland which we naturally do not want to remove together with a thyroid gland but sometimes their function is nevertheless impaired.

00:11:50: However this can usually be well managed medically as long needed With vitamin D and calcium supplements And this issue Usually affects patients temporarily In upto twenty percent But thankfully is only permanent in under one percent.

00:12:06: What exactly does the follow-up care look like, especially after undergoing thyroid surgery?

00:12:12: And what specific points should patients both men and women be mindful of?

00:12:17: Even patients who wish to conceive should not immediately become pregnant after surgery but should first be naturally and properly adjusted with thyroid hormones so that they have a balanced metabolic state meaning neither an overactive nor an underactive thyroid function.

00:12:36: And, uh... you should also of course determine this TRAB that is the TSH receptor antibody because it can also pass across the placenta into so to speak The baby's blood.

00:12:49: That's why this TRAB level Should then be significantly lowered ideally within the normal range before women who are hoping to conceive following and operation are advised not to get pregnant too early.

00:13:04: Otherwise, it's just the usual post-operative checkups.

00:13:07: The wound should heal well which is usually not a problem at all.

00:13:12: Normally patients can be discharged from hospital two days after operation already shower and engage in sports activities.

00:13:21: If no problems occur after surgery And people feel well after thyroid surgery they could start exercising.

00:13:31: After two and a half weeks, wounds are typically well healed.

00:13:35: And strong enough to withstand stress.

00:13:37: Patients could go swimming or the sauna.

00:13:40: that would all be no problem.

00:13:43: after four to six weeks The blood should check once to see if thyroid hormone medication which we already initiated during inpatient stay is properly adjusted.

00:13:54: Otherwise family doctor have make small adjustments until patients are regulated and then a lab check once a year is usually sufficient.

00:14:04: Mrs Von Schenck, if this particular illness isn't recognised in time what exactly could happen to the human body?

00:14:12: Fortunately an overactive thyroid condition typically does not go undiagnosed for extended period of time because it quite clearly places very significant and noticeable burden on patient.

00:14:25: These symptoms make one feel unwell.

00:14:27: This involuntary weight loss which is usually at least unintended.

00:14:32: The rapid heart rate, the nervousness ,the sleep disturbances... All of this naturally puts a significant strain on the cardiovascular system and can for example in older people with pre-existing heart conditions or a history of heart attack Or difficult to manage high blood pressure Make the whole situation even worse And In these cases Can quite acutely send patients To the hospital Because the Heart can no longer cope With the Strain it essentially decompensates.

00:15:01: This can indeed have serious consequences, but also in the long term.

00:15:06: an overactive thyroid for example over many years due to the significantly increased metabolism including the bone metabolism can be a causative factor for bone loss also known as osteoporosis or specifically for patients with Graves' disease.

00:15:24: Grave's disease when left untreated can in certain instances manifest with ocular symptoms, which means it can lead to swelling of the upper or lower eyelids.

00:15:36: Or even through the enlargement of the fatty tissue and the muscles located behind the eyeball ultimately causing the eyes to protrude.

00:15:45: If left untreated this particular condition could ultimately result in a total loss of vision.

00:15:51: It's important to start treatment early.

00:15:53: This means if patients report some problems it's not necessarily visible in the appearance of the eyes, as sometimes its just fluid retention.

00:16:03: then cortisone therapy should be considered specifically high dose intravenously.

00:16:10: So these are infusions that are administered once a week over a period of six to twelve weeks.

00:16:16: It is important if treated early.

00:16:18: by essentially disabling the autoimmune system one can achieve significant relief improvement and even complete cure.

00:16:27: In advanced stages, when the eyes are already quite prominent patients complain of burning and a sensation of dryness in their eyes.

00:16:36: Their eyes are clearly protruding And they may also experience double vision!

00:16:41: In such cases A specialized ophthalmologist should definitely be consulted.

00:16:47: What can one do personally to prevent this disease from ever appearing?

00:16:51: Is there anything one could do regarding their nutrition?

00:16:55: It's a topic of intense discussion whether factors in nutrition are to be considered or if stress is also an important contributing factor.

00:17:04: Of course it is always highly desirable to maintain a healthy lifestyle.

00:17:08: however, A very significant risk-factor for the development of this condition known as thyroid eye disease which means that this specific problem is smoking.

00:17:20: Once the disease has been diagnosed, it is absolutely imperative to stop smoking immediately.

00:17:26: For heavy smokers with a high potential for addiction this should certainly be done with the aid of psychological support nicotine patches and every other available resource without delay.

00:17:38: This is the main significant risk factor for thyroid eye disease which essentially means problems affecting the eyes.

00:17:45: that Is The Main Risk Factor?

00:17:48: When is it truly beneficial to consult a specialized clinic like yours at an early stage?

00:17:54: It's most useful when, if we have high antibody load.

00:17:58: We must therefore assume that the illness even though might be can initially brought into state of dormancy but there are very high risk that will recur and one already start thinking about definitive solution or alternatively If the thyroid gland noticeably enlarges while on thyroid-suppressing medications, that is also a possibility.

00:18:21: And then... The alternative of radioiodine therapy would also no longer be effective and before the thyroid glands takes on monstrous proportions which will complicate surgery it'd be advisable to consider early in order at least get some consultation.

00:18:39: So first you go your family doctor for that Then they refer you.

00:18:43: How does one get to you?

00:18:45: Exactly.

00:18:47: You can reach us through the, er... phone numbers or the email address provided on our website.

00:18:53: Our office hours are somewhat limited and it may not always be possible to establish phone contact immediately.

00:18:59: In such cases please feel free to send us an e-mail.

00:19:03: We will promptly answer it And if necessary quickly arrange an introductory appointment.

00:19:09: Mrs Von Schenck I really appreciate your conversation.

00:19:13: Thank you as well.

00:19:41: Join us again next time when we return with our popular segment, which is called Medicine for Your Ears.