What are the symptoms and treatment options for hyperthyroidism?

Symptoms of Hyperthyroidism

Hyperthyroidism presents with distinctive clinical manifestations including tremors, nervousness, insomnia, excessive sweating, heat intolerance, tachycardia, hypertension, and goiter. 1 These symptoms result from the excessive production or release of thyroid hormones, affecting multiple body systems.

Common Clinical Manifestations

Cardiovascular Symptoms

• Tachycardia (often persistent)
• Palpitations
• Hypertension (often systolic)
• Atrial fibrillation (especially in older patients)
• High-output heart failure in severe cases 1, 2

Neuropsychiatric Symptoms

• Anxiety and nervousness
• Insomnia
• Fine tremor of outstretched hands
• Emotional lability
• Difficulty concentrating 1

Dermatologic Manifestations

• Warm, moist skin
• Excessive sweating
• Hair loss
• Pretibial myxedema (in Graves' disease) 1

Gastrointestinal and Metabolic Symptoms

• Unintentional weight loss (despite increased appetite)
• Diarrhea or frequent bowel movements
• Increased appetite 3

Ophthalmologic Signs

• Eyelid lag or retraction
• Exophthalmos (in Graves' disease)
• Stare appearance 1

Musculoskeletal Symptoms

• Proximal muscle weakness
• Fatigue (paradoxically)
• Osteoporosis (with long-standing hyperthyroidism) 1, 4

Diagnosis

Diagnosis of hyperthyroidism is confirmed through laboratory testing:

• Low or suppressed TSH (<0.4 mIU/L)
• Elevated free T4 and/or T3 levels 1

Overt hyperthyroidism is characterized by low TSH with elevated T4 or T3, while subclinical hyperthyroidism shows low TSH with normal T4 and T3 levels 1.

Treatment Options

Symptomatic Management

• Beta-blockers (e.g., propranolol or atenolol) provide rapid symptom control by:
  • Reducing heart rate and tremor
  • Alleviating anxiety and palpitations
  • Improving muscle weakness 1, 2

Definitive Treatment

1. Antithyroid drugs (e.g., methimazole, propylthiouracil):

   • First-line treatment for most patients
   • Typical treatment duration: 12-18 months
   • Note: 50% recurrence rate after discontinuation 1
   • Special consideration: Propylthiouracil is preferred in first trimester of pregnancy 5

2. Radioactive iodine ablation:

   • Widely used in the United States
   • Preferred for toxic nodular goiter
   • Contraindicated in pregnancy and breastfeeding 1

3. Surgical thyroidectomy:

   • Option for large goiters
   • Indicated when suspicious nodules are present
   • When other treatments are contraindicated 1

Special Considerations

Thyroid Storm

Thyroid storm is a rare but life-threatening complication requiring:

• Hospitalization
• High-dose antithyroid drugs
• Beta-blockers
• Corticosteroids
• Supportive care 1

Pregnancy

• Untreated hyperthyroidism increases risk of:
  • Maternal heart failure
  • Spontaneous abortion
  • Preterm birth
  • Fetal/neonatal hyperthyroidism 1, 5
• Medication considerations:
  • Propylthiouracil preferred in first trimester
  • Methimazole preferred in second and third trimesters 1, 5

Elderly Patients

• Treatment recommended for subclinical hyperthyroidism in patients ≥65 years with TSH <0.10 mIU/L
• Higher risk of cardiovascular complications, including atrial fibrillation 1

Complications

Untreated hyperthyroidism can lead to:

• Increased all-cause mortality
• Cardiovascular events (especially atrial fibrillation)
• Osteoporosis and fractures
• Heart failure
• Adverse pregnancy outcomes
• Thyroid storm 1, 4

Monitoring

Regular monitoring is essential:

• Thyroid function tests (TSH, FT4)
• Complete blood count
• Liver function tests (especially with antithyroid medications)
• Bone health assessment (particularly in postmenopausal women) 1

Early recognition and appropriate treatment of hyperthyroidism are crucial to prevent complications and improve outcomes. The choice of treatment should be based on the underlying cause, severity of symptoms, and patient-specific factors.