How and Why Graves Disease Attacts Women Under Forty

Graves' Disease

Identify the Disease

Graves' disease is a disorder of the immune system that results in too many thyroid hormones being produced, a situation that is called hyperthyroidism. Thyroid hormones impact many different body functions, so the " ... signs and symptoms" that are linked to Graves' disease cannot easily be zeroed in on specifically (Mayo Clinic). Anyone can be stricken with Graves' disease but it is far more common among women who haven't reached the age of 40 yet. To summarize, Graves' is actually caused by a "malfunction of disease-fighting immune system," which is, too many thyroid hormones are being produced.

The Mayo Clinic provides a list of signs and symptoms that a person may have Graves' disease. Some of the signs associated with Graves' disease include: being irritable or anxious; a fine tremor in hands or fingers; sensitive to heat and increased perspiration; losing weight though eating normally; enlarged thyroid gland; interruption of normal menstrual cycles; erectile dysfunction / reduced libido; frequent bowel movements; bulging eyes; rapid heartbeat; and thick, red skin on the feet.

When it comes to bulging eyes, about 30% of those who have Graves' disease experiences these symptoms, called Graves' ophthalmopathy. What happens is the muscles and tissues around the eyes cause a bulging, along with painful eyes, puffy eyelids, double vision, loss of vision and sensitivity to light (Mayo Clinic).

The risk factors include: a family history of Graves' disease; as noted, women are more likely to be afflicted with Graves' disease; people younger than 40 are most apt to struggle with Graves' disease; those with rheumatoid arthritis or type 1 diabetes are candidates for Graves' disease; when a person is in a stressful situation, Graves' is more likely to be triggered; pregnant women have increased risk; and those who smoke tobacco are among the likely sufferers of Graves' disease (Mayo Clinic).

If Graves' disease isn't treated properly, it can lead to heart rhythm disorders and to brittle bones. Graves can cause miscarriage in a pregnant women, or "fetal thyroid dysfunction, poor fetal growth," and even heart failure (Mayo Clinic). And Graves' disease can lead to "thyroid storm," which is very rare but potentially life-threatening (Mayo Clinic).

On the subject of Graves' disease and pregnancy, the history of this problem dates back to 1825, when a doctor described a pregnancy that ended in a miscarriage " ... due to thyrotoxicosis" (Bahn, 2015). A 1929 study (Gardiner-Hill) was conducted of 26 cases of Graves' disease during pregnancy; of those, 12 were diagnosed during adolescence and a dozen of the 14 women who developed Graves' disease as adults presented the disease during pregnancy or during the postpartum period (Bahn, 168). Hence it became medically known that women getting Graves' disease "at times other than pregnancy or postpartum is relatively rare" (Bahn, 168).

TWO: Discuss the etiology of the disease and pathogenesis of the disease (components of disease process arranged in order, logically, clearly, and accurately) including the relationship between the components of the disease.

Etiology: The etiology of Graves' disease: it is an autoimmune disorder that is caused by " ... an IgG immunoglobulin stimulating the TSH receptor (TSI -- thyroid-stimulating immunoglobulin)" (Bahn, 168). In a pregnant woman, her immune system automatically undergoes a "selective immunosuppression" that allows the woman to accept the "fetal allograft" (Bahn, 168). Essentially, the immunosuppression causes a slow decline in the "titer of TSI with a concomitant improvement in the severity" of the presence of Graves' disease when the woman's pregnancy continues through the three trimesters (Bahn, 168).

That having been pointed out, once a woman with Graves' disease enters into the postpartum period her immune system tends to get a "rebound," Bahn explains. After about six months during the postpartum period, the TSI levels tend to return to that titer that had been present prior to conception, however the "immunologic rebound during the postpartum period" could open the door for other problems: a) a recurrence of Graves' disease that may have been in remission prior to pregnancy; b) or a relapse of Graves' disease that was in remission during pregnancy; and c) the possible occurrence of de novo Grave's disease (Bahn, 168).

Pathogenesis of Graves' disease: In Graves' disease the B and T lymphocyte-mediated autoimmunity " ... are known to be directed at 4 well-known thyroid antigens," including thyroglobulin, thyroid peroxidase, sodium-iodide symporter and the thyrotropin receptor" (Yeung, 2015). In Graves' disease what is believed to be the primary autoantigen (responsible for the occurrence of hyperthyroidism) is thyrotropin receptor, Yeung explains. And it is important to note that the thyroid gland (one of the most important glands in the human body) is under "continuous stimulation" because it is circulating auto-antibodies "against the thyrotropin receptor"; this suppresses the secretion of the pituitary gland (another pivotal gland in the body) by the fact that there are more thyroid hormones being produced (Yeung, p. 1).

As to the relationship between the components of Graves' disease Basil Rapoport and Sandra McLachlan explain that the relationship between the " ... circulating immunoglobulins" located in Graves' disease and the "pathogenesis of dermopathy" are not clear to researchers (Rapoport, 2000). However, some researchers believe that the antibodies could provide enhancement for "glycosaminoglycan and proteoglycan production in fibroblasts" (Rapoport). In Scholarly Editions (213) the authors' research in Shanghai showed that rs9463772 polymorphism showed "a significant association with Graves' disease" and the related Graves' Ophthalmopathy patients (Acton, 2013).

THREE: Discuss the clinical manifestations of the disease

Graves' disease is known as an autoimmune disorder that has a negative impact on other organs in the human body. The disease can be triggered by some kind of trauma to the thyroid, " ... including surgery of the thyroid gland, percutaneous injection of ethanol" or thyroid adenoma (Yeung, 2015). Most of the physical manifestations of Graves' disease include the following: a) there are changes in the skin (in pretibial areas); b) weight loss; c) widening of the palpebral fissures, lagging lids, and visual losses in "severe optic nerve"; d) in the neck the thyroid gland is enlarged; e) in the chest heart murmurs, extopic beats and irregular heartbeats; f) in the abdomen, hyperactive bowel activity; g) in the extremities, edema, acropachy, and onycholysis; h) neurologically there can be hand tremors and tendon reflexes; and i) psychiatrically, a person is restless, and irritable (Yeung, p. 2). The atypical manifestations of Graves' disease include: anemia (33% of patients have anemia); and 22% of Graves' disease patients have abnormal mean corpuscular volume (Hegazi, et al., 2012).