|Overview of the clinical manifestations of hyperthyroidism in adults
Douglas S Ross, MD
David S Cooper, MD
Jean E Mulder, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan 2012. | This topic last updated: Nov 18, 2010.
INTRODUCTION — The clinical manifestations of hyperthyroidism are largely independent of its cause. (See "Disorders that cause hyperthyroidism".) However, the disorder that causes hyperthyroidism may have other effects. In particular, Graves' disease, the most common cause of hyperthyroidism, causes unique problems that are not related to the high serum thyroid hormone concentrations. These include Graves' ophthalmopathy and infiltrative dermopathy (localized or pretibial myxedema). Most patients with Graves' hyperthyroidism have a diffuse goiter, but so do patients with other, less common causes of hyperthyroidism such as painless thyroiditis and thyrotropin (TSH)-secreting pituitary tumors.
The major clinical manifestations of hyperthyroidism (thyrotoxicosis) will be briefly reviewed here. More detailed discussions of its effects on specific organ systems as well as the diagnostic approach to patients with hyperthyroidism are discussed separately. (See "Diagnosis of hyperthyroidism".)
SKIN — The skin is warm (and may rarely be erythematous) in hyperthyroidism due to increased blood flow; it is also smooth because of a decrease in the keratin layer . Other changes include:
Sweating, which increases due to increased calorigenesis; this is often associated with heat intolerance
Onycholysis (loosening of the nails from the nail bed, Plummer's nails) and softening of the nails
Hyperpigmentation, which can occur in severe cases; it appears to be mediated by accelerated cortisol metabolism, leading to increased corticotropin (ACTH) secretion 
Pruritus and hives, which are occasional findings, primarily in patients with Graves' hyperthyroidism 
Vitiligo and alopecia areata, which can occur in association with autoimmune disorders
Thinning of the hair
Infiltrative dermopathy occurs only in patients with Graves' hyperthyroidism. The most common site is the skin overlying the shins, where it presents as raised, hyperpigmented, violaceous, orange-peel-textured papules. (See "Pretibial myxedema in autoimmune thyroid disease".)
EYES — Stare and lid lag occur in all patients with hyperthyroidism. They are due to sympathetic overactivity, possibly mediated by increased alpha-adrenergic receptors in some tissues . Lid lag is evaluated by having the patient follow the examiner's finger as it is moved up and down. The patient has lid lag if sclera can be seen above the iris as the patient looks downward.
As noted above, only patients with Graves' disease have ophthalmopathy. It is characterized by inflammation of the extraocular muscles and orbital fat and connective tissue, which results in proptosis (exophthalmos), impairment of eye-muscle function, and periorbital and conjunctival edema. Ophthalmopathy is more common in patients who smoke cigarettes. (See "Pathogenesis and clinical features of Graves' ophthalmopathy (orbitopathy)".)
Patients with ophthalmopathy may have gritty feeling or pain in their eyes, and may have diplopia due to extraocular muscle dysfunction. Corneal ulceration can occur as a result of proptosis and lid retraction, and severe proptosis can cause optic neuropathy and even blindness.
CARDIOVASCULAR — Patients with hyperthyroidism have an increase in cardiac output, due both to increased peripheral oxygen needs and increased cardiac contractility. Heart rate is increased, pulse pressure is widened, and peripheral vascular resistance is decreased . Systolic hypertension is common . The left ventricular ejection fraction does not increase appropriately during exercise, suggesting the presence of a true cardiomyopathy . High- or normal-output congestive heart failure can occur in patients with severe hyperthyroidism and congestive heart failure worsens in patients who already have it. (See "Cardiovascular effects of hyperthyroidism".)
Atrial fibrillation occurs in 10 to 20 percent of patients with hyperthyroidism, and is more common in elderly patients. In one study, 8 percent of all patients and 15 percent of patients between ages 70 to 79 developed atrial fibrillation within 30 days of the diagnosis of hyperthyroidism . Even subclinical hyperthyroidism is associated with an increased rate of atrial ectopy and a threefold increased risk of atrial fibrillation (figure 1) .
In 60 percent of hyperthyroid patients with atrial fibrillation, the rhythm converts spontaneously to sinus rhythm when the hyperthyroidism is treated; in one study, all who spontaneously converted did so within four months after becoming euthyroid . Among those who do not convert spontaneously to sinus rhythm and who undergo successful electrical cardioversion, the two-year risk of recurrent atrial fibrillation was 59 percent compared with 83 percent of patients whose atrial fibrillation was not associated with hyperthyroidism .
The role of anticoagulation is controversial in hyperthyroid patients with atrial fibrillation. In several studies, 10 to 40 percent of patients with hyperthyroidism and atrial fibrillation had an arterial embolus . Left atrial enlargement, which is a risk factor for thrombus formation, is present in about 90 percent of hyperthyroid patients with atrial fibrillation and two percent of hyperthyroid patients with sinus rhythm. Based on these results, we usually anticoagulate hyperthyroid patients with atrial fibrillation. This recommendation is in agreement with guidelines published in 2006 by the American College of Cardiology/American Heart Association/European Society of Cardiology .
Other abnormalities, including mitral valve prolapse, mitral regurgitation, and an increase in left ventricular mass index have also been reported. (See "Cardiovascular effects of hyperthyroidism".)
METABOLIC / ENDOCRINE
Serum lipids — Patients with hyperthyroidism tend to have low serum total and high-density lipoprotein (HDL) cholesterol concentrations and a low total cholesterol/HDL cholesterol ratio. These values increase after treatment .
Hyperglycemia — Although thyroxine is not a counterregulatory hormone, hyperthyroidism can interfere with glucose metabolism. It is associated with both increased sensitivity of pancreatic beta cells to glucose, resulting in increased insulin secretion, and antagonism to the peripheral action of insulin . The latter effect usually predominates, leading to impaired glucose tolerance in untreated patients .
Adrenal function — Interpretation of the cortisol response to ACTH stimulation testing may be misleading in patients with hyperthyroidism because cortisol binding globulin (CBG) levels decrease, resulting in lower total serum cortisol concentrations. In one report of 49 hyperthyroid patients undergoing ACTH testing, 35 percent had subnormal total serum cortisol values (<18 mcg/dL), while only 11 percent had a subnormal free cortisol index (ratio of serum total cortisol to CBG) .
RESPIRATORY — Dyspnea and dyspnea on exertion may occur for many reasons in hyperthyroidism (see "Respiratory function in thyroid disease"):
Oxygen consumption and CO2 production increase. These changes result in hypoxemia and hypercapnia, respectively, both of which stimulate ventilation.
Respiratory muscle weakness is an important cause of dyspnea , and reduced exercise capacity may be largely due to respiratory muscle weakness and decreased lung volume .
There may be tracheal obstruction from a large goiter.
Hyperthyroidism may exacerbate underlying asthma.
Pulmonary arterial systolic pressure is increased .
GASTROINTESTINAL — Weight loss is due primarily to increased metabolic rate (hypermetabolism), and secondarily to increased gut motility and the associated hyperdefecation and malabsorption; rare patients have steatorrhea. Celiac disease is also more prevalent in patients with Graves' disease . Most patients have hyperphagia, but an occasional patient with mild hyperthyroidism may have sufficient appetite stimulation that weight is gained (more commonly in younger patients) . Anorexia may be prominent in elderly hyperthyroid patients .
Other changes that may occur include:
Vomiting  and abdominal pain, rarely
Dysphagia due to goiter
Abnormalities in liver function tests, particularly high serum alkaline phosphatase concentrations, and rarely cholestasis
HEMATOLOGIC — The red blood cell mass is increased in hyperthyroidism, but the plasma volume is increased more, resulting in a normochromic, normocytic anemia . Serum ferritin concentrations may be high.
Graves' hyperthyroidism may be associated with autoimmune hematologic disorders such as idiopathic thrombocytopenic purpura and pernicious anemia, and some patients have antineutrophil antibodies.
Hyperthyroidism may also be prothrombotic [26,27]. As an example, in one small study of thyroid cancer patients taking levothyroxine in doses causing mild hyperthyroidism, levels of fibrinogen, prothrombin fragment 1+2, protein S, antithrombin, tPA, PAI-1, and PAI-1/tPA were significantly higher than in euthyroid controls . Overt hyperthyroid patients have increased von Willebrand factor and shortened in vitro platelet plug formation times, indicating enhanced platelet function .
GENITOURINARY — Urinary frequency and nocturia are common in hyperthyroidism, although the mechanism is uncertain. Possible causes include primary polydipsia  and hypercalciuria. Enuresis is common in children.
In women, serum sex hormone-binding globulin (SHBG) concentrations are high, which results in high serum estradiol concentrations and low-normal serum free (unbound) estradiol concentrations, high serum luteinizing hormone (LH) concentrations, a reduced mid-cycle surge in LH secretion, oligomenorrhea, and anovulatory infertility [31,32]. Amenorrhea can occur in women with severe hyperthyroidism.
In men, the increase in serum SHBG concentrations results in high serum total testosterone concentrations, but serum free (unbound) testosterone concentrations are normal or low [33,34]. Serum LH concentrations may be slightly high. Extragonadal conversion of testosterone to estradiol is increased, so that serum estradiol concentrations are high. These changes can cause gynecomastia, reduced libido, and erectile dysfunction [31,35]. Spermatogenesis is often decreased or abnormal, eg, more spermatozoa are abnormal or non-motile .
BONE — Thyroid hormone stimulates bone resorption, resulting in increased porosity of cortical bone and reduced volume of trabecular bone . The loss in cortical bone density is greater than that of trabecular bone. Serum alkaline phosphatase and osteocalcin concentrations are high, indicative of increased bone turnover. The increase in bone resorption may lead to an increase in serum calcium concentrations, thereby inhibiting parathyroid hormone secretion and the conversion of calcidiol (25-hydroxyvitamin D) to calcitriol (1,25-dihydroxyvitamin D). In addition, the metabolic clearance rate of calcitriol is increased. These changes can result in impaired calcium absorption and an increase in urinary calcium excretion. The net effect is osteoporosis and an increased fracture risk in patients with chronic hyperthyroidism. (See "Bone disease with hyperthyroidism and thyroid hormone therapy".)
Graves' disease may also be associated with thyroid acropathy, with clubbing and periosteal new bone formation in the metacarpal bones or phalanges. Patients with thyroid acropachy commonly present with asymptomatic clubbing, severe ophthalmopathy, and dermopathy; a high percentage is cigarette smokers .
NEUROPSYCHIATRIC — Patients with thyrotoxicosis may experience behavioral and personality changes, such as psychosis, agitation, and depression. Less overt manifestations that are more common in less severe thyrotoxicosis include anxiety, restlessness, irritability, and emotional lability . Insomnia is also common. Symptoms often worsen in patients with preexisting psychiatric disorders.
These behavioral manifestations are accompanied by cognitive impairments, particularly impaired concentration, confusion, poor orientation and immediate recall, amnesia, and constructional difficulties. Other neurologic manifestations are discussed separately. (See "Neurologic manifestations of hyperthyroidism and Graves' disease".)
GERIATRIC HYPERTHYROIDISM — Hyperthyroidism in elderly patients may be apathetic, rather than having hyperactivity, tremor, and other symptoms of sympathetic overactivity . However, two-thirds of such patients have symptoms similar to those in younger patients . In cross-sectional studies of patients with hyperthyroidism, older patients had a reduced risk for the presence of several classical symptoms (ie, heat intolerance, tremor, nervousness) but a higher prevalence of weight loss and shortness of breath compared with younger patients [40,41]. Older patients also had a higher rate of atrial fibrillation and moderate to severe ophthalmopathy .
Elderly patients with Graves' hyperthyroidism are less likely to have a goiter. Toxic multinodular goiter is more common in the elderly, although the majority of hyperthyroid patients at any age have Graves' hyperthyroidism. In addition, elderly patients often have persistent constipation. Tachycardia of 100 beats per minute is absent in 40 percent of elderly hyperthyroid patients, due primarily to coexistent conduction system disease.
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Basics topics (see "Patient information: Hyperthyroidism (overactive thyroid) (The Basics)")
Beyond the Basics topics (see "Patient information: Hyperthyroidism (overactive thyroid) (Beyond the Basics)" and "Patient information: Antithyroid drugs (Beyond the Basics)")
The classic symptoms of hyperthyroidism include weight loss, heat intolerance, tremor, palpitations, anxiety, increased frequency of bowel movements, and shortness of breath. Goiter is commonly found on physical examination. (See individual sections above.)
Elderly patients may have fewer classical manifestations of hyperthyroidism. However, weight loss, shortness of breath, and atrial fibrillation occur more commonly in older than younger patients. (See 'Geriatric hyperthyroidism' above.)
The clinical manifestations of hyperthyroidism are largely independent of its cause. However, the disorder that causes hyperthyroidism may have other effects. In particular, Graves' disease causes unique problems that are not related to the high serum thyroid hormone concentrations. These include Graves' ophthalmopathy and infiltrative dermopathy (localized or pretibial myxedema). (See "Pathogenesis and clinical features of Graves' ophthalmopathy (orbitopathy)" and "Pretibial myxedema in autoimmune thyroid disease".)
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