Intended for healthcare professionals

Clinical Review

Diagnosis and management of thyrotoxicosis

BMJ 2006; 332 doi: (Published 08 June 2006) Cite this as: BMJ 2006;332:1369
  1. Elizabeth N Pearce, assistant professor of medicine (
  1. Boston University Medical Center, 88 East Newton Street, Evans 201, Boston, MA 02118, USA
  1. Correspondence to: E N Pearce
  • Accepted 25 April 2006

Who gets thyrotoxicosis?

Thyrotoxicosis occurs in approximately 2% of women and 0.2% of men.w1 Thyrotoxicosis due to Graves' disease most commonly develops between the second and fourth decades of life, whereas the prevalence of toxic nodular goitre increases with age. Autoimmune forms of thyrotoxicosis are more prevalent among smokers.w2 w3 Toxic nodular goitre is most common in regions where dietary iodine is insufficient.


I searched Medline for English language papers with the topics “thyrotoxicosis”, “Graves' disease”, and “goitre”, searched the Cochrane Database of Systematic Reviews by using the keyword “thyroid”, and used a personal archive of references.

How do patients with thyrotoxicosis present?

Symptoms of overt thyrotoxicosis include heat intolerance, palpitations, anxiety, fatigue, weight loss, muscle weakness, and, in women, irregular menses. Clinical findings may include tremor, tachycardia, lid lag, and warm moist skin.1 Symptoms and signs of subclinical hyperthyroidism, if present, are usually vague and nonspecific.

What causes thyrotoxicosis?

To treat thyrotoxicosis appropriately, determining the cause is essential. The most common causes of thyrotoxicosis are discussed below; other causes are listed in the table.

View this table:

Causes of thyrotoxicosis

Graves' disease

Graves' disease is an autoimmune disorder in which thyroid stimulating immunoglobulin (TSI) binds to and stimulates the thyroid stimulating hormone (TSH) receptor on the thyroid cell membrane, resulting in excessive synthesis and secretion of thyroid hormone.2 Patients with Graves' disease usually have diffuse, nontender, symmetrical enlargement of the thyroid gland. Ophthalmopathy, consisting of protrusion of the eyes with periorbital soft tissue swelling and inflammation, and inflammatory changes in the extraocular muscles resulting in diplopia and muscle imbalance, is clinically evident in 30% of patients with Graves' disease.1

Toxic nodular goitre

Toxic adenomas are benign monoclonal thyroid tumours that secrete excess thyroid hormone autonomously. Thyrotoxicosis may develop in patients with a single autonomous thyroid nodule or in those with multiple autonomous nodules (toxic multinodular goitre, also known as Plummer's disease). Nodular autonomy typically …

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