Graves’ disease and Hashimoto’s disease are the two most common autoimmune diseases affecting the thyroid gland. These are a result of immune system malfunction and where antibodies against one’s own normal thyroid tissue. Both are also the most common causes of thyroiditis, or inflammation of the thyroid gland. Furthermore, Graves’ is the most common cause of hyperthyroidism (too much thyroid hormone) in most countries, while Hashimoto’s disease is by far the most common cause of hypothyroidism (too little thyroid hormone production).

Graves’ Disease vs. Hashimoto’s Disease: Top 4 Things to Know

Hashimoto’s disease is more common than Graves’. Hashimoto’s disease affects roughly 4 out of 1000 women and 1 out of 1000 men each year. Overall, 10-12% of the general population will develop Hashimoto’s at some point in their life. Most women are diagnosed between the age of 30-50 years old. Similarly, Graves’ disease is more common in women than men (lifetime risk 3% vs 0.5%) and most often diagnosed in people ages 20-50 years-old. The incidence of hyperthyroidism in the United States is 1.2%, with Graves’ disease accounting for up to 80% of the cases. Clearly, both of these conditions are prevalent. Below I will discuss the top 4 distinguishing factors and provide a closer look at these two common thyroid disorders.

Learn more about Hashimoto’s disease.

Learn more about Graves' disease.

Graves’ Disease vs Hashimoto’s Disease

Top 4 Things to Know #1: Both are autoimmune diseases, but very different

As mentioned above, these two autoimmune thyroid conditions are very common with respect to causing thyroid dysfunction. Hashimoto’s thyroiditis is an autoimmune disease where the immune system malfunctions (autoimmune disease) and self- antibodies attack one’s own thyroid tissue as if it was foreign. We do not know exactly why it occurs, but we think multiple factors may play a role. Excessive iodine may trigger thyroid disease. There is likely a hormonal component because women are affected much more commonly than men. Lastly, there is likely a genetic factor as well because Hashimoto’s thyroiditis is seen in families where multiple people have thyroid disease or autoimmune disease. 

Hashimoto’s disease involves your immune system causing inflammation and scarring in the thyroid gland. This process is often cyclical and causes repeated damage to the thyroid gland itself (Figures 1 and 2). This ultimately leads to decreased thyroid hormone production (hypothyroidism) and subsequent symptoms. Common symptoms include fatigue, weight gain, memory problems or brain fog, depression, neck/thyroid discomfort, thinning hair or hair loss, heat/cold intolerance, skin and nail changes, joint and muscle pain, constipation, difficulty sleeping, and changes in appetite.

Graves’ disease is named after the physician who discovered and described the condition in 1835. Graves’ disease is an autoimmune condition whereby the immune system malfunctions and produces antibodies against your own normal thyroid tissue. When these antibodies attach to the receptors in the thyroid gland, it leads to the overproduction of thyroid hormone and often an enlargement of your thyroid gland itself (goiter). Having too much thyroid hormone is dangerous from a clinical standpoint more on that below) and also produces numerous symptoms (fast heart rate, abnormal heart rhythm, tremors and anxiety, hair and weight loss, shortness of breath, insomnia, and many more) (Figure 3). These abnormal antibodies can also attach to the same or similar receptor in other tissues in the body, primarily behind the eyes, and cause additional symptoms (dry eyes, red or itchy eyes, changes in vision, bulging eyes, and swelling).

Figure 1: Hashimoto’s disease on ultrasound. Note the irregular, moth-eaten, scalloped appearance of the thyroid tissue outlined in orange.

Figure 2: Normal thyroid tissue on ultrasound

Figure 3: Numerous symptoms of Graves’ Disease

Graves’ Disease vs Hashimoto’s Disease

Top 4 Things to Know #2: Graves’ is more dangerous clinically

Both of these thyroid disorders can produce numerous and significant symptoms as noted above. Graves’ disease, however, is unique due to some more serious symptoms that can lead to hospitalization, and in very rare circumstances, death. Patients with Graves’ disease have too much thyroid hormone. Too much thyroid hormone is more dangerous from a clinical standpoint and also produces numerous symptoms such as: fast heart rate, abnormal heart rhythm, tremors and anxiety, hair and weight loss, shortness of breath, insomnia, and many more (Figure 3). These abnormal antibodies can also attach to the same or similar receptor in other tissues in the body, primarily behind the eyes, and cause permanent damage to the eyes and vision. Furthermore, patients with Graves’ disease can also have their body overwhelmed by thyroid hormone, causing what is known as a thyroid storm (thyrotoxicosis). This requires hospitalization and emergent treatment. In the past before the development of numerous medications to treat the thyroid storm and symptoms, this acute condition was fatal in some cases. Thankfully, the anti-thyroid medications and treatments for the symptoms allow patients to be managed safely without complications in most instances.

Patients with Hashimoto’s disease can have significant symptoms and feel bad over all, even despite optimal medical management. Common symptoms include fatigue, weight gain, memory problems or brain fog, depression, neck/thyroid discomfort, thinning hair or hair loss, heat/cold intolerance, skin and nail changes, joint and muscle pain, constipation, difficulty sleeping, and changes in appetite. While Hashimoto’s is certainly unwanted and challenging to treat and manage in some cases, having too little thyroid hormone and Hashimoto’s is not very likely to land a person in the hospital. The main takeaway is that if you had to choose which thyroid disease to have, Hashimoto’s Disease would be the pick over Graves’ disease without question.

Graves’ Disease vs Hashimoto’s Disease

Top 4 Things to Know #3: Both can be managed and treated medically

All patients with Graves’ disease and most patients with Hashimoto’s disease will need some form of medical management. For Graves’ disease, this involves utilizing anti-thyroid medications along with radioactive iodine ablation in some patients. Hashimoto’s disease is almost always treated medically with thyroid hormone medication.

Patients with Graves’ disease are started on anti-thyroid medication to treat the associated hyperthyroidism. This type of medication ensures that the thyroid levels do not get dangerously high (thyroid storm) and that symptoms are controlled or eliminated. There are two medications which are commonly prescribed to control hyperthyroidism. The first is Methimazole and the second is propylthiouracil (PTU). These drugs ultimately prevent the thyroid from making thyroid hormone. These medications need to be prescribed by endocrinologists that understand how these medications work and potential side effects and complications from their use. The drugs usually take several weeks to work. Importantly, these medications are generally not used long- term for the management of Graves' disease. The hyperthyroidism will generally return following the stoppage of either of these two medications.

Radioactive iodine is another option to try and cure Graves’ disease. This is given to patients in a capsule or pill form. The radioactive iodine therapy may take months to actually produce the desired effect. Repeated treatments of radioactive iodine may be required to ultimately control, or in some cases, eliminate Graves' disease in up to 70% of patients. Radioactive iodine is not sought as a therapeutic option if the patient has eye disease/symptoms as a result of their Graves' disease.

The goal of radioactive iodine for Graves' disease is to give enough iodine to effectively treat the Graves' disease and still maintain adequate, normal thyroid hormone production by the remaining thyroid cells. In most circumstances, however, Graves' disease patients treated with radioactive iodine will eventually develop low thyroid hormone production (hypothyroidism) and therefore require thyroid hormone replacement long- term.

A good portion of patients have persistent Graves’ disease despite the radioactive iodine therapy. Additionally, some patients have their Graves’ disease temporarily treated or controlled only to have the disease come back months or years later. Importantly, if you are pregnant or plan on becoming pregnant within the next 12 months, radioactive iodine therapy should not be used. Learn more about treatment for Graves' disease.

Hashimoto’s disease is treated once the thyroid gland is so affected that it is unable to meet the body’s physiologic demands for thyroid hormone. At this point, patients are started on thyroid hormone medication and are monitored for the rest of their life. The vast majority of patients do very well on thyroid medication as long as they take the medication as directed, live a healthy lifestyle, and have their thyroid levels checked regularly (typically 1-2 times per year). Occasionally, a small percentage of patients need additional treatment for Hashimoto’s disease and the symptoms. In the short-term, some patients need anti-inflammatory medications and/or steroids to alleviate symptoms from the inflammation, particularly the pain and swelling. Learn more about treatment for Hashimoto’s disease.

Graves’ Disease vs Hashimoto’s Disease

Top 4 Things to Know #1: Surgery is curative, but more often needed for Graves’ Disease

Surgery is the best and most definitive treatment option for curing autoimmune thyroid disorders. Many patients with Graves’ disease and Hashimoto’s disease also have other thyroid conditions that necessitate surgery (cancer, nodules, goiter, etc.). From a clinical standpoint, Graves’ disease requires surgery in a larger percentage of this patient population than Hashimoto’s disease does. Let’s examine surgery for these conditions more closely.

Total thyroid removal (total thyroidectomy) is the best and most definitive way to treat Graves’ disease. Simply put, you cannot have Graves’ disease if you do not have a thyroid gland. With the offending organ (the thyroid) removed, the dysfunction of the immune system with regards to the antibodies that are causing the symptoms and abnormal thyroid physiology halts. In some cases, surgery is also the preferred treatment due to other factors noted below:

• Large thyroid/goiter
• Graves’ disease with eye symptoms
• Inability to take or tolerate antithyroid medication
• Ineffectiveness of antithyroid medication and/or radioactive iodine therapy

Total thyroid removal for Graves’ disease should only be performed by highly-experienced thyroid surgeons. Typically, folks with Graves’ disease have a large, inflamed, angry thyroid gland that is stuck to surrounding structures and tissue. There are also very important structures near the thyroid that need to be preserved during thyroid surgery (nerves to the voice box and calcium control glands). Additionally, complete thyroid removal is riskier than thyroid surgery for half the thyroid. This is because both sides of the neck are worked on, exposing all 4 parathyroid glands (calcium control glands) as well as all the nerves to the voice box to potential damage. Thus, thyroid surgery involving total thyroid removal should only be done by high-volume, experienced thyroid surgeons at busy centers like the Hospital for Endocrine Surgery.

The vast majority of patients with Hashimoto’s disease are treated medically. A smaller percentage of patients with Hashimoto’s disease benefit from surgery to cure this illness itself. As noted above, some patients with Hashimoto’s disease are symptomatic despite having normal or optimal thyroid hormone labs while taking a consistent dose of thyroid hormone medication. Additionally, a small number of patients are not able to remain on a consistent dose of thyroid medication and continue to have fluctuating symptoms and medication dosages over a long period of time. These clinical situations can be frustrating, exhausting, and overwhelming for patients and their endocrinologists. Fortunately, thyroid surgery to remove the entire gland is curative.

Similar to Graves’ disease, you cannot have Hashimoto’s disease, or its symptoms, if you do not have a thyroid gland! More and more studies are showing that expert thyroid surgery done at the right center with very low complication rates is very effective at resolving many, if not all of, the symptoms associated with the illness. Some of our patients have felt noticeably better within 24 hours of thyroid surgery.

Due to the scarring and inflammation from Hashimoto’s thyroiditis, surgery can be very challenging. The entire thyroid gland must be removed to cure Hashimoto’s disease. Complete thyroid removal is riskier than thyroid surgery for half the thyroid as noted above. Total thyroid removal for Hashimoto’s disease should only be done by high-volume, experienced surgeons at busy centers such as ours.

Our team of thyroid cancer experts is here to help and guide you every step along the way and will be there for you after your thyroid surgery for Graves’s disease or Hashimoto’s disease. To learn more and become a patient, please see our resources below.

Summary

Graves’ disease and Hashimoto’s disease are two very common thyroid disorders. Both are caused by dysfunction of the immune system (autoimmune condition), but each is different in numerous ways. Graves’ is the most common cause of hyperthyroidism (too much thyroid hormone) in most countries, while Hashimoto’s disease is by far the most common cause of hypothyroidism (too little thyroid hormone production). While both produce many clinical symptoms and side effects, Graves’ disease is more dangerous clinically and requires surgery in a larger percentage of patients with the disorder. Medical management of Graves’ and Hashimoto’s is paramount, and in some cases, all that is needed. Expert surgery remains the best and most reliable treatment option to definitively cure both of these thyroid conditions.

Additional Resources

• Become our patient by filling out the form at this link. 
• Learn more about The Clayman Thyroid Center here. 
• Learn more about our sister surgeons at the Scarless Thyroid Surgery Center, Norman Parathyroid Center, and Carling Adrenal Center
• Learn more about the Hospital for Endocrine Surgery.