Last reviewed: February 2018
Last updated: January  2018



History and exam

Key diagnostic factors

  • heat intolerance
  • nervousness
  • small non-tender goitre
  • tremulousness

Other diagnostic factors

  • palpitations
  • weight loss
  • excessive fatigue
  • bloating
  • muscle cramps
  • weight gain
  • poor concentration
  • cold intolerance
  • tachycardia

Risk factors

  • postnatal period
  • female sex
  • thyroid peroxidase (TPO) antibodies
  • cytokine therapy
  • biological agent therapy
  • lithium therapy
  • type 1 diabetes and other autoimmune conditions
  • autoimmune FHx

Diagnostic investigations

1st investigations to order

  • thyroid-stimulating hormone (TSH)
  • serum free T4 and T3
  • thyroid peroxidase (TPO) antibodies
  • TSH-receptor antibodies (TRAb)
  • 4-, 6-, or 24-hour radioiodine uptake
  • total T3/T4 ratio
Full details

Investigations to consider

  • technetium-99m pertechnetate scan
  • serum thyroglobulin
  • thyroid biopsy
Full details

Emerging tests

  • colour-flow Doppler
Full details

Treatment algorithm


Authors VIEW ALL


Department of Endocrinology

Newcastle upon Tyne Hospitals NHS Foundation Trust

Newcastle upon Tyne



PP has sat on the advisory board for Roche Pharmaceuticals, undertaken consultancy work for Guidepoint Global, and received research grants from Fight for Sight and the British Thyroid Foundation. PP has undertaken lectures and educational events, and received academic meeting expenses from the British Endocrine Societies, the European Thyroid Association, and the European Group On Graves' Orbitopathy. PP has also worked on manuscripts on behalf of the European Group on Graves' Orbitopathy.

Dr Petros Perros would like to gratefully acknowledge Dr Douglas S. Ross, the previous contributor to this monograph. DSR declares that he has no competing interests.

Peer reviewers VIEW ALL

Centre for Endocrine and Diabetes Sciences

Cardiff University School of Medicine

University Hospital of Wales

Heath Park




JL declares that he has no competing interests.

Professor of Surgery

Virginia Commonwealth University




RM declares that he has no competing interests.

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