Patient Bulletins

By Richard J. Harding, MD, FACS

Graves’ disease is the most common cause of hyperthyroidism, a condition in which the thyroid gland produces too much thyroid hormone. When hormone levels rise too high, patients may experience symptoms such as rapid heartbeat, anxiety, tremors, heat intolerance, and weight loss. For more than a century, physicians have worked to develop safer and more effective ways to treat this condition. Today, most patients are treated with antithyroid medications, radioactive iodine, or surgery. In recent years, however, new minimally invasive techniques have emerged that may offer additional options for selected patients. This bulletin reviews the history of Graves’ disease treatment, the strengths and limitations of current therapies, and the potential role of thermal and non‑thermal ablation techniques in the future.

A Brief History of Graves’ Disease Treatment

In the early 1900s, Graves’ disease was a life‑threatening condition. Its causes were not yet understood, and no medical therapy existed. Surgeons recognized that the thyroid gland played a role in the disease, but early operations were extremely risky. Removing half of the thyroid gland was not enough to control the disease, and patients often continued to suffer from severe heart complications. Removing the entire gland carried a high risk of death and resulted in profound hypothyroidism, which at the time could not be safely managed.

A major turning point came in 1912, when surgeon Thomas Dunhill published his experience treating patients with exophthalmic goiter. He described removing approximately 80% of the thyroid gland—a procedure known as subtotal thyroidectomy—and observed that patients often experienced rapid improvement in their cardiac symptoms. Although his approach was initially met with skepticism, it eventually became a cornerstone of Graves’ disease treatment. Over the next century, advances in surgical technique, anesthesia, and endocrine physiology transformed thyroidectomy into a safe and reliable option for many patients.

Current Standard Treatments

Today, Graves’ disease is typically managed with one of three approaches: antithyroid medications, radioactive iodine, or surgery. Each option has benefits and limitations, and the choice of therapy depends on the patient’s age, medical history, severity of disease, and personal preferences.

Antithyroid medications such as methimazole and propylthiouracil reduce the production of thyroid hormone. These medications are effective and generally well tolerated. A standard course of therapy lasts 18 to 24 months, but relapse occurs in roughly half of patients who discontinue treatment. Longer treatment durations may reduce the risk of relapse and are safe for many individuals.

Radioactive iodine (RAI) is another widely used treatment. RAI works by damaging thyroid cells so that they produce less hormone. It is effective, but many patients become hypothyroid and require lifelong thyroid hormone replacement. It may also take several months for RAI to achieve full effect.

Surgery remains a definitive treatment for Graves’ disease. Total thyroidectomy reliably cures hyperthyroidism but results in hypothyroidism and carries a small risk of complications involving the parathyroid glands or recurrent laryngeal nerves. Subtotal thyroidectomy, which removes most but not all of the gland, avoids hypothyroidism but is less precise in achieving stable thyroid function. For this reason, it is now rarely performed in developed countries.

Despite the effectiveness of these treatments, many patients and clinicians continue to seek alternatives that avoid lifelong hypothyroidism, radiation exposure, or surgical risks.

What Is Thyroid Nodule Ablation?

Thyroid nodule ablation is a minimally invasive procedure that uses energy to shrink or deactivate thyroid tissue. It is performed through a tiny skin puncture under ultrasound guidance, and most patients go home the same day. Ablation has been used for more than a decade to treat benign thyroid nodules that cause pressure, difficulty swallowing, or cosmetic concerns. It is also used to treat toxic thyroid nodules that produce excess hormone.

There are several types of ablation. Radiofrequency ablation (RFA) uses controlled heat to treat thyroid tissue. Microwave ablation (MVA) works in a similar way but uses microwave energy. (RFA and MVA are known as “thermal” ablation techniques). A newer technique, nanosecond pulsed field ablation (nsPFA), uses brief electrical pulses instead of heat. Because nsPFA does not rely on thermal injury, it may allow treatment closer to important structures such as nerves, blood vessels, and cartilage. Early studies have shown that nsPFA can shrink benign thyroid nodules while preserving surrounding tissues.

Although thyroid nodule ablation is not currently approved as a treatment for Graves’ disease in the United States, its success in treating benign and toxic nodules has led researchers to explore whether similar techniques could help selected patients with Graves’ disease.

Thermal Ablation as a New Option for Graves’ Disease

Building on the success of RFA for benign thyroid nodules, surgeons in several countries have begun using thermal ablation to treat Graves’ disease in carefully selected patients. Under ultrasound guidance, thermal energy is applied to both thyroid lobes to reduce the amount of functioning thyroid tissue. This approach has been described as a “non‑surgical subtotal thyroidectomy,” because it aims to achieve the same effect as the Dunhill procedure without the need for an incision or general anesthesia.

Studies from Hong Kong have shown promising results. Many patients treated with thermal ablation experienced significant reductions in thyroid hormone levels and became euthyroid for extended periods. Some patients also showed reductions in thyroid antibody levels, which may help improve symptoms of thyroid eye disease. In these studies, the rate of hypothyroidism after ablation was low, and the complication rate was roughly one‑tenth that of surgery. Patients who did not achieve full remission often required much lower doses of antithyroid medication after treatment.

The effectiveness of thermal ablation may depend on the size of the thyroid gland. Larger glands may require more than one treatment session, but repeat ablation has been shown to be safe and does not prevent patients from undergoing surgery in the future if needed.

Non‑Thermal Ablation (nsPFA): A Future Possibility

Non‑thermal ablation, also known as pulsed‑field or nano‑pulse ablation, is an emerging technology that alters cell function using brief electrical pulses. Unlike thermal ablation, nsPFA does not rely on heat, which means it has minimal effect on nerves, blood vessels, and cartilage. This safety profile has made it an attractive option for treating benign thyroid nodules.

Early observations in patients with Graves’ disease are encouraging. Initial reports suggest that nsPFA may reduce thyroid hormone levels, lower thyroid antibody levels, and decrease the number of immune cells within the thyroid gland that contribute to the autoimmune process. These findings raise the possibility that nsPFA could help some patients achieve remission more quickly than with existing therapies. However, formal clinical trials are still needed, and there are currently no active U.S. trials studying nsPFA for Graves’ disease.

Looking Ahead

Just as Thomas Dunhill advanced surgical care for Graves’ disease more than a century ago, today’s clinicians are exploring new ways to treat this condition with less risk and faster recovery. Both thermal and non‑thermal ablation techniques offer the potential for reduced complication rates, minimal downtime, and preservation of thyroid tissue. Early research suggests that these approaches may one day provide an alternative for patients who do not achieve remission with medication or who wish to avoid radioactive iodine or surgery.

As research continues, ablation may become an important addition to the treatment options available for Graves’ disease. Patients should work closely with their endocrinologist or thyroid specialist to determine which approach is best suited to their individual needs and medical circumstances.

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References & Additional Resources

(1) Dunhill, T.P. Surgical Treatment of the Exophthalic Goiter. Intercol. Med J Australia. 1908;13:293.Full text: https://www.thyroidnoduletreatment.center/_files/ugd/e5b602_06f269bf5068459e8dcfc080a69fabbb.pdf

(2) Dunhill, T.P. Partial Thyroidectomy Under Local Anaesthesia with Special Reference to Exophthalmic Goiter. Lancet. 1912;I:422. Full text: https://www.thyroidnoduletreatment.center/_files/ugd/e5b602_84949fd9cc2a4adfa9d0377a26527c00.pdf

(3) Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016;26(10):1343‑1421. Full text: https://www.thyroidnoduletreatment.center/_files/ugd/e5b602_31d815cad676480f854527f18b777b45.pdf

(4) Kuo JH, Lee JA. The Adoption of Ultrasound‑Guided Radiofrequency Ablation of Thyroid Nodules in the United States. Ann Surg. 2021;273(1):e10‑e12.Full text: https://www.thyroidnoduletreatment.center/_files/ugd/e5b602_282a3e22e07747f4859c6090e672b42f.pdf

(5) Sinclair CF, Baek JH, Hands KE, et al. General Principles for the Safe Performance, Training, and Adoption of Ablation Techniques for Benign Thyroid Nodules: An American Thyroid Association Statement. Thyroid. 2023;33(10):1150‑1170.Full text: https://www.thyroidnoduletreatment.center/_files/ugd/e5b602_2f1825d0d75e42c9810a56e5581f4601.pdf

(6) Spiezia S, et al. First‑in‑Human Clinical Feasibility Study of Ablation of Benign Thyroid Nodules Using Pulsed Field Ablation. Thyroid. 2025;35(9):1024‑1029.Full text: https://www.thyroidnoduletreatment.center/_files/ugd/e5b602_ef52acf74523457eb92d53dc66ae19aa.pdf

(7) Peng C.C‑H. Mortality Risks Associated with Antithyroid Drugs, Radioactive Iodine, and Surgery for Hyperthyroidism: A Systematic Review and Network Meta‑Analysis. Thyroid. 2025;25(10):1099‑1107.Full text: https://www.thyroidnoduletreatment.center/_files/ugd/e5b602_a614daf360224f1c99b5158d71655641.pdf

(8) Fung MHM, Luk Y, Yuen KKW, Lang BHH. Two‑Year Results of Radiofrequency Ablation as a Novel Treatment for Persistent or Relapsed Graves’ Disease: A Prospective Study. Full text: https://www.thyroidnoduletreatment.center/_files/ugd/e5b602_a435786a4e634aa1ada809be746d87b0.pdf

(9) Fung MHM, Lang BHH. Efficacy of Single‑Session Radiofrequency Ablation in Rendering Euthyroidism for Persistent/Relapsed Graves’ Disease: A Pilot Study. European Radiology. 2023;33(9):6534‑6544. Abstract: https://pubmed.ncbi.nlm.nih.gov/37036479

(10) Comparing Health‑Related Quality of Life at Two Years After Successful Treatment of Relapsed Graves’ Disease With Radiofrequency Ablation, Surgery, or Radioiodine. World J Surg. 2025;49(11):3142‑3151. Publisher page: https://onlinelibrary.wiley.com/doi/10.1002/wjs.70035

(11) Liu X, Wong CKH, Chan WWL, et al. Outcome of Graves’ Disease Patients Following Antithyroid Drugs, Radioactive Iodine, or Thyroidectomy as First‑Line Treatment. Ann Surg. 2021;273(6):1197‑1206. Full text: https://www.thyroidnoduletreatment.center/_files/ugd/e5b602_005f1920490c46a7a5b8c348f5c856e2.pdf

(12) Stan MN, Dosiou C. The Evolving Therapeutic Landscape of Graves’ Disease in Adults: Present and Future. Eur Thyroid J. 2025;14(4):e250078. Full text: https://www.thyroidnoduletreatment.center/_files/ugd/e5b602_b41169176928423f91a61ebee7962988.pdf

(13) Harding, R. “Avoid Surgery for Benign Diseased Thyroid Nodules.” YouTube. https://www.youtube.com/watch?v=vgHgYi2-9-I

(14) Harding, R. “Comparing Cutting‑Edge Thyroid Treatments.” YouTube. https://youtu.be/1eG6x0W9CW0

(15) Harding, R. “Thyroid Nodule RFA Explainer Video.” YouTube. https://youtu.be/2NznOFpm9bE

(16) Harding, R. “Thyroid Ultrasound‑Guided FNA.” YouTube. https://youtu.be/58pckPHl5ss