Updated December 18, 2014.

RAI is not considered risky. In fact, the primary "risk" of RAI is actually lifelong hypothyroidism. While some practitioners and patients are concerned about possible cancer risks of RAI, most studies have found no increased risk of cancer, leukemia, infertility or birth defects associated with RAI. Some studies have found a slightly increased risk of thyroid and small bowel cancer after RAI. Further study of the long-term risks of RAI for Graves' disease and hyperthyroidism is clearly needed.

RAI is not given to pregnant women, as there are significant risks to the fetal thyroid development. Before getting pregnant, most doctors also recommend waiting from six months to a year after RAI to avoid any risk of residual radiation on the fetus.

Surgical Treatment

Thyroid surgery -- known as thyroidectomy -- is considered the last choice in the United States for treating an overactive thyroid. Surgery is, however, recommended in certain situations:

• If antithyroid drugs and/or RAI have been unable to control the condition
• If a patient has suspicious nodules or thyroid cancer has already been found
• If a patient is experiencing an obstructed airway/difficulty breathing or swallowing
• If a patient is pregnant and not responding to antithyroid drugs
• If the patient has a very large goiter

Outside the United States, where surgery is more commonly used as a hyperthyroidism treatment, many practitioners recommend surgery rather than RAI for children, women of childbearing age who haven't responded to antithyroid drugs and women who want to get pregnant soon after treatment.
Surgery is considered very effective and can provide rapid relief of symptoms to most patients, particularly when they have a large goiter and/or severe symptoms.

Surgery is, however, invasive and has some risks, including hypoparathyroidism and damage to the laryngeal nerve. In the hands of an experienced surgeon, these risks are low, usually less than 3%. Surgical mortality from thyroid surgery is almost nonexistent.

Detailed information on thyroid surgery is featured in these articles:

• An overview of Thyroid Surgery
• Thyroid Surgery and Thyroidectomy: An In-depth Look
• Finding a Top Thyroid Surgeon
• Recuperating After Thyroid Surgery
• Complications After Thyroid Surgery

Beta Blockers

While it's not a treatment for hyperthyroidism specifically, some people with hyperthyroidism are also treated with "beta adrenergic receptor antagonists" -- known more commonly as beta-blockers -- because they help alleviate the effects of excess thyroid hormone on the heart and circulation, especially rapid heart rate, blood pressure, palpitations, tremor and irregular rhythms. Beta blockers also reduce the breathing rate, reduce excessive sweating and heat intolerance and generally reduce feelings of nervousness and anxiety. Some beta-blockers also can help prevent T4-to-T3 conversion. They don't, however, slow the metabolic rate itself.
Propranolol (pronounced "proe PRAH no lall") is the most recommended and studied beta-blocker for hyperthyroidism. The most common brand name for propranolol is Inderal. While propranolol is considered the first beta-blocker to try for Graves' and hyperthyroidism patients, other beta-blockers sometimes given include atenolol (Tenormin) and metoprolol (Lopressor, Toprol XL).

The effects of most beta-blockers are usually fairly rapid, sometimes even within 10 to 15 minutes.

Beta blockers may not be recommended to patients with asthma, severe allergies, emphysema or any lung disease or bronchial conditions. Beta blockers also interact with a number of medications. You can check the interactions of any drugs at About.com's Drugs A to Z interactions checker.

Temporary Thyroid Problems

For the temporary or "self-limited" forms of hyperthyroidism -- i.e., subacute thyroiditis, painless /silent thyroiditis, postpartum thyroiditis, Hashitoxicosis, Transient Hyperthyroidism of Hyperemesis Gravidarum (THHG) -- the focus is primarily on treating the symptoms. So, for example, pain relievers may be given for pain and inflammation or beta blockers for heart-related symptoms. Occasionally, an antithyroid drug is prescribed for a short time.

New Developments

The thyroid community is always looking for better ways to treat Graves' disease and hyperthyroidism. One promising new direction is the use of thyroid arterial embolization as a treatment option for Graves' disease. Another technique, argonplasma resection, allows for minimum blood loss during surgery, with less scarring and faster recovery. More thyroid surgery is now being done with endoscopy or laparoscopy, with incisions in either the breast or under the arm, so there is no visible scar on the neck and minimal scarring.

Holistic and Natural Approaches

Natural health practitioners recommend a variety of various natural, alternative medicine and integrative approaches to Graves' disease and hyperthyroidism. Dr. Richard Shames has developed a complementary antithyroid protocol, using a variety of supplements and foods, including l-carnitine, to help treat hyperthyroidism. These approaches are outlined in detail in the book Living Well With Graves'Disease and Hyperthyroidism. Author Kate Flax has detailed a variety of natural approaches to hyperthyroidism in her book Healing Options: A Report on Graves' Disease Treatments.

Choosing an Approach

With antithyroid drugs, treatment only has an effect while the medications are being taken, but remission is possible in some patients. RAI and surgery are permanent, irreversible treatments that almost always result in lifelong hypothyroidism for the patient. For this reason, some practitioners believe that antithyroid drugs should almost always be the first choice for treating an overactive thyroid, except in special circumstances.