The primary disease of parathyroid glands is overactivity, with too much parathyroid hormone (PTH) being produced. In this condition, one or more of the parathyroid glands behaves inappropriately by making excess hormone regardless of the level of calcium. In other words, the parathyroid glands continue to make large amounts of parathyroid hormone even when the calcium level is normal and they should not be making hormone at all.
The most common cause of excess hormone production is the development of a benign tumor in one of the parathyroid glands. This enlargement of one parathyroid gland is called a parathyroid adenoma which accounts for 87-93% of all patients with primary hyperparathyroidism. Typically, one of the parathyroid glands has developed a tumor which is secreting all the hormone. The other three glands are small and responding appropriately to the high calcium by becoming dormant. This out of control parathyroid gland is essentially never cancerous (less than 1 in 500), however, it slowly causes damage to the body because it induces an abnormally high level of calcium in the blood which can slowly destroy a number of tissues. Parathyroid adenomas typically are much bigger than the normal pea-sized parathyroid and will frequently be about the size of a walnut.
Approximately 7-11% of all patients with primary hyperparathyroidism will have an enlargement of all four parathyroid glands, a term called parathyroid hyperplasia. In this instance, all of the parathyroid glands become enlarged and produce too much parathyroid hormone. An even rarer situation occurs in approximately 3% of the people who have two parathyroid adenomas while having two normal glands.
Since hyperparathyroidism was first described in 1925, the symptoms have become known as “moans, groans, stones, and bones”. Although most people with primary hyperparathyroidism claim to feel well when the diagnosis is made, the majority of these will actually say they feel better after the problem has been cured. This can only be known retrospectively when patients are allowed to comment on how they feel several months after the operation. Many patients who thought they were asymptomatic preoperatively will claim to sleep better at night, be less irritable, and find that they remember things much easier than they could when their calcium levels were high (nervous system problems).
Signs, symptoms & indicators of Hyperparathyroidism
Constant/frequent thirst
Weak appetite
Recent loss of appetite
Epigastric pain
Unexplained nausea
Fatigability
Irritability
Emotional instability
Poor muscular strength
Tender muscles
(Possible) bone pain
Patients with persistently elevated calcium levels due to overproduction of parathyroid hormone also can have complaints of bone pain. In the severe form, bones can give up so much of their calcium that the bones become brittle and break (osteoporosis and osteopenia). This problem is even more of a concern in older patients. Bones can also have small hemorrhages within their center which will cause bone pain.
Decreasing stature
Itchy skin
Conditions that suggest Hyperparathyroidism
Risk factors for Hyperparathyroidism
Hypercalcemia
Over 98% of ALL people who have a blood test that shows too much calcium will have a parathyroid problem.
TESTS NEEDED: In summary, you need to have your calcium and PTH measured… that’s it! Preferably, you should have two different types of blood calcium measured: 1) serum calcium, and 2) ionized calcium. Parathyroid Hormone (PTH) must also be measured. This is all that is needed to make the diagnosis of hyperparathyroidism in more than 95% of patients. You do NOT need any x-rays or scans to make the diagnosis of hyperparathyroidism. Scans are NOT to be used to determine if you have this disease. [www.parathyroid.com]
Having elevated ALP levels
History of hyperparathyroidsim
Counter Indicators
Absence of parathyroid problem
Hyperparathyroidism suggests the following may be present
Sarcoidosis
When hyperparathyroidism is present, the likelihood of elevated serum calcium being caused by other conditions is obviously reduced.
Prescription Drug Side-Effects
When hyperparathyroidism is present, the likelihood of elevated serum calcium being caused by other conditions is obviously reduced.
Vitamin D Toxicity
When hyperparathyroidism is present, the likelihood of elevated serum calcium being caused by other conditions is obviously reduced.
Tuberculosis
When hyperparathyroidism is present, the likelihood of elevated serum calcium being caused by other conditions is obviously reduced.
Increased Risk of Lung Cancer
When hyperparathyroidism is present, the likelihood of elevated serum calcium being caused by other conditions is obviously reduced.
Increased Risk of Breast Cancer
When hyperparathyroidism is present, the likelihood of elevated serum calcium being caused by other conditions is obviously reduced.
Cancer / Risk - General Measures
When hyperparathyroidism is present, the likelihood of elevated serum calcium being caused by other conditions is obviously reduced.
Multiple Myeloma
When hyperparathyroidism is present, the likelihood of elevated serum calcium being caused by other conditions is obviously reduced.
Hyperparathyroidism can lead to
Recommendations for Hyperparathyroidism
Test Electrolytes, Serum
Calcium is the most closely controlled substance in the blood. The biologic variation of total calcium is approximately 2% and of the biologically active free (ionized, ionic) calcium only 1%. Thus, the monitoring of calcium in blood requires analytic procedures of high precision and accuracy. For patients with asymptomatic primary hyperparathyroidism, calcium monitoring involves the measurement of total calcium and free calcium.
Calcium
Contrary to popular medical belief, calcium supplementation can be useful, even when calcuim levels are already too high in hyperparathyroidism. This high level of calcium is being maintained by taking calcium from your bones. Supplemental oral calcium helps prevent calcium being taken from your bones! In the mean time, one should be looking for a surgeon who specializes in this operation.
The following study results indicate that calcium loading inhibits bone resorption in postmenopausal women with mild primary hyperparathyroidism.
Oral calcium loading is known to decrease parathyroid hormone levels in primary hyperparathyroidism. We have examined the effects of a calcium supplement on bone resorption in postmenopausal primary hyperparathyroidism. Fasting blood and urine samples were obtained in 12 postmenopausal women (median age 64 yr) with primary hyperparathyroidism associated with mild hypercalcemia (plasma calcium less than 3.00 mmol/l). Further samples were obtained 12 hours after a 1 g calcium supplement given at 2100 h. After calcium administration there were rises in plasma ionized calcium (p less than 0.02), plasma phosphate (p less than 0.05) and the renal tubular maximum reabsorption capacity for phosphate (p less than 0.01) and falls in parathyroid hormone (p less than 0.05) and the renal tubular maximum reabsorption capacity for calcium (p less than 0.05). The urinary calcium/creatinine increased (p less than 0.01) and the urinary hydroxyproline/creatinine (p less than 0.02) fell. [Horm-Metab-Res. 1994 Jan; 26(1): 39-42]
Surgery
Hyperparathyroidism can be cured with a routine operation which caries a success rate of about 95% and a complication rate of around 1% or less. Some centers are even performing minimal surgery for this disease which can be accomplished under local anesthesia on an outpatient basis. See www.parathyroid.com for additional excellent information about this condition and the importance of selecting an experienced surgeon.
If you have mild hyperparathyroidism, you may not need any treatment, although your blood-calcium levels, kidney function and bone health will need to be regularly checked. When your kidneys or bones are affected, or you have bothersome symptoms, surgery may be the best option.
Vitamin D
Hyperparathyroidism is caused by a malfunction of the parathyroid glands in the neck, which regulate calcium in the blood by parathyroid hormone (PTH). The disease most often strikes women, particularly older women. It can cause fatigue, disorientation, and depression, and can also lead to bone loss, kidney stones, and even coma.
A study published in the Journal of Clinical Endocrinology and Metabolism found an inverse relationship between the severity of the disease and patients’ intake of vitamin D through diet and supplements. Such a link has long been suspected, but hadn’t been shown until now, and the finding may affect the way some physicians treat the disease. Vitamin D hormone replacement reduces the production of PTH.
Dr. Rao says there is a myth among both doctors and patients that people with hyperthyroidism should avoid calcium and vitamin D, since they have too much calcium in their bloodstreams. But this is “biologically implausible,” he says, and the myth only aggravates the situation.
Dr. De Papp echoes his concern. “The fear is if they take supplements, they will make their blood calcium go higher,” de Papp says. “Although there is some truth to that, their blood calcium will be higher, it is at the expense of their bones, because if they don’t take calcium supplements they are much more likely to … end up with nutritional osteoporosis from vitamin D and calcium deficiency on top of the primary hyperparathyroid bone disease that they may have. So they get bad bones for two reasons.
“If you restrict vitamin D, PTH levels go up, which stimulates bone loss, specifically cortical bone, which is in your wrist and your hip,” she says. “Hip fractures are a tremendous cause of morbidity and mortality among postmenopausal women in this country.”
“In other words, people with hyperparathyroidism need as much vitamin D and calcium, and perhaps more, than the general public,” says Dr. Rao
Study Results:
Vitamin D -25 is suppressed and Vitamin D-1-25 is increased in patients with primary hyperparathyroidism in linear fashion as calcium levels increase, returning to normal within weeks of tumor removal. A protective mechanism is in play.
Overview: Vitamin D-25 is converted to Vitamin D-1-25 in patients with primary HPT in a linear fashion as calcium levels increase. Thus the vast majority of patients with primary HPT will have low Vit D-25 that normalizes by itself in most patients within several months.
Objective: Vitamin D-25 is often measured in patients with apparent primary HPT to rule out a possible secondary cause. This study was undertaken to examine if a relationship exists between Vit-D levels and parathyroid pathology in patients with elevated calcium levels.
Methods: A prospective, single institution study measured preoperative Vitamin D (25OH and 1-25OH) in 1,587 patients undergoing surgery for sporadic primary hyperparathyroidism (PHPT) over a 1-year period. All patients underwent curative parathyroidectomy with pathology noted. Patients were put on nominal doses of Vit-D postop contained within supplemental calcium tablets (Citracal+D; 250 IU cholecalciferol daily) for two months; none took additional Vit-D. Blood levels were measured at 1 and 2 months post-op.
Results: All patients had primary HPT with high serum calcium and PTH preop that normalized at all postop measures indicating cure. The average preop Vit-D25 was 25.8+10 ng/ml (range 4-65). 1039 patients (67%) had Vit-D25 levels below 30 ng/ml preop, while 594 patients (38%) had levels below 20 ng/ml preop (mean 14.6, range 4-19), No patient had high Vit-D25 preop. Vit-D25 levels decreased linearly as calcium levels increased such that 71% of those with levels above 12 mg/dl had Vit-D25 <20 (p<0.01, R=0.91).The levels of Vit-D1-25 were low in 0%, normal in 58.5%, and high in 41.5% (mean 56.2 + 14)(p<0.01). The findings at surgery were identical (p=0.98) for those with low vs. normal Vit-D25 (single adenoma=92%, double adenoma=6%, 4-gland hyperplasia=3%). 82% of patients with low preop Vit-D25 had increased levels at 1 month postop (mean 41.4+12, range 17-63, p<0.005), increasing to 91% at 2 months. All patients with normal Vit-D25 preop remained normal postop. 68% showed decreased Vit-D1-25 into the normal range (p<0.001) within 1 month of surgery.
Conclusion: Vit-D25 levels decrease in a linear fashion as calcium levels rise in patients with primary HPT. Overall, 38% will have Vit-D25 levels less than 20 ng/ml, increasing to 71% of those with calcium levels above 12mg/dl. Vit-D1-25 shows the opposite pattern suggesting a protective mechanism. The pathology found at surgery is identical in PHPT patients with low versus normal Vit-D25 indicating no causal relationship. Low Vit-D25 should not be interpreted as signaling secondary HPT in patients with elevated calcium levels. The vast majority of patients will normalize their low Vit-D25 and high Vit-D1-25 levels within 2 months of tumor removal.
Key
| Weak or unproven link |
| Strong or generally accepted link |
| Proven definite or direct link |
| Strongly counter-indicative |
| Very strongly or absolutely counter-indicative |
| Likely to help |
| Highly recommended |
Glossary
Parathyroid Hormone
A hormone released by the parathyroid glands that acts to keep a constant level of calcium in body tissues.
Hormones
Chemical substances secreted by a variety of body organs that are carried by the bloodstream and usually influence cells some distance from the source of production. Hormones signal certain enzymes to perform their functions and, in this way, regulate such body functions as blood sugar levels, insulin levels, the menstrual cycle, and growth. These can be prescription, over-the-counter, synthetic or natural agents. Examples include adrenal hormones such as corticosteroids and aldosterone; glucagon, growth hormone, insulin, testosterone, estrogens, progestins, progesterone, DHEA, melatonin, and thyroid hormones such as thyroxine and calcitonin.
Calcium
The body's most abundant mineral. Its primary function is to help build and maintain bones and teeth. Calcium is also important to heart health, nerves, muscles and skin. Calcium helps control blood acid-alkaline balance, plays a role in cell division, muscle growth and iron utilization, activates certain enzymes, and helps transport nutrients through cell membranes. Calcium also forms a cellular cement called ground substance that helps hold cells and tissues together.
Benign
Literally: innocent; not malignant. Often used to refer to cells that are not cancerous.
Parathyroid Gland
One of many small structures, usually four, joined to the lobes of the thyroid gland. The parathyroid glands release a hormone that helps to keep the level of blood calcium normal.
Adenoma
An ordinarily benign growth of epithelial tissue in which the tumor cells form glands or gland-like structures that tend to exhibit glandular function.
Asymptomatic
Not showing symptoms.
Nervous System
A system in the body that is comprised of the brain, spinal cord, nerves, ganglia and parts of the receptor organs that receive and interpret stimuli and transmit impulses to effector organs.
Osteoporosis
A disease in which bone tissue becomes porous and brittle. The disease primarily affects postmenopausal women.
Serum
The cell-free fluid of the bloodstream. It appears in a test tube after the blood clots and is often used in expressions relating to the levels of certain compounds in the blood stream.