Hyperparathyroidism

1 What is Hyperparathyroidism?

Hyperparathyroidism (HPT) results when there is excessive secretion of parathyroid hormone (PTH).

PTH is secreted by the four parathyroid glands, located in the neck behind the thyroid gland. It regulates serum calcium and phosphate levels and also plays a part in bone metabolism.

High levels of PTH cause serum calcium levels to increase and serum phosphate levels to fall.
HPT may be:

  • Primary - one parathyroid gland (or more) produces excess PTH. This may be asymptomatic.
  • Secondary - there is increased secretion of PTH in response to low calcium because of kidney, liver, or bowel disease.
  • Tertiary - there is autonomous secretion of PTH, usually because of chronic kidney disease (CKD).

2 Symptoms

The commonest symptoms of hyperparathyroidism include:

  • Decreased energy, easy fatigability
  • Lack of concentration
  • Depression
  • Osteoporosis
  • Pain in most parts of the body
  • Decreased sleep
  • Easily irritable
  • Forgetfulness
  • Heart burns, acid reflux, GERD
  • Decrease in sex drive
  • Thinning of hair
  • Kidney stones and eventually kidney failure
  • High blood pressure
  • Recurrent headaches
  • Heart palpitations
  • Pancreatitis
  • Nausea, vomiting
  • Polyuria, polydypsia
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3 Causes

The causes of Hyperparathyroidism (HPT) may vary depending on its type.

HPT may be:

  • Primary - one parathyroid gland (or more) produces excess PTH. This may be asymptomatic.
  • Secondary - there is increased secretion of PTH in response to low calcium because of kidney, liver, or bowel disease.
  • Tertiary - there is autonomous secretion of PTH, usually because of chronic kidney disease (CKD).

Causes of primary hyperparathyroidism

Excess PTH is produced by one or more of the parathyroid glands, due to:

  • A single parathyroid gland adenoma (85% of cases).
  • 4-gland hyperplasia (10-15%).
  • Double adenomas (3-5%).
  • Parathyroid carcinoma (less than 1%).
  • The aetiology of adenomas or hyperplasia is largely unknown.
  • There may be an association with ionising radiation.
  • Familial cases can occur as part of the multiple endocrine neoplasia syndromes (MEN 1 or MEN 2a), hyperparathyroid-jaw tumour (HPT-JT) syndrome, or familial isolated hyperparathyroidism (FIHPT).

Causes of secondary hyperparathyroidism

Secondary hyperparathyroidism (SHPT) is most commonly seen in the setting of chronic kidney disease (CKD).

  • The parathyroid glands become hyperplastic after long-term stimulation in response to chronic hypocalcaemia.
  • It is seen in almost all patients with dialysis-dependent CKD. Most patients with CKD stage 5 develop SHPT. 
  • It can, however, occur in any condition with chronic hypocalcaemia such as deficiency in vitamin D or malabsorption.

Causes of tertiary hyperparathyroidism

Tertiary hyperparathyroidism (THPT) usually occurs after prolonged SHPT.

  • The glands become autonomous; producing excessive PTH even after the cause of hypocalcaemia has been corrected.
  • This results in hypercalcaemia.
  • Long-standing kidney disease is the most common cause.
  • It can persist after a renal transplant.

4 Making a Diagnosis

Making a diagnosis of hyperparathyroidism is done by performing several tests.

Blood tests

Hyperparathyroidism is diagnosed based upon levels of blood calcium and parathyroid hormone (PTH). In most people with hyperparathyroidism, both levels are higher than normal. Occasionally, a person may have an elevated calcium level and a normal or minimally elevated PTH level. Since PTH should normally be low when calcium is elevated, a minimally elevated PTH is considered abnormal and indicates hyperparathyroidism.

Skeletal assessment: Bone density testing

Bone density testing is usually recommended for people with hyperparathyroidism. This test can help determine if the bones have become weakened as a result of abnormal blood calcium levels. Dual x-ray absorptiometry (DXA) testing is the most commonly used method for measuring bone density. Bone density is lowest at the forearm in patients with primary hyperparathyroidism.

In addition, because of the possibility of asymptomatic vertebral fractures in patients with primary hyperparathyroidism, a plain radiograph of the spine or a vertebral fracture assessment of DXA image to identify the presence of such fractures is sometimes recommended.

Kidney assessment

Hypercalcemia may adversely affect kidney function. Measurement of 24-hour urinary calcium excretion (to assess risk of kidney stones) and serum creatinine (to estimate the glomerular filtration rate [eGFR]) are routinely performed in patients with asymptomatic primary hyperparathyroidism in order to assess the risk of renal complications (when urine calcium is high or eGFR is low) and thus determine subsequent management.

In some patients, an abdominal radiograph or an ultrasound or computed tomography (CT) of the kidneys is obtained to detect silent kidney stones, which if present, also determine subsequent treatment.

Alkaline phosphatase levels are usually elevated in hyperparathyroidism.

A sestamibi scan is a procedure in nuclear medicine which is performed to identify hyperparathyroidism.

5 Treatment

Several treatment methods are used for hyperparathyroidism.

Non-surgical treatment

Non-surgical treatment may be recommended for people who have no symptoms and whose blood calcium is only mildly elevated, provided they do not have low bone density, asymptomatic vertebral fractures, impaired renal function, or silent kidney stones. Blood calcium levels should be measured every six months, and tests of kidney function are recommended once per year. Bone density testing is usually recommended every one to three years, depending upon your situation.

General measures

Patients with hyperparathyroidism who do not have symptoms are advised to:

  • Avoid lithium (a mood stabilizer used for bipolar illness) and thiazide diuretics (used to treat high blood pressure) since these drugs may further increase blood calcium levels.
  • Avoid excessive loss of body fluids (e.g., dehydration), prolonged bed rest or inactivity, and a high calcium diet since these can increase blood calcium levels.
  • Minimize bone loss by remaining active.
  • Drink an adequate amount of fluid throughout the day. This may help to minimize the risk of kidney stones.
  • Maintain a moderate calcium intake (about 1000 mg/day). Lower calcium intake will stimulate more parathyroid hormone (PTH) secretion while higher calcium intake may worsen high calcium levels.
  • Consume a moderate amount of vitamin D (400 to 600 international units daily). Vitamin D deficiency can stimulate PTH secretion and bone resorption and should be avoided. 

Treat bone loss

Medications that inhibit bone resorption may be prescribed if you have evidence of decreased bone density (osteopenia or osteoporosis). These medications can protect the bones from the bone thinning effects of excess PTH but will not normalize the calcium levels in the blood.

Surgical treatment

Surgery is recommended for people with symptoms. It is often also recommended for people with moderately elevated blood calcium levels, impaired kidney function, low bone density, high urine calcium levels, and silent kidney stones or fractures.
It is also recommended if the person is less than 50 years old or if periodic follow-up would be difficult (e.g., if a person lived a great distance from a healthcare provider or travels to places where it is difficult to find medical care).

Traditional surgery

Surgery is usually performed while the person is under anesthesia. An incision is made in the lower neck measuring 2.5 to 10 cm (1 to 5 inches). Usually, at least one abnormal-appearing gland is removed while the normal-appearing glands are left in place.

Minimally invasive surgery

Several kinds of minimally invasive surgery can be performed in cases where one abnormal parathyroid gland has been located by a pre-operative imaging study.

The surgery can be performed under local nerve block, and is a good alternative for patients who are at high-risk for general anesthesia. During the surgery, a small incision (1 to 4 cm or 0.4 to 1.8 inches) is made in the neck and the abnormal tissue is removed. The patient's blood level of PTH is tested before and immediately after removal to confirm that the PTH level drops significantly after the abnormal tissue is removed.

The advantage of minimally invasive surgery compared with traditional surgery is that it requires a smaller incision, less time under anesthesia, and a shorter hospital stay. This type of procedure is only available for people with certain characteristics and it requires an experienced surgeon and medical center.

6 Prevention

Prevention of hyperparathyroidism is unique and depends on underlying conditions, so speak with your doctor.

Early and aggressive management of hypertension can help avoid chronic kidney disease and the secondary hyperparathyroidism that frequently results. Likewise, diabetes requires aggressive, optimal management to reduce complications. Weight management and proper nutrition could help prevent the huge burden of type 2 diabetes and the resulting kidney damage and secondary hyperparathyroidism.

Prevention of hyperparathyroidism in chronic renal failure requires aggressive phosphorus management early in the progression of renal failure and adequate replacement of the active form of vitamin D (1, 25-dihydroxyvitamin D). Calcium levels can be managed in the dialysis fluid of the patients requiring dialysis. Low-phosphorus diets and the use of phosphorus-binding drugs that prevent enteric absorption can help limit hyperphosphataemia. Phosphorus binders containing aluminum are avoided as they can be toxic to the skeleton.

To prevent vitamin D deficiency, it is recommended that individuals are exposed to direct sunlight on their arms, legs, or face for 5 to 30 minutes at least twice a week.

Family members should be warned of the possibility, albeit rare (<5%), of familial disease. First-degree relatives should consider serum calcium assessments.

7 Alternative and Homeopathic Remedies

Several alternative and homeopathic remedies are used for hyperparathyroidism.

Nutrition and Supplements

Do not take supplements without your health care provider's supervision. Following these nutritional tips may help reduce symptoms of hyperparathyroidism:

  • Eliminate all potential food allergens, including dairy, wheat (gluten), soy, corn, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
  • Eat calcium-rich foods, including beans, almonds, and dark green leafy vegetables (such as spinach and kale).
  • Avoid refined foods, such as white breads, pastas, and sugar.
  • Use healthy cooking oils, such as olive oil or coconut oil.
  • Reduce or eliminate trans-fatty acids, found in commercially-baked goods, such as cookies, crackers, cakes, and donuts. They are also found in French fries, onion rings, processed foods, and margarine.
  • Limit carbonated beverages. They are high in phosphates, which can leach calcium from your bones.
  • Avoid coffee and other stimulants, alcohol, and tobacco.
  • Drink 6 to 8 glasses of filtered water daily.
  • Exercise moderately at least 30 minutes daily, 5 days a week.

You may address nutritional deficiencies with the following supplements:

  • A daily multivitamin, containing the antioxidant vitamins A, C, E, the B-complex vitamins and trace minerals, such as magnesium, calcium, zinc, and selenium.
  • Calcium citrate, 500 to 1,000 mg daily, for bone support.
  • Vitamin D, 1,000 to 3,000 IU daily, for immunity.
  • Ipriflavone (soy isoflavones) standardized extract, 200 mg, 3 times a day, for bone loss. Because hyperparathyroidism may lead to osteoporosis, taking ipriflavone may help treat this cause of bone loss. Ipriflavone can lower white blood cell counts and has the potential to interact with a variety of medications. Speak with your physician.
  • Foods rich in calcium, which include:
      • Almonds
      • Legumes
      • Dark leafy greens
      • Blackstrap molasses
      • Oats
      • Sardines
      • Tahini
      • Prunes
      • Apricots

Your doctor may recommend you take calcium with a glass of orange juice

Some forms of calcium are better absorbed in an acidic environment. You can also add acid to your diet by squeezing lemon juice over leafy greens.

Herbs

Herbs are generally available as standardized dried extracts (pills, capsules, or tablets), teas, or tinctures/liquid extracts (alcohol extraction, unless otherwise noted).

Mix liquid extracts with favorite beverage. Dose for teas is 1 to 2 heaping teaspoonfuls/cup water steeped for 10 to 15 minutes (roots need longer).

The following herbs are sometimes used to counter the bone loss that can occur from hyperparathyroidism, though scientific studies are lacking. Talk to your health care provider before taking any herbs if you have hyperparathyroidism.

  • Chaste tree (Vitex agnus castus) standardized extract, 20 to 40 mg daily before breakfast, for support of the parathyroid gland. Chaste tree extract has many possible drug interactions and can have hormone-like effects in the body. People with a history of hormone-related conditions, or those who take hormone medications, should be particularly cautious. Speak with your physician.
  • Dandelion (Taraxacum officinale) leaf tincture, 5 to 10 mL, 2 to 3 times a day, for its high mineral content. You can also prepare teas from the leaf. Certain drugs can interact with Dandelion, including lithium and some antibiotics. Speak with your physician. People with Ragweed allergies may also have an allergic reaction to Dandelion.

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of hyperparathyroidism based on their knowledge and experience.

  • Calcarea carbonica (calcium carbonate)
  • Calcarea phosphorica (calcium phosphate)

Before prescribing a remedy, homeopaths take into account a person's constitutional type - your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

8 Risks and Complications

The various complications of hyperparathyroidism include:

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