Hyperparathyroidism Treatment

Hyperparathyroidism is a disease where one or more of the small glands behind the thyroid (a gland in the neck) are working too hard. These four glands are called parathyroid glands, and they produce parathyroid (PTH) hormone. PTH regulates the amount of calcium in the blood. Calcium is important for strong bones and teeth, but it also helps muscles, nerves and other parts of the body function as they should.

When calcium levels in the blood are too low, the parathyroid glands make and release more PTH into the blood. PTH works like a chemical message telling the body it needs more calcium.

Hyperparathyroidism happens when one or more of the parathyroid glands is enlarged or has a tumor (growth). This causes the glands to work too hard and make more PTH than the body needs. As a result, the amount of calcium in the blood rises higher than it should. There are three types of hyperparathyroidism.

Primary Hyperparathyroidism

Primary hyperparathyroidism happens when one or more of the parathyroid glands make too much PTH, which then raises the calcium level in the blood higher than it should be.

Secondary Hyperparathyroidism

Secondary hyperparathyroidism happens when calcium levels in the blood are always low and the parathyroid glands make too much PTH in response. Calcium levels that are always low can happen in patients with kidney failure, vitamin D deficiency and malabsorption syndrome.

Tertiary Hyperparathyroidism

Tertiary hyperparathyroidism happens when the parathyroid glands make too much PTH in patients after kidney transplant surgery.

Hyperparathyroidism Symptoms

Symptoms of hyperparathyroidism vary based on disease severity.

Patients with more severe disease may experience:

●      Kidney stones

●      Bone pain

●      Fractures (broken bones)

●      Sleep problems

●      Confusion

Patients with mild disease may have vague (not specific) symptoms such as:

●      Weakness and fatigue

●      Moodiness/irritability

●      Memory loss

●      Constipation

●      Having to urinate more than usual

●      Heartburn

Hyperparathyroidism can cause serious health problems if left untreated. These problems include osteoporosis, cardiovascular disease, stroke and kidney disease.

At Weill Cornell Medicine, we offer patients a thorough evaluation for hyperparathyroidism. This evaluation includes checking levels of PTH and calcium in the blood; high levels are a main sign of hyperparathyroidism. Urine studies and genetic testing are also performed in select patients.

If the diagnosis is confirmed, then imaging tests are used to help determine treatment. These tests include:

●      Thyroid and parathyroid ultrasound

●      CT scan

●      Sestamibi scan

Treatment for hyperparathyroidism depends on many factors, including the type of disease, the severity of symptoms and the risk of worsening disease. Treatment may include medication or surgery. 

For primary hyperparathyroidism, surgery to remove the affected gland(s) is offered to patients with severe disease and symptoms caused by hyperparathyroidism. However, the decision to offer surgery for patients with subtle symptoms, or without symptoms, is more complex. Since about 25 percent of patients with mild disease will eventually progress to have more severe disease, we offer surgery to patients with the following factors who may be at risk to develop worsening disease:

●      Age less than 50

●      Calcium level greater than 1mg/dL above the upper limit of normal range

●      Elevated calcium in the urine

●      Osteoporosis

●      Reduced kidney function

In addition, if subtle symptoms cannot be explained by other factors, patients can choose to proceed with surgery.

For secondary hyperparathyroidism, many patients can initially be managed with medications in conjunction with a transplant nephrologist. Surgery can be considered in patients with severe disease who do not respond well to medical management or who cannot tolerate the medical regimen.

For tertiary hyperparathyroidism, patients with mild disease can be medically managed; however, those with worsening disease, notable symptoms or severe electrolyte conditions that do not improve with medications are candidates for surgery.

Surgery for hyperparathyroidism has been associated with improved bone mineral density (correcting or improving osteoporosis), better kidney function and reduced long-term cardiovascular risk. Additionally, several studies have suggested that neuro-cognitive symptoms may resolve after surgery, thus also improving quality of life. Your endocrine surgeon will discuss if surgery is the right option for you.

At Weill Cornell Medicine, we work with patients to design treatment plans that fit their needs.

Parathyroid Surgery

Most patients usually recover quickly after surgery and resume their regular activities within a couple of days. Your surgeon will discuss the details of your surgery and recovery with you and answer any questions you have.

Our goal is to cure primary hyperparathyroidism using a minimally invasive surgical approach to remove the unhealthy parathyroid gland or glands. The operation can be performed under local or general anesthesia through a small incision (surgical cut) in your neck using intraoperative PTH monitoring. Typically all four glands are visualized during the surgery. Since parathyroid hormone in the bloodstream breaks down within minutes on its own, we also measure the level at the beginning of surgery and then again 10 minutes after the affected parathyroid gland(s) have been removed. This is a second way to confirm that a successful operation has been performed. 

In secondary and tertiary hyperparathyroidism, all four parathyroid glands are usually affected, and thus patients require a multi-gland exploration to ensure that no unhealthy parathyroid glands remain. Our typical approach is to remove 3.5 glands, while leaving a 0.5 gland remaining to ensure healthy PTH and calcium levels after surgery.

The risks of parathyroid surgery include bleeding, nerve injury that could affect your vocal cords and the quality of your voice, and damage to the remaining parathyroid glands resulting in low calcium levels in the bloodstream. Our surgeons, due to their expertise, have minimized these risks to some of the lowest in the country. Though the incidence of voice complications is exceedingly low in our hands, if necessary, we can evaluate your vocal cords before and after surgery to assess for any signs of complication. Additionally, during the parathyroid operation itself, our surgeons may use nerve-monitoring technology, which helps assess the integrity of your vocal cord nerve during the procedure.

After parathyroid surgery, most patients will be able to go home the same day after a four- to six-hour observation period. Patients with secondary and tertiary hyperparathyroidism may need to stay in the hospital a few days for close calcium level observation. Regardless, recovery is quick and the procedure causes little discomfort. Patients usually resume daily activity within a couple days. Your surgeon will discuss in detail with you the expected recovery period.

Follow-Up and Monitoring

After parathyroid surgery, patients are enrolled in our active surveillance (monitoring) program. Although uncommon, hyperparathyroidism can return after surgery. Active surveillance includes checking the blood every year for PTH and calcium levels. If levels rise, follow-up with further testing will be done to identify the cause.