Parathyroid Frequently Asked Questions

What causes primary hyperparathyroidism?

Primary hyperparathyroidism is caused by a condition that affects one or more parathyroid glands causing exaggerated release of its hormone (parathyroid hormone, or PTH). This condition could be a benign tumor of the parathyroid gland called an adenoma, benign enlargement affecting multiple glands (hyperplasia), or very rarely carcinoma (malignant tumor).  The causes of these tumors are generally unknown but may include exposure to radiation of the head and neck area in the past, lithium use, and rarely, a syndrome that runs in the patient’s family.

How is hyperparathyroidism diagnosed?

An abnormal parathyroid gland releases high levels of parathyroid hormone (PTH).  Through PTH’s action in the bones, the intestines, and the kidney, there is an increase in the level of calcium in the body. So, the blood is examined for both PTH level and calcium level.  Elevated levels of calcium and PTH in the absence of secondary causes such as renal failure are diagnostic of the disease.

What is a normal parathyroid level?

Although values differ with different laboratories, the average parathyroid hormone (PTH) level ranges between 10 and 65 pg/mL.  An increase in the level of PTH is one factor that can lead a doctor to suspect hyperparathyroidism.  It is, however, important to examine all factors of a case and not rely on one value for diagnosis.

Why is my parathyroid hormone level high?

The calcium level in the body is regulated by the parathyroid glands.  Normally, a low calcium level in the body signals the glands to release parathyroid hormone (PTH), and once the calcium level is back to normal the gland stops releasing PTH.  However, when a tumor or cancer arises from the parathyroid gland, this auto-regulation is broken and PTH release is unchecked.

What might it mean if my calcium level is normal and my PTH is high?

If your calcium level is normal and your level of parathyroid hormone (PTH) is high, it’s likely due to early presentation of hyperparathyroidism.  Random blood levels may demonstrate high calcium occasionally. Some patients will eventually develop the full disease and its complications.  Many never go on to develop the classic form of the disease.  Although surgery in the case of normal calcium with high PTH normalizes the PTH levels, much is unknown of its benefit in the long run.

What might it mean if my calcium level is high and my PTH is normal?

When your calcium level is high, the normal response of the parathyroid glands is to stop producing parathyroid hormone, so the parathyroid hormone should be very low.  If the calcium is elevated and parathyroid hormone is still being produced in significant amounts, this could be a sign of primary hyperparathyroidism. A PTH in the “normal” range may not be appropriate for someone with hypercalcemia and could be a sign of hyperparathyroidism.  It is important to meet with your doctor to discuss these possibilities, and your doctor may order additional tests to determine if there is a problem with your parathyroid glands.

In addition, there are certain medical conditions or medications that can cause a high calcium levels with a low or normal parathyroid hormone (PTH) level. Those conditions include:  sarcoidosis, multiple myeloma, Paget’s disese, milk alkali syndrome, and high vitamin D levels.  Advanced cancers that spread to the bone, such as breast cancer, lung cancer, and kidney cancer, may cause breakdown of bone and release of calcium.

What can cause an elevated calcium level?

Parathyroid hormone (PTH) removes calcium from the bones.  In the gut, PTH indirectly causes increased absorption of the calcium we eat.  In the kidney, PTH prevents the elimination of the extra calcium by promoting calcium re-absorption.  All these mechanisms account for the elevation of calcium in the blood.

How common is parathyroid cancer?

Parathyroid cancer is extremely rare.  Cases of parathyroid cancer make up less than 1% of the total number of patients with primary hyperparathyroidism.  Patients with parathyroid cancer typically have a very high calcium level (greater than 14 mg/dL) and a very high parathyroid hormone (PTH) level (usually greater than 300 pg/mL or more).  The diagnosis of parathyroid cancer is made by the patient’s symptoms, blood tests, and findings in the operating room.

What is parathyroid cancer?

Parathyroid cancer is a clinical diagnosis, meaning that you make the diagnosis of parathyroid cancer by the patient’s symptoms, blood tests, and findings in the operating room. The pathologist may not be able to tell if this is cancer even by looking at it under the microscope. The best chance of curing parathyroid cancer is to catch the disease early and remove it promptly.

What is the treatment of parathyroid cancer?

The best chance of curing parathyroid cancer is to catch the disease early and operate on the patient promptly.  By the time it is diagnosed, parathyroid cancer may have grown into surrounding structures like the thyroid.  The best treatment for parathyroid cancer is an operation to remove the parathyroid cancer along with the thyroid lobe on that same side.  Chemotherapy and radiation therapy do not work well against parathyroid cancer.  Fortunately, parathyroid cancer is often slow-growing, and patients can have repeat operations to remove disease as it comes back.

What is a parathyroid localization study?

In most patients with primary hyperparathyroidism (80%), only one of the four parathyroid glands is diseased.  Localizing tests are radiology tests designed to help identify which parathyroid gland(s) are hyperactive.  The types of imaging obtained is surgeon specific.  The most commonly performed localizing tests are a sestamibi scan and ultrasound of the neck.  Increasingly, high resolution CT (computed tomography or CAT scans) and MRI (magnetic resonance imaging) scans are also showing significant promise.

What is a sestamibi scan?

In most patients with primary hyperparathyroidism (80%), only one of the four parathyroid glands is diseased. Localizing tests are radiology tests designed to help identify which parathyroid gland(s) are hyperactive. One such localizing test is a sestamibi scan which involves injecting a small amount of special radioactive material into a vein and taking an X-ray image of the chest, neck, and head. The advantages of sestamibi scans are their widespread availability and their ability to evaluate for diseased glands outside of the neck.

If imaging studies are negative, should I still have parathyroid surgery?

Yes. Imaging studies help a surgeon determine if a patient is a candidate for a focused parathyroidectomy (an operation where the surgeon examines and removes just one hyperactive gland). Imaging studies do not determine if a patient has hyperparathyroidism, they only help determine the type of operation that is necessary.  A patient with negative imaging studies will likely require a traditional bilateral neck exploration. In this technique, all four of the parathyroid glands are examined in the operating room and the surgeon determines which glands are diseased based on their size and appearance.

What is bilateral exploration in parathyroid surgery?

Bilateral exploration is the traditional surgical approach to parathyroid surgery and may also be referred to as a 4-gland exploration.  This approach involves exploring and looking at all 4 parathyroid glands (typically two on the right, and two on the left).  This allows the surgeon to determine if there is a single abnormal parathyroid, or if more than one of the parathyroid glands are abnormal.  Pre-operative localization tests and intra-operative adjuncts such as parathyroid hormone (PTH) monitoring are not required, but may be used to facilitate bilateral exploration. This approach has proven over time to be highly successful with cure rates of 95% or greater when performed by an experienced surgeon. Bilateral exploration is still done through a midline incision that is quite small, often around 3-4 cm, which is just over one inch in size.

What is minimally invasive parathyroid surgery?

Minimally invasive parathyroid surgery, alternatively called focused or unilateral parathyroid exploration, involves exploration and resection of a single abnormal parathyroid gland through a small incision.  This approach requires that pre-operative imaging has localized a single abnormal parathyroid gland.  Intra-operative parathyroid hormone monitoring (IOPTH) is generally used to prove that resection of the single abnormal parathyroid gland results in a biochemical cure.  The cure rate using this approach is the same as for bilateral exploration when patients are selected carefully and the surgeon is experienced in parathyroid surgery.  Advantages of focused exploration include a somewhat smaller scar, shorter operative time, and fewer problems with low calcium after surgery.

What is radio-guided parathyroid surgery?

Radio-guided parathyroidectomy is a form of minimally invasive parathyroid surgery that involves giving the patient a small injection of Tc-99 sestamibi the morning of surgery.  This substance is taken up by the parathyroid glands (particularly abnormal parathyroid glands).  The surgeon then uses a hand held probe to identify the hyperactive parathyroid gland during surgery.  All patients are not eligible for this procedure, and very few surgeons continue to use this procedure.  It has been, for the most part, replaced by use of intra-operative parathyroid hormone testing (IOPTH) or by the traditional bilateral exploration.

What is video-assisted parathyroidectomy?

Video-assisted parathyroidectomy is also known as minimally invasive video-assisted parathyroidectomy and endoscopic parathyroidectomy.  This technique involves making a small incision and using a camera and small instruments to locate and remove the abnormal parathyroid gland.  Some surgeons routinely use video assistance to see better when using smaller incisions, other surgeons just use the video camera equipment when the abnormal parathyroid is challenging to find or is in an unusual location.

What is intra-operative PTH testing?

Intra-operative parathyroid hormone testing (IOPTH) is an adjunct to many types of parathyroid surgery but is most definitely used by the vast majority of surgeons if a minimally invasive approach is contemplated.  IOPTH involves testing the patient’s PTH level both before and after removal of the suspected abnormal parathyroid gland.  PTH is rapidly degraded in the body, which allows the surgeon to determine if parathyroidectomy has been successful while the patient is still anesthetized by observing a drop in the PTH level.  If the PTH level remains high, the surgeon may need to perform a bilateral exploration to identify all 4 parathyroid glands.

The size of the scar depends on the type of surgery being performed.  If you are having what is called minimally invasive parathyroid surgery, where one well-localized parathyroid is removed, then your scar may be one to two inches.  If, however, the surgeon needs to examine the other glands, he/she may need to extend that scar to 2-3 inches in order to have a better view. The size also depends on the surgeon’s preference and ease of visualization of necessary structures at the time of the procedure.

How much pain will I have after parathyroid surgery?

Most patients tolerate the pain after parathyroid surgery very well. For most, acetaminophen or ibuprofen will suffice.  Some patients may require a small amount of narcotics for breakthrough pain. Most will feel better in a few short days.  If the pain has worsened or is associated with redness or swelling around the scar, please contact your surgeon promptly.

Will I lose my voice after parathyroid surgery?

The risk of losing your voice is extremely small with parathyroid surgery.  However, it is not zero.  Most experienced parathyroid surgeons have a <1% rate of permanent hoarseness after surgery.  A complete loss of your voice would be exceedingly rare and would only happen if the nerves that innervate your voice box are injured on both sides.  If permanent hoarseness does occur, there are procedures that can be performed to bring your voice as close to normal as possible.

How will I feel after parathyroid surgery?

How you feel after surgery will partly depend on whether you had general or local anesthesia. The side effects of anesthesia depend on the medications given, often being more significant for a general anesthetic.  You have to give time for the anesthesia to leave your system.  The way you feel may also depend on the symptoms you had prior to your surgery (e.g., fatigue).  These should slowly improve with time if surgery was successful.

What should I do if I have numbness and tingling after parathyroid surgery?

Numbness and tingling in your lips or fingers occurs when your body senses decreased levels of calcium.  This is a common occurrence after parathyroid surgery.  You may feel these symptoms when your calcium levels have decreased to normal, but since you have been living with much higher calcium levels your body feels like the normal level is not enough.  This could also be a sign that the parathyroid glands are not functioning yet, as in the case when all four of your glands are removed and a portion of one is reimplanted.  In this case, it will take up to 6 weeks for the calcium levels to normalize.

You should contact your surgeon if these symptoms occur or discuss a plan for treating these symptoms with your surgeon before leaving the hospital.

Will parathyroid surgery help my fatigue?

Research has shown that surgery can improve fatigue and improve the quality of life for a majority of patients (up to 80% to 95%).  However, it is important to note that although many patients notice an improvement, not all patients do because there are many possible other causes for these non-specific symptoms.

Could my parathyroid problem be the reason for my fatigue?

Patients with hyperparathyroidism have been shown to have more neuropsychological symptoms, including fatigue, when compared with the general population.  However, it is difficult to ascertain if hyperparathyroidism is the actual cause of fatigue, as there are many other reasons that could be contributing.

Will parathyroid surgery improve my memory?

Memory has been found to be impaired in many patients with hyperparathyroidism when tested.  How primary hyperparathyroidism causes memory difficulty is unclear.  Research has shown that patients with primary hyperparathyroidism demonstrated improved functioning (up to 80% of patients) across several areas, including attention, memory, and reasoning following parathyroidectomy.

Will parathyroid surgery fix my kidney stones?

Surgery for primary hyperparathyroidism will not fix existing kidney stones but it decreases the formation of new kidney stones among those patients with kidney stones and primary hyperparathyroidism.  A small group of patients (around 10%) will continue to form stones following parathyroid surgery.

Will my bone density improve after parathyroid surgery?

Studies show that after successful parathyroid surgery the bone density will improve by as much as 8 to 12% and the risk of fracture will decrease.  Improvements are measurable one year following surgery and continue for the next ten years.  All patients with hyperparathyroidism, from mild to severe disease, have significant benefits in bone health following surgery.

What is the risk my hyperparathyroidism will come back?

It depends on whether you have the most common single gland disease (85%) or the multi-gland disease (15%) or the rarest, parathyroid cancer (<1%).  The risk of recurrence for each of these can be 1%, 30%, or up to 70%, respectively.

What is persistent hyperparathyroidism?

Persistent hyperparathyroidism means that your calcium level never normalized after your parathyroid exploration.  This is usually caused by a ‘missed gland’ – the failure to identify or to remove an abnormal parathyroid gland at the initial exploration.  It is well documented that exploration performed by an experienced parathyroid surgeon has a success rate that exceeds 95%.  The failures are attributed to ectopic (abnormally located) glands, the presence of additional (fifth) glands, and/or unrecognized multi-gland disease.  In patients who have undergone a failed first operation, the most common findings at the second operation are single-gland disease with the abnormal gland located at its normal anatomic position.  It was simply not recognized at the time of the first operation.  Inexperienced surgeons could have failure rates as high as 30%.

What is recurrent hyperparathyroidism?

Recurrent hyperparathyroidism means that your calcium level is elevated again after a period of normalization. The period is arbitrarily set as 6 months after your parathyroid exploration.  This is usually caused by re-growth of abnormal parathyroid tissue.

What can I do if my parathyroid surgery was unsuccessful?

This could be problematic because re-operative parathyroid surgery is technically challenging.  It has higher complication rates, as well as higher failure rates; this is why we underscore the importance of having it done right the first time.

Following a failed initial operation, your endocrinologist or your endocrine surgeon must first ascertain your diagnosis, so a complete set of your blood and urine tests need to be repeated.  This is particularly essential if you were initially explored by an experienced parathyroid surgeon.  There should be a higher threshold to re-do your surgery.  The decision to re-operate is multifactorial.  If you have a mild elevation of calcium level, without significant effect on your bone, kidney, or neurocognitive function, you might want to consider observation or medical treatment to lower your calcium level.

If re-operative surgery is indicated and pursued, you should obtain all your medical records related to your initial surgery.  You may need a more extensive evaluation prior to surgery, including additional imaging studies and vocal cord evaluation.

Find an Endocrine Surgeon