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I'm really worried about becoming hypOparathyroid after parathyroid surgery. How do you prevent that?

Postoperative permanent hypoparathyroidism (a lifelong deficiency of PTH) is a known risk of thyroid and parathyroid surgery. It is a terrible complication, but fortunately it is extremely rare. Note that everyone will have some temporary hypoparathyroidism after parathyroid surgery - this is expected, since the remaining parathyroid glands have been suppressed and are not making much PTH. This...

Postop complications HypOparathyroidism Hyperplasia

Do I need surgery if I don't have symptoms? I am a 65 year old woman who was recently diagnosed with primary hyperparathyroidism. My calcium and PTH levels are both high. I have osteoporosis, but have not had any fractures, and otherwise I am very healthy. I don't have any of the symptoms that other people report. If I feel pretty good overall, do I really need the operation?

This is a great question. It's odd to hear that you might need an operation for something that isn't really bothering you. In cases of clear primary hyperparathyroidism, I do usually end up recommending surgery. We know that the disease does not go away on its own. And we know that the symptoms and the complications from parathyroid disease get worse with time. It is actually pretty common for ...

Symptoms Operation

After parathyroid surgery, my thyroid became overactive. Was this caused by the parathyroid surgery?

Parathyroid surgery can cause a temporary hyperthyroidism (overactive thyroid). Here is what can happen: during manipulation of the thyroid, which occurs during parathyroid surgery, the thyroid can get irritated. It then starts dumping out too much thyroid hormone. This is called postoperative thyroiditis. It is a self-limiting process, which generally resolves within several weeks. In the firs...

Thyroiditis Postop complications

Over the last few years my calcium levels have been a little low, between 8.8 and 9.1 mg/dl. My PTH levels have been very high, up to 200 pg/ml. I had a gastric bypass 7 years ago, and one doctor told me that the PTH was a result of that. Another doctor told me that I have primary hyperparathyroidism and need surgery to remove a parathyroid tumor. Do I have primary hyperparathyroidism? Do I need surgery?

This clinical picture is most consistent with secondary hyperparathyroidism (not primary) due to intestinal malabsorption of calcium (as a result of the gastric bypass). Secondary hyperparathyroidism occurs when blood calcium levels are chronically low. Most people should have calcium levels in the mid to high 9s in mg/dl, or between 2.32 and 2.5 mmol/l. If calcium levels are consistently b...

Secondary HPT Gastric bypass Malabsorption

Hi Dr. Boone, I had 3 glands removed earlier this year. My question is do I have to worry about my 4th gland? Do they ever go bad over time? Is the way to put my mind at ease to keep checking calcium and PTH levels, and not worry unless they both go high? But I'm taking vitamin D, which will lower my PTH result, right?

This is a great question. Short answer: your 4th parathyroid gland is likely not completely normal. But that doesn't mean it will cause problems. I would recommend following calcium levels annually, just as I recommend for other parathyroid patients. Long answer: First let's review what you had done. You had parathyroid surgery for primary hyperparathyroidism, and during the operation y...

Hyperplasia Operation

For personal reasons, I cannot have parathyroid surgery until next year. How often should I get my labs checked during that time to make sure that the disease isn't getting worse?

Regarding how often labs should be checked, if someone is not having surgery right away: they don't need to be checked that often. Often, the labs stay very similar for many years. The severity of the disease is not related to how high the calcium is (for patients with high calcium). The severity of the disease is related to how long it is present. So there is no number cutoff where you can say...

I have been on lithium for bipolar disease for over 20 years. Recently I was diagnosed with high calcium. One doctor says the high calcium is just a result of the lithium, while another thinks I have primary hyperparathyroidism. Which is it?

This clinical picture is most consistent with lithium-associated primary hyperparathyroidism. Lithium is well-known to cause both hypercalcemia (high calcium) and primary hyperparathyroidism (which itself causes high calcium). In some cases, lithium can cause high calcium that is reversible if you stop lithium. If the calcium has been high for many years, it is less likely to be reversible. It ...

Multigland disease Lithium Hyperplasia

Do you need to correct your calcium based on albumin levels? My doctor told me that my high calcium level was actually normal once he corrected for albumin.

The short answer is that you cannot “correct” a high calcium down to normal by looking at albumin. We use albumin to correct for low calcium levels. But this is a tricky issue, which requires a longer explanation. First, let me explain how calcium and albumin are related. Calcium in the blood can be free (not bound to anything) or bound to albumin. The free calcium is the ionized calcium, which...

Albumin Normal calcium Diagnosis

Why don’t you use intraoperative PTH? Another surgeon I saw said that he uses intraoperative PTH (ioPTH) to confirm that the patient is cured. You said that you do not use ioPTH. Why is that?

I prefer to evaluate all four parathyroid glands rather than rely on intraoperative PTH. Here is why: intraoperative PTH is just not that accurate. Here is the thinking behind ioPTH: a surgeon can remove one parathyroid, often one seen on preoperative imaging, test the PTH level in the blood, then wait 5 to 10 minutes and test again, then wait 5 or 10 more minutes and test again. If the PTH dr...

Operation Operative technique Cure rate Intraoperative PTH

I have been feeling awful for the last 6 months. I'm 60 years old but feel like 90. I'm tired all the time, even after a nap (and I never needed naps before). The only abnormality I have on labs is a calcium level of 10.4 mg/dl, but my doctor tells me that this isn't high enough to cause symptoms. I don't have any other explanation. Could this cause my symptoms?

A calcium level of 10.4 mg/dl (2.59 mmol/l) is definitely high enough to cause symptoms. At your age, this calcium level is too high, and usually indicates primary hyperparathyroidism. (We would also need a PTH level to confirm - if your PTH is in the high or "normal" range, then we could diagnose parathyroid disease.) One interesting thing about parathyroid disease is that the calcium level...

Over the last 5 months my calcium levels have been above 10.0 mg/dl, up to 10.3 mg/dl. My doctor tells me this is normal. I'm 75 years old, and my calcium levels before this were always between 9.1 and 9.7 mg/dl. Why is my calcium rising?

At your age, a calcium of 10.3 mg/dl (2.57 mmol/l) is too high. Most adults over about age 40 should have calcium levels in the mid to high 9s, up to 10.0 mg/dl (2.5 mmol/l). Sometimes adults in their 40s will still have calcium levels in the low 10s, but generally these levels drop as you age. By the time you are 75, you should not have any calcium levels above 10.0, especially if your calcium...

Normal calcium Diagnosis

Hello! I'm planning on getting my Covid-19 vaccine before surgery but I'm a little nervous because I already have lots of symptoms from hypercalcemia like fatigue, gastritis, constipation, bloating and heart palpitations. My immune system appears fine on cbc tests though. Should I expect my symptoms to get tremendously worse in combination with the vaccine temporal symptoms or most patients report is bearable? Thank you!

Great question! Unfortunately we don't have enough information on how parathyroid patients react to the vaccine for me to be able to give a definitive answer. A lot of people who get a Covid vaccine do have some temporary side effects, and if you are already feeling bad then that could make you feel worse. Generally, though, the effects of the vaccine are short-lived, and are preferable to ...

Can I have surgery with a negative scan? I was diagnosed with primary hyperparathyroidism last year, but no one can seem to find a parathyroid tumor. I have had two sestamibi scans, a CT, and ultrasound but they were all negative. My surgeon says he will not operate until something is seen on the scan. I am having bad bone pain and want to get this done. How can we find this parathyroid?

Imaging studies should not be used to determine when to operate. We diagnose parathyroid disease with labs, not with imaging, so we know that you have at least one diseased parathyroid gland. If the diagnosis is clear, then there is no reason to wait to have surgery, as long as you have an experienced surgeon who can evaluate all four parathyroid glands. If you have a surgeon who wants to see t...

Operation Imaging Operative technique

I have had high calcium levels for over 30 years, but have never been diagnosed with parathyroid disease. I’ve never had any health problems. Do I have primary hyperparathyroidism?

In most cases, persistently high calcium levels indicate primary hyperparathyroidism. But we need more information to confirm the diagnosis. To diagnose primary hyperparathyroidism, we check the calcium and PTH together. If something else (not parathyroid disease) is causing the high calcium, then the normal parathyroid glands will be suppressed - that is, they will make very little hormone. Th...

FHH Diagnosis Primary HPT Hypercalcemia

Are there medications to treat primary hyperparathyroidism?

There are no medications that cure primary hyperparathyroidism. The only cure is with an operation to remove the diseased parathyroid glands. There are medications that can decrease calcium and PTH levels, but they are not treating the underlying problem. They can make your levels look better on paper, but not necessarily make you any healthier. Cinacalcet (Sensipar) is a medication that is ...

Cinacalcet (Sensipar) Treatment

When can I expect to feel better after surgery? I’ve been feeling terrible.

This is a great question. Unfortunately there isn’t a single answer for everyone. On average, most people will feel better within a few weeks after surgery, and this improvement can continue for months. But that is just the average. I have had patients who wake up after surgery and felt like a cloud was lifted. They feel amazing, right after the operation. These patients are rare, but they happ...

Outcomes Primary HPT Operation Postop expectations FAQ

Will having parathyroid surgery affect my thyroid? My thyroid function is normal, but I know someone who became hypothyroid after parathyroid surgery.

There are two issues that can occur with the thyroid: hyperthyroidism (overactive thyroid) or hypothyroidism (underactive thyroid). Both can occur after parathyroid surgery, but are both uncommon. When we operate on the parathyroids, we are manipulating the thyroid somewhat - we may need to push it over to reach the parathyroids, for example. Most thyroids are fine with that, and most peop...

Postop complications Thyroiditis Hypothyroidism

My doctors can't figure out what is going on with me. My calcium levels have been between 9.8 and 10.5 mg/dl over the last year. My PTH was 25 pg/ml. My Vitamin D was 89 ng/ml. I was diagnosed with a Vitamin D deficiency years ago so I have been taking 5000 units of Vitamin D daily since then. My doctor isn't sure if I have a parathyroid tumor or not. I've been feeling all of the symptoms of parathyroid disease and think this is what is wrong. What do you think?

This clinical picture looks typical for overuse of Vitamin D. One of the main roles for Vitamin D is to help your intestines absorb calcium. Vitamin D is a fat soluble vitamin, so it builds up in your body over time. You are currently on a very high dose of Vitamin D, which is why your Vitamin D level is high. Your lab might not label your Vitamin D as being in the "toxic" range, but it is high...

Vitamin D Diagnosis

Do you have any thoughts on why there are so many varying opinions on what lab values actually confirm a diagnosis? For example many very well respected experienced surgeons and endocrinologists correct calcium for albumin even when it’s not low. This can bring a high calcium down to normal or even low and possibly miss a diagnosis.

It's a great question. It seems like we should all be able to agree on which lab values are normal. Unfortunately this is not the case, and there are a few reasons. First, when the lab gives the results, it gives a "normal range" - but this is looking at all humans in aggregate. A normal human can have a calcium of 10.5 mg/dl when she is 20 years old, but should not have that when she is 80...

Diagnosis Normal calcium Albumin

I have been feeling very sick. My PTH intact level is 134.4 pg/ml and my calcium is 11 mg/ld. Also I have blurry vision and just feel really sick.

Thanks for writing in. I'm not surprised that you are feeling badly. Your calcium and PTH indicate primary hyperparathyroidism, and most people with this will develop symptoms. The most common symptoms are often non-specific, things like fatigue, insomnia, and brain fog. People also report that they just don't feel like themselves anymore. They feel generally unwell, though it might be hard to ...

Diagnosis Symptoms

What is Parathyroid Disease?

Parathyroid disease refers to problems with the parathyroid glands. Almost everyone has four parathyroid glands, located in the neck near the thyroid. These glands exist to regulate blood calcium levels, so parathyroid disease is fundamentally a problem of calcium. The calcium in your blood is kept in a very tight range - your body doesn't want it too low or too high. The parathyroids are what ...

Diagnosis Primary HPT Secondary HPT Popular Parathyroid Disease Basics FAQ

What are the risks of parathyroid surgery?

Parathyroid surgery is generally a very safe operation, especially when performed by an expert at the operation. There is a risk of complications with every operation, though. The main risks with parathryoid surgery are postoperative bleeding, voice changes, and thyroiditis. Bleeding is a risk with any operation. It occurs in about 1 in 500 cases (about 0.2%). It is more likely in patients w...

Postop complications Operation

Will I need to take medications after parathyroid surgery?

After surgery, you will need two things, which are over-the-counter: 1. Calcium and Vitamin D 2. Pain control Most patients will not need any prescription medications after surgery. I generally recommend over-the-counter medications for pain control, such as ibuprofen (Motrin, Advil) and acetaminophen (Tylenol). Narcotics have side effects and are usually not more effective than the over-...

Postop expectations Vitamin D

I've had high calcium levels for the last four years. Over the last six months I have started having more frequent headaches and body aches. Sometimes I feel really tired even when getting lots of sleep. I think these symptoms may be due to parathyroid disease, but on other days I feel just fine, so I think they may be caused by something else. Can symptoms of parathyroid disease come and go like this?

Yes, it is common for the symptoms of parathyroid disease to come and go. Patients will report that on some days they are too tired to get out of bed, but other days feel great. Often, the symptoms of primary hyperparathyroidism will gradually increase in frequency and severity. Many people start out not feeling all that bad, but then after a few years with the disease they notice that they are...

Symptoms Primary HPT

Can celiac disease cause hyperparathyroidism?

Celiac disease, or any disease that causes chronic diarrhea or intestinal malabsorption, can cause secondary hyperparathyroidism - not primary hyperparathyroidism. In secondary hyperparathyroidism due to celiac disease, the calcium is chronically low because the intestines have difficulty absorbing it. The PTH rises in response to the low calcium. All four parathyroid glands will produce more P...

Secondary HPT Malabsorption Celiac disease

Is it safe to wait for surgery? I was diagnosed with primary hyperparathyroidism and told that I need surgery. Unfortunately I cannot get the operation done this month. Is it safe to delay the operation for a few months?

It is fine to delay. This is a disease that causes problems over decades. A delay of months, or even a year, is not likely going to cause any harm. You have likely had this growing for several years already before being diagnosed (this is true for most patients), so a little longer won't significantly harm you. While you are waiting for the operation, the best things to do are: stay hydrated...

Primary HPT Operation Treatment

Regarding surgery, many swear by intraoperative PTH while others say no. As a patient it would seem that having a confirmed appropriately lowered PTH while the patient is still in the OR would make more sense than waiting until they are in the recovery room. Can a surgeon really just look at a parathyroid gland and tell it’s abnormal even when it’s just at the beginning stages?

Looking at the parathyroids is currently the best way to evaluate the parathyroids - if you have enough experience with it. Intraoperative PTH does seem logical, but in practice does not work as well as expected. In my experience, viewing all four parathyroid glands is a more accurate and faster way to evaluate the parathyroid glands and ensure a cure. In my residency and endocrine surgery fell...

Intraoperative PTH

Hi Dr. Boone, Can hyperparathyroidism cause MGUS? If so, are you aware of any patients whose MGUS healed after parathyroidectomy? Thank you.

This is a very good question, and somewhat difficult to answer. Here is the short answer: We do not have definitive evidence that parathyroid disease causes MGUS or that MGUS will resolve after parathyroidectomy. Long answer: Monoclonal gammopathy of undetermined significance (MGUS) is a condition characterized by abnormal proteins in the blood. In most cases, this condition is benign a...

Is a parathyroid surgery out-patient? What is the recovery time? What are the risks?

Thanks for asking! Parathyroid surgery is nearly always outpatient, and you go home the same day as the operation. There are some rare exceptions, so occasionally someone will need to spend the night in the hospital. For example, patients who are on dialysis for kidney failure or patients with very severe heart or lung disease that might need to be monitored for a little longer after surger...

Operation Postop expectations Popular Postop complications

Three years ago I had a parathyroid tumor removed. I did very well, but recently my PTH has gone up to 85 pg/ml (normal range up to 65 pg/ml). Do I have another parathyroid tumor? My last calcium was 9.1 mg/dl.

Your labs are now more consistent with secondary hyperparathyroidism (not primary hyperparathyroidism, which is what you had three years ago). That is, the parathyroid glands are making more hormone in response to a low calcium level. Ideally you want your calcium level to be closer to the mid to high 9s in mg/dl. Your remaining parathyroid glands are doing exactly what we want them to do when ...

Postop expectations Diagnosis Secondary HPT

Does a high level of calcium cause you to become crazy?

It depends on what you mean by "crazy." Your brain works best when calcium levels are normal. When the calcium is too high, things don't work quite as well. High calcium can cause psychiatric symptoms such as depression and anxiety. And it causes brain fog and memory loss, which can make patients feel like they are going crazy. Sometimes, especially in older patients, high calcium can mimic dem...

I recently had a very painful kidney stone and want to prevent that from ever happening again. I read that primary hyperparathyroidism can cause kidney stones. How can I figure out if that is what is going on?

If you've had a kidney stone, I definitely understand the desire to avoid another one! Primary hyperparathyroidism can cause kidney stones, and it is appropriate to evaluate for this in anyone who has had a stone. The first thing to do is check your blood calcium levels. If you have a high calcium level, then this could be the cause of your kidney stones. You would then want to check calcium an...

Symptoms Kidney stones Diagnosis

I have all of the symptoms of parathyroid disease. I'm exhausted, can't concentrate, have back pain, can't sleep at night, and just feel awful. I discovered parathyroid disease and it seems to account for all of my symptoms over the last year. My calcium level, though, was normal at 9.8 mg/dl. My doctor checked a PTH and it was 43 ng/ml. She says I don't have parathyroid disease. Could I still have it, even with normal labs?

Your symptoms are consistent with the common symptoms of primary hyperparathyroidism, but with normal calcium and PTH levels that is not likely to be your underlying problem. We diagnose parathyroid disease with labs: primarily calcium and PTH; Vitamin D is also helpful in many cases. If the calcium and PTH levels are consistently normal, then parathyroid disease is very unlikely. The one t...

Diagnosis Normal calcium

I have been having difficulty swallowing, along with a soreness and tightness in my neck. I can also feel a lump in my neck. I had a thyroid ultrasound, which showed a possible thyroid nodule vs. parathyroid adenoma. Could I be feeling the parathyroid adenoma?

It is usually nearly impossible to feel parathyroid tumors. Even when large, they tend to be soft and squishy, and don't cause pain. Sometimes, if you have a large and deep adenoma, you can feel something when swallowing, though this rarely causes actual difficulty swallowing. What you are describing actually sounds more like thyroiditis, or an inflammatory condition of thyroid. The most co...

Thyroid nodule Thyroiditis Diagnosis

I have been following my calcium levels for the last few years, and they seem to fluctuate a lot. I read that this could indicate parathyroid disease. My calcium levels over the last four years were as follows: 9.7, 9.2, 9.1, 9.8, 9.9, 9.1. Do you think I have parathyroid disease? I'm a 52 year old man.

As long as your calcium levels are staying in the normal range (which they are), then some fluctuation is normal. In general, your parathyroid glands do try to maintain a relatively steady calcium level, but this does not mean that the level will be exactly the same every time it is checked. Your labs appear completely normal. My answer would change if you had calcium levels fluctuating int...

Normal calcium Diagnosis

I had parathyroid surgery three days ago. I felt great until yesterday, when I started noticing tingling in my hands. Today I feel weak and jittery, like I'm buzzing all over. I have been taking calcium. What is going on?

This sounds like you are experiencing symptoms of low calcium. After surgery, the PTH drops quickly, and then the calcium drops over the next few days. If symptoms of low calcium are going to occur, they usually occur 2 to 3 days after surgery. The first symptom is usually numbness or tingling in the fingertips or around the mouth. The tingling can then spread up your arms. Eventually you may f...

Postop expectations

I am a 31 year old female and my calcium level just came back at 10.4. My albumin and chloride were also slightly elevated. Should I be worried about parathyroid or what next steps should I take as precaution? I'm on 5000 units daily of Vitamin D3.

At your age, a calcium of 10.4 mg/dl is borderline. Adults in their 30s can have calcium levels in the low 10s, which will tend to drop down into the 9s as they get older. A calcium of 10.4 is on the highest end of where I would expect your calcium levels to be at your age. I am concerned about your dose of Vitamin D. 5000 units daily is a lot, and if you have been on that dose for a long t...

Diagnosis Vitamin D

My calcium level has been high-normal for the last two years. My PTH level is high (85 pg/ml). My doctor says I do not need to be concerned because the calcium is still normal - around 10.2 mg/dl. I'm a 73 year old woman. Do I have parathyroid disease?

For your age, this calcium level is not "high-normal" - it is high. A normal calcium range for someone in her 70s would go up to about 10.0, not higher. While I cannot diagnose someone over the internet, I can say that in general, multiple calcium levels over 10.0 and a PTH of 85 in a woman in her 70s are consistent with a diagnosis of primary hyperparathyroidism. Even though your calcium l...

Normal calcium Diagnosis

My calcium levels have been normal (around 9.5 mg/dl) but my PTH is consistently elevated, between 60 to 80 pg/ml (normal range up to 65 pg/ml). Do I have parathyroid disease?

Most of the time, this clinical picture does not indicate primary hyperparathyroidism. The PTH is a little bit over the "normal" range, but with calcium levels that remain in the normal range, a parathyroid tumor is unlikely. If your calcium level were high (that is, over around 10.0 mg/dl for adults over age 40), then I would diagnose primary hyperparathyroidism. But with normal calcium levels...

Diagnosis Secondary HPT

I've just been told that I have a parathyroid tumor. Cancer runs in my family. Could this tumor be cancerous?

Parathyroid cancer is extremely rare. It does exist, but it is so uncommon that most doctors will never see it. Nearly all parathyroid tumors are benign, even if cancer runs in your family or if you have had cancer in the past. The treatment for both benign parathyroid tumors and cancerous parathyroid tumors is parathyroidectomy, removal of the diseased parathyroid. Although parathyroid tum...

How is parathyroid hyperplasia different from a parathyroid tumor? I had a parathyroid operation for primary hyperparathyroidism and was told that I had hyperplasia. Am I going to have the same benefit from surgery as someone with a tumor?

Parathyroid hyperplasia is a form of hyperparathyroidism in which all four glands are overactive. In the most common form of primary hyperparathyroidism, a patient will have one or two parathyroid adenomas, benign tumors that grow from the parathyroid glands. But some patients have hyperplasia, which is not caused by parathyroid tumors. It is simply an enlargement and overactivity of all of the...

Hyperplasia Outcomes Postop expectations

My teenage daughter was recently found to have a calcium of 10.5 mg/dl. The lab says this is high, and her doctor says that she probably needs surgery to remove a parathyroid tumor. What do you think?

A calcium of 10.5 mg/dl (2.62 mmol/l) is normal for a teenager. Teenagers have higher calcium levels than older adults. While a calcium of 10.5 would definitely be high for a 50 year old, it is within the normal range for children and teenagers. Your daughter's lab is not correcting for her age. Her calcium level does not indicate a parathyroid tumor, and so she does not need surgery.

Normal calcium Diagnosis

How is parathyroid disease treated?

For the most common type of parathyroid disease, called primary hyperparathyroidism, the only treatment is an operation. During the operation, one or more diseased parathyroid glands are removed. Primary hyperparathyroidism is characterized by high calcium (generally over 10.0 mg/dl in adults over age 40, slightly higher for younger adults). If you have parathyroid disease with high calcium, th...

Operation Treatment FAQ Popular

During parathyroid surgery for primary hyperparathyroidism (high calcium preoperatively), I was found to have hyperplasia. My calcium is now normal but I have read that patients with hyperplasia have a higher chance of developing recurrent disease. What are the chances that I will get this again?

Parathyroid hyperplasia in primary hyperparathyroidism is interesting. Adenomas are straightforward: one "bad" gland is removed, and the normal ones are left behind to act normal. With hyperplasia, all four glands are involved, by definition. There are no completely normal glands. This is why we have to remove 3.5 glands, to debulk the parathyroids. In most cases, this produces a long-term cure...

Primary HPT Hyperplasia Secondary HPT Cure rate

I had parathyroid surgery four days ago. I had some tingling yesterday and took extra calcium, and that has resolved. My issue is that I'm having loose stools and abdominal cramping. Do you know what is causing this?

This may be a gastrointestinal reaction to the calcium you are taking. Calcium citrate is a form of calcium I frequently recommend because it tends to not cause constipation as much as some other forms. But it can cause the opposite problem of loose stools. If you are taking calcium citrate, you may want to try a different form of calcium. The most common form of calcium supplement is calcium c...

Postop expectations Postop complications

I have been diagnosed with Primary Hyperparathyroidism and Osteoporosis. I had a 4D CT on the parathyroids and it was normal. Do you think a Sestamibi scan or another test will be better for diagnose or should I wait until my next blood check to see if my Vitamin D3 helped. My endocrinologist said I don't need to take calcium supplements and just keep taking the vitamin K and my ENT doctor said I'm not a good candidate for surgery based on the 4D CT results. I will have the surgery If I can get better. What do you think about my tests levels? My calcium is 9.1 mg/dl and PTH 91 pg/ml. Based on your Analysis Tool I have Secondary Hyperparathyroidism not Primary. Can you please help me?

There are really two separate questions here: 1. What do I do if the 4D CT scan does not show a parathyroid tumor? 2. Is this primary hyperparathyroidism or secondary? For the first question: 4D CTs, or any other scan used to find parathyroid tumors, are not used to diagnose parathyroid disease or determine whether you need surgery. We use lab results to diagnose primary hyperparathyroidi...

Diagnosis Imaging

What are the most common symptoms of primary hyperparathyroidism?

Primary hyperparathyroidism can affect multiple organ systems and produce many different symptoms. The most common symptoms of parathyroid disease are **fatigue and a general sense of not being well.** Most patients will report some fatigue, which can range from mild tiredness to severe fatigue that makes it difficult to work or perform normal daily activities. This, along with other symptoms, ...

Symptoms Popular Primary HPT FAQ

Do I need to take Vitamin D? My latest calcium was 10.7 mg/dl and PTH 60. My doctor is very concerned about my Vitamin D of 15 ng/ml, and says that I should get my Vitamin D level up with supplementation before undergoing parathyroid surgery. Someone else said I should not take Vitamin D. Should I take it?

When you have high calcium, it does not make sense to take Vitamin D supplements, because this can raise your calcium further. One of the main roles for Vitamin D is to help your intestines absorb calcium, thus increasing your blood calcium level. If your blood calcium level is already high, you don't want to take Vitamin D and raise your calcium further. Patients with primary hyperparathy...

Vitamin D Vitamin D deficiency

Hi Dr Boone. I have high calcium. Does it mean I have parathyroid disease? Also your website doesn’t mention primary parathyroid disease. Is it by design? Thanks.

High calcium is almost always caused by parathyroid disease (specifically, primary hyperparathyroidism), but just knowing a calcium level is not enough for a definitive diagnosis. We also need to see a PTH level. Once you have a calcium and PTH level together (ideally taken from the same day), you can usually make the diagnosis. A high calcium combined with a high or normal PTH is diagnostic of...

Diagnosis Primary HPT

I had a parathyroid tumor removed three weeks ago. I feel fine, but my surgical site is concerning me. At the incision site, the skin is red and bumpy, and feels hard. There isn't much swelling, and it doesn't hurt, but it really doesn't look good. What can I do?

When my patients report this to me, the first thing I do is ask them to send me a photo. This is the best way for me to assess it (other than seeing it in person). Before I would make any conclusions about your incision, I would want to see a picture. Having said that, though, what you are describing sounds normal. In the weeks after surgery, the incision tends to look red (at the incisio...

Postop expectations

Does parathyroid disease run in families? I just had parathyroid surgery. Do I need to have my kids check their calcium levels?

Most of the time, parathyroid disease is not familial - it doesn't run in families. Most people who get parathyroid disease will be the only one in their family with it. But occassionally we do see parathyroid disease run in families, and multiple family members across multiple generations will need surgery for parathyroid disease. This can occur in some rare genetic syndromes like MEN (multipl...

Genetics Etiology: the cause of parathyroid disease

Did lithium cause my parathyroid disease? Many years ago, I took lithium for several months. Recently I was diagnosed with primary hyperparathyroidism. Is the lithium to blame?

Lithium is a known cause of primary hyperparathyroidism, but likely did not cause it in this case. Lithium-associated primary hyperparathyroidism usually occurs after many years (think decades) of lithium therapy. It can cause parathyroid disease in less time, but if the lithium was only taken for several months, many years ago, it is most likely unrelated. Interestingly, lithium-associated...

Primary HPT Multigland disease Lithium Hyperplasia

Hello Dr. Boone, I have low vitamin D 25 (19), high vitamins D 1-25 (79), high end of normal calcium (high 9’s), and PTH typically in the high 40’s (same blood draw). I am a 42 years old. I also have calcium phosphate kidney stones. However, due to all of my labs being “normal” other than vitamin D, I have been told I do not have hyperparathyroidism. Can low vitamin D mask the disease? Vit. D supplements make me terribly sick from and I develop stroke symptoms when taking. Therefore, I stopped taking the recommended vitamin D. Without taking the vit d I feel significantly better. Any help is appreciated. Thank you.

Thanks for writing. Low Vitamin D levels are associated with primary hyperparathyroidism, but do not diagnose it. The diagnosis of primary hyperparathyroidism relies mostly on calcium and PTH levels. Sometimes Vitamin D levels can help support the diagnosis (or point away from it). But with calcium and PTH levels in the true normal range, Vitamin D does not play a big role in the diagnosis of p...

What causes primary hyperparathyroidism?

Primary hyperparathyroidism is usually caused by a benign tumor in one or more of the parathyroid glands. In most cases, the tumor grew spontaneously. It was not due to anything that you did, and we do not have an explanation for why it occurred. There are a few known conditions that will cause primary hyperparathyroidism, though these only apply to a small number of patients. Here are the ...

How do I know if I have parathyroid disease?

We diagnose parathyroid disease using lab tests, particularly calcium and parathyroid hormone (PTH) levels. (If you know your calcium and PTH, you can use the <a href="https://www.southwestparathyroid.com/app" target= "_blank">Parathyroid Analysis Tool</a> for an assessment of what your labs mean.) A high serum calcium level (checked on routine labs like a Basic Metabolic Panel or Comprehens...

Diagnosis FAQ Popular

Does parathyroid surgery have to be performed for primary hyperparathyroidism if I don't have any symptoms? Can nutrition or natural medicine correct hyperparathyroidism?

The only known cure for primary hyperparathyroidism (pHPT) is an operation: parathyroidectomy. It's natural to wonder whether this needs to be done, though, if you aren't experiencing any ill effects from the condition. Many patients with pHPT report symptoms like fatigue, brain fog, low energy, body aches, and insomnia. But a few patients say that they feel just fine. These patients often ask ...

Operation Primary HPT Treatment

Last year I was diagnosed with parathyroid disease. My doctor recommended just watching it. Last year my calcium was 10.5, but now it is 9.8 and my doctor says that I don't have parathyroid disease. Does it sometimes go away without treatment?

Primary hyperparathyroidism does not resolve on its own, but the calcium levels can fluctuate back into the normal range. This does not mean that the diseased parathyroid glands have improved. Diseased parathyroid glands act inappropriately; they often don't make a steady amount of PTH. Some days they dump out more PTH, some days less. The PTH thus fluctuates, and so the calcium fluctuates. Thi...

Normal calcium Diagnosis

Is surgery going to help my symptoms? I am exhausted, and just don't feel like myself any more. I have had high calcium levels for the last four years. My doctor recently diagnosed primary hyperparathyroidism but said that I don't need surgery. He doesn't have an explanation for why I feel so bad. My doctor does not think these symptoms are related to the parathyroid, or that parathyroid surgery will help.

Fatigue is the most common symptom reported in patients with primary hyperparathyroidism. It is very likely that your parathyroid condition is a major cause of why you are feeling exhausted. It is also common for patients to state that "I'm no myself any more." Fortunately, these symptoms improve once the parathyroid disease is treated (once the diseased parathyroid gland is removed). Based on ...

Symptoms Operation Postop expectations

My calcium is always noted to be “high-normal” but doctors are not concerned. Could I have parathyroid disease?

<p> It depends on what your actual calcium levels are. <strong>Sometimes what is called "high-normal" is actually too high. </strong> Adults over about age 40 will generally have calcium levels at or below 10.0 mg/dl (or 2.5 mmol/L). If it is persistently above that, then your calcium levels are high, not high-normal. (If you are under 40 years old, then you can have calcium levels that are sl...

Normal calcium Primary HPT Diagnosis

I have had hypothyroidism for many years. Recently I was diagnosed with hyperparathyroidism. Are these related?

Although the word "thyroid" is in parathyroid, the glands are completely separate. Hypothyroidism is very common, so there are many patients with primary hyperparathyroidism who also happen to have hypothyroidism. The hypothyroidism did not cause the parathyroid condition. You just happen to have an underactive thyroid and overactive parathyroids.

Why do you look at all four parathyroid glands during the operation? Doesn’t that pose a risk to the glands?

Seeing all four parathyroid glands is the best way to ensure that you are removing all of the diseased glands and leaving in normal ones. However, there can be a risk: when you look at all four parathyroid glands (or even attempt to look at all four parathyroid glands), you are creating scar tissue, which could then make future operations more difficult. There is even a risk that during the dis...

Operation Primary HPT Operative technique Cure rate

I had a calcium level of 10.6 and then 10.4 on a recheck a week layer. PTH is 58. I am 56 years old. I will discuss with doctor. He might say it is normal and to monitor. Any thoughts?

Thanks for posting your question! From the information that you have given, it looks like you have parathyroid disease. At your age, calcium levels of 10.6 and 10.4 mg/dl are definitely not normal, and usually indicate primary hyperparathyroidism. To diagnose this, we also need the PTH level. Your PTH level is in the higher end of normal, which means that you have primary hyperparathyro...

Diagnosis Primary HPT

I had surgery two days ago. The area around my incision is extremely itchy. The skin is red and bumpy around it. I feel fine otherwise, but can't take this itchiness any more! What should I do?

This sounds like an allergic reaction. If you have a steri-strip, then it is likely an allergic reaction to to the glue that holds the steri-strip in place (usually mastisol). You could also have a reaction to the soap that is used to clean the area just prior to the operation. You should call your surgeon and let him or her know about this. Your surgeon will advise you on the next steps. ...

Postop complications

I had parathyroid surgery last year. I am still on calcium and Vitamin D supplements but wondering if I can stop. My calcium has been normal. When can I stop the calcium?

I usually determine when calcium can be stopped based on two things: 1. Your serum calcium level. If it is low (under 9.3 mg/dl), then I usually recommend continuing to take calcium. If it is truly in the normal range, then it may be possible to stop. 2. Your bone health. If you have osteopenia or osteoporosis, I usually recommend staying on calcium and Vitamin D for the sake of your bones....

Postop expectations

I'm in my early 50s. My calcium has fluctuated between 10.1 and 10.5 over the past two years. My PTH was high normal until this past winter. Now it's above normal in the 90s. My vitamin D has stayed around 29. I am delaying surgery due to Covid and finances. My endocrinologist told me to take 2000 IU of vitamin D daily to lower my PTH. Does supplementing with vitamin D lower PTH and is it safe with hyperparathyroidism? I do know that when I've taken D I feel very tired the next day.

You should not take Vitamin D supplements if your calcium level is high. I'll explain why below. Primary hyperparathyroidism (pHPT) very often causes Vitamin D deficiency, and so it is common for patients to be told to take Vitamin D supplements. Unfortunately, if you have a parathyroid tumor, taking Vitamin D is not going to help, and may hurt. One of the main roles for Vitamin D in your b...

I had parathyroid surgery last week, and I'm feeling worse than I did before the operation. I'm exhausted and feel weak. What is wrong with me? My calcium is normal but it seems like the operation did not help.

I'm sorry that you are having such a tough time. Fortunately, you are most likely cured and what you are going through is normal, and will improve in the next few weeks. It is actually not that uncommon to feel worse in the first week or two after surgery, as your body adjusts to the new hormone and calcium levels. Think about it: your body had years to adjust to having parathyroid disease, wit...

Postop expectations

Others have said that calcium levels do not change with age. Why do you say that they do?

It is not controversial to state that calcium levels vary with age - this has been known for a long time. Studies have shown for decades that healthy children have calcium levels up into the high 10s (mg/dl) range. You are not born with a calcium level that persists for a lifetime. This is not in debate. Over time, the calcium level drops as children become young adults. There is no magic a...

For those with primary hyperparathyroidism, are the symptoms of a parathyroid tumor different from hyperplasia?

Primary hyperparathyroidism can be caused by a benign tumor, multiple benign tumors, or hyperplasia (all four parathyroid glands diseased). The symptoms are all the same. With an adenoma, or tumor, there is one diseased parathyroid and the other three glands are all normal. Sometimes you can have multiple adenomas, with two or even three benign tumors and one normal gland. In hyperplasia, all f...

Hyperplasia Symptoms FAQ

What is a normal calcium level?

Calcium levels vary with age, and normal range drops as you get older. For children and teenagers, calcium levels can range from about 9.3 mg/dl (2.32 mmol/l) to 10.9 mg/dl (2.72 mmol/L). That upper range of normal drops after the teenage years. Adults in their 20s can still have calcium levels up to the mid 10s (or around 2.64 mmol/l). Adults in their 30s tend to have calcium levels in the mid...

Normal calcium FAQ

I was just told that my PTH is 90 pg/ml (normal up to 65 pg/ml). Does this mean I have parathyroid disease?

To interpret this, we need more information. A PTH of 90 is above the "normal" range, but we cannot yet give a diagnosis because we need the calcium level. PTH should only be interpreted in the context of calcium levels. The parathyroid glands make PTH in order to regulate calcium levels. If the blood calcium level is low, then the parathyroids will make more PTH in order to get the calcium ...

Does anyone who has had this illness have issues falling down? Not losing consciousness but just collapsing and falling due to weak legs.

Yes, parathyroid disease can cause you to have more falls. There are primarily two ways it can do this: 1. **Muscle weakness**: Primary hyperparathyroidism causes muscle weakness, especially in the "proximal" muscles, the muscles closer to the center of your body. This includes the muscles involved in helping you stand and walk. Often this is mild - you feel weak but can still do normal ...

Is this primary hyperparathyroidism? Over the last year my calcium levels have been: 10.5, 10.9, and 10.6 mg/dl. My PTH was 57 pg/ml. I'm 75 years old. My physician said that my PTH is normal and so this cannot be primary hyperparathyroidism.

These are classic labs for primary hyperparathyroidism. Your calcium is high for your age. PTH levels can only be interpreted in relation to calcium levels. If your calcium is normal, then you expect the PTH to be in the "normal" range listed on the lab result. But if the calcium is high, normal parathyroid glands will be suppressed, and thus the PTH should be low (under 20 pg/ml). If the PTH i...

Diagnosis Hypercalcemia FAQ

I had parathyroid surgery one week ago. My fatigue has improved, but I've been getting daily cramps in my legs. Is this low calcium? What should I do?

Cramps can be a symptom of low calcium, especially if you are also feeling the more classic symptoms of low calcium such as numbness or tingling in yours hands or face. If the numbness and tingling is also present, then taking extra calcium will likely help with the cramps as well. For anyone with postop cramps, I recommend taking magnesium supplements in addition to calcium and Vitamin D....

Postop expectations

I just found out on routine bloodwork that my calcium is 12.4 mg/dl. I know I need parathyroid surgery but I won't be able to see the surgeon until next month. Since my calcium is so high, I'm worried that my health is going to deteriorate before I get this operation. How quickly do I need to get this done?

The odds are that you have had high calcium levels for years. Your calcium did not jump from normal range to 12.4 in a day, or you likely would have noticed acute symptoms of high calcium (nausea, vomiting, confusion). Since this was found incidentally, it is very likely that you have had rising calcium levels for a while. The severity of primary hyperparathyroidism is unrelated to how high the...

Hypercalcemia Operation

Hi there. I am 56, diagnosed with osteoporosis in 2019 to the tune of -3.5. Initially I ruled out parathyroid disease.....sent my labs to Norman Clinic etc. They said they thought it was unlikely. My question is: Does a DXA showing that my forearm is worse than my spine or femeral neck indicate that there could still be a parathyroid issue? During the course of getting a bunch of labs, I did ask for a right arm dxa.....and it was indeed, worse than the other locations. I have been treating with Tymlos for two years.....with not much improvement so thinking of trying a new med (Evenity) but still have this question in the back of my mind if the osteoporosis could be the result of a parathyroid issue. My calcium before Tymlos was 9.7 mg/dl and PTH ranges from 24 to 50 pg/ml. Any insight? Thanks!

Parathyroid disease does cause osteoporosis, and typically the worst bone loss is seen in the forearm. Whenever someone has more significant bone loss in the forearm than the hip or spine, it is reasonable to think about primary hyperparathyroidism as the cause. The way we diagnose primary hyperparathyroidism is with labs, primarily calcium and PTH levels. Since your calcium and PTH levels ...

Is it common for PTH levels to fluctuate after removal of 1 parathyroid gland? I had surgery and a week later, my PTH was at 96.7. Calcium and Vit D were closer to normal.

The simple answer is yes, it is common (and even expected) for PTH levels to fluctuate after surgery. Right after a parathyroid tumor is removed, PTH levels plummet. If the other parathyroid glands are normal, then they are dormant, and making very little PTH. A day after surgery, I expect the PTH level to be low. Calcium levels drop soon after that as a result of the drop in PTH. In the we...

Operation Postop expectations

Why do you not use the radioguided technique?

When I was at the Norman Parathyroid Center, every patient received a radioguided parathyroid operation. Now that I have my own practice, I perform the radioguided operation in some patients, but not all. The main reason is that most people do not need a radioguided approach. It is extra radiation that most people do not need. What exactly is radioguided parathyroid surgery? It is referring...

Operation Operative technique

What does it mean when your Calcium is 10.7 mg/dL and your Albumin is 4.9 g/dL?

There are two main issues here. First, what does a calcium of 10.7 mg/dl mean? And second, does the albumin change that? Let's address the calcium first. If you are over the age of 30, then that calcium level is high. The most common cause of high calcium is primary hyperparathyroidism. To make that diagnosis, we first have to look at a calcium and PTH level together. If your calcium is hig...

Diagnosis primary hyperparathyroidism Vitamin D Albumin

I believe I've had primary hyperparathyroidism for at least 12 years. I am 73. I also have low Vitamin D in the 26 range. Twice over the years and currently I've been prescribed high doses of vitamin D which does raise my Vitamin D level to 40 ng/ml or within normal range, but each time it also raises my PTH. I was given 50,000 IU of D weekly for 2 months and my PTH went up to 140 pg/ml, not down. I'm now on 4,000 daily of Vitamin D and my PTH has gone up to 174.2-147.4. Why would my Vitamin D going up also cause my PTH to go up? My Calcium stays consistent at 10.2-10.5 mg/dl.

Great question! The short answer is: You have primary hyperparathyroidism, so Vitamin D is not going to fix your problem. Taking Vitamin D will not be able to overcome the parathyroid tumor. The only way to cure this is with parathyroid surgery, to remove the diseased parathyroid gland(s). Long answer: A lot of doctors will see low Vitamin D levels and high PTH levels and prescribe Vita...

Diagnosis Vitamin D

What type of doctor do I need to diagnose primary hyperparathyroidism?

Most people will be diagnosed by their primary care doctor or by an endocrinologist. You do not necessarily need to see a specialist to diagnose primary hyperparathyroidism, but if there is any question, your doctor will likely want you to see an endocrinologist or an endocrine surgeon. Since primary care doctors are often the ones checking routine labs, they are usually the first to notice ...

I am 69. My calcium levels have run consistently 10.8 range for the past 2 years. It has been 11.9 and 11 as recently as a few days ago. My PTH was 86 in September 2021 but is normal range now. However I feel really bad. Fatigue, difficult concentration, tingling lips, constipation, absolutely no appetite with weight loss, nervous internally and eye sight changes. Could I have parathyroid issues even with a normal PTH? I have seen doctors but they just say they don't know why my calcium is high or what is causing my symptoms. My whole life has changed. I'm desperate for answers and where to find them. Please help.

Your lab results indicate primary hyperparathyroidism. You are experiencing the classic symptoms of the disease, which should improve once you get it treated. The diagnosis of primary hyperparathyroidism is based mostly on calcium and PTH levels, but you do not need to have a "high" PTH to make the diagnosis. The important thing is the calcium and whether the PTH is appropriate given the ca...

Diagnosis Hypercalcemia primary hyperparathyroidism

I am set to have surgery for primary hyperparathyroidism in the near future. So far testing has not been able to detect the location of a hyperparathyroid tumor. I have been told that during the exploratory surgery if the parathyroid glands cannot be located, my thyroid will be removed in an attempt to lower calcium levels. I was also told that if a tumor appeared in the future additional surgery would be necessary. I would like to know if the removal of a thyroid is the normal course of action when parathyroid glands cannot be located.

Thanks for writing. The short answer is that removing the entire thyroid is almost never necessary in parathyroid surgery, but occasionally removing a piece of thyroid can help. There is one very specific scenario in which I will remove a piece of thyroid. Here is the scenario: I am performing an operation for primary hyperparathyroidism and have found three normal parathyroid glands, but I...

Operation Postop complications Operative technique

How soon after surgery are calcium and vitamin D levels checked? Who follows the patient after surgery to check calcium/vit-D levels (primary care doctor, endocrinologist, Dr. Boone), and how often and how long should a patient be followed after surgery to check these two levels? Thank you.

I like to check the calcium, PTH, and Vitamin D around four to six weeks after surgery. Immediately after surgery, your PTH level will drop. Then over the next few days your calcium will drop as well. In the couple of weeks after the operation, your levels will be fluctuating. I don't check them routinely at this point, since the fluctuating levels may not give a very accurate picture. Afte...

Postop expectations

Can excess parathyroid hormone cause loss of energy?

Yes! One of the most common symptoms of parathyroid disease is low energy. Excess parathyroid hormone (PTH) usually causes elevated calcium levels. Both the elevated PTH and elevated calcium levels cause problems throughout the body. The most common symptoms are often non-specific: fatigue, low energy, insomnia, aches and pains. These symptoms can be debilitating. Excess PTH can also lead t...

Symptoms primary hyperparathyroidism

I had parathyroid surgery last week - two glands were removed. The biopsy came back as hyperplasia instead of adenoma. My understanding is that if it is hyperplasia, all FOUR glands are affected. My surgeon did find a 3rd gland "lumped in" next to one of the enlarged glands and he originally took it as well, upon further inspection, realized it was not part of the bad gland and appeared normal, so he re-implanted it. He did NOT look at the 4th gland at all. My question is, since the pathology came back as hyperplasia instead of adenoma, will I need another surgery at some point to remove the other gland?

Thank you for bringing up this really important topic! The full answer to your question is complicated, so here is the brief summary: Pathology is not used to determine whether you had adenomas or hyperplasia. In most cases, we can't determine hyperplasia vs. adenoma on pathology slides. The report is really just confirming that your surgeon removed parathyroids. An adenoma may be called "hy...

Operation Pathology

I have thyroid nodules. One has grown. Do I need a biopsy before having parathyroid surgery? I want all of them removed. Thank you.

Thyroid nodules are very common, and most of the time they are completely benign. If there is a concern for cancer, then it makes sense to have the nodule biopsied before undergoing parathyroid surgery, since the thyroid operation can be done at the same time as the parathyroid. If your nodules all appear benign on ultrasound (the best imaging study for thyroid nodules) then getting a biops...

Thyroid nodule Operation

Why would my serum calcium be high but Ionized calcium low? Does low ionized calcium mean no parathyroid issue? Should I follow-up or wait for next year annual blood work? I'm 66 years old. Recent blood work showed: Serum Calcium: 10.5 mg/dl Follow-up 1 week later (non-fasting): Ionized Calcium = 1.08 Vit D = 32 ng/ml PTH = 37.8 pg/ml

Most commonly, the total serum calcium and ionized calcium will show a similar pattern - that is, they will both be on the high end or both on the low end. But not always. There are multiple factors that could make one or more of these results less reliable. Total calcium levels depend on albumin, so a low albumin can give you a falsely low calcium level. Ionized calcium levels depend on the pH...

Do you know what causes the parathyroid tumours to grow in the first place? What if the tumour grows back? Do you have to keep getting surgery to remove them?

Most cases of primary hyperparathyroidism are due to benign tumors (adenomas) on one or more parathyroid glands. And in most of those cases, we don't have a good explanation for why the tumor grows. We know that the risk for developing a parathyroid tumor is higher in women, and is higher in older people. And we know that there are genetic causes for parathyroid tumors, though most people with ...

Etiology: the cause of parathyroid disease