In this episode of PodMD, Specialist Endocrine and General Surgeon Dr Nicole Rodrigues will be discussing the topic of primary hyperparathyroidism. We discuss what primary hyperparathyroidism is, how patients typically present, treatment options, which patients GPs should screen for, and more.
- Transcript
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Today I’d like to welcome to the PodMd studio Dr Nicole Rodrigues.
Dr Rodrigues is a specialist Endocrine and General Surgeon practicing in Canberra. After spending 11 years in the city completing her medical degree at the Australian National University and General Surgery training through the Canberra training network, she went on to pursue advanced subspecialty training in Endocrine Surgery.
She completed the prestigious ANZES Endocrine Surgery Fellowship at two of Australia’s leading centres — St George Hospital in Sydney and The Alfred Hospital in Melbourne.
Dr Rodrigues has a special interest in the surgical management of thyroid, parathyroid, and adrenal disorders, including thyroid cancer, Grave’s disease, hyperparathyroidism, and adrenal lesions, both functional and non-functional.Alongside her endocrine practice, she also performs a broad range of general surgical procedures such as laparoscopic hernia repairs, laparoscopic cholecystectomy and skin cancer excisions.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
Today, we’ll be discussing the topic of Primary Hyperparathyroidism. Nicole, thanks for talking with us on PodMD today.
Nicole: Thank you for having me.
The topic of today’s discussion is primary hyperparathyroidism. Nicole, can you describe for our listeners what primary hyperparathyroidism is?
Nicole: Yeah, so high primary hyperparathyroidism is where one of or more of parathyroid glands become overactive, resulting in an overproduction of parathyroid hormone. This is a condition where the parathyroid glands then become autonomous and no longer respond to the usual negative feedback. This leads to the parathyroid hormone having effect on the bones, kidneys and gastrointestinal tract to result in increased calcium being reabsorbed from those sites, and an overall elevation in the serum calcium level. This condition is not common, but it affects up to 1% of the population and up to 3% in postmenopausal women.
Question 1
How would a patient with primary hyperparathyroidism typically present?Nicole: So as you will all know, in patients having blood tests you often see an increased calcium level and that’s generally how most patients with primary hyperparathyroidism present, an incidental finding of hypercalcemia, and in these patients they subsequently have a parathyroid hormone measured and that also shows an elevation in their PTH.
Patients might also present with some non specific symptoms such as fatigue, brain fog, memory loss, difficulties concentrating, constipation, frequent urination, even depression or muscle aches. And it’s very difficult to pinpoint this to any specific condition and sometimes patients don’t even realise that they feel unwell with this condition.
In more advanced scenarios, patients might also develop renal stones and osteoporosis, as well as minimal trauma fractures, and that might lead them to have investigations that diagnose primary hyperparathyroidism.
Question 2
And what are the long term effects of this condition?Nicole: So the overall effect of having a raised parathyroid hormone level is that increase in calcium in the bloodstream, and so this calcium is leached mainly from the bones and that results in a reduced bone mineral density and over time the patient can develop osteopenia and then osteoporosis, which increases their fracture risk.
This increase in serum calcium also can result in calcium being deposited in the kidneys, leading to nephrolithiasis as well as formation of renal calculi, with the subsequent development of ureteric colic or even renal impairment as a result of this calcium deposition. Calcium in the bloodstream can also be deposited in the vessels, leading to cardiovascular disease and atherosclerosis over time. And so we know that in this condition of primary hyperparathyroidism that it will progress over time in its natural history, and that surgery is the only known definitive cure from this condition.
Question 3
What are the treatment options?Nicole: So yes, I’ve mentioned earlier, surgery is the only definitive cure for this condition. There are medications that can help with reducing serum calcium levels, such as cinacalcet as well as medications to manage the bone mineral density in the form of bisphosphonates. However, none of the medical treatment options deal with the underlying cause, which is the overactivity of the parathyroid glands. So there was a position statement that was released in 2023 from the Australian Endocrine Society that recommended that anyone with the biochemical diagnosis of primary hyperparathyroidism and a life expectancy of 10 years or more who are fit for surgery should have parathyroidectomy, regardless of the presence of symptoms. As we know that this condition does progress overtime and if there is a biochemical diagnosis that there is not any need to wait until someone develops complications before we treat this condition.
Question 4
Have there been any developments in treatments in the last years?Nicole: So in recent times, there’s been increasing use of minimally invasive parathyroidectomy or focused parathyroidectomy, due to the advances in parathyroid imaging. So traditionally we’ve liked to have dual localisation for a parathyroid gland once someone has been confirmed by a chemically to have the condition.
I would normally organise an ultrasound and sestamibi nuclear medicine scan to help localise the culprit parathyroid gland and once we have two modalities that are concordant, then the patient would be suitable for a focused or minimally invasive parathyroidectomy aimed at removing just that culprit parathyroid. If someone had discordant imaging, then I would proceed to also organising a 4D CT scan which gives us more anatomical information to try and localise this gland.
Question 5
Which patients should a GP screen for this condition?Nicole: So often primary hyperparathyroidism can go unnoticed and certainly there are certain population groups that should have a calcium and parathyroid hormone measured just to ensure that their symptoms or condition isn’t due to a hypercalcemia. Certainly anyone with osteoporosis and younger patients with a reduced bone mineral density should have screening performed. As well as patients with minimal trauma fractures or renal stones.
Patients on lithium say for bipolar disorder, we know that lithium is associated with parathyroid gland hyperplasia and primary hyperparathyroidism. As well as anyone with sort of non specific symptoms or fatigue or musculoskeletal aches and pains, and any neuropsychiatric complaints such as depression or irritability or difficulty concentrating. Certainly you know majority of these people will not have primary hyperparathyroidism, but of the few that you might pick up, they could have a surgical cure for their condition.
Certainly I remember last year I managed 80 something year old patient who thought she was developing dementia with memory loss and difficulty concentrating and just a general sort of fatigue and lethargy. She had a biochemical diagnosis of primary hyperparathyroidism and we’re able to localise one parathyroid adenoma, and after her minimally invasive parathyroidectomy she told me that she never felt this good in sort of her recent memory. She had a completely new lease on life. She could think clearly again, she was full of energy, and on her subsequent follow-up told me that she had won her seniors golf tournament and, you know, was really happy with the result of the surgery.
So, you know, you’re never too old to have treatment for this condition, cause it can definitely improve your quality of life.
Question 6
What is the likelihood of recurrence of the condition?Nicole: So after surgery, recurrent hyperparathyroidism can be reported in one to two percent of patients and this can either be due to an adenoma forming in one of the remaining glands, or a potential for an atopic or a supernumerary gland developing this condition as well. And in that situation we would start the workup again from the beginning with repeating bloods and urine, and repeating all the imaging to try and sort of relocalise the condition. And then we discuss with the patient, depending on the severity of the calcium elevation and the imaging, whether it’s worth sort of going back into surgery to you know look for this other culprit or whether long term monitoring would be recommended.
Question 7
When should a GP refer?Nicole: So certainly as early as possible. So once you detect a hypercalcemia and showing that the parathyroid hormone is also elevated, it would be good to exclude any secondary causes of hyperparathyroidism. With checking the vitamin D to ensure there’s no vitamin D deficiency, and also checking their renal function to make sure that sort of within the normal range as those two conditions can contribute to hyperparathyroidism.
But if there’s sort of persistent elevation in the calcium and parathyroid hormone, then that’s when the patient should be referred to an endocrine surgeon like myself for further work up to confirm the biochemical diagnosis. So what I would also do once I see the patient is get a urine, calcium and creatinine to exclude familial hypocalciuric hypercalcemia, and then proceed to imaging to localise the parathyroid glands.
Question 8
Nicole, what role does the GP play in the treatment of the condition?Nicole: So GP’s have a vital role in early recognition and referral because you guys are the first line in seeing these patients and seeing these blood tests and seeing patients with the symptoms that are associated with this condition. It’s up to you to, I guess, recognise that this is a problem and then helping with the work up in terms of measuring the calcium and the parathyroid hormone and the vitamin D and renal function, and referring early to enable this patient to have their surgical management. I think that’s, you know, the most important step in this whole process.
And the other thing is if the patient has an established osteoporosis, then you also have a key sort of role in helping to manage that, you know, with or without the help of an endocrinologist, but I know a lot GPS are very experienced in managing osteoporosis, so you may or may not need that sort of assistance, but those would be the main, I guess effects of hyperparathyroidism is the effect on the bone mineral density.
Question 9
Thanks for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on primary hyperparathyroidism?Nicole: Well, thank you for having me. I think the three take home messages are one, early recognition and referral is I think the most important step.
Two, that surgery is the only known definitive cure for this condition, and we now know that anyone fit to have surgery should have it before the complications develop. It’s always better to prevent these complications rather than try and rebuild the bone mineral density or to try and treat the renal stones after they’ve already developed. So I think prevention is better than cure.
Then also that you know the so called asymptomatic patients are often not asymptomatic at all. They just get used to feeling tires and loss of concentration or memory, and they don’t realise how much you know better they feel after they have the culprit parathyroid gland removed and you know certainly it’s been very gratifying from my end to see this, you know, huge improvement in their quality of life. And so I find that this is one of the, you know, more satisfying operations that I do.
Thanks Nicole. Thanks for your time and the insights you’ve provided.
Nicole: Thank you very much.
