Frequently Missed Calcium, Bone & Parathyroid Problems
“There is no other disease that is so easy to cure which has such a huge impact on a person’s overall health and their quality of life.” – Dr James Norman, 2011 address to the American College of Surgeons.
Parathyroid glands are small glands of the endocrine system which are located in the neck behind the thyroid and there are 4 of them. They are very small, usually the size of a grain of rice. The sole purpose of the parathyroid glands is to control calcium within the blood in a very tight range between 9.0 and 10.1. In doing so, parathyroid glands control how much calcium is in the bones, as well as how strong and dense the bones are. (Almost all adults live with calcium levels in the mid 9 range; there are almost no adults who feel well with calcium levels below 9 or above 10.2).
Any change in the amount of calcium in our bodies can cause us to feel bad (see symptom list below). Calcium is one of the most important elements in our bodies because it controls many cellular functions. Calcium allows the nervous system to have normal electrical currents. Our entire brain works because of calcium flowing into and out of the nerve cells and the brain demands a steady calcium level. Calcium also is the primary element that causes muscles to contract, (including your heart), regulates your kidneys and even your intestinal system to function normally.
Parathyroid disease (hyperparathyroidism) occurs when one or more of the four parathyroid glands grows into a tumor and makes excess parathyroid hormone. Sometimes hyperparathyroidism makes people miserable within the first year or two of having high blood calcium. Other times it can go over 10 years without causing too many problems other than fatigue, bad memory, kidney stones, and osteoporosis. But hyperparathyroidism can kill people–it just takes 20 or so years to do so.
The most common symptoms for someone with parathyroid disease are related to the brain, including depression and lack of energy. Osteoporosis, or thinning of the bones, occurs in almost all people with hyperparathyroidism. Fortunately osteoporosis caused by hyperparathyroidism is reversible.
Kidney stones are usually made of calcium, and hyperparathyroidism is a major cause of kidney stones. Nearly half of all people with kidney stones have a parathyroid tumor.
Symptoms of Parathyroid Disease (Hyperparathyroidism), from www.parathyroid.com
Loss of energy. Don’t feel like doing much. Tired all the time. Chronic fatigue. (#1 symptom)
Just don’t feel well; don’t quite feel normal. Hard to explain but just feel kind of bad.
Feel old. Don’t have the interest in things that you used to.
Can’t concentrate, or can’t keep your concentration like in the past.
Depression.
Osteoporosis and Osteopenia.
Bones hurt; typically it’s bones in the legs and arms but can be most bones.
Don’t sleep like you used to. Wake up in middle of night. Trouble getting to sleep.
Tired during the day and frequently feel like you want a nap (but naps don’t help).
Spouse claims you are more irritable and harder to get along with (cranky).
Forget simple things that you used to remember very easily (worsening memory).
Gastric acid reflux; heartburn; GERD.
Decrease in sex drive.
Thinning hair (predominately in middle aged females on the front part of the scalp).
Kidney Stones (and eventually kidney failure).
Excessive urination.
Abdominal pain, nausea, vomiting, or loss of appetite.
High Blood Pressure (sometimes mild, sometimes quite severe; up and down a lot).
Recurrent Headaches (usually patients under the age of 40).
Heart Palpitations (arrhythmias). Typically atrial arrhythmias.
Atrial Fibrillation (rapid heart rate, often requiring blood thinners and pacemakers).
High liver function tests (liver blood tests).
Development of MGUS and abnormal blood protein levels.
Frequent complaints of illness with no apparent cause.
Most people with hyperparathyroidism will have 5 – 6 of these symptoms. Some will have lots of them. A few people will say they don’t have any… but after an operation they will often say otherwise. In general, the longer you have hyperparathyroidism, the more symptoms you will develop.
People of every age get parathyroid disease. It is most common in patients in their 50s, 60s, and 70s. Women get hyperparathyroidism three times more commonly than men. Yet as more and more young people are getting their blood calcium checked, we are finding more parathyroid problems in younger adults (30’s and 40’s).
Diagnosis of Hyperparathyroidism – made primarily by symptoms, and several weekly blood calcium & parathyroid hormone levels
Almost all normal adults have calcium levels in the 9’s. It is very rare for an adult (over 30) to have persistent calcium levels above 10.1 or below 9.2. Rarely a normal person can have a calcium level in the low 10’s, but when checked again it should be back in the 9’s. Calcium levels that are consistently in the low to mid 10’s (in an adult over 30) is almost never normal and will almost always be caused by a parathyroid tumor.
It is classically taught that the diagnosis of hyperparathyroidism requires a high calcium and a high PTH level at the same time. However, about 20-25% of patients will not follow this pattern, with some having high calcium levels and normal PTH levels (16%), while others have normal calcium levels with high PTH levels usually around 100 (4-6%). A high calcium and a high PTH at the same time is absolutely NOT required to diagnose primary hyperparathyroidism! It is absolutely not necessary to have high PTH levels to make the diagnosis of hyperparathyroidism… but if the PTH is not high, then the calcium must be high (and the PTH levels are usually over 35 pg/ml).
It has been suggested (wrongfully) that low Vitamin D levels will cause normal parathyroid glands to hypertrophy and over-produce PTH… which in turn will cause the calcium to rise. According to Dr. Norman, this does not happen. Low Vitamin D levels will never cause the calcium to increase above normal. It is possible that low vitamin D levels in patients with low normal or low calcium levels will be associated with modest elevations in the PTH. About 83% of all patients with tumor-proven primary hyperparathyroidism will have low Vitamin D levels. Nearly 90% of these patients will have normal Vitamin D levels within 1 month of parathyroid tumor removal, and 96% will have normal levels at two months post-op. Parathyroid glands respond almost exclusively to low calcium levels; and low vitamin D levels have very little effect on normal parathyroid glands… as long as the calcium is normal.
Imaging studies: Many providers like to get ultrasounds (of thyroid and parathyroid glands) and/or parathyroid nuclear scans. According to Dr. Norman of the Norman Parathyroid Center, these are not routinely needed.
In summary, the diagnosis of primary hyperparathyroidism is made by evaluating a person’s clinical symptoms and their labs. Most people have a chief complaint of fatigue, but many other problems will be present in most with hyperparathyroidism. You must remember that a person can have primary hyperparathyroidism with normal calcium levels or normal PTH levels. Also, it is almost never normal to have high calcium levels, and this should generally be worked up with the presumption that a parathyroid tumor is present. Calcium and PTH levels in normal people are very constant from week to week, measure to measure, however those with primary hyperparathyroidism have calcium and PTH levels that are variable and go up and down from day to day, week to week. There is no medical reason to “wait 6 months and get more tests”. The patient either has a parathyroid tumor or they do not. The key to making the diagnosis of primary hyperparathyroidism is REPEATED measures of 1) serum calcium, 2) ionized calcium, 3) PTH. Measure them weekly for 2 or 3 weeks and the diagnosis will be clear in most all cases. Adults over 30 live in the 9’s, not the 10’s. Teens and young adults in their 20’s who are building bone can have calcium levels up to 10.7 on more than one occasion. Generally, this is not true for adults over 30. There is no reason to get a urine calcium level on the vast majority of patients.
TREATMENT:
Surgery is the only way to treat parathyroid disease (hyperparathyroidism). Parathyroid tumors are usually the size of an olive or a grape and up to 30% of people with hyperparathyroidism will have more than one tumor. It is reassuring to know that we can live just fine with less than four normal parathyroid glands. There are no medications or pills that work to cure or treat parathyroid problems or high calcium. The parathyroid tumor must be removed by a surgeon, and it is a very low risk surgery when done by an experienced head and neck ENT surgeon. The good news is that parathyroid tumors are nearly always benign. As soon as the parathyroid tumor has been removed, you are cured! This very likely will change your life!
“Hyperparathyroidism is a simple benign disease that will slowly destroy your body and take away the “joy of life” while it does so. It will make you miserable!” For more information please refer to Dr. Norman’s website, www.parathyroid.com.
Blessings & prayers always, and praises to our awesome God for His continual wisdom, teaching, and healing!
Dr. Lisa
