Hyperparathyroidism: Causes, Symptoms, Treatment, Prognosis, Ayurveda Understanding

Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S

Parathyroid Glands

These are small glands located behind the thyroid gland, at the bottom of your neck. They are about the size of a rice grain. These glands produce a hormone which is named after them i.e. ‘parathyroid hormone’.

Importance of Parathyroid Hormone

This hormone plays a role in regulating the body’s blood level of calcium and phosphorus. It also helps in maintaining the needed balance of calcium in the bloodstream. It also maintains the right balance of calcium in the tissues which are ‘calcium dependent’ for their proper functioning. Mainly this is important for functions of nerves and muscles and for bone health.

Hyperparathyroidism

Hyperparathyroidism is a condition caused when the parathyroid glands make higher amounts of parathyroid hormone than desired in the bloodstream. In short, ‘increased parathyroid hormone in the bloodstream = hyperparathyroidism’.

Types of Hyperparathyroidism

Hyperparathyroidism is of two types. They are –

1. Primary Hyperparathyroidism
2. Secondary Hyperparathyroidism

1. Primary Hyperparathyroidism

Mechanism / Pathogenesis – In this condition there occurs enlargement of one or more of parathyroid glands. This in turn leads to over production of parathyroid hormone. Due to this, the calcium levels increase in the bloodstream. A high level of blood parathyroid hormones leads to a variety of health problems.

Enlargement of parathyroid glands

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Over production of parathyroid hormone

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Increase of parathyroid hormone

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High levels of parathyroid hormone in bloodstream

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Primary Hyperparathyroidism

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Symptoms of hyperparathyroidism and variety of health issues

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The most common treatment – Hyperparathyroidism is commonly treated with surgery.

2. Secondary Hyperparathyroidism

Mechanism / Pathogenesis – This condition happens secondary to some other disease and hence the name. The pre-existing disease will be the one which might have already caused low levels of calcium in the body creating a backdrop for the disease to occur. As a feedback mechanism and response to low levels of calcium, the parathyroid hormones get increased over a period of time. This happens when the body fights to keep the calcium levels to a balanced level. This is common in kidney disease and after some intestinal diseases and surgeries.

Kidney disease, intestinal diseases (some), intestinal surgeries, some other diseases

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Cause low levels of calcium in the body

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Body responds to this situation by producing high levels of parathyroid hormones to keep the calcium levels under check (feedback)

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Increase of parathyroid hormones in the blood

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Secondary hyperthyroidism

Symptoms of Hyperparathyroidism

When elevated levels of calcium are found in blood during routine blood tests, the physician will dig deep and diagnose primary hyperparathyroidism much before the signs and symptoms of the disease occurs. So in many cases the diagnosis of this condition comes earlier even before the patient gets to experience its signs and symptoms.

The symptoms of hyperparathyroidism occur once the damage or dysfunction in other organs or tissues has set in reflecting high blood calcium or high urine calcium or too little calcium in the bones.

Symptoms of active disease may range from being mild and nonspecific (of disease or parathyroid function) or severe.

Below mentioned are the important (noticeable) signs and symptoms of hyperparathyroidism –

–        Osteoporosis

–        Bone pain

–        Joint pain

–        Kidney stones

–        Weakness / easy tiredness

–        Excessive urination

–        Abdominal pain

–        Nausea / vomiting

–        Loss of appetite

–        Depression / forgetfulness

–        Frequent complaints of illness (without any known cause)

What is the right time to see the doctor?

One can immediately see the doctor if he or she is experiencing any signs and symptoms of hyperparathyroidism. The same symptoms may also alert other diseases. Therefore it is important that a medical opinion is sought for as soon as possible so that a prompt and accurate diagnosis can be made and also the right treatment shall be started at the right time.

Causes of Hyperparathyroidism

Any factors which cause an increase in ‘parathyroid hormone production’ will cause hyperparathyroidism.

How does this happen?

1. Low calcium levels in the body –

When the ‘blood calcium levels’ fall too low, the parathyroid glands release enough parathyroid hormone. This would help in restoring the balance of calcium levels. This hormone raises calcium levels by different mechanisms (mentioned below) –

–        by releasing calcium from the bones,

–        increasing the amount of calcium absorbed from the small intestine and

–        decreasing the amount of calcium lost in urine

2. High calcium levels in the body –

On the contrary when the ‘blood calcium levels’ are too high, the parathyroid glands produce less parathyroid hormone.

Apart from keeping the bones and teeth healthy, calcium also aids in transmission of signals in nerve cells and also in muscle contraction. In these areas, phosphorus works along with calcium. Sometimes high amounts of hormones are produced by one or more of the parathyroid glands. This can happen as a consequence of the body’s response to high calcium levels, to keep them in standard range. On the other hand they may be inappropriately elevating the calcium in the blood. Which mechanism happens depends on the underlying problem.

Primary Hyperparathyroidism – will occur due to a problem with one or more of the four parathyroid glands. The most common cause is an adenoma on the gland. In most other cases hyperplasia (enlargement) of two or more glands may be the cause. On the other hand, a cancerous tumor may be a very rare cause of this condition.

High amounts of parathyroid hormone are produced by one or more of the parathyroid glands. This causes high calcium and low phosphorus levels in the blood.

Primary hyperparathyroidism usually occurs randomly but some people inherit a gene that causes this condition.

Secondary Hyperparathyroidism – results from another condition / disease that lowers blood calcium. This would affect the functioning of the gland / glands. This causes overworking of parathyroid glands and production of high amounts of parathyroid hormone so as to restore or maintain the calcium level to normal (standard) range.

Below mentioned are the factors that may result in secondary hyperparathyroidism –

1. Severe calcium deficiency – due to inability of the digestive system to absorb calcium usually following intestinal surgery (includes weight loss surgery)
2.   Severe vitamin D deficiency – which might lead to dropping of calcium levels (vitamin D helps in maintaining calcium levels in blood and also helps the digestive system to absorb calcium from food)
3. Chronic kidney failure – kidneys convert vitamin D into a form that can be used by the body. Usable Vitamin D may decrease and calcium levels drop in presence of poorly working kidneys. This eventually causes high levels of parathyroid hormone production. Chronic kidney failure is the most common cause of secondary hyperparathyroidism.

Tertiary Hyperparathyroidism

End stage kidney disease may lead to long term secondary hyperparathyroidism. In this condition the parathyroid glands enlarge and start releasing parathyroid hormone on their own. This doesn’t respond to medical treatment and subsequent high levels of blood calcium. This condition is called tertiary hyperparathyroidism. Surgery may be required in this condition to remove parathyroid tissue.

Risk Factors

Below mentioned may be considered as risk factors of primary hyperparathyroidism –

–        being a woman who has gone through menopause

–        having had prolonged, severe calcium or vitamin D deficiency

–        having multiple endocrine neoplasia type 1 – a rare inherited disorder which usually affects multiple glands

–        having had radiation treatment for cancer in which the neck has been exposed to radiation

–        have taken lithium as a part of treatment for bipolar disorder

Complications

Long term effects of too little calcium in bones and too much calcium in the bloodstream usually are related to complications of hyperparathyroidism. Below mentioned are the common complications of hyperparathyroidism –

Osteoporosis – weak and brittle bones that break easily (due to loss of calcium from bones)

Kidney stones – too much calcium in urine is caused by too much calcium in the blood. This leads to formation of kidney stones.

Cardiovascular disease – high calcium levels are associated with heart and blood vessel conditions such as high blood pressure and some types of heart disease.

Neonatal hypoparathyroidism – dangerous low calcium levels in newborns are found in cases of severe, untreated hyperparathyroidism in pregnant women.

Diagnosis of Hyperparathyroidism

Blood tests – Elevated calcium levels found by blood tests is the main criteria of diagnosis of hyperparathyroidism. There are many conditions which cause raised calcium levels in blood but if the blood tests also show that one has high levels of parathyroid hormones along with raised calcium levels the doctor will reach the diagnosis of hyperparathyroidism.

Other tests – these tests might be required to rule out possible conditions causing hyperparathyroidism, to find out possible complications of the disease and determine the severity of the disease. These tests include –

Bone mineral density test – to check if one has developed osteoporosis. DEXA (Dual Energy X-ray Absorptiometry is the most common test used for this purpose.

Urine test – is done to

–        check the functioning of kidneys

–        to find out the quantity of calcium passed in the urine

–        to determine the severity of hyperparathyroidism

–        to diagnose a kidney disorder causing hyperparathyroidism

Very low urine calcium levels indicate that the given condition will not need any treatment.

Imaging tests of kidneys (X-rays or other imaging tests of the abdomen) – are done to determine if one has kidney stones or other kidney problems.

Sestamibi parathyroid scan either alone or combined with CT scan or ultrasound scan may be preferred if surgery is recommended.

Treatment

The three main treatment options / strategies for hyperparathyroidism include –

–        waiting watchfully

–        surgery

–        medications

1. Waiting – Doctors would prefer to wait and watch without hurrying up with treatment in the below mentioned conditions –

If there is slight elevation of calcium levels

If the kidney functions are intact and well and if the patient doesn’t have kidney stones

If the bone density is within standard range or slightly below the normal range

If there are no other symptoms which might improve with treatment

In this ‘wait and watch’ strategy your doctor might recommend you with regularly scheduled tests to monitor your blood-calcium levels and bone density.

2. Surgery – This is the most common treatment for primary hyperparathyroidism. In most cases it also provides a cure. The glands which are enlarged or have a tumor will be surgically removed. A small portion of the fourth gland may be left out after removing the other three glands in case all four glands are affected. This is with an intention to leave some functioning parathyroid tissue intact. During surgery there is a risk of damage to vocal cord nerves. One might also have long term low calcium levels and might require calcium and vitamin D supplements post-surgery. The body cannot produce enough parathyroid hormone to keep the calcium levels in balance (standard or normal range).
3. Medications –

Calcimimetics (sold as cinacalcet / Sensipar) – are drugs which mimic calcium circulating in the blood. They are considered to trick the parathyroid glands into releasing their hormones. It is used for treating primary hyperparathyroidism in those people who are either not eligible for surgery or if surgery has failed to successfully cure this disorder. Along with vitamin D analogs it is used to manage secondary hyperparathyroidism in chronic kidney disease. They decrease the work load on parathyroid glands by keeping the balance of calcium and phosphorus levels.

Joint and muscle pains, nausea, diarrhea and respiratory infections are common side effects of this drug.

Hormone Replacement Therapy – HRT may help bones to retain calcium especially in women having signs of osteoporosis following menopause but it does not address the underlying problems with parathyroid glands. Its prolonged use can increase risk of blood clots and breast cancer. Breast pain and tenderness, dizziness and headaches are the common side effects of HRT.

Bisphosphonates – They prevent loss of calcium from bones and may lessen hyperparathyroidism induced osteoporosis. Fever, vomiting and low blood pressure are some known side effects associated with these medicines. It does not address the underlying problems with parathyroid glands and the blood calcium levels remain above normal range.

Self Care

One needs to self care and try to follow the below mentioned suggestions so as to prevent complications of primary hyperparathyroidism especially if his or her doctor chooses to ‘wait and watch’ (monitor) the condition in favor of treating it. They are –

–        One needs to monitor the quantity of calcium and vitamin D included in the diet – these may vary for different persons and at different age groups. One needs to speak to his or her doctor and chart out the dietary guidelines that are right for him or her.

–        Hydration – One needs to drink enough (plenty) of fluids (water). This would help lessen the risk of formation of kidney stones.

–        Regular Exercise – One should exercise regularly. Strength training included in the exercise schedule will help in maintaining strong bones. Exercise programs can be planned by talking to one’s doctor.

–        Quit smoking – Smoking not only increases bone loss but also is a risk factor for several serious health problems. Therefore one should talk to his or her doctor and find out ways to quit smoking.

–        Avoid medicines which tend to raise calcium levels – Medicines like lithium diuretics etc tend to raise calcium levels. Ask for alternatives with your doctor for such medications.

Research works related to Hyperparathyroidism

Study – The results of a study published in Jama network about ‘Analysis of Comorbidities, Clinical Outcomes and Parathyroidectomy in Adults with Primary Hyperparathyroidism’ suggest that the Primary Hyperparathyroidism (pHPT) is associated with increased risk of fractures, CVEs and death. This study highlights the importance of identifying patients with this condition to prevent serious unfavorable outcomes. The reduced risk of these outcomes associated with PTX suggests a clinical benefit of surgery.

Study – A study – ‘Calcium intake and risk of primary hyperparathyroidism in women: prospective cohort study’ shows that ‘increased calcium intake is independently associated with a reduced risk of hyperparathyroidism in women’.

Study – Another study suggests ‘Gender differences in the presentation of primary hyperparathyroidism may exist but do not seem to result in different outcomes’. The same study also draws many other conclusions. The findings of this study support the association between primary hyperparathyroidism and breast carcinoma observed in previous studies.