Hyperparathyroidism is more than just a random name. You may have never heard of it or heard it mentioned in passing.
If you have thyroid disease, it could be a hidden source of many stubborn symptoms. This blog will help you know if it could be an issue for you.
I had never heard about hyperparathyroidism until I reached medical school. The impression that it got was that it was:
Key Insight: If you have symptoms that include some mixture of fatigue, digestive issues, anxiety, or muscle aches, this could be the hidden reason. If you have thyroid disease, your risks for parathyroid disease are higher.
Over the years of treating thyroid disease, I have come to realize that none of these things are true.
Parathyroid disease is not as rare as you would think. And it can cause the most common symptoms we suffer from. It is easily missed unless a doctor knows exactly how to find it.
“Jonell” was a patient of mine in my early years of practice. Like most, she first came in already on thyroid treatment but was not at her best just yet.
A bunch of symptoms came on around the same time and she thought her thyroid was the culprit.
Once diagnosed with thyroid disease, she went on treatment and it did get easier to manage her weight. However, her symptoms of IBS, fatigue, and anxiety did not get any better.
She hoped that if I helped her optimize her thyroid treatment, these other symptoms could improve also.
For the first steps, I made sure that medication was appropriate, that she was on the best type, and that her iodine intake was correct.
She did improve with these steps, but not as much as she or I would have liked. It seemed like certain foods triggered reactions but it also seemed like the more foods she tried, the more foods she reacted to.
What are the parathyroid glands? “Para” means next to and the parathyroid glands are located next to your thyroid. Typically people have four parathyroid glands, two on each side of the lower portion of their thyroid.
However, there is some variation in:
The parathyroid glands secrete parathyroid hormone (PTH), also called parathormone or parathyrin. It pulls calcium out of your bones and into your bloodstream.
It works in opposition with a thyroid hormone called calcitonin which mostly moves calcium out of the blood and into the bones. One of the reasons that overdosing on thyroid hormones hurts the bones. It blocks the gland from releasing calcitonin.
How much calcium we have in our bodies is ultimately from how much we consume. That said, PTH and calcitonin adjust how much goes in the blood and how much goes elsewhere.
In some cases, the parathyroid glands produce too much PTH. This can cause too much calcium to enter the bloodstream. Ultimately, this is the condition called hyperparathyroidism.
After seeing this elevated level of calcium, I decided to test her parathyroid function. I was not highly suspicious of it being abnormal because her blood calcium was normal all the rest of the time. Instead, I was trying hard to find something.
Her retest showed that her calcium levels were fine but parathyroid hormones were 50% higher than normal. These findings were diagnostic of primary hyperparathyroidism.
I referred Jonelle to a local surgeon who specializes in parathyroid disease. He evaluated her and agreed with the diagnosis. Within weeks after surgery, her symptoms were better than they had been in years.
She found that she could eat a broader range of foods. Jonell also noticed that everyday life stressors did not trigger her anxiety the way they did in the past. We also found it easy in the following months to keep her thyroid levels regulated with less testing and adjustment.
Bottom Line: Jonell’s case radically changed the way I’ve come to understand parathyroid disease. Many doctors have been taught that unless there are high levels of blood calcium, parathyroid disease is not possible. This is not true.
Sadly, I’ve also had many cases in which people have apparent elevations of calcium in the blood. And yet, their doctors tell them it is normal or insignificant.
Key Insight: High levels of blood calcium are never insignificant and always need to be diagnosed. Besides parathyroid disease, the next common culprits are hidden cancers or kidney disease. None of these should ever be missed.
There are three main kinds of hyperparathyroidism:
In the case of primary hyperparathyroidism, the parathyroid glands have grown some unhealthy cells (adenoma) and are making too much parathyroid hormone (PTH).
80% of the time, with PHPT, a single parathyroid gland is overactive. In 15-20% of cases, multiple glands are involved1. If this goes on to a large enough degree in a long enough duration, it can cause higher levels of calcium in the blood.
Too much calcium does not sound like a big deal, but you will soon discover that it is always significant. Besides parathyroid disease, hypercalcemia can be caused by:
Key Insight: If vitamin D levels are low, they can trigger parathyroid disease. However, too much is also not good. If vitamin D levels are too high, they can unmask latent parathyroid disease2.
Secondary hyperparathyroidism is entirely different. In a case like this, the parathyroid glands are working harder for a good reason because the body is losing too much calcium.
The most common reason for this is kidney failure, which can also occur due to severe deficiencies of calcium or vitamin D.
The rarest of all types of hyperparathyroidism is parathyroid cancer.
This represents 1% or less of the cases and it occurs when the parathyroid glands develop a malignant overgrowth of cells.
The parathyroid glands can also become underactive. This is called hypoparathyroidism. When it does happen, it is most common after surgery to the thyroid or the parathyroid glands.
In rare cases, this can occur soon after birth or later in life for no apparent reason. For the remainder of our discussion, we will be talking about primary hyperparathyroidism (PHPT) which I will refer to as parathyroid disease.
Like thyroid disease, parathyroid disease is more common in women. The ratio is about 3:4 (women to men).
In 2008, it was estimated that 0.86% of the US population was diagnosed with hyperparathyroidism.
Key Insight: For comparison’s sake, this is roughly as common as celiac disease. The rates have tripled in some areas like California, most likely due to better screening.
However, in those with thyroid disease, hyperparathyroidism can be as much as six times more common3.
By and large, parathyroid disease comes on unexpectedly and for no apparent reason. There are known genetic components and no known risk factor for those who have a family history.
In addition, early-life radiation to the neck is known to be a large risk factor. In the past, it was common to have tonsils irradiated as a treatment for tonsillitis and this was a risk factor.
Exposure to certain medications can also be a risk factor. Those with the most documentation include lithium and thiazide diuretics such as hydrochlorothiazide4.
Hyperparathyroidism can also show up by itself or, more rarely, in a cluster of endocrine-related cancer called multiple endocrine neoplasia syndrome (MENS).
This condition is more common for those who have a family history of the condition.
People who have thyroid nodules have a higher risk of PHPT. Those who have had to have thyroid surgery also have higher risks for it.5
In the case of Hashimoto’s thyroiditis, the risks for parathyroid disease may be six-fold higher than it is in the general population.
Some estimates say that there may be as high as a 5% overlap between autoimmune thyroid disease and parathyroid disease.6
Ultimately, untreated parathyroid disease raises the risk, long term, of:
It has also been shown that the higher one’s serum calcium is for an extended period, the greater the risks are for breast cancer.
There is also a known overlap between parathyroid disease and esophageal and oral cancers8.
In medical school, we were taught a mnemonic to memorize the symptoms associated with parathyroid disease: “Stones, bones, moans, groans, thrones, and psychic overtones.”
These categories can be helpful ways to think about how abnormal parathyroid levels can affect the body causing:
Because calcium levels are too high, people are at greater risk for kidney stones. There is also some evidence that gallstones and gallbladder disease are more prevalent with parathyroid disease.9
When parathyroid glands release too much hormone because of a higher rate of release of calcium from stores in the bones.
Over time, this can lead to:
Optimal levels of blood calcium are essential for nerve conduction and almost every part of normal biochemistry.
The classic symptoms include:
The term ‘Groans’ refers to gastrointestinal symptoms. When calcium levels are abnormal, the digestive fluids are not secreted properly.
This can trigger all of the classic symptoms that get misdiagnosed as IBS, SIBO, or heartburn:
This one is probably the least intuitive, but it did make for a handy rhyme.
Have you ever heard of the “porcelain throne”? People with parathyroid disease can have severe constipation that does not respond well to typical treatments.
They may also have an abnormally high thirst and, therefore, frequent urination is common.
Some even end up having to spend a lot of time on the throne.
The brain is far from immune to the effects of normal calcium levels. It renders it far less able to carry out its proper cellular interactions.
I have seen many patients with debilitating anxiety that led to years of unsuccessful treatments through medication, talk therapy, or lifestyle. Only to disappear in a matter of days after treatment.
Common symptoms here can include:
You can see that these symptoms are numerous and common.
Some, like anxiety, fatigue, and muscle pains, are symptoms that doctors all too often give up on finding explanations to help diagnose and treat.
In classic cases, hyperparathyroidism shows up with elevated levels of calcium in the blood.
Too often, though, patients are told that elevated calcium is not significant.
It always is and should never be ignored. But, the even more challenging part is that many doctors do not know that it can also show up with normal levels of blood calcium.
Key Insight: Because PTH is not routinely used as a screening test, a doctor can completely miss hyperparathyroidism in someone with normal calcium levels unless they are suspicious enough to dig deeper.
If calcium levels are:
Here is where it gets tricky. For 20% of people with hyperparathyroidism, their calcium levels are not elevated.
If someone has high-normal levels of calcium and they have good parathyroid function, their PTH should be low.
If not, they have primary hyperparathyroidism.
Here are some images courtesy of parathyroid.com, which is a production of the Norman Parathyroid Center. Both are excellent resources for parathyroid information and care.
In the first image, you can see that ‘normal’ blood calcium levels in the range of 9.8 – 10.5 can still be associated with hyperparathyroidism and symptoms of hypercalcemia.
You can see that a large number of patients with hyperparathyroidism have normal calcium levels (some even have normal levels of both calcium and PTH).
How would you know they had hyperparathyroidism if both calcium and PTH were normal? If one is up, the other should be down.
If calcium is high normal, PTH should be low normal; if PTH is high normal, calcium should be low normal.
When calcium and PTH are on the higher side of normal, and the person has suspicious symptoms, there may be a problem.
Many doctors assume that high calcium and high PTH must be present and that kidney stones and distinct patterns of bone loss must be present.
There are many patients in which all of these findings are present. However, in over 80% of those with parathyroid disease, they are not.
There are other ways of evaluating calcium such as calculating albumin-corrected calcium or measuring ionized calcium.
These methods help when a person has symptoms of hypercalcemia but normal calcium levels. Still, they are not necessary for diagnosis and do not prevent the need for measuring PTH levels.
The following table can summarize the diagnosis based on serum calcium and PTH:
| Calcium (8.5 – 10.4 mg/dL) | |||||
| Low | Normal | High normal | Elevated | ||
| PTH (10-65 nmol/L) | Low | hypoparathyroidism | hypoparathyroidism | High calcium – excessive intake, malignancy | High calcium – excessive intake, malignancy |
| Normal | hypoparathyroidism | Healthy | Primary hyperparathyroidism | Primary hyperparathyroidism | |
| Elevated | Secondary hyperparathyroidism
Low calcium: low intake, chronic kidney disease, etc |
Primary hyperparathyroidism | Primary hyperparathyroidism | Primary hyperparathyroidism | |
The answer is quite clear: Surgery.
There is no diet, supplement, essential oil, or medication that will help primary hyperparathyroidism. Roughly, 95% of the time, surgery is curative.
When surgery does not work, it is almost always because the surgeon failed to find all the overactive parathyroid glands. In these cases, follow-up surgery is nearly always curative.
Complications are rare but include damage to the recurrent laryngeal nerve. This can impact speech and swallowing.
The remaining parathyroid glands can be damaged. This can leave them underactive or spur them into overactivity.
In the rarest complications, the thyroid gland can be traumatized by surgery and change how it works.
Bottom Line: The success of the surgery and the rate of complications is highly dependent on the experience of the surgeon. The glands can be hard to see during surgery. It also may not be clear which of the glands are involved. It is worth working with one of the small number of surgeons who specialize specifically in parathyroid surgery.
In the hands of the right doctor, the whole procedure can take as little as 20 minutes and may not even require general anesthesia.
I can think of very few situations that affect health so deeply that can be resolved that quickly.
There is a medication called cinacalcet (Sensipar) that “looks” to your parathyroid like PTH and may lower its activity. They are appropriate for hyperparathyroidism secondary to dialysis.
Some doctors may offer this in place of surgery but new data shows it is harmful and that surgery is still the best answer10.
Good surgeons can leave healthy parathyroid glands intact. It is helpful to get enough calcium after surgery so that they do not have to work too hard.
Once the first few weeks have passed, the remaining glands pick up the slack for those that were lost and the calcium balance is normal again.
Serum calcium is a typical part of nearly every routine blood tests.
If your levels have ever been elevated, please work with a good doctor to find out why that is the case.
Have you had any ongoing symptoms like:
Key Insight: If you have been unable to improve the symptoms, even if you and your doctor think you know why they are happening, please do consider hyperparathyroidism.
Next, your best step forward is to have a doctor who is familiar with this condition do proper testing and see if it may be relevant for you.
Not only is it important to treat because it may resolve troublesome symptoms. If it is not identified, it can create other problems that can shorten your lifespan.
1 – https://www.ncbi.nlm.nih.gov/pubmed/28923463
2 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4663778/
3 – https://www.ncbi.nlm.nih.gov/pubmed/23865082
4 – https://twin.sci-hub.tw/6635/1c2f138b1a2fdf710095845684ff6649/bilezikian2017.pdf?download=true
5 – https://www.ncbi.nlm.nih.gov/pubmed/19040989
6 – https://www.ncbi.nlm.nih.gov/pubmed/23865082
7 – https://academic.oup.com/eurheartj/article/25/20/1776/497057
8 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603029/
9 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6014369/
10 – https://www.parathyroid.com/Sensipar-high-calcium.htm
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Dr. Alan Christianson
Alan Christianson is a Naturopathic Medical Doctor (NMD) who is a board-certified Naturopathic Endocrinologist with a focus on thyroid disorders. He is the author of The Metabolism Reset Diet and the New York Times bestselling book The Adrenal Reset Diet.
He founded Integrative Health, a physician group dedicated to helping people with thyroid disease and weight-loss resistance regain their health.
He has been named a Top Doctor in Phoenix magazine and has appeared on national TV shows and in numerous print media.
Dr. Christianson resides in the woods by a lake in Northern Minnesota with his wife Kirin.
