How do the parathyroid glands work?

“Just as a thermostat regulates the temperature of a room, the parathyroids determine the correct calcium levels by allowing or inhibiting the secretion of parathyroid hormone. The balance is maintained by if calcium decreases, parathormone is secreted. Thus this hormone releases calcium from the bones and increases its absorption from the small intestine. If calcium levels are high, the production of parathormone decreases with the opposite effect,” says Mr. Emmanuel Tsigos, Endocrine Gland SurgeonDirector of the 1st Surgery Clinic and founder of the Thyroid and Endocrine Surgery Center at Metropolitan General.

What types of hyperparathyroidism are there?

There are three types of hyperparathyroidism: primary, secondary and tertiary.

• Primary: It is a relatively rare disease, it occurs at older ages with women being affected more often than men in a ratio of 2 to 1. It is usually sporadic, but can have a familial distribution and is part of the multiple endocrine neoplasia syndrome (MEN 1 and MEN 2A ), and is due to:

o In an adenoma that develops in one of the glands in 80% of cases
o In presence of adenoma in 2 glands (5-10%)
o In diffuse hyperplasia of all parathyroids (5-10%)
o In primary parathyroid malignancy (1%)

Parathyroid cancer is extremely rare, is almost always accompanied by severe hypercalcemia and very high parathyroid hormone levels, and has been shown to have a genetic predisposition in 10-20% of patients.

• Secondary: It is more rare and the increased production of parathormone is due to hyperplasia of all the glands after their constant stimulation due to low blood calcium levels, in the context of chronic renal failure or malabsorption problems, which can lead to vitamin D deficiency.

• Tertiary: It is extremely rare, it occurs in some patients with secondary hyperparathyroidism, who after years may develop autonomously functioning hyperplastic glands, i.e. glands that do not obey the normal regulation mechanism and hyperfunction regardless of the calcium value.

What are the symptoms of hyperparathyroidism?

Most patients are asymptomatic, with subclinical hyperparathyroidism usually found on random blood work. Some may complain of weakness, fatigue, and undefined pain.

Over time, the following may develop: kidney stones, abdominal pain, thirst, loss of appetite, nausea, vomiting, pancreatitis, osteoporosis, bone fractures, memory disorders, confusion, and muscle weakness.

How is hyperparathyroidism diagnosed?

Diagnosis and control of hyperparathyroidism includes the following:

• Blood test for calcium and parathormone
• Radiological check, such as x-ray of kidneys, ureters, bladder to check for nephrolithiasis
• Bone density measurement

Pathological parathyroid glands are identified by:

• Ultrasound
• Scintigraphy with technetium sestamibi (the patient receives a very small amount of a radioactive substance, which is only absorbed by the overactive parathyroid gland and helps us to locate it).

What health problems are associated with hyperparathyroidism?

The increased amount of parathormone circulating in our body can lead to serious health problems, such as:

• Osteoporosis: The more parathyroid hormone is oversecreted, the more calcium the bones lose, causing them to become weak, brittle, with an increased chance of fractures.
• Nephrolithiasis: The body tries to eliminate the extra calcium with the urine, as a result of which the risk of developing kidney stones increases.
• Peptic ulcer: High calcium levels stimulate hydrochloric acid secretion.
• Arterial hypertension: Increased risk of arterial hypertension and heart failure, possibly due to vasoconstriction and kidney damage.
• Psychological disorders: Depression, behavioral change, emotional instability, etc.

How is hyperparathyroidism treated?

Treatment depends on the type and each case and can range from simple observation to surgery.

• Primary hyperparathyroidism: Surgical treatment is the method of choice. In cases where it is an adenoma, the specific parathyroid gland is removed. If it is hyperplasia of all 4 glands, the surgeon removes 3 and part of the 4th.
• Secondary hyperparathyroidism: Treatment can be conservative with the administration of vitamin D and calcium, substances that mimic calcium, avoidance of phosphorus, hemodialysis and, in some cases, surgery (removal of three and a half glands). Also, some patients after a successful kidney transplant seem to normalize their calcium levels.
• Tertiary hyperparathyroidism: Initially, conservative treatment is followed with calcium and vitamin D preparations. In some cases and with specific indications, surgical treatment is followed.

“The operation of choice is minimally invasive parathyroidectomy with or without the use of a video camera, which is now performed in all specialized endocrine centers with intraoperative measurement of parathyroid hormone to confirm correct resection. A parathyroidectomy is performed under general anaesthesia, through a small transverse incision of 1.5-2.5 cm in the lower part of the anterior surface of the neck, along a natural skin fold, just like a thyroidectomy.

The postoperative course is excellent and the patient leaves the clinic in less than 24 hours from his/her admission with an excellent aesthetic result”, concludes Mr. Tsigos.