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Hyperparathyroidism - parathyroid dysfunction
Hyperparathyroidism is an overactive parathyroid gland (parathyroid hyperfunction) that is associated with an increased formation and release of the parathyroid hormone and thus with changes in the calcium and phosphate levels in the blood. The hormone disorder that is more common in women can occur in different ways. The spectrum of possible symptoms is commonly summarized as "stone, leg and stomach pain". The most common and primary form usually requires surgical removal of the diseased glandular tissue to enable healing.
A brief overview
The following overview summarizes the most important facts about the clinical picture of an overactive parathyroid gland. The following article provides more detailed information.
- definition: The term hyperparathyroidism refers to a functional disorder and hyperfunction of the parathyroid gland. The hormonal disorder is characterized by an excessive release of the parathyroid hormone, which affects the calcium and phosphate levels in the blood. Hypercalcaemia (increased calcium levels) occurs after a long period of illness.
- Symptoms: Different symptoms are assigned to this hormone disorder with different causes. The first rather uncharacteristic symptoms also include loss of appetite, nausea, constipation and general fatigue. A typical combination of symptoms occurs later, known as “stone, leg, stomach pain”. The disease can also be asymptomatic at the beginning.
- causes: Most diseases are of primary cause and can be attributed to a disease of the parathyroid gland itself, such as a benign or malignant tumor. If the trigger is secondary in nature, underlying diseases of other organs cause excessive production of parathyroid hormone. Over a longer period of time, the secondary variant can also be combined with the first (tertiary disease).
- diagnosis: A blood test provides the most important information. In routine examinations, the evidence of an excessively high parathyroid hormone level and other parameters often leads to a random diagnosis. Ultrasound examinations and a scintigraphy of the parathyroid gland can be considered for protection and further clarification.
- treatment: In the most common primary form, an operation to remove the diseased glandular tissue is usually necessary to enable healing. Drug treatment is only possible in a few cases, but it only has a limited symptomatic effect.
- Naturopathy: Bioenergetic diagnostic methods and naturopathic treatment methods, such as electroacupuncture, can offer an alternative for those affected, especially in the secondary variant with certain regulatory disorders in the vitamin D, calcium and phosphate balance.
Hyperparathyroidism (HPT) refers to an overactive parathyroid gland. The parathyroid gland consists of four hormone-producing glands, the so-called epithelial bodies (upper and lower parathyroid glands), which can be found directly behind the thyroid gland in the neck area. The primary task of this hormone gland is the formation and release of parathyroid hormone (PTH), which regulates the calcium and phosphate balance in the body. The parathyroid hormone increases the calcium level in the blood while it lowers the phosphate level. Calcium and phosphate play a major role in bone growth and breakdown and keep these processes in the necessary balance as long as the parathyroid gland functions normally. In addition, vitamin D is significantly involved in the calcium and phosphate balance and thus takes on a central function in bone care.
Hyperfunction leads to an excessive formation of parathyroid hormone, which is released into the bloodstream and increases the calcium content in the blood. If this condition persists, hypercalcaemia occurs. The increased provision of calcium in the blood is achieved through changed metabolic processes. Calcium is increasingly released in the bone metabolism, which leads to an increased breakdown of lime (calcium carbonate) from the bones. There are also further metabolic changes, for example in the kidneys and intestines. Phosphate is increasingly excreted in the urine.
There are three different forms. Primary hyperparathyroidism (pHPT) is the most common cause of parathyroid disorders. In diseases of other organs as the cause of the disease, one speaks of secondary hyperparathyroidism (sHPT). The rare third form, tertiary hyperparathyroidism (tHPT), can arise as a result of an ongoing secondary variant.
The primary variant of hyperthyroidism is one of the most common endocrine disorders (hormone and metabolic disorders). Diabetes mellitus comes first, but hyperthyroidism and hypothyroidism are both common and overactive.
The hormone disorder can occur at any age, but most cases are noted after the age of 45. Women are affected about twice as often as men. There is a presumption that the increasing bone loss (osteoporosis) in women after the menopause enables an increased diagnosis rate of previously undetected parathyroid functions.
Symptoms: stone, leg, stomach pain
There are usually no symptoms at the onset of the disease and the disease can be asymptomatic for years. Sometimes, however, those affected report unspecific symptoms at an early stage, such as:
- High blood pressure,
- Loss of appetite,
- Gastrointestinal complaints such as nausea and vomiting or constipation,
- chronic fatigue,
- poor mental and physical performance.
If the disease is not recognized and treated early, typically a combination of symptoms occurs at an advanced stage, which is summarized under the term "stone, leg, stomach pain". This describes the following often painful sequelae:
- Stone pain: Kidney stones or gallstones, limescale deposits in muscles, joints, kidneys (diffuse nephrocalcinosis) and pancreas.
- Leg pain: Back pain, body aches, bone pain, bone inflammation, broken bones, bone deformities.
- Stomach pain: Gastric ulcers.
The reason for these complaints is the excess of calcium in the blood. Deposits and calcifications caused by this (stone pain) can affect the kidneys and lead to chronic underactive kidneys. In addition, the body is urged to urinate frequently and there is an increased feeling of thirst. This can lead to severe fluid loss. Stones in the pancreas can also lead to inflammation of the pancreas (pancreatitis).
Due to the excess of parathyroid hormone, calcium is released from the bones and bone is broken down (leg pain). The consequent calcium deficiency in the bones can lead to osteoporosis, bone cysts or extremely rarely to bone tumors, for example an osteoclastoma (giant cell tumor).
It is believed that the increased calcium content leads, among other things, to increased acid production in the stomach, which favors the formation of stomach ulcers (stomach pain). In connection with hypercalcemia syndrome, weight loss and anorexia can also occur.
In patients with secondary or tertiary hyperparathyroidism, the same symptoms can occur as in the most common, first variant. However, the exact symptoms depend on the underlying disease.
The causes of an overactive parathyroid gland and associated parathyroid hormone overproduction can be primary or secondary in nature. In most cases, these are primary causes that relate exclusively to disorders of the parathyroid function itself (pHPT). Diseases such as a benign hormone-producing tumor (adenoma), enlargement and functional overproduction of the parathyroid gland (hyperplasia) and very rarely a malignant carcinoma (parathyroid cancer) come into question as triggers. Usually only one epithelial body is affected. Hypercalcemia follows the unregulated or autonomous (independent) overproduction of the parathyroid hormone.
The hereditary disease of multiple endocrine neoplasia type 1 (MEN1 syndrome) is very rarely identified as the cause. In this disease, several tumors of hormone-producing organs and non-docrine tumors (for example lipomas) occur at the same time. The parathyroid gland is most commonly affected and over 90 percent of those affected by MEN1 develop an overactive state. Typically, at least two organs are affected, with the pancreas and intestine or pituitary gland often still being affected. Hypercalcaemia and hyperparathyroidism can also occur in multiple endocrine neoplasia type 2 (MEN2 syndrome).
Secondary causes (sHPT) are basic diseases of other organs, which as a subsequent consequence trigger an excessive production of parathyroid hormone. The most common secondary cause is chronic kidney disease or renal failure.
Inflammatory bowel diseases or cirrhosis of the liver can also be the cause of this. These diseases cause a calcium deficiency in the blood (hypocalcaemia) for various reasons (increased calcium loss, insufficient calcium and vitamin D intake) and in the further course there are also phosphate deficiency and vitamin D deficiency or vitamin D utilization disorders. This in turn stimulates hormone production in the parathyroid gland and hyperplasia occurs, affecting all four epithelial cells.
These shortages and deficiency symptoms occur very rarely due to improper nutrition.
If there is a secondary hyperfunction over a very long period of time, an adenoma similar to the primary form can also occur. This combination of causes is then the tertiary form of the disease.
It is not uncommon for the disease to be noticed or suspected in the course of routine examinations when a blood count is taken. In the primary variant, the blood values typically show an increased calcium value (serum calcium value), a reduced phosphate value and a high parathyroid hormone level. If, on the other hand, the calcium level is low, with a high level of parathyroid hormone, these laboratory values provide an indication of the presence of the secondary variant.
If there is a suspicion of hyperparathyroidism, specialist medical care especially for hormone disorders (endocrinology) is advisable. In this context, further clarification and precise diagnosis are made. This includes, among other things, a determination of the calcium in the urine over 24 hours. An ultrasound examination (sonography) and scintigraphy of the parathyroid gland serve to identify possible pathological tissue changes.
With the help of thyroid scintigraphy, normal areas can be distinguished from those with reduced or increased metabolic activity. With this examination, it is possible to differentiate benign tumors (so-called "hot nodules") from cancer. In addition, other imaging methods such as magnetic resonance imaging or computer tomography are also used. The latter are mainly used when diseases of other organs are suspected to be the cause.
To further clarify whether it is a secondary form, the kidney function (determination of serum creatinine) and the vitamin D supply in the body (vitamin D metabolites, 25-OH-cholecalciferol) are also checked. Additional blood tests can expand general laboratory diagnostics, such as for alkaline phosphatase.
In general, the therapy depends on the existing form of hyperparathyroidism and the respective cause. The general goal is to restore calcium levels to normal levels. The secondary variant focuses on measures to treat the underlying disease. The rare multiple endocrine neoplasia also requires a special therapy concept.
The treatment and healing of a primary and tertiary disease usually requires an operation in which the affected tissue of the parathyroid gland is removed. Medications are only used for this disease under certain conditions, but in principle do not lead to a cure.
If only one of the four parathyroid glands is affected, the adenoma is removed using a minimally invasive procedure. The healthy glands remaining in the body take over the complete function after a short time, so that usually no further complications are expected.
If all four glands are affected, there is a major intervention and skin incision in the neck area. In principle, all epithelial bodies would have to be removed. However, due to a lack of hormone replacement therapy, this would lead to a permanent lack of parathyroid hormone and calcium in the blood. To avoid this, an attempt is made to maintain sufficient healthy parathyroid tissue.
There are two surgical methods for this: the incomplete removal of the parathyroid glands (subtotal parathyroidectomy or 3 1/2 resection) and the complete removal (total parathyroidectomy) with autotransplantation of epithelial cell fragments, for example into the muscles of an arm. The remaining parts of the parathyroid gland (also elsewhere in the body) can take over the complete function of hormone production after a certain time.
With medication it is possible to increase the sensitivity of the calcium receptor with the drug Cinacalcet and thus to reduce the release of parathyroid hormone. However, this medication should only be given under the control of calcium and parathyroid hormone levels. This is symptomatic treatment and surgery is usually preferred.
If the parathyroid function could no longer be maintained after an operation, an underfunction (hypoparathyroidism) and a calcium deficiency occurred. In this case, the calcium level must be regulated by medication. Calcium can be used in combination with vitamin D supplements. However, a lack of parathyroid hormone complicates the production of the metabolically active vitamin D form.
If there is a so-called hypercalcemic crisis in the course of the disease, there is a life-threatening medical emergency that leads to death in around half of all those affected. Because of this, immediate measures are necessary, which also require the administration of drugs such as bisphosphonates (pamidronate, neridronate) and calcitonin.
With regard to secondary hyperfunction, naturopathic diagnosis and treatment can offer an alternative option for those affected. Clinically not immediately apparent relationships of regulatory disorders in the vitamin D, calcium and phosphate balance can be determined with the help of bioenergetic diagnostic methods from naturopathy and alternative medicine. There are also numerous naturopathic treatments that can effectively compensate for such fine (also energy-related) regulatory and functional disorders. In this context, the methods of electro-acupuncture, bio-functional diagnostics, vegatest and kinesiology are worth mentioning.
If other therapy options are excluded, an alternative therapy is used to alleviate the symptoms. This consists primarily of ingesting plenty of fluids, eating a low-calcium and high-phosphate diet and possibly taking vitamin D and phosphate tablets under medical supervision. (jvs, cs; updated on December 17th, 2018)
Author and source information
This text corresponds to the requirements of the medical literature, medical guidelines and current studies and has been checked by medical doctors.
Dr. rer. nat. Corinna Schultheis
- German Society for Children's Endocrinology and Diabetes (DGKED): S1 guideline: primary hyperparathyroidism, as of March 2016, awmf.org
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- Deutsches Schilddrüsenzentrum GmbH: Disorders of the parathyroid glands (accessed: 03.07.2019), deutsches-schilddruesenzentrum.de
- Mayo Clinic: Hyperparathyroidism (accessed: 03.07.2019), mayoclinic.org
- Bilezikian, John P. / Bandeira, Leonardo / Khan, Aliya / et al .: Hyperparathyroidism, The Lancet, 2017, thelancet.com
- The National Institute of Diabetes and Digestive and Kidney Diseases: Primary Hyperparathyroidism (accessed: July 3, 2019), niddk.nih.gov
- National Health Service UK: Hyperparathyroidism (access: 03.07.2019), nhs.uk
- Herold, Gerd: Internal Medicine 2019, self-published, 2018
ICD codes for this disease: E21ICD codes are internationally valid encryption for medical diagnoses. You can find e.g. in doctor's letters or on disability certificates.