My Doctor Online The Permanente Medical Group

Causes and Types

.

Causes

We don't know the causes of hyperparathyroidism, but research is ongoing. According to the National Institutes of Health's National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), "In the United States, about 100,000 people develop the disorder each year. Women outnumber men two to one, and risk increases with age. In women 60 years and older, two out of 1,000 will develop hyperparathyroidism each year."

Types

There are 2 main types of hyperparathyroidism.

Primary hyperparathyroidism is caused by enlargement of one or more parathyroid glands. This might occur because of a problem with the parathyroid glands themselves or because another disease affects the way that the glands function. Causes of primary hyperparathyroidiam may include:

• A noncancerous (benign) growth (adenoma) on a gland
• Enlargement (hyperplasia) of 2 or more parathyroid glands
• A genetic predisposition to hyperparathyroidism
• A cancerous (malignant) tumor, an extremely rare cause

Secondary hyperparathyroidism occurs when the body produces excess PTH because your calcium levels are too low. This often occurs when vitamin D levels are low or your body cannot absorb sufficient calcium from your diet. A specific type of secondary hyperparathyroidism is also common in individuals with known kidney problems.

Symptoms

.

You might not recognize that you have symptoms at first. Many patients who have primary hyperparathyroidism and a mild increase in their blood calcium do not experience any symptoms. The diagnosis is suggested when a test for blood calcium shows a high level. This high calcium may be related to being dehydrated, so confiming the level is always a good idea. More serious increases in the blood calcium can develop and cause potentially serious symptoms.

Even subtle symptoms of hyperparathyroidism can be related to a variety of conditions, some of which are potentially dangerous. The symptoms of a high calcium level may include:

• Impaired kidney function, including kidney stones (pain in your side and back, below your ribs) or frequent urination
• Bone disease, including fragile or brittle bones that can fracture easily, osteoporosis, bone aches
• Loss of appetite, nausea, or vomiting
• Fatigue, depression, or memory loss

If you have any of these symptoms, you should contact your personal physician, as you may need to come see us so that we can provide screening and effective treatment. We can often diagnose hyperparathyroidism before your symptoms become serious.

Untreated hyperparathyroidism may rarely result in the development of a hypercalcemic crisis, a condition in which the blood calcium level becomes quite high (typically 13 mg/dL or higher), and this may need to be treated with temporary measures to lower the calcium level. You may sometimes need to be treated and monitored for this in the hospital.

Diagnosis

.

We use 4 tests to diagnose hyperparathyroidism:

• A blood test to measure your calcium and PTH (parathyroid hormone) levels
• A urine test to determine the amount of calcium removed by the kidneys
• A test to measure your vitamin D levels to make sure they are normal, as low vitamin D will cause abnormally high PTH
• A bone density test to find out the amount of bone loss

Primary hyperparathyroidism is present when the blood calcium and PTH are both high. We often confirm the diagnosis with repeat blood testing after stopping any calcium supplements or medications that could be causing high calcium.

We diagnose secondary hyperparathyroidism when there is a high PTH level but a low or normal calcium level. This may indicate vitamin D deficiency or poor absorption of calcium. 

Some medications can also cause an increase in calcium levels in the blood. If you are taking lithium (a mood stabilizer) or diuretics (water pills used to treat hypertension) such as hydrochlorthiazide or chlorthalidone, the excess calcium in your blood may be corrected by a simple change in medication. If needed, your personal physician will make any medication changes before we proceed with testing for primary hyperparathyroidism. We will discuss your medications and may consider alternatives.

Treatment

.

If your condition is mild (only slightly increased calcium and parathyroid levels with no sign of kidney stones or thinning bones), we recommend that you get regular medical checkups and calcium blood tests to confirm the stability of the condition. Avoid getting dehydrated, to prevent your blood calcium from rising. In serious cases, in which the excess calcium may be harming the kidney function, we recommend a surgical procedure called parathyroidectomy.

Before your surgery

To prepare for surgery, we conduct a localizing study that helps us see the exact location of the abnormal parathyroid gland or glands, and this may allow for a less invasive surgery. There are 2 kinds of localization studies:

• Parathyroid scan. We inject a radioactive tracer to evaluate your parathyroid glands in the front of your neck. Before the parathyroid scan, tell us if you are, or may be, pregnant or breastfeeding, or if you have difficulty lying flat or have severe claustrophobia.
• Ultrasound. We scan your lower neck using sound waves to determine the position of the abnormal parathyroid gland or glands.

Surgery

Parathyroidectomy is a surgical procedure to remove your parathyroid gland or glands. You will be asleep during the surgery. We take out the gland or glands through a cut (incision) in the front of your neck. We typically confirm that the blood hormone level has dropped while you are undergoing the procedure. This helps us perform most parathyroid operations as "minimally invasive" surgery. 

You may go home the day of your surgery or 1 to 2 days after surgery, depending on the extent of your procedure. You will have blood tests over the next few weeks to assess how the surgery has affected your calcium level. You may have a small tube just under the chin in your neck for 1 to 4 days after surgery to drain fluid from the incision. You may be able to return to work or your normal routine after a few weeks (generally less than 2 weeks), depending on the kind of work you do and how you feel.

Complications

.

Parathyroid surgery carries some general risks that can be associated with most surgeries:

• Bleeding. There is always a risk of bleeding after a surgical procedure. Make sure to tell us if you take aspirin, ibuprofen, or other anti-inflammatory drugs that can thin your blood.
• Infection. If your incision becomes red and painful as time goes on, it can be a sign of an infection. While infection is unlikely, please call us right away if this occurs.
• Neck Scar. All surgeries result in a scar. We use expert suturing techniques to minimize this, but in the first few weeks your scar will be somewhat red and swollen. This will rapidly improve with time. We do not recommend scar treatments on the wound for the first 3 weeks after surgery. Please discuss this with us if you have questions or concerns.

Parathyroid surgery carries some unique risks that, while uncommon, can be serious:

Temporary low calcium levels

Short-term, lower calcium levels after surgery are common because the remaining glands may not be functional right after the procedure. In addition, you may have a condition called bone hunger in which your bones reabsorb the calcium they were not getting while you had the abnormally functioning parathyroid(s).

Low calcium levels usually last only a few days or weeks and then return to normal. To prevent this from happening, we will send you home with calcium supplements after surgery. Sometimes, however, even with calcium supplements, your calcium level may be low for a short time because your glands take a while to return to normal functioning.

Please call us right away if you experience these symptoms:

• Muscle cramping in your arms, hands, legs, or feet
• Tingling in your hands and feet
• Tingling around your mouth
• Heart palpitations

These symptoms are easily treated and usually respond to additional calcium and vitamin D, but in rare cases they can require rehospitalization.

Persistent hyperparathyroidism

Occasionally, despite our best efforts, the hyperparathyroidism does not improve after surgery. This occurs because we are unable to find the abnormal gland during surgical exploration. It may also develop after an initial drop in calcium immediately after surgery and may be due to your having more than one parathyroid gland affected by the same tendency to be overactive (this is referred to as hyperplasia).

Permanent hypoparathyroidism

In rare situations, you can develop the opposite condition, called hypoparathyroidism. This occurs when the remaining parathyroid glands don't produce enough PTH and your calcium level becomes too low, instead of too high. In this case, you will need to take calcium and vitamin D supplements for the rest of your life.

Vocal cord paralysis

The nerves that make your vocal cords work are very close to the parathyroid glands. If a nerve is injured during surgery, you could have a weak or hoarse voice or difficulty breathing for the rest of your life. We know where the nerves are located and how to protect them, so fortunately this is a very rare event. 

Lifestyle Management

.

Depending on the severity of your condition, we may recommend that you follow one or more of these suggestions designed to make you more comfortable:

• Avoid calcium supplements.
• Take vitamin D supplements, usually 800 to 1000 international units a day.
• Drink 6 to 8 glasses of water every day to reduce the risk of kidney stones.
• Exercise regularly to maintain strong bones.
• Don't smoke, as smoking may increase bone loss and increase your risk of a number of serious health problems. If you are ready to quit, we can refer you to our program.
• Avoid diuretics, lithium, and other drugs that can raise calcium levels.

Your Care with Me

.

If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If specialty care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might call me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we will discuss your medical and family history and I will perform a physical exam. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options, and together we will create a treatment plan that is right for you.

.

.

If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

If you have urgent concerns or issues while my office is closed, or need general medical advice, you can call the Appointment and Advice line, available 24 hours a day, 7 days a week. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

.

Coordinating Your Care

.

Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures we will schedule an appointment with the Radiology department. When the results are ready I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

If surgery or a procedure is a treatment option

I will recommend you review educational information and tools to help you prepare for your procedure or surgery. The information will often help you decide whether surgery is right for you. If you decide to have a surgery or procedure, the information will provide details about how to prepare and what to expect.

If we proceed with surgery, I will have my Surgery Scheduler contact you to determine a surgery date and provide you with additional instructions regarding your procedure. Once your surgery is scheduled, a medical colleague of mine will contact you to conduct a preoperative medical evaluation that will assure that you are properly prepared for your surgery.

.

Convenient Resources for You

.

As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

.