Asymptomatic Hyperparathyroidism (HPT)
Asymptomatic hyperparathyroidism is a very confusing term. There is no clear consensus between endocrinologists about this term. But generally speaking it refers to a person that has hyperparathyroidism (laboratory proven) but does not have osteoporosis, fragility fractures (low impact fractures that should not be happening with such a light force), kidney malfunction or kidney stones. The problem here is that these are not the most common symptoms of hyperparathyroidism (HPT); the graph below shows the most common symptoms and their frequency.
It is immediately obvious that bone fractures, kidney failure and kidney stones are not the most common symptoms of hyperparathyroidism. But because the most common symptoms hyperparathyroidism are so non-specific it would be hard for most physicians to connect these symptoms to hyperparathyroidism. And in the case of endocrinologists to tell the person with HPT treatment is going to improve the symptoms.
Because of these challenges, there are a group of endocrinologists and parathyroid surgeons that get together once every few years and try to go through the published scientific articles and come up with guidelines to how to address people who they characterize of asymptomatic. These recommendations/guidelines were called the NIH guidelines when they were first created, but now are called the International Workshop on Management of Asymptomatic Primary Hyperparathyroidism. The table below shows their recommendations over the years.
What are the latest recommendations?
The recommendations in 2013 include a lot more reasons to proceed with treatment of hyperparathyroidism. The most clear recommendation that has the most amount of scientific support is osteoporosis. The reason for this is that most people who have hyperparathyroidism that is untreated will have continuous bone loss, which increases the risk of bone fractures. Even more promising is that most research shows everyone who is successfully treated for HPT will have improvement in their bone density, even if their bone density was in the normal range. Meaning no matter what, your bones well get stronger when you treat your hyperparathyroidism
There’s also strong research showing when you are young (younger the age 50), if you were to treat they hyperparathyroidism then you will have less complications for the remainder of your life and have a healthier life. This is common sense, and is supported by very good quality research, but does this mean if you are over the age of 50, you wont qualify. NO! Just that being under the age of 50 in and of itself is enough resason to proceed with surgery. While if you are over the age of 50 other factors such as impact on bone or kidney function needs to be considered.
What about the other 2 qualifiers 1) calcium levels being more then 1mg/dl above the normal, or 2) 24 hour urine calcium being higher then 400 mg/day or reduced kidney function. Although used as reasons to proceed with surgery, there is low quality research evidence supporting these recommendations. And in fact the calcium levels being more then 1 mg/dl above normal is purely an arbitrary guideline. And in terms if the kidney function, there is a lot research that shows the impact of treatment may be very little, and if there is impact on kidney stone production, it may take years to get close to normal. It is possible that the impact is not on reversing the kidney condition but rather stop the progression of kidney disease.
The latest guidelines recommend more extensive work up of a person with asymptomatic HPT, so that they know in more detail if the HPT is affecting them in ways that may not be visible. You may show the table below to your primary/general doctor to see if they can order them, so that you can make a more informed decision about treating your HPT.
The short answer is that it does not! You may have bone loss that hasn’t reached osteoporosis level or to the extent that is causing fractures. It has not overworked your kidneys yet to cause it to essentially burn out and do it job less, or produce kidney stones. You could have as many of the other symptoms caused by hyperparathyroidism and feel awful but your calcium is not high enough for your endocrinologist to take notice, and if you are, like me, over the age of 50 the guidelines consider you old; so you should go on suffering and get worse.
The best advice at this point is to see if you are being deeply impacted by the symptoms of hyperparathyroidism; if the quality of your life is being affected by these symptoms then you should treat it to improve the quality of your life. The quality of your life should be of utmost importance.
FAQ (Frequently Asked Questions)
- Can asymptomatic hyperparathyroidism transform into symptomatic hyperparathyroidism?
Yes, It isn’t that one condition transforms into the other, but rather that a large group of people who have asymptomatic HPT will progress to develop osteoporosis or kidney problems.
- Do all cases of asymptomatic hyperparathyroidism transform into symptomatic hyperparathyroidism?
No. It is hard to know how quickly the disease progresses, if at all, during a person’s lifetime. As such, it is recommended that all people with hyperparathyroidism annually check their calcium/PTH/Vitamin D, and kidney function. Every two years do a bone density study (DEXA Scan) to make sure they don’t have progression of bone loss.
- Can bone loss in the osteopenic range in an asymptomatic hyperparathyroidism person improve on its own?
Unlikely that bone loss would not reverse unless the person is taking meds or heavily involved in weight lifting.
- Can a person with asymptomatic hyperparathyroidism chose to have surgery?
Yes, I would say that choice is met with a lot of hurdles by most endocrinologists; it is not without reason that endocrinologists have trepidation about parathyroid surgery in this group. There are research studies that show surgery helps and others that show that improvements are not a lot. Having said that all research shows the bone density improves in everyone. So the decision to proceed with surgery I would say has to do with how many of the listed symptoms you have and how much it is impacting your life.
- Are there any research articles that compel endocrinologists not to recommend treatment for a person with asymptomatic hyperparathyroidism?
Yes, research and publications by Professor Jens Bollerslev is one of the main reasons.
In depth look at these studies show some of the limitations in the study. Yet, even his studies showed that all patients had improvement in their bone density.
- Can a person with asymptomatic hyperparathyroidism wait to treat?
Yes, as long as they continue to closely monitor their labs, kidney status, and bone health.
If you need help in diagnosing hyperparathyroidism, decide if you should get treatment, or are considering minimally invasive parathyroidectomy, schedule a consultation with Dr. Larian or give us a call at 310.461.0300 today!