Refer to an Endocrinologist
For asymptomatic primary hyperparathyroidism, refer the patient to an endocrinologist who will coordinate the comprehensive workup and determine surgical candidacy in collaboration with an experienced endocrine surgeon 1.
Rationale for Endocrinology Referral
The 2025 French expert consensus statement—representing over 80 physicians and surgeons from multiple specialties—emphasizes that PHPT management requires a multidisciplinary approach coordinated by endocrinology 1. Here's why:
Initial Assessment Requirements
Even "asymptomatic" patients require systematic evaluation for target organ involvement:
- Renal assessment: 24-hour urine calcium, eGFR, renal imaging (preferably low-dose CT scan for kidney stones/nephrocalcinosis) 1
- Bone assessment: Bone densitometry at three sites (lumbar spine, femur, distal radius), height measurement, screening for vertebral fractures 1
- Biochemical workup: Correction of vitamin D deficiency before PTH interpretation, exclusion of secondary causes 1
Specialist Coordination Based on Findings
The endocrinologist orchestrates referrals to additional specialists when indicated 1:
- Nephrologist: If eGFR <60 mL/min/1.73 m² or kidney stones present
- Urologist: If symptomatic stones, stones in solitary kidney, or stones at risk of migration
- Endocrine surgeon: Once surgical decision is made (see below)
When Surgery Becomes Indicated
The endocrinologist determines if the patient meets surgical criteria. Surgery is recommended when 1:
- Clinical consequences are present (bone fractures, kidney stones)
- Hypercalciuria is documented
- Target organ damage is identified on systematic screening
Critical point: Even patients labeled "asymptomatic" often have subtle manifestations that improve after parathyroidectomy, including bone density improvements and reduced fracture risk 2, 3. The 2025 guidelines recognize three phenotypes: asymptomatic hypercalcemic (with or without target organ impact), symptomatic hypercalcemic, and normocalcemic hyperparathyroidism 1.
Surgical Referral Pathway
Once surgical candidacy is established, the patient must be referred to an experienced endocrine surgeon 1. Certain complex situations require referral to expert centers:
- Poorly localized lesions on imaging
- Aggressive forms
- Revision surgery if not cured initially
- Multiglandular disease 1
Imaging Before Surgery
Pre-surgical localization includes parathyroid ultrasound combined with either double isotope scintigraphy (¹²³I/⁹⁹mTc-Sestamibi) or ¹⁸F-Choline PET-CT. If inadequate, expert centers perform MRI or 4D CT 1.
Common Pitfalls to Avoid
Don't assume "asymptomatic" means no intervention needed: Systematic screening often reveals target organ involvement that warrants surgery 1, 4
Don't delay vitamin D correction: PTH interpretation requires adequate vitamin D levels first 1
Don't skip bone densitometry: Even if surgery is already indicated by other criteria, baseline DXA serves as reference for follow-up 1
Don't refer directly to surgery without endocrine evaluation: The biochemical diagnosis must be confirmed and differential diagnoses excluded (familial hypocalciuric hypercalcemia, secondary hyperparathyroidism, medication effects) 1
Bottom Line
Start with endocrinology referral. They will complete the diagnostic workup, assess for target organ complications, determine surgical candidacy, and coordinate appropriate specialist involvement including eventual referral to an experienced endocrine surgeon when indicated 1, 5.