What are the symptoms and treatment options for hyperparathyroidism, particularly in postmenopausal women?

Symptoms of Hyperparathyroidism

In countries with routine biochemical screening like the United States, primary hyperparathyroidism predominantly presents as an asymptomatic disorder discovered incidentally, with up to 80% of patients having mild or no symptoms at diagnosis. 1

Clinical Presentation by Disease Type

Primary Hyperparathyroidism (PHPT)

Asymptomatic Presentation (Most Common in Developed Countries)

• Most patients in the US, Canada, and Europe are discovered through incidental laboratory findings showing elevated calcium and PTH levels 1
• Postmenopausal women are the most commonly affected demographic group 1, 2

Symptomatic Presentation (When Target Organs Are Affected)

Skeletal manifestations:

• Bone demineralization and osteoporosis 1
• Pathological fractures 1
• Osteitis fibrosa cystica (severe bone disease) 3

Renal manifestations:

• Nephrolithiasis (kidney stones) 1, 4
• Nephrocalcinosis (calcium deposition in kidney tissue) 1, 4

Neuromuscular symptoms:

• Muscle weakness 1
• Generalized fatigue and asthenia 3

Neuropsychiatric symptoms:

• Neurocognitive disorders 1
• Lethargy, stupor, and potentially coma in severe hypercalcemia (calcium >13.5 mg/dL) 3

Gastrointestinal symptoms:

• Anorexia 3
• Nausea and vomiting (particularly with severe hypercalcemia) 3
• Persistent constipation 3

Cardiovascular complications:

• Progressive vascular calcification with persistent hypercalcemia 5

Secondary Hyperparathyroidism (SHPT)

Severity-Based Symptom Progression:

Moderate elevation (PTH 500-800 pg/mL):

• Progressive skeletal and articular pain 5
• Elevated alkaline phosphatase reflecting increased bone turnover 5
• Early renal complications 5

Severe elevation (PTH >800-1000 pg/mL):

• Persistent hypercalcemia causing progressive renal damage 5
• Severe bone pain with pathological fractures and skeletal deformities 5
• Intractable pruritus resistant to conventional therapies 5
• Calcium-phosphate product exceeding 70 mg²/dL² with extraskeletal calcifications 5
• Significant cardiovascular morbidity from vascular calcification 5

Critical Diagnostic Considerations

The diagnosis must be confirmed biochemically before attributing symptoms to hyperparathyroidism:

• Measure serum calcium (corrected for albumin) and intact PTH simultaneously 6
• Assess vitamin D status, as vitamin D deficiency can cause secondary hyperparathyroidism and complicate PTH interpretation 6
• PTH assays vary significantly between laboratories, so use assay-specific reference values 6

Treatment Implications Based on Symptoms

Parathyroidectomy is indicated for symptomatic PHPT including:

• Kidney stones 6
• Bone pain or fractures 6
• Neuromuscular symptoms 6
• Osteoporosis on DEXA scan 6
• Hypercalciuria 6

Even asymptomatic PHPT typically warrants surgery given the potential negative effects of long-term hypercalcemia. 1

For secondary hyperparathyroidism, surgical intervention is recommended when:

• PTH persistently exceeds 800 pg/mL with hypercalcemia and/or hyperphosphatemia refractory to medical therapy 6, 7
• Severe symptoms including intractable pruritus, progressive bone disease, or persistent hypercalcemia develop 5

Common Pitfalls to Avoid

• Do not assume normal calcium rules out hyperparathyroidism—check ionized calcium and PTH levels, as compensatory mechanisms can maintain normal total calcium initially 1
• Do not overlook vitamin D deficiency as a cause of elevated PTH before diagnosing primary hyperparathyroidism 6
• Recognize that in countries without routine screening, symptomatic presentation with target organ damage is more common than in the US 1
• Be aware that PTH levels alone do not determine symptom severity—calcium levels and duration of disease are equally important 5