Understanding Parathyroid Disease
Parathyroid Function
Parathyroid glands are four pea-sized glands located behind the thyroid gland. Despite their name and proximity, they function independently of the thyroid, serving as the body's primary regular of calcium. Hyperparathyroidism occurs when one or more of the parathyroid glands malfunctions, growing uncontrollably and oversecreting parathyroid hormone (PTH). This growth is typically a parathyroid adenoma—a benign (non-cancerous) tumor that acts like a broken thermostat.
The Mechanism of Malfunction
In a healthy state, these glands sense calcium levels in the blood and shut off when levels are sufficient. In hyperparathyroidism, the gland's calcium sensor fails. It becomes "blind" to high calcium levels, continually pumping out PTH and forcing the body to maintain an abnormally high blood calcium concentration.
Diagnosing Primary Hyperparathyroidism
Understanding your bloodwork
The diagnosis of hyperparathyroidism is purely biochemical. It is based on blood tests. If blood calcium is elevated and PTH is elevated, this is primary hyperparathyroidism. If your calcium level is elevated just above the upper limit, it should be repeated along with a PTH. If you were to ingest a lot of calcium (for example by taking Tums or drinking a lot of milk quickly), the blood calcium level will generally not rise significantly. Instead, within minutes, the parathyroid glands sense the rising calcium and quickly shut off parathyroid hormone production, quickly bringing the calcium back to normal. This is why there is an inverse relationship between calcium and PTH when the parathyroid glands function correctly.
Diagnosing Hyperparathyroidism: The Biochemical Signature
The diagnosis of primary hyperparathyroidism is purely biochemical, meaning it is confirmed through blood chemistry rather than imaging like ultrasounds or CT scans.
The Diagnostic Criteria
The condition is identified by a specific relationship between two markers:
- Elevated Blood Calcium
- Elevated (or inappropriately "normal") PTH
If a blood test shows calcium levels slightly above the upper limit, clinical protocol is to repeat the test alongside a PTH level to confirm the trend.
The Inverse Relationship: How a Healthy Body Responds
In a healthy person, calcium and PTH share an inverse relationship. Think of it as a see-saw:
- The "Calcium Challenge": If you were to ingest a large amount of calcium (via supplements like Tums or dairy), your blood calcium doesn't simply spike and stay high.
- The Response: Within minutes, healthy parathyroid glands sense the rising calcium and immediately shut off PTH production.
- The Result: Without PTH, the body stops pulling calcium from the bones, and levels quickly return to a tight, normal range.
Why High PTH + High Calcium = Malfunction
When both levels are high simultaneously, the "see-saw" is broken. It indicates that the parathyroid gland has lost its ability to sense the calcium "off-switch." Even though the blood is already saturated with calcium, the malfunctioning gland (the adenoma) continues to pump out PTH as if the body were starving for it.
Do I have hyperparathyroidism
Here are several examples:
Calcium 10.3 (ref. 8.6-10.2 mg/dL)
PTH 66 (ref. 15-65 pg/ml)
This is classic primary hyperparathyroidism
Calcium 11.3 mg/dl (ref. 8.6-10.2 mg/dL)
PTH 118 pg/ml
This is classic primary hyperparathyroidism
Calcium 10.3 mg/dl (ref. 8.6-10.2 mg/dL)
PTH 41 pg/ml (ref. 15-65 pg/ml)
Even though the PTH is within the "normal range" it is "inappropriately elevated" or "inadequately suppressed" - implying that one of the parathyroid glands is not sensing the high calcium and is producing an inappropriate amount of PTH. If the calcium is high the PTH should be below normal (<15) nor sometimes low normal (15-20 pg/ml).
This is sometimes called "normohormonal" primary hyperparathyroidism
Calcium 9.9 (ref. 8.6-10.2 mg/dL)
PTH 122 pg/ml (ref. 15-65 pg/ml)
This is a more challenging case. This either represents secondary hyperparathyroidism or "normocalcemic" primary hyperparathyroidism. Other causes of elevated PTH need to be evaluated including chronic kidney disease, low vitamin D, and malabsorption problems. We often need to repeat labs. Some centers will try a "calcium challenge" - purposely giving patients more oral calcium and vitamin D. Appropriately functioning parathyroid glands will sense the rising calcium and should "suppress" into the low normal range. If the PTH does not drop and the calcium rises further, this helps establish the diagnosis of primary hyperparathyroidism.
Calcium 12.5 (ref. 8.6-10.2 mg/dL)
PTH 9 pg/ml (ref. 15-65 pg/ml)
This is not hyperparathyroidism. The parathyroid glands are functioning correctly and suppressing PTH production. In this case, there is a non-parathyroid cause of high calcium. Some malignancies may cause this.
Symptoms of Hyperparathyroidism
The "Classic" Symptoms: Bones, Stones, Groans, and Psychiatric Overtones
For decades, medical students have used this mnemonic to memorize the systemic impact of hyperparathyroidism. While the rhyme is simple, the symptoms are often complex and life-altering.
🦴 Bones (Skeletal & Muscular)
Excess PTH acts like a "leach," pulling calcium directly from your skeleton.
- Bone Density Loss: Progressing from Osteopenia to Osteoporosis.
- Fragility Fractures: Breaking a bone from minimal trauma due to underlying weakness.
- Physical Pain: Deep bone pain, persistent joint aches, and muscle soreness.
💎 Stones (Renal/Kidney)
High levels of calcium must be filtered by the kidneys, leading to kidney stones.
- Kidney Stones: Frequent or recurrent painful stones.
- Declining Kidney Function: Long-term strain that can lead to chronic kidney disease.
😫 Groans (Gastrointestinal & General Malaise)
"Groans" refers to both physical GI distress and the general "feeling lousy" that patients report.
- GI Issues: Chronic constipation and acid reflux (GERD/heartburn).
- Vitality: Profound chronic fatigue, insomnia, and a general sense of feeling unwell.
🧠 Psychiatric Overtones (Neurocognitive/Neuropsychiatric)
Perhaps the most overlooked symptoms, these affect the "quality of life" and mental clarity.
- "Brain Fog": Difficulty with concentration and memory.
- Cognitive Friction: Word-finding problems, mental lapses
- Mental Health: Increased anxiety, depression, and irritability.
Indications for Surgery
Traditonal Indications:
The only curative treatment for hyperparathyroidism is parathyroidectomy. We recommend surgery for all patients that are symptomatic. Most asymptomatic would also benefit from surgery. There are guidelines providing further indications for surgery in "asymptomatic" patients:
Criteria for Surgery in Asymptomatic Patients
Medical guidelines establish specific thresholds where the benefits of surgery outweigh "watchful waiting." Surgery is typically recommended if a patient meets any of the following Traditional Indications:
- Age (< 50): Younger patients have a longer "at-risk" window for bone loss and kidney damage, making early intervention more beneficial.
- Very High Calcium Levels: A blood calcium level consistently > 1.0 mg/dL above the upper limit of normal.
- Bone Health: A T-score of -2.5 or worse (Osteoporosis) on a DEXA scan, or the presence of a vertebral fracture.
- Kidney Health:
- High 24-hour urinary calcium levels (> 250 mg in women or > 350 mg in men).
- The presence of "silent" kidney stones found via ultrasound or X-ray.
- Significant decline in overall kidney filtration (eGFR < 60).
Note on "Asymptomatic" Patients:
Many patients labeled as "asymptomatic" realize—only after surgery—that their chronic fatigue, brain fog, or bone aches were actually symptoms they had simply grown used to. For this reason, many surgeons recommend a curative procedure even when these strict clinical thresholds haven't been fully met.
What to expect during your consultation with Dr. Davidov
What to bring
Dr. Davidov will typically review all your bloodwork, imaging, and office notes from your referring endocrinologist or primary care physician before meeting with you. During his exam, he will perform an informal bedside neck ultrasound.
It is very helpful to have the following printed results:
Most important: At least one set of calcium and PTH
Helpful: several other calcium and PTH results over the past few years (if done)
most recent Vitamin D (25-OH) level
Thyroid function tests (TSH and Free T4)
basic chemistry or comprehensive chemistry (includes calcium, creatinine, GFR, albumin)
Helpful but not essential: phosphate
Very helpful: 24 hour urine calcium and creatinine or Litholink kidney stone analysis (if done)
Most recent DEXA (bone density) scan (if done; ideally including radius in addition to hip, femoral neck, and lumbar spine)
Abdominal or Renal ultrasound (or CT of the abdomen if done in past 3 years) - looking for silent kidney stones (if done)
Thyroid/parathyroid ultrasound (if done; not mandatory)
Parathyroid nuclear sestamibi scan (if done; not mandatory)
Completed intake form (download below)
Parathyroidectomy
Parathyroidectomy
The only effective treatment for primary hyperparathyroidism is a parathyroidectomy. Most endocrine surgeons will obtain preoperative "localization studies" to help identify which of the four parathyroid glands are abnormally enlarged and provide the surgeon with a roadmapoffer a "focused" or minimally invasive" parathyroidectom. By that, they mean, using "localization studies" such as neck ultrasound, parathyroid nuclear sestamibi scan, or 4D CT to identify which of the four parathyroid glands has become enlarged and needs to be removed. These studies will "localize" or identify a suspicious parathyroid gland 80% of the time. This allows for a "focused" or "minimally inavsive parathyroidectomy" where a small incision is made and only the abnormal gland is removed. Many center
The Path to Surgery: Localization and Innovation
The only definitive treatment for primary hyperparathyroidism is a parathyroidectomy. Modern surgical techniques have transformed this procedure from a major exploration into a precise, targeted operation.
Preoperative "Localization": The Surgical Roadmap
Before entering the operating room, most endocrine surgeons utilize localization studies. These tests act as a "roadmap," identifying which of the four parathyroid glands is enlarged (the adenoma) so the surgeon can plan the most direct approach.
Common localization tools include:
- Sestamibi Scan: A nuclear medicine test where a mild radioactive tracer is absorbed specifically by the overactive gland.
- High-Resolution Ultrasound: A non-invasive look at the soft tissues of the neck to visualize enlarged glands.
- 4D-CT Scan: A highly detailed, multi-phase CT scan that tracks how the parathyroid glands handle blood flow over time.
The "Focused" or Minimally Invasive Approach
When these studies successfully "localize" or identify the suspicious gland—which happens approximately 80% of the time—the surgeon can offer a minimally invasive parathyroidectomy.
What this means for the patient:
- A Focused Incision: Instead of a traditional wide neck exploration, a small, targeted incision is made directly over the site of the abnormal gland.
- Targeted Removal: Only the specific gland identified by the roadmap is removed, leaving the healthy glands undisturbed.
- Faster Recovery: This approach typically results in less post-operative discomfort, a smaller scar, and a quicker return to daily activities.
Note: Even if localization studies are negative (the 20% "not seen" on scans), an expert endocrine surgeon can still perform a successful surgery by briefly examining all four glands to find the culprit.
Surgical Safeguards: Ensuring a Precise and Successful Outcome
A successful parathyroidectomy isn't just about removing a gland; it’s about confirming—in real-time—that the problem is solved. At specialized centers, surgeons use three key "safeguards" to ensure the highest success rates and patient safety.
1. Intra-operative PTH Monitoring (The "Cure Confirmation")
Since parathyroid hormone (PTH) has a very short half-life (it disappears from the blood within minutes), we can measure your levels while you are still on the operating table.
- How it works: We draw blood before the surgery and again 10 minutes after the suspicious gland is removed.
- The Result: If the PTH level drops significantly (usually by 50% or more), it provides immediate biochemical proof that the overactive gland is out and the surgery is a success. This prevents the need for a second surgery later.
2. Frozen Section Analysis (Pathological Verification)
Once the surgeon removes the suspicious tissue, it is immediately sent to a pathologist for a "frozen section."
- The Process: The pathologist freezes the tissue, slices it thinly, and examines it under a microscope immediately.
- The Goal: This confirms that the tissue removed is indeed parathyroid tissue and, more importantly, identifies it as an adenoma (the benign tumor). This acts as a second "checkpoint" to ensure the correct target was reached.
3. Intra-operative Nerve Monitoring (Voice Protection)
The parathyroid glands sit very close to the recurrent laryngeal nerves, which control your vocal cords.
- The Technology: We use a specialized "nerve monitor" (often via the breathing tube) that provides real-time audio and visual feedback to the surgeon.
- The Benefit: This allows the surgeon to identify and map the location of the nerves throughout the procedure, minimizing the risk of injury and protecting your voice, breathing, and swallowing function.
Minimally Invasive and Focused Parathyroidectomy
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Intraoperative PTH monitoring
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Intraoperative nerve monitoring
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What to expect on the day of surgery
Before Your Procedure
- Fasting: Please do not have anything to eat or drink after midnight the night before your surgery.
- Medications: Dr. Davidov will review your current medications prior to the procedure. He will provide specific instructions on which medications to continue, which to hold, and the appropriate timing for each.
- Arrival: Please arrive at the hospital 1.5 hours before your scheduled surgery time to allow for check-in and preparation.
During the Operation
You will be under general anesthesia, meaning you will be completely asleep and comfortable for the duration of the procedure. To ensure you wake up with minimal discomfort, we will administer local numbing agents and pain medication during the surgery. Removing a parathyroid gland takes 10-20 minutes but the entire process (with checking frozen section and rapid intraoperative PTH blood testing) will be closer to 1.5 hours.
Postoperative care and followup
1. Follow-Up & Lab Work
- 10-Day Follow-Up: Call our office at 609-936-9100 to schedule your post-op appointment.
- 5-Day Blood Work: Please have your calcium and PTH levels checked 3-8 days after surgery.
- Location: Ideally at the Princeton Medical Center Lab (609-853-6800), though your local LabCorp or Quest is also acceptable.
- Endocrinology: Schedule a visit with your endocrinologist for 2–3 months from now. They will likely repeat blood work at 3-month and 6-month.
2. Medications & Supplements
- Calcium (Citracal Slow Release): Take 2 tablets (1 dose), twice daily. Note: This is higher than the bottle's standard dosage. We will taper this off over 2–4 weeks.
- If you feel tingling/numbness in lips or fingers: Increase to 2 tablets, three times daily and get your blood work done early. Call us if symptoms persist after 6 hours.
- Vitamin D & Thyroid Meds: Continue taking these as you did before surgery.
- Pain Management:
- Baseline: Take 2 Extra-Strength Tylenol (500mg) every 8 hours for the first 48 hours.
- Mild/Moderate Pain: Take 2–3 Ibuprofen (Advil/Motrin 200mg) every 6 hours as needed. These can be taken with Tylenol.
- Digestion: To prevent constipation from surgery meds, consider Prune juice, Colace (100mg twice daily), or Miralax as needed until regular.
3. Activity & Incision Care
- Showering: You may shower tomorrow. Let water run directly over the incision.
- Bandages: The surgical glue and Steri-strips will fall off on their own in about 3 weeks.
- Diet: Stick to soft foods for the first 2 days and chew thoroughly. You may resume a normal diet thereafter.
- Exercise: Resume light activity as tolerated. Wait 2–3 weeks before resuming jogging, cycling, or swimming.
4. What to Expect
- Sore Throat: A sore throat or weak voice is normal and may last from a few days up to 2 weeks.
- Calcium Drops: Mild tingling in the first 3 days is common as your body adjusts.
🚩 When to Call the Office Immediately
Sudden neck swelling (especially in the first 48 hours).
Tingling/Numbness that does not improve 6 hours after an extra calcium dose.
Severe chest pain or shortness of breath (Call 911 or go to the ER).
Office Number: 609-936-9100
Scar Gallery
Parathyroid incision 4 months after surgery
Parathyroid incision 4 months after surgery
Parathyroid incision 4 months after surgery
Parathyroid incision 2 months after surgery
Parathyroid incision 4 months after surgery
Parathyroid incision 4 months after surgery
Testimonials
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Dr. Davidov is an excellent choice in surgeon's if you want to feel a personal but professional connection to your doctor while receiving skilled and gifted care. I recently had parathyroid surgery and would highly recommend Dr. Tomer Davidov. He is a caring, respectful person and excellent surgeon who sincerely wants to help his patient from the initial consultation to the post surgery follow up.
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My endocrinologist sent me to Dr. Davidov for parathyroid surgery. I had been feeling awful for a year- no energy, concentration problems, achy bones, was found to have osteoporosis and after many tests, I was diagnosed with hyperparathyroidism. I did a test to locate the problem parathyroid, but it did not show anything wrong. My endocrinologist explained that I still have an enlarged parathyroid and I needed an experienced parathyroid surgeon who will be able to find the enlarged parathyroid gland so she referred me to Dr. Davidov. It appears that this is a tricky operation and Dr. Davidov is only one of a few surgeons who perform this surgery in the region. After meeting him, I felt at ease. His office is organized and his scheduler was excellent and accommodating. The hospital experience was excellent - staff was nothing but professional. Dr. Davidov found and removed my enlarged parathyroid gland. My blood tests are finally normal. I am amazed that my energy level is already better. I can’t thank Dr. Davidov and his team enough. He is a great choice if you are looking for an experienced parathyroid surgeon who is also a caring doctor.
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