What are the treatment options for hyperparathyroidism?

Hyperparathyroidism is often caused by an adenoma. This is a growth that makes too much parathyroid hormone. It is made out of parathyroid tissue. If there are no symptoms and the calcium level in the blood is only slightly high, it is usually safe to wait and see. Then you have check-ups every 1 to 2 years. Otherwise, the tissue is surgically removed.

Surgery is mainly considered if you have

• symptoms, such as belly pain
• kidney stones or damage to the kidneys or bones
• a greater risk of complications, such as heart rhythm disorders

The surgery is usually done at a hospital that has a lot of experience with this type of procedure. In order to do the surgery with as little tissue damage as possible, the doctors first try to find out exactly where the parathyroid adenoma is – for example, using an ultrasound scan and a nuclear medicine scan known as a SPECT. This is a specialized form of scintigraphy that is often combined with computed tomography (CT scans).

If the adenoma is found and it's unlikely that there are any other adenomas, the surgeon can remove only the affected parathyroid gland. To do this, they make a cut in the skin on the neck, about 2 to 3.5 centimeters long.

The hormone level in the blood can be checked during surgery to make sure that the removed gland was the only thing causing the hyperparathyroidism. If the hormone level doesn't go down, there may be another adenoma in a different parathyroid gland. Then the surgeon also has to look for adenomas in other parathyroid glands.

If it's likely from the start that there's more than one adenoma, both parathyroid glands on one side – or all four – are looked at during the surgery.

There are also various surgical techniques that aim to preserve even more tissue – for example, by doing open surgery but making a slightly smaller cut. Endoscopic surgery is also an option, but quite rarely done. Here, the necessary surgical instruments – and a camera, if needed – are inserted through even smaller cuts.

Regardless of which surgical approach is used, the operation is done under general anesthesia and you stay in the hospital for about three days.

Once the affected gland has been removed, the hyperparathyroidism almost always goes away. As with any surgery, there's a small risk of damage to healthy tissue, blood vessels, or nerves – such as the vocal cord nerve in neck surgery – and a small risk of anesthesia-related complications. But complications such as severe bleeding or cardiovascular (heart and circulation) problems are rare.

After surgery, it may take days – or even a few weeks – for the regulation of parathyroid hormone and calcium levels to return to normal. Because the body suddenly makes less parathyroid hormone, blood calcium levels may also drop for a while. This usually doesn't cause any problems – but the calcium level is checked anyway, just to be on the safe side. If it drops a lot, you may have muscle cramps. To prevent this, you are usually prescribed calcium tablets and a vitamin D supplement for some time. Calcium infusions (given through a drip) are rarely needed.

Sometimes all four parathyroid glands need to be removed because all of them contain tissue that makes too much parathyroid hormone on its own. But the body might no longer be able to make this hormone at all after the surgery. For this reason, a small amount of parathyroid tissue is transplanted to another part of the body – for example, the forearm. The gland tissue can grow in that area and continue to make parathyroid hormone there. For the vast majority of people, this is enough to ensure a healthy balance of calcium in the body. If the tissue becomes enlarged again and makes too much of the hormone, it's easier to remove it there than in the neck.

If surgery would be too much of a strain or you don't want to have surgery, medication may be an option. Medications known as bisphosphonates can be prescribed if hyperparathyroidism is causing bone damage. These medications stop too much calcium from being taken from the bones due to the high parathyroid hormone levels, preventing the bones from becoming brittle. The medication is taken as a tablet with plenty of liquid. The possible side effects include headaches, gastrointestinal problems, flu-like symptoms or allergic reactions.

Some treatments aim to slow down the production of parathyroid hormone. For example, calcimimetics bind to the cells in the parathyroid glands and act in a similar way to calcium, reducing the production of parathyroid hormone.

It is also important to avoid other things that can increase the calcium levels in your body – such as calcium tablets that are dissolved in water, diuretics (thiazide diuretics), proton pump inhibitors, and lithium-containing medications for mental health problems. It is best to talk to your doctor about this. In general, you should drink plenty of fluids so that any extra calcium can leave your body in your urine (pee).

Various medical conditions cause the body to either lose calcium or not absorb enough of it. If the parathyroid glands produce more parathyroid hormone to make up for the resulting lack of calcium, surgery is not the treatment of first choice. Then it's important to treat the underlying medical condition first instead.

If the underlying condition that leads to low levels of calcium is chronic and can't be cured, it's important to take calcium tablets. Then the parathyroid glands will no longer have to make up for the lack of calcium, and they can start making normal levels of parathyroid hormone again. If that's not enough, you can also take calcimimetics, which affect the parathyroid glands in a similar way to calcium, reducing the production of parathyroid hormone. Calcimimetics are considered to be well tolerated. If they cause any side effects, these mainly include nausea, vomiting and feeling weak.

If hyperparathyroidism is caused by chronic kidney disease, the level of phosphate in your blood is often higher too. Then doctors recommend that you avoid foods that are high in phosphates, such as ready-to-eat meals, organ meats (offal), sausages or dairy products. You can also take medications that bind phosphate in your digestive tract, so that your body absorbs less of it. It is best to talk to your doctor about what to keep in mind when taking the various medications and how long you need to take them.