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Operation

An operation (parathyroidectomy) is the only cure for primary hyperparathyroidism. During parathyroidectomy, one or more diseased parathyroid glands are removed.

Why do you look at all four parathyroid glands during the operation? Doesn’t that pose a risk to the glands?

Seeing all four parathyroid glands is the best way to ensure that you are removing all of the diseased glands and leaving in normal ones. However, there can be a risk: when you look at all four parathyroid glands (or even attempt to look at all four parathyroid glands), you are creating scar tissue, which could then make future operations more difficult. There is even a risk that during the dis...

Operation Primary HPT Operative technique Cure rate

Why don’t you use intraoperative PTH? Another surgeon I saw said that he uses intraoperative PTH (ioPTH) to confirm that the patient is cured. You said that you do not use ioPTH. Why is that?

I prefer to evaluate all four parathyroid glands rather than rely on intraoperative PTH. Here is why: intraoperative PTH is just not that accurate. Here is the thinking behind ioPTH: a surgeon can remove one parathyroid, often one seen on preoperative imaging, test the PTH level in the blood, then wait 5 to 10 minutes and test again, then wait 5 or 10 more minutes and test again. If the PTH dr...

Operation Operative technique Cure rate Intraoperative PTH

Is it safe to wait for surgery? I was diagnosed with primary hyperparathyroidism and told that I need surgery. Unfortunately I cannot get the operation done this month. Is it safe to delay the operation for a few months?

It is fine to delay. This is a disease that causes problems over decades. A delay of months, or even a year, is not likely going to cause any harm. You have likely had this growing for several years already before being diagnosed (this is true for most patients), so a little longer won't significantly harm you. While you are waiting for the operation, the best things to do are: stay hydrated...

Primary HPT Operation Treatment

When can I expect to feel better after surgery? I’ve been feeling terrible.

This is a great question. Unfortunately there isn’t a single answer for everyone. On average, most people will feel better within a few weeks after surgery, and this improvement can continue for months. But that is just the average. I have had patients who wake up after surgery and felt like a cloud was lifted. They feel amazing, right after the operation. These patients are rare, but they happ...

Outcomes Primary HPT Operation Postop expectations FAQ

Do I need surgery if I don't have symptoms? I am a 65 year old woman who was recently diagnosed with primary hyperparathyroidism. My calcium and PTH levels are both high. I have osteoporosis, but have not had any fractures, and otherwise I am very healthy. I don't have any of the symptoms that other people report. If I feel pretty good overall, do I really need the operation?

This is a great question. It's odd to hear that you might need an operation for something that isn't really bothering you. In cases of clear primary hyperparathyroidism, I do usually end up recommending surgery. We know that the disease does not go away on its own. And we know that the symptoms and the complications from parathyroid disease get worse with time. It is actually pretty common for ...

Symptoms Operation

Is surgery going to help my symptoms? I am exhausted, and just don't feel like myself any more. I have had high calcium levels for the last four years. My doctor recently diagnosed primary hyperparathyroidism but said that I don't need surgery. He doesn't have an explanation for why I feel so bad. My doctor does not think these symptoms are related to the parathyroid, or that parathyroid surgery will help.

Fatigue is the most common symptom reported in patients with primary hyperparathyroidism. It is very likely that your parathyroid condition is a major cause of why you are feeling exhausted. It is also common for patients to state that "I'm no myself any more." Fortunately, these symptoms improve once the parathyroid disease is treated (once the diseased parathyroid gland is removed). Based on ...

Symptoms Operation Postop expectations

Can I have surgery with a negative scan? I was diagnosed with primary hyperparathyroidism last year, but no one can seem to find a parathyroid tumor. I have had two sestamibi scans, a CT, and ultrasound but they were all negative. My surgeon says he will not operate until something is seen on the scan. I am having bad bone pain and want to get this done. How can we find this parathyroid?

Imaging studies should not be used to determine when to operate. We diagnose parathyroid disease with labs, not with imaging, so we know that you have at least one diseased parathyroid gland. If the diagnosis is clear, then there is no reason to wait to have surgery, as long as you have an experienced surgeon who can evaluate all four parathyroid glands. If you have a surgeon who wants to see t...

Operation Imaging Operative technique

For personal reasons, I cannot have parathyroid surgery until next year. How often should I get my labs checked during that time to make sure that the disease isn't getting worse?

Regarding how often labs should be checked, if someone is not having surgery right away: they don't need to be checked that often. Often, the labs stay very similar for many years. The severity of the disease is not related to how high the calcium is (for patients with high calcium). The severity of the disease is related to how long it is present. So there is no number cutoff where you can say...

What are the risks of parathyroid surgery?

Parathyroid surgery is generally a very safe operation, especially when performed by an expert at the operation. There is a risk of complications with every operation, though. The main risks with parathryoid surgery are postoperative bleeding, voice changes, and thyroiditis. Bleeding is a risk with any operation. It occurs in about 1 in 500 cases (about 0.2%). It is more likely in patients w...

Postop complications Operation

I just found out on routine bloodwork that my calcium is 12.4 mg/dl. I know I need parathyroid surgery but I won't be able to see the surgeon until next month. Since my calcium is so high, I'm worried that my health is going to deteriorate before I get this operation. How quickly do I need to get this done?

The odds are that you have had high calcium levels for years. Your calcium did not jump from normal range to 12.4 in a day, or you likely would have noticed acute symptoms of high calcium (nausea, vomiting, confusion). Since this was found incidentally, it is very likely that you have had rising calcium levels for a while. The severity of primary hyperparathyroidism is unrelated to how high the...

Hypercalcemia Operation

How is parathyroid disease treated?

For the most common type of parathyroid disease, called primary hyperparathyroidism, the only treatment is an operation. During the operation, one or more diseased parathyroid glands are removed. Primary hyperparathyroidism is characterized by high calcium (generally over 10.0 mg/dl in adults over age 40, slightly higher for younger adults). If you have parathyroid disease with high calcium, th...

Operation Treatment FAQ Popular

Hi Dr. Boone, I had 3 glands removed earlier this year. My question is do I have to worry about my 4th gland? Do they ever go bad over time? Is the way to put my mind at ease to keep checking calcium and PTH levels, and not worry unless they both go high? But I'm taking vitamin D, which will lower my PTH result, right?

This is a great question. Short answer: your 4th parathyroid gland is likely not completely normal. But that doesn't mean it will cause problems. I would recommend following calcium levels annually, just as I recommend for other parathyroid patients. Long answer: First let's review what you had done. You had parathyroid surgery for primary hyperparathyroidism, and during the operation y...

Hyperplasia Operation

Hello! I'm planning on getting my Covid-19 vaccine before surgery but I'm a little nervous because I already have lots of symptoms from hypercalcemia like fatigue, gastritis, constipation, bloating and heart palpitations. My immune system appears fine on cbc tests though. Should I expect my symptoms to get tremendously worse in combination with the vaccine temporal symptoms or most patients report is bearable? Thank you!

Great question! Unfortunately we don't have enough information on how parathyroid patients react to the vaccine for me to be able to give a definitive answer. A lot of people who get a Covid vaccine do have some temporary side effects, and if you are already feeling bad then that could make you feel worse. Generally, though, the effects of the vaccine are short-lived, and are preferable to ...

Is a parathyroid surgery out-patient? What is the recovery time? What are the risks?

Thanks for asking! Parathyroid surgery is nearly always outpatient, and you go home the same day as the operation. There are some rare exceptions, so occasionally someone will need to spend the night in the hospital. For example, patients who are on dialysis for kidney failure or patients with very severe heart or lung disease that might need to be monitored for a little longer after surger...

Operation Postop expectations Popular Postop complications

Does parathyroid surgery have to be performed for primary hyperparathyroidism if I don't have any symptoms? Can nutrition or natural medicine correct hyperparathyroidism?

The only known cure for primary hyperparathyroidism (pHPT) is an operation: parathyroidectomy. It's natural to wonder whether this needs to be done, though, if you aren't experiencing any ill effects from the condition. Many patients with pHPT report symptoms like fatigue, brain fog, low energy, body aches, and insomnia. But a few patients say that they feel just fine. These patients often ask ...

Operation Primary HPT Treatment

Why do you not use the radioguided technique?

When I was at the Norman Parathyroid Center, every patient received a radioguided parathyroid operation. Now that I have my own practice, I perform the radioguided operation in some patients, but not all. The main reason is that most people do not need a radioguided approach. It is extra radiation that most people do not need. What exactly is radioguided parathyroid surgery? It is referring...

Operation Operative technique

Is it common for PTH levels to fluctuate after removal of 1 parathyroid gland? I had surgery and a week later, my PTH was at 96.7. Calcium and Vit D were closer to normal.

The simple answer is yes, it is common (and even expected) for PTH levels to fluctuate after surgery. Right after a parathyroid tumor is removed, PTH levels plummet. If the other parathyroid glands are normal, then they are dormant, and making very little PTH. A day after surgery, I expect the PTH level to be low. Calcium levels drop soon after that as a result of the drop in PTH. In the we...

Operation Postop expectations

I am set to have surgery for primary hyperparathyroidism in the near future. So far testing has not been able to detect the location of a hyperparathyroid tumor. I have been told that during the exploratory surgery if the parathyroid glands cannot be located, my thyroid will be removed in an attempt to lower calcium levels. I was also told that if a tumor appeared in the future additional surgery would be necessary. I would like to know if the removal of a thyroid is the normal course of action when parathyroid glands cannot be located.

Thanks for writing. The short answer is that removing the entire thyroid is almost never necessary in parathyroid surgery, but occasionally removing a piece of thyroid can help. There is one very specific scenario in which I will remove a piece of thyroid. Here is the scenario: I am performing an operation for primary hyperparathyroidism and have found three normal parathyroid glands, but I...

Operation Postop complications Operative technique

I had parathyroid surgery last week - two glands were removed. The biopsy came back as hyperplasia instead of adenoma. My understanding is that if it is hyperplasia, all FOUR glands are affected. My surgeon did find a 3rd gland "lumped in" next to one of the enlarged glands and he originally took it as well, upon further inspection, realized it was not part of the bad gland and appeared normal, so he re-implanted it. He did NOT look at the 4th gland at all. My question is, since the pathology came back as hyperplasia instead of adenoma, will I need another surgery at some point to remove the other gland?

Thank you for bringing up this really important topic! The full answer to your question is complicated, so here is the brief summary: Pathology is not used to determine whether you had adenomas or hyperplasia. In most cases, we can't determine hyperplasia vs. adenoma on pathology slides. The report is really just confirming that your surgeon removed parathyroids. An adenoma may be called "hy...

Operation Pathology

I have thyroid nodules. One has grown. Do I need a biopsy before having parathyroid surgery? I want all of them removed. Thank you.

Thyroid nodules are very common, and most of the time they are completely benign. If there is a concern for cancer, then it makes sense to have the nodule biopsied before undergoing parathyroid surgery, since the thyroid operation can be done at the same time as the parathyroid. If your nodules all appear benign on ultrasound (the best imaging study for thyroid nodules) then getting a biops...

Thyroid nodule Operation

After surgery is done, how many days off do you need to recuperate before one can go back to work?

This can vary a lot. In general, I tell patients to take off a week from work if they can. If they cannot or do not want to take off a week, then I say to at least take a couple of days off. Most people can get back to regular activities within a few days. But you do not always know how your body is going to react, so I recommend taking the week off just in case it takes you a little longer...

Postop expectations Operation

Primary Parathyroid issue since 2016. Endocrinologist wants me to take Sensipar. I have osteoporosis on wrist on dexa scan. I am debating what is the best option for me as I got told that I might have all 4 glands involved. On scan it looks like left upper one but images are not great. In past I follow Mayo clinic and just wait and watch game. Do you have any advice for me? I am from Iowa. My calcium level is not high but in range of 10-10.5 mg/dl, Vitamin D is always low. PTH between 80 to 129 pg/ml. I am 75 years old.

Your labs are diagnostic for primary hyperparathyroidism, with elevated calcium and PTH levels. Low Vitamin D is also classic in primary hyperparathyroidism. The only cure for primary hyperparathyroidism is an operation to remove the abnormal parathyroid gland or glands. Sensipar is a medication that can reduce your calcium and PTH levels. It will make your labs look better on paper, but wi...

Operation Diagnosis

Dear Dr. Boone, I reached out to you earlier this year when I suspected I had parathyroid disease. I have just recently been definitely diagnosed. I am presently researching and planning to have the surgery in the near future. The doctor here in Chicago with whom I consulted uses General anesthesia but I have read that others use a "light" anesthesia (with no intubation required). What type of anesthesia do you typically use when you perform your surgeries? Thank you!

Thanks for asking. Most surgeons use general anesthesia for parathyroid surgery. I use general anesthesia for all patients, and this is what I did when I was at the Norman Parathyroid Center as well. The terms regarding anesthesia can be confusing. "Light anesthesia" is not really a term that physicians use. The major categories of anesthesia are as follows: 1. General Anesthesia: This m...

Operation Operative technique

Should I be taking Vitamin D? I am a 53 year old man. I had parathyroid surgery in 2/2023. Prior to surgery, my calcium levels had been high, 10.1 to 10.9 mg/dl for the previous 3 years. Upon diagnosis I was told to take Vitamin D3 (3000 IU) daily. In 6/2023 I began having neck pain and dizziness. My PTH was measured at 121 pg/ml, with Calcium 10.7 mg/dl. In 10/20/2023 I stopped taking Vitamin D3. In 11/23 I was feeling abnormal. Dysphagia came back, very frequent urination etc. I requested labs as a result and my blood calcium came back as 10.7 and PTH was 53, the lowest in 2 years (since being measured). Yet, I feel worse than ever. Should I resume D3? I just do not know. Thank you.

Thanks for writing in. Typically I recommend taking calcium and Vitamin D after parathyroid surgery, but in your case I would advise against it, since your calcium is still high. Unfortunately, your lab results indicate that you still have primary hyperparathyroidism (pHPT). The calcium level is high for your age, and the PTH is not suppressed, which is inappropriate for the elevated calciu...

Operation Diagnosis Vitamin D

I am 6 weeks past parathyroid surgery. Prior blood tests showed 12.3 calcium, 425 PTH. One large tumor was removed and the other 3 parathyroids were checked as normal and left in situ. PTH one hour after surgery was 33. Blood test today is 9.3 calcium and 131 PTH. Is it normal for the PTH to fluctuate for awhile? Or, do I need additional calcium or Vitamin D? I am taking 650mg calcium and 25mcg of Vit D daily since surgery.

Yes, it is common for PTH levels to fluctuate after parathyroid surgery, especially when the calcium drops down into the low-normal range after being elevated for so long. Your calcium level is now in the low-normal range, which is a good sign. The PTH is high, but this is may be appropriate for your calcium. Your body was dealing with parathyroid disease for years, and you had a pretty hi...

Operation Postop expectations

I had a parathyroid adenoma removed when I was 37 years old. I am now 73 years old and have been diagnosed with a second parathyroid adenoma (calcium is 10.8 mg/dl and PTH 78 pg/ml) which will require surgery. How common is this and are most doctors aware it can reoccur?

Thanks for asking! There are a couple of aspects to your question. First, how common is it to have recurrent parathyroid disease? It's hard to get firm numbers on exactly how many people end up having more than one parathyroid operation, because patients often follow up with different providers, and a recurrence can take many years to present (like in your situation). So I can't give an exa...

Multigland disease Primary HPT Operation Outcomes Pathology primary hyperparathyroidism

This question is regarding Direct Visualization of all 4 parathyroids versus radioguided parathyroidectomy. When directly visualizing the 4 parathyroids, is it easy to tell a normal gland versus a hyperactive gland? I'm sure it is easy to tell if one is grossly enlarged but if it is going abnormal (producing too much PTH) but not yet enlarged, can that be seen or can it only detected by the radioactivity? If 2 of the glands are abnormal or will become abnormal, do they usually become abnormal at the same time? The reason I ask this question is that I see you worked at the Norman Parathyroid Center who uses the radioguided method while you prefer the direct visualization method. Do you still run a sestamibi scan before each surgery but simply don't take a sample of each gland to test individually for radioactivity? Is it just a difference in your views on sampling via visual and being able to tell by size or texture or other feature rather than radioactivity and consequential exposure for patients? Since 20% have more than one gland hyperactive, I'm wondering how certain the visualization is or if in certain cases you do test. I see your method is different now from what you did at Norman Center and just wondered why you changed.

Thank you for your question. It touches on several important aspects of parathyroid surgery. I was at the Norman Parathyroid Center for six years, and was the Medical Director when I left to start my own practice. In starting my own center, I took a close look at our practices in Florida and critically evaluated each one. For the most part, the operation that I do here is the same as the one I ...

Operative technique Primary HPT Treatment Operation

The local endocrinologist diagnosed me with primary hyperthyroidism. Ultrasound showed a 22 mm thyroid nodule. Should I have a FNA prior to having a surgical evaluation at your center? My calcium is 10.6 mg/dl and PTH 116 pg/ml.

Thyroid nodules are very common, especially as we get older. It is very common for thyroid nodules to be discovered on imaging for parathyroid disease. Do the nodules need to be biopsied prior to parathyroid surgery? It depends. I would want to see more information about the nodule before giving a recommendation. Most thyroid nodules are completely benign; some nodules will contain cancer. ...

Thyroid nodule Primary HPT Diagnosis Operation Treatment