Update – Is The Ketogenic Diet Safe For Those With Thyroid Disease?
May 2, 2019
Update – Supplements To Take For Hashimoto’s
May 9, 2019

Hyperparathyroidism – hidden cause of anxiety, IBS, and fatigue.

It is more than just a mouthful when it comes to hyperparathyroidism. You may have never heard of it, or heard it mentioned in passing, but if you have thyroid disease it may have piqued your interest – let me help you understand it better.

Hyperparathyroidism: The Truth

I had never heard about hyperparathyroidism until I reached medical school. The impression that it got was that it was:

  • Rare
  • Caused unusual/recognizable symptoms
  • Easy to diagnose

Key Insight: If you have symptoms that include some mixture of fatigue, digestive issues, anxiety, or muscle aches, this could be the hidden reason. If you have thyroid disease, your risks for parathyroid disease are higher.

Over the years of treating thyroid disease, I have come to realize that none of these things are true. It is not rare, it can cause the most common symptoms we suffer from, and it is easily missed unless a doctor knows exactly how to look for it.

Comprehensive Thyroid Care Telemedicine

I would love to be able to give you a really good understanding of parathyroid disease, and what you need to know about it, so that you can know for sure if this applies to you – and which next steps you can begin to take.

Jonell’s Story

“Jonell” was a patient of mine in my early years of practice. Like most, she first came in already on thyroid treatment but was not at her best just yet. A bunch of symptoms came on around the same time and she thought her thyroid was the culprit.

When she was diagnosed with thyroid disease, she went on treatment and it did get easier to manage her weight. However, her symptoms of IBS, fatigue, and anxiety did not get any better. She hoped that if I helped her optimize her thyroid treatment that they could improve also.

For the first steps, we helped her liver function, improved her micronutrient levels, and dialed in her medication. She did improve with these steps, but not as much as she or I would have liked. It seemed like certain foods triggered reactions but it also seemed like the more foods she tried, the more foods she reacted to.

Considering Less Common Culprits

“Para” means next to and the parathyroid glands are located next to your thyroid. Typically people have four parathyroid glands, two on each side of the lower portion of their thyroid.

However, there is some variation in:

  • Where they are located
  • How large they are
  • How many there are

The parathyroid glands secrete parathyroid hormone (PTH), also called parathormone or parathyrin. It pulls calcium out of your bones and into your bloodstream. It works in opposition with a thyroid hormone called calcitonin which mostly moves calcium out of the blood and into the bones. One of the reasons that overdosing on thyroid hormones hurts the bones is that it blocks the gland from releasing calcitonin.

How much calcium we have in our bodies is ultimately from how much we consume, but PTH and calcitonin adjust how much goes in the blood and how much goes elsewhere.

In some cases, the parathyroid glands produce too much PTH which can cause too much calcium to enter the bloodstream. This condition is called hyperparathyroidism.

Back to Jonell’s case. After seeing this elevated level of calcium, I decided to test her parathyroid function. I was not highly suspicious of it being abnormal because her blood calcium was normal all the rest of the time, but I was trying hard to find something.

Her retest showed that her calcium levels were fine but parathyroid hormones were 50% higher than normal. These findings were diagnostic of primary hyperparathyroidism.

I referred Jonelle to a local surgeon who specializes in parathyroid disease. He evaluated her and agreed with the diagnosis. Within weeks after surgery, her symptoms were better than they had been for years.

She found that she could eat a broader range of foods without symptoms. She also noticed that normal life stressors did not trigger her anxiety the way they did in the past. We also found it easy in the following months to keep her thyroid levels regulated with less testing and adjustment.

Bottom Line: Jonell’s case radically changed the way I’ve come to understand parathyroid disease. Many doctors have been taught that unless there are high levels of blood calcium, parathyroid disease is not possible. This is not true.

Comprehensive Thyroid Care

Since the doctors at Integrative Health see so many people with thyroid disease, they truly understand parathyroid disease. In fact, we diagnose 1 new case of hyperparathyroidism every week. To us, it is definitely not rare (1).

Sadly, I’ve also had many cases in which people have obvious elevations of calcium in the blood yet their doctors tell them it is normal or insignificant.

Key Insight: Please know this, high levels of blood calcium are never insignificant and always need to be diagnosed. Besides parathyroid disease, the next common culprits are hidden cancers or kidney disease. None of these should ever be missed.

There are three main kinds of hyperparathyroidism:

  • Primary
  • Secondary
  • Parathyroid cancer

Primary Hyperparathyroidism

In the case of primary hyperparathyroidism, the parathyroid glands have grown some unhealthy cells (adenoma) and are making too much parathyroid hormone (PTH).

In 80% of the time, with PHPT, a single parathyroid gland is overactive. In 15-20% of cases, multiple glands are involved1. If this goes on to a large enough degree in a long enough duration, it can cause higher levels of calcium in the blood.

Too much calcium does not sound like a big deal, but you will soon discover that it really is huge. Besides parathyroid disease, hypercalcemia can be caused by:

  • Some cancers
  • Vitamin D overdose
  • High levels of thyroid hormones
  • Abnormal adrenal function (2)

Key Insight: If vitamin D levels are low, they can trigger parathyroid disease. However too much is also not good. If vitamin D levels are too high, they can unmask latent parathyroid disease2.

Secondary Hyperparathyroidism

Secondary hyperparathyroidism is completely different. In this case, the parathyroid glands are working harder for a good reason because the body is losing too much calcium.

The most common reason for this is kidney failure, and can also occur due to severe deficiencies of calcium or vitamin D.

Parathyroid Cancer

The rarest of all types of hyperparathyroidism is parathyroid cancer. This represents 1% or less of the cases and it occurs when the parathyroid glands themselves develop a malignant overgrowth of cells.

Hypoparathyroidism

The parathyroid glands can also become underactive, and this is called hypoparathyroidism. When it does happen, it is most common after surgery to the thyroid or the parathyroid glands.

In rarer cases, this can occur soon after birth or later in life for no clear reason. For the remainder of our discussion, we will be talking about primary hyperparathyroidism (PHPT) which I will refer to as parathyroid disease.

How Common is Parathyroid Disease?

Like thyroid disease, parathyroid disease is more common in women. The ratio is about 3:4 (women to men).

In 2008, it was estimated that 0.86% of the US population was diagnosed with hyperparathyroidism.

Key Insight: For comparison’s sake, this is roughly as common as celiac disease. The rates have tripled in some areas like California, most likely due to better screening.

However, in those with thyroid disease, hyperparathyroidism may be six times more common3.

What Causes Parathyroid Disease?

By in large, parathyroid disease comes on unexpectedly and for no clear reason. There are known genetic components, but there is no known risk factor for those who have a family history of it.

Early-life radiation to the neck is known to be a large risk factor. In the past, it was common to have tonsils irradiated as a treatment for tonsillitis and this was a risk factor.

Exposure to certain medications can also be a risk factor. Those with the most documentation include lithium and thiazide diuretics such as hydrochlorothiazide4.

Hyperparathyroidism can also show up by itself or, more rarely, in a cluster endocrine-related cancer called multiple endocrine neoplasia syndrome (MENS). This condition is more common for those who have a family history of the condition.

Overlap With Thyroid Disease

People who have thyroid nodules have a higher risk of PHPT. Those who have had to have thyroid surgery also have higher risks for it5.

In the case of Hashimoto’s thyroiditis, the risks for parathyroid disease maybe 6 fold higher than it is in the general population. Some estimates say that there may be as high as a 5% overlap between autoimmune thyroid disease that may have parathyroid disease6.

Other Disease Risks

Untreated Parathyroid disease raises the risk, long term, of:

  • Heart attack
  • Stroke
  • Congestive heart failure7

It has also been shown that the higher one’s serum calcium is for an extended period, the greater the risks are for breast cancer. There is also known overlap between parathyroid disease and esophageal and oral cancers8.

What Are Symptoms of Parathyroid Disease?

In medical school, we were taught a mnemonic to memorize the symptoms associated with parathyroid disease: “Stones, bones, moans, groans, thrones, and psychic overtones.”

These categories can be useful ways to think about how abnormal parathyroid levels in calcium levels can affect the body in which symptoms arise from that…

Stones

Because calcium levels are too high, people are at greater risk for kidney stones. There is also some evidence that gallstones and gallbladder disease are more prevalent with parathyroid disease9.

Bones

When parathyroid glands release too much hormone because a higher rate of release of calcium from stores in the bones. Overtime, this can lead to:

  • Arthritis
  • Bone pain
  • Early thinning
  • Osteoporosis
  • Hip and spinal fractures

Moans

Optimal levels of blood calcium are essential for nerve conduction and almost every part of normal biochemistry. Classic symptoms include:

  • General malaise
  • Fatigue
  • Lethargy
  • Muscle pain

Groans

The term ‘Groans’ refers to gastrointestinal symptoms. When calcium levels are abnormal, the digestive fluids are not secreted properly. This can trigger all of the classic symptoms that get misdiagnosed as IBS, SIBO, or heartburn:

  • Constipation
  • IBS
  • Bloating
  • Nausea
  • Vomiting
  • Ulcers
  • Hyperacidity

Thrones

This one is probably the least intuitive, but it did make for a handy rhyme. Ever heard of the “porcelain throne”? People with parathyroid disease can have severe constipation that does not respond well to typical treatments.

They may also have an abnormally high thirst and, therefore, frequent have troublesome urination. Some even end up having to spend a lot of time on the throne.

Psychic Overtones

The brain is far from immune to the effects of normal calcium levels. It renders it far less able to carry out its proper cellular interactions.

I have seen many patients with debilitating anxiety that led to years of unsuccessful treatments through medication, talk therapy, or lifestyle – only to disappear in a matter of days after treatment.

Common symptoms here can include:

  • Anxiety
  • Confusion
  • Depression
  • Memory loss
  • Brain fog
  • Difficulty walking

You can see that these symptoms are numerous and common. Some, like anxiety, fatigue, and muscle pains, are symptoms that doctors all too often give up on finding explanations to help diagnose and treat.

Do you have parathyroid disease?

In classic cases, hyperparathyroidism shows up with elevated levels of calcium in the blood. Too often, though, patients are told that elevated calcium is not significant.

It always is and should never be ignored. But, the even tougher part is that many doctors do not know that it can also show up with normal levels of blood calcium.

Key Insight: Because PTH is not routinely used as a screening test, a doctor can completely miss hyperparathyroidism in someone with normal calcium levels unless they are suspicious enough to dig deeper.

If calcium levels are elevated and the parathyroid gland is working correctly, it will lower its production of PTH. PTH will be low and the calcium is high for some other reason. If calcium is high and the PTH is normal or elevated, the parathyroid glands are not working correctly.

Here is where it gets tricky. For 20% of people with hyperparathyroidism, their calcium levels are not elevated. If someone has high-normal levels of calcium and they have good parathyroid function, their PTH should be low. If not, they have primary hyperparathyroidism.

Here are some images courtesy of parathyroid.com, which is a production of the Norman Parathyroid Center. Both are excellent resources for parathyroid information and care.

In the first image, you can see that ‘normal’ blood calcium levels in the range of 9.8 – 10.5 can still be associated with hyperparathyroidism and symptoms of hypercalcemia. In this image, you can see that a large number of patients with hyperparathyroidism have normal calcium levels (some even have normal levels of both calcium and PTH).

How would you know they had hyperparathyroidism if both calcium and PTH were normal? If one is up, the other should be down.

If calcium is high normal, PTH should be low normal. If PTH were high normal, calcium should be low normal. If they both are on the higher side of normal and the person has suspicious symptoms, there may be a problem.

Many doctors assume that high calcium and high PTH must be present and that kidney stones and distinct patterns of bone loss must be present. There definitely are patients in which all of these findings are present. However, in over 80% of those with parathyroid disease, they are not.

There are other ways of evaluating calcium by calculating albumin-corrected calcium or measuring ionized calcium. These methods can make hypercalcemia more evident when patients serum calcium is high normal but they are not necessary for diagnosis and do not prevent the need for measuring PTH levels.

The following table can summarize the diagnosis based on serum calcium and PTH:

Calcium (8.5 – 10.4 mg/dL)
Low Normal High normal Elevated
PTH (10-65 nmol/L) Low hypoparathyroidism hypoparathyroidism High calcium – excessive intake, malignancy High calcium – excessive intake, malignancy
Normal hypoparathyroidism Healthy   Primary hyperparathyroidism Primary hyperparathyroidism
Elevated Secondary hyperparathyroidism

Low calcium: low intake, chronic kidney disease, etc

Primary hyperparathyroidism Primary hyperparathyroidism Primary hyperparathyroidism

How is parathyroid disease treated?

The answer is quite clear: Surgery.

There is no diet, supplement, essential oil, or medication that will help primary hyperparathyroidism. Roughly, 95% of the time, surgery is curative.

When surgery does not work, it is almost always because the surgeon failed to find all of the parathyroid glands that were overactive. In these cases, follow-up surgery is nearly always curative.

Complications are rare but include damage to the recurrent laryngeal nerve, which can impact speech and swallowing. The remaining parathyroid glands can be damaged which can leave them underactive or spur them into overactivity.

In the rarest complications, the thyroid gland can be traumatized by surgery and change how it works.

Bottom Line: The success of the surgery and the rate of the complications is highly dependent on the experience of the surgeon. The glands can be hard to see during surgery. It also may not be clear which of the glands are involved. It is worth working with one of the small number of surgeons who specialize specifically in parathyroid surgery.

In the hands of the right doctor, the whole procedure can take as little as 20 minutes and may not even require general anesthesia. I can think of few situations that affect health so deeply that can be resolved that quickly.

There is a medication called cinacalcet (Sensipar) that “looks” to your parathyroid like PTH and may lower its activity. They are appropriate for hyperparathyroidism secondary to dialysis. Some doctors may offer this in place of surgery but new data shows it is harmful and that surgery is still the best answer10.

What happens after surgery?

Nothing, really. Good surgeons are able to leave healthy parathyroid glands intact. It is helpful to get enough calcium after surgery so that they do not have to work too hard.

Once the first few weeks have past, the remaining glands pick up the slack for those that were lost and the calcium balance is normal again.

What should you make of this?

Serum calcium is a typical part of nearly every routine blood tests. If your levels have ever been elevated, please work with a good doctor to find out why that is the case.

Have you had any ongoing symptoms like:

  • IBS (3)
  • Bloating
  • Mood changes
  • Anxiety
  • Fatigue
  • Constipation
  • Frequent urination
  • Muscle pain
  • Brain fog

Key Insight: If you have been unable to improve the symptoms, even if you and your doctor think you know why they are happening, please do consider hyperparathyroidism.

Your best next steps are to have a doctor who is familiar with this condition do proper testing and see if it may be relevant for you.

Not only is it important to treat because it may resolve troublesome symptoms, but if it is not identified, it can create other problems that can shorten your lifespan.

Did you know you can get answers from a doctor from Integrative Health right away from the comfort of your home? Learn more about our Comprehensive Thyroid Care program today (4).

1 – https://www.ncbi.nlm.nih.gov/pubmed/28923463
2 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4663778/
3 – https://www.ncbi.nlm.nih.gov/pubmed/23865082
4 – https://twin.sci-hub.tw/6635/1c2f138b1a2fdf710095845684ff6649/bilezikian2017.pdf?download=true
5 – https://www.ncbi.nlm.nih.gov/pubmed/19040989
6 – https://www.ncbi.nlm.nih.gov/pubmed/23865082
7 – https://academic.oup.com/eurheartj/article/25/20/1776/497057
8 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603029/
9 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6014369/
10 – https://www.parathyroid.com/Sensipar-high-calcium.htm

Dr. Alan Glen Christianson (Dr. C) is a Naturopathic Endocrinologist and the author of The NY Times bestselling Adrenal Reset Diet.

Dr. C’s gift for figuring out what really works has helped hundreds of thousands of people reverse thyroid disease, lose weight, and regain energy. Learn more about the surprising story that started his quest.