How do we diagnose parathyroid disease when most people have never heard of a parathyroid gland until their doctor tells them that they have a problem with one of their parathyroids? The typical response is "Doc, what is a parathyroid gland? I've never heard of a parathyroid or parathyroid gland. How can we diagnose this to be sure that I really have parathyroid disease and how can we be sure this bad parathyroid gland is causing me a problem?" "Hey doc, are you talking about the thyroid?? Or the parathyroid? What is a parathyroid? What does it mean to have a high calcium level in my blood? How can I have a tumor in my parathyroid gland when I've never heard of a parathyroid gland!?" If you can read and understand this ONE page, you will know more about parathyroid disease than 90% of doctors.

Well... Everybody has 4 parathyroid glands, and sometimes one or more of them goes bad. We discuss the symptoms of parathyroid disease on a different page (click here for symptoms). On this page we discuss how to make the diagnosis of parathyroid disease and how to know for sure if you have a parathyroid problem that needs to be addressed.

You must be diagnosed with parathyroid disease (hyperparathyroidism) if your parathyroid hormone level is high and your calcium level is also high.  The excess parathyroid hormone is the CAUSE of the high calcium.

Under normal conditions, a normal calcium level will be associated with a normal parathyroid hormone level. Also under normal conditions, a low serum calcium level will be associated with a high parathyroid hormone level; and a high calcium level will be associated a with low parathyroid hormone level. These are all appropriate ways in which a parathyroid gland will react to calcium which is circulating in the blood as the parathyroid glands attempt to regulate calcium in the narrow "normal" range. More detail about the normal function of parathyroid glands is covered on our "function" page. However, it is extremely rare for people to have high calcium levels in their blood... and not have a parathyroid tumor. If you have high calcium in your blood, chances are extremely high you have hyperparathyroidism, unless your PTH is VERY LOW. Parathyroid disease, hyperparathyroidism, calcium, parathyroid calcium disease, parathyroid gland problem. Parathyroid problem and parathyroid disease.

It is NORMAL for patients with hyperparathyroidism (parathyroid disease) to have calcium levels that are high one time it is checked, and normal the next time it is checked. ALL patients with hyperparathyroidism will have calcium levels that change from day to day, week to week, month to month. MOST patients with hyperparathyroidism have calcium levels that FLUCTUATE from high to slightly high, to high-normal.  This does NOT mean that you don't have the disease...you do, and this is how it affects most people.  Fluctuating levels of calcium is one of the '10 Parathyroid Rules of Norman'.  One mistake that is often made by physicians who don't see much of this disease (it is pretty rare), is that they will measure the calcium repeatedly to see if it is "staying the same" or "slowly trending up" over time. They (and you) can get a false sense of security when you see that your calcium is only slightly elevated and not getting any worse over time.  This is one of the basic BAD assumptions you can make with parathyroid gland disease. Remember, once you have this disease, it will not get better on its own. Furthermore, it will always get worse...slowly perhaps, but it will get worse. Read more of this web site to understand this basic principle. Something else to keep in mind, the calcium in your blood and in your urine is coming from somewhere--your bones! If you haven't looked at our page of pictures of parathyroid tumors you need to do so.... look at the tumors we have removed from patient's necks and compare their calcium levels to yours.  Parathyroid disease, calcium, parathyroid calcium disease, parathyroid gland problem. Parathyroid problem and parathyroid disease.
Hyperparathyroidism (over-activity of the parathyroid gland) is relatively easy to detect because the parathyroid glands will be making an inappropriately large amount of parathyroid hormone in the face of an elevated serum calcium. This is straightforward and simple to measure. Another way to confirm this diagnosis is by measuring the amount of calcium in the urine over a 24-hour period of time. (note: this is not done very often any more, and typically is done only if the patient's calcium and/or parathyroid hormone levels are only a little out of the normal range and the doctor wants to really be sure of the diagnosis). If the kidneys are functioning normally they will filter much of this calcium in an attempt to rid the body of calcium leading to an abnormally large amount of calcium in the urine. Measuring calcium in the urine, however, is an indirect measure of parathyroid activity and is only accurate in about 25 to 40 percent of the time (in other words, MANY patients with hyperparathyroidism will have NORMAL amounts of calcium in their urine--so having a normal urine calcium test does NOT mean you don't have hyperparathyroidism). The most accurate and definitive way to diagnose primary hyperparathyroidism (disease of the parathyroid glands) is by showing an elevated parathyroid hormone level at the same time you have elevated serum calcium.

MOST DOCTORS DO NOT KNOW HOW TO DIAGNOSE PARATHYROID DISEASE. Normally, parathyroid disease is found because your doctor checked your blood for abnormalities and found the calcium level was too high. Typically, the doctor will repeat the calcium to see if it really is high, or if it was just a 'lab error'. If the calcium is high again, the doctor will order a parathyroid hormone level to be checked. If the parathyroid hormone comes back elevated...that's it... you have parathyroid disease (hyperparathyroidism). If the PTH level is "normal"... that's it, you still have hyperparathyroidism.. YES. High calcium and ANY PTH LEVEL that is not very low means you have hyperparathyroidism. This is a very important sentence!! Many of you will need to print this page and take it to your doctor so you can show him or her this sentence. And then, print one of our pictures of parathyroid tumors and show it to your doctor too... and show that these tumors come from patients with high calcium levels and "normal" PTH levels. Geeezzz, it breaks our hearts every day to see the number of people who are feeling poorly because of parathyroid disease who aren't being treated correctly because their doctor doesn't know much about parathyroid disease... and won't go through the trouble of looking it up on the Internet, or making a phone call to another doctor who knows. MANY patients with large parathyroid tumors have high calcium levels and NORMAL PTH levels... THIS IS STILL HYPERPARATHYROIDISM, AND THIS STILL MUST BE FIXED! We operate because the CALCIUM is high, regardless of the PTH level!  KEEP READING!

The chart below shows examples of patient's calcium levels, PTH levels, and whether or not they have hyperparathyroidism and whether or not they need surgery to remove a parathyroid tumor. These are just some examples, and there are a few more different variations... but these are the most common presentations of parathyroid disease, representing at least 99% of all patients with hyperparathyroidism.

Who has Hyperparathyroidism?

Patients 1 through 6 are very routine patients with hyperparathyroidism. The diagnosis of hyperparathyroidism should be made by most/all doctors. It's simple, these people have a parathyroid tumor that is making too much parathyroid hormone which makes the calcium go too high in the blood. These patients do not need any more testing. They don't need to measure calcium in the urine, and they don't need any x-rays or scans. They need to find an expert surgeon and have their parathyroid tumor removed. Patients 7 and 8 also have hyperparathyroidism and they also have a parathyroid tumor making too much hormone. These patients are more difficult for the average doctor to diagnose, because the doctor will say "it can't be hyperparathyroidism because your PTH level is normal". This is a very serious mistake. If the parathyroid glands were NORMAL (no tumor present) then the high calcium would make the normal parathyroid glands go to sleep and the PTH levels would be between very low (say, between 5 and 8). At least 20% of ALL patients with hyperparathyroidism are NOT DIAGNOSED appropriately because their doctor does not understand this. Patient number 9 is a little harder, but good doctors will figure it out. This CANNOT be ignored, and is 99% chance due to a parathyroid tumor. Remember, humans just don't live with calcium levels in the 10's... this is almost never normal. Patient 10 is the hardest patient to diagnose. In cases where the calcium is normal or intermittently slightly elevated and the PTH is high normal, we rely on lots of other information (for example, do they have significant osteoporosis?, do they have kidney stones?, do they have symptoms of hyperparathyroidism?, do they have excess calcium in their urine (These are the only people that really need a urine calcium test), etc, etc. Patient number 10 needs a more extensive workup, and a more lab studies than patients number 1-8 prior to heading off to the operating room. As a final part of this exercise, look at the colorful graph at the bottom of this page and see where calcium levels are in normal humans and those with parathyroid disease.

Most surgeons will not operate on a patient unless they have two or more documented blood tests showing elevated calcium and at least one blood test showing elevated parathyroid hormone (although we do not require this in many patients). Also, most surgeons have only seen patients with scenarios 1 through 6 above, and they will get nervous operating on the 25% of patients who don't present with "classic" labs. Heck, many surgeons won't operate on patients 1-6 unless they have a positive sestamibi scan. This is fortunate for you, because you probably want a very experienced parathyroid surgeon operating on you anyway!

Parathyroid calcium level hormone calcium calcium controlled by parathyroid hormone.

TREATMENT OPTIONS FOR PRIMARY HYPERPARATHYROIDISM

The only two choices available for patients with primary hyperparathyroidism are to do nothing, or to have surgery to remove the diseased parathyroid gland (tumor) (or infrequently, more than one diseased parathyroid gland). Some physicians will elect not to refer their patients for an operation if they have a "mild" form of primary hyperparathyroidism. Much of this management style stems from the fact that standard parathyroid surgery in the past required the use of general anesthesia and was a major operation. Parathyroid operations are not as "involved" as they once were, and usually patients go home within 2 hours of the operation (when the operation is performed by a parathyroid surgeon). Some new techniques of radioguided parathyroidectomy are also changing some of this "wait and see" attitude. To read more about how endocrine doctors are changing the way they treat parathyroid disease Click Here.  Bottom Line: The days of doing nothing for hyperparathyroidism are pretty much gone... it is better for the patient and cheaper in the long run to have a mini-parathyroid operation and fix the problem (usually 20 minutes or even less by some experts -- go home in an hour or two).

IMPORTANT! If your doctor tells you that you have "MILD" hyperparathyroidism and it can wait... then click on our page of pictures of parathyroid tumors. You will see that MILD hyperparathyroidism people have the same big tumor in their neck as people with higher levels of calcium in their blood. You will also see that patients with calcium levels above 12 can often have HUGE tumors... and by then, these patients have severe osteoporosis and some have even had a stroke. The advice to wait until your calcium goes higher makes no sense, and is advice from the 1970's. We know much more now.  Parathyroid disease will ALWAYS get worse. It will NEVER get better, and it will NEVER stay the same.

A dangerous trend occurred in the late 1990's! Some physicians began using one the osteoporosis drugs (Fosamax, Actonel, Evista, Boniva) to increase bone calcium rather than referring a patient for surgery. These are very good drugs but must be used appropriately. They are NOT a substitute for removal of the overactive parathyroid gland!!! IMPORTANT! These drugs work through a different mechanism than does the overproduced parathyroid hormone. There has NEVER been a clinical study that shows Fosamax or Actonel (or any other drug) can be used in patients with parathyroid disease. These drugs do not work on the bone in the same place as parathyroid hormone (PTH), and they CAN NOT overpower the powerful effects of PTH.  There is more written about this on other pages of Parathyroid.com. Remember, parathyroid disease is caused by a tumor on one or more of the parathyroid glands. Giving an osteoporosis medicine will not make the tumor go away. Read more about Fosamax, Actonel and other osteoporosis drugs on our Osteoporosis Page and our Frequently Asked Questions Page.

Normal and Abnormal Blood Calcium Levels

The following graph of normal blood calcium levels appears quite complex, but it is not. Do not let it confuse you. If you are reading this web page, chances are you have had at least one high calcium level and aren't sure what this means. You are on this graph in the red area. Remember, patients with hyperparathyroidism have a parathyroid tumor that prevents accurate regulation of calcium levels in the blood... thus the calcium levels bounce around a lot. Most people with a parathyroid tumor have calcium levels that bounce around from high to the high end of normal. People with normal parathyroid glands have calcium levels that are very constant from week to week, month to month, and year to year--their calcium levels do not bounce around between high and normal. Study this graph carefully. Start at the top left of the graph and work your way around the graph clockwise to understand what normal calcium levels are and what it means to have a high calcium level.

There are several mistakes we see on a daily basis when doctors are trying to make the diagnosis of hyperparathyroidism in a patient who has a high calcium. The first mistake is that they say "it could be a lab error so we'll check it again". Lab errors are extremely rare these days, but checking it again is correct. The mistake comes when the next calcium level comes back in the "normal range" and the doctor says..."your calcium is normal, there is nothing to worry about". This is a mistake we see in about 80% of ALL patients with hyperparathyroidism. This is why MOST patients who undergo surgery to remove the tumor have had the disease for a minimum of 5 years. The doctor was on the right track, but got fooled when the calcium level came back in the normal range. These doctors don't understand that people with hyperparathyroidism have calcium levels that bounce around, and so we EXPECT the calcium level to be up one day and down the next (in fact, almost all people with hyperparathyroidism have good days and days when they feel real bad... this is due to the fluctuations in calcium levels that normal people do not have... when the calcium is high, they are feeling down, tired, depressed, fatigued). People with normal parathyroid glands do not have calcium levels that bounce around. Our brains run on calcium... this is why the human body controls calcium to a much higher degree than any other element in our bodies. We feel good when our calcium is constant, not fluctuating, and somewhere in the 9's.

The second major mistake regarding calcium levels is that doctors think that having calcium levels in the "low 10's" is normal since it says so on the lab slip (ALL lab reports come with a "normal range" printed right next to the result). The fact is, it is normal to OCCASIONALLY have calcium levels in the low 10's (the yellow area on the graph above). Most humans do not like having calcium levels in the 10's. Almost ALL humans feel best with a calcium level somewhere in the 9's. The graph BELOW will show you where calcium levels are in 7000 patients that we operated on to remove a parathyroid tumor. These are their AVERAGE calcium levels, so each patient here had some calcium levels that were higher than this average number and each one had some calcium levels that were lower than this average number.

You can see from this graph that most people with a parathyroid tumor have average calcium levels in the mid to upper 10's. The third major mistake we see doctors make when looking at blood calcium levels is that they will say "your calcium levels are abnormal, but they aren't all that high, so we'll just watch it".  These doctors will wait and see if your calcium goes any higher, possibly past some "magic" number like 11.5 (a common "magic" number we hear). Well it turns out that only 32% of the last 7000 patients we operated on EVER had even ONE calcium level that was 11.5 or higher. So if you are waiting for this "magic" number, your tumor will continue to grow, you will continue to feel bad (see our symptoms page), you will continue to get worsening of your osteoporosis, and you will lose the joy of life.  And... while you are feeling bad and your bones, heart, and kidneys slowly get destroyed by the high calcium, chances are that you will never get to the "magic" number of 11.5. Most people will never get calcium levels that high, and if they do, they have more damage done to their bodies. The severity of hyperparathyroidism CANNOT be measured by how high the calcium levels are. The size of the tumor cannot be predicted based upon how high the calcium levels are. You either have parathyroid disease or you do not. How high the calcium is doesn't matter... you have a parathyroid problem or you do not. It is a yes/no question. It is not a question of "mild" or "severe". Yes or no. If you do have a parathyroid problem, then get the tumor removed.

If you haven't seen our page of pictures of parathyroid tumors, this would be a good time, since they came from people who are in the middle of this graph.

For the scientists in the crowd that are interested, the statistics for calcium levels in 5000 patients who had a parathyroid tumor removed from their neck at the Norman Parathyroid Clinic in the past 3 years ending October, 2007 are: Mean calcium: 10.894;  Median: 10.8;  Mode: 10.7;  Standard Deviation: 0.597.  Percent with average calcium at or below 11.4: 85.57%;  Percent with average calcium at or above 11.5: 14.43%.  Percent who never had a single calcium level of 11.5 or higher: 68.03%,  percent that had one calcium level of 11.5 or higher: 31.97%. (Two-thirds of patients will never get a calcium level that high, so waiting until your calcium goes above 11.5 is dumb (not based on medical facts)).

One final note... this graph shows blood CALCIUM levels in patients with primary hyperparathyroidism. This graph is DIFFERENT from the graph on our Hyperparathyroidism page which shows PTH levels in patients with primary hyperparathyroidism. These graphs have the same shape and thus you could confuse them... but one looks at the calcium levels in the blood, and the other looks at the PTH levels in the blood. These two graphs are central to the diagnosis of hyperparathyroidism.

Finally, we'd like to point out that measuring the amount of calcium in the urine is not mentioned on this page because it is a test that is not used much anymore to diagnose parathyroid disease (only about 20% of endocrinologists order this test anymore). If your blood calcium is high, then it really doesn't matter what your urine calcium is--- you have parathyroid disease. Also note that measuring Vitamin D is not mentioned on this page, because Vitamin D has nothing to do with the diagnosis of primary hyperparathyroidism. This is VERY confusing to most endocrinologists, and most will order this test. However, it doesn't matter what your Vitamin D level is, if your calcium level is high, you have a parathyroid tumor. We have an entire page on Vitamin D... but it is an advanced page... don't go there yet... BOTTOM LINE... Vitamin D levels and Urine Calcium levels are almost never used to determine if somebody has hyperparathyroidism or not!

We have another large and complex page that discusses the diagnosis of primary hyperparathyroidism in more detail. This page is written for the benefit of doctors. If you are a patient... do not go there yet until you read about surgery and mini-parathyroid surgery that will fix your problem almost always in less than 20 minutes. If you are a doctor, then the advanced page is for you. If you are a patient and you are really getting into this... then our Advanced Diagnosis page is for you. It is the best page of parathyroid.com

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