Parathyroid disease and parathyroid treatment is discussed by parathyroid doctors and parathyroid surgeons for parathyroid patients.

 

Low Vitamin D levels in parathyroid disease. Primary hyperpathyroidims and Vitamin D, secondary hyperparathyroidism and Vitamin D
Low Vitamin D levels are very common in patients with hyperparathyroidism. Many patients with parathyroid disease will have low Vitamin D levels in their blood. Low Vitamin D is quite common, but MANY endocrinologists don't understand the connection between low Vitamin D and parathyroid tumors... and will confuse the issue (and the patient with parathyroid disease) by saying the patient with low Vitamin D levels has "Secondary" hyperparathyroidism... THIS IS NOT TRUE. THIS IS A MYTH.......  We will bust the Low Vitamin D myth on this page...
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Low Vitamin D and secondary hyperparathyroidism. Vitamin D levels.LOW VITAMIN D is discussed on this page of parathyroid.com. This is an advanced parathyroid page, and if you have recently been told that you have hyperparathyroidism (parathyroid disease) and/or high calcium in your blood, then PLEASE read our other parathyroid pages first. We will give a short synopsis of Vitamin D in the blood, and low vitamin D levels... with some facts and take away points.  Then, this page will get more complex. If your endocrinologist tells you that your calcium is high because your Vitamin D levels are low... and wants to give you Vitamin D to make your calcium go down... then you MUST print this page and take it to them. THIS IS WRONG. The bottom of this page is complex and written for doctors and advanced patients. The top of this page on Vitamin D is for most patients...  Here we go.

Overview of Vitamin D

Low Vitamin D, Vit D is low in blood. Vitamin D is essential to our bodies. We can't make it, so we have to get it in our diet, or get outside and have the sun make it for us (yep, sun light on our skin causes our skin to make Vitamin D.

Low Vitamin D, Vit D is low in blood.Vitamin D does ONE THING in our bodies. ONLY ONE THING... it helps our intestine to absorb calcium from the foods we eat. Thus, Vitamin D increases the amount of calcium in our bodies. If our Vitamin D levels are low, then our intestines have a hard time absorbing calcium. This is why milk is fortified with Vitamin D. Did you ever notice that the milk you buy has "Vitamin D Fortified" written on it. We want our kids to drink milk so they get lots of calcium to build their bones strong... but without the Vitamin D, most of the calcium in the milk won't get absorbed. Our intestines MUST have at least a little Vitamin D to absorb calcium. For you older people out there, did you notice that most of the calcium supplements (Citracal, Oscal, Caltrate, etc, etc) will have Vitamin D added to the calcium pills?  This is because our intestines need the Vitamin D molecule to absorb the calcium molecule through the intestinal wall and transport it into our blood.  AGAIN.... Vitamin D does only ONE thing in the human... it helps our intestine to absorb calcium.

Low Vitamin D, Vit D is low in blood.Thus, increasing a person's Vitamin D levels will increase the amount of calcium they absorb from their diet. If a person takes more Vitamin D, then the intestines will become more efficient at absorbing the calcium molecules in our diet, and these calcium molecules will be absorbed... your calcium will go UP.

Vitamin D and It's Relationship to Hyperparathyroidism

Low Vitamin D, Vit D is low in blood.Hyperparathyroidism is associated with high calcium in the blood. The cause is a parathyroid tumor. This is discussed throughout this website, so we will not go into it here. Basically, a tumor grows from one of your parathyroid glands... this tumor produces parathyroid hormone which takes calcium out of your bones and puts it into your blood. You get osteoporosis and feel bad because of the high calcium in the blood.

Low Vitamin D, Vit D is low in blood.The body doesn't want the calcium to be high... So, it will try to get rid of the calcium in the urine... which is why many patients (about 1/3) will have high calcium in the urine (they can get kidney stones from this).

Low Vitamin D, Vit D is low in blood.The body also wants to shut down calcium absorption from your intestines. It does this by limiting the amount of Vitamin D in your body. Thus, if your body determines that your calcium is too high... it can decrease the amount of calcium that is absorbed from your intestines by decreasing the amount of Vitamin D available. If your Vitamin D levels are decreased, you can't absorb so much calcium from your diet. This is a protective measure.

Vitamin D in Patients with PRIMARY Hyperparathyroidism

We began measuring Vitamin D levels in patients with hyperparathyroidism in the mid-1990's. For the past several years, we have measured it in most patients, and beginning in 2006 we began measuring Vitamin D in every patient with PRIMARY hyperparathyroidism. Here is what we found:

Vitamin D levels low38.2% of all patients with primary hyperparathyroidism will have LOW Vitamin D-25 Levels! This is over 600 patients in our study, and their average Vitamin D level was 14.4.

Vitamin D levels normal.61.8% of all patients with primary hyperparathyroidism will have NORMAL Vitamin D-25 Levels. This is over 1000 patients in our study, and their average Vitamin D level was 31.3.

Vitamin D levels high.0 % of all patients with primary hyperparathyroidism will have HIGH Vitamin D-25 Levels (we've never seen it).

Low Vitamin D is seen in one third of all patients with primary hyperparathyroidism.We have graphed this information so you can see it clearly. This shows that nearly 40% of all patients with PRIMARY hyperparathyroidism have LOW vitamin D levels, 60% have NORMAL vitamin D levels, and nobody with a parathyroid tumor has high Vitamin D levels. Thus, their body is trying to protect them from the high calcium, decreasing the amount of Vitamin D levels so they don't absorb so much calcium.

Low Vitamin D is seen in many patients with primary hyperparathyroidism.Well....... what is happening in these patients? What is the difference? Each of these patients had a high calcium levels in their blood and high (or inappropriately normal) PTH levels. Thus, each of them had primary hyperparathyroidism. Well, every one of these patients was operated on by us, and we found (as expected) that they all have the exact same parathyroid tumor! (sorry, we are getting complex now... if we lose you, then go to the basic pages and come back here later). That is, 97% of those with LOW vitamin D levels have a parathyroid adenoma and 3% have hyperplasia. 97% of those with NORMAL Vit D levels have a parathyroid adenoma and 3% have hyperplasia. Thus, there is no difference in these people's necks.......they all have the same parathyroid tumors causing their hyperparathyroidism... The Vitamin D levels have NOTHING to do with their disease.

Low Vitamin D levels have NOTHING to do with parathyroid pathology.
This graph shows that 97% of people with primary hyperparathyroidism have a parathyroid adenoma (tumor) and 3% have hyperplasia... REGARDLESS of what their Vitamin D level is. Thus, if your calcium is high, you have a parathyroid tumor and it doesn't matter what your Vitamin D level is. The vitamin D is not causing the parathyroid problem... The low vitamin D is GOOD... it is protecting you from even higher calcium levels.

Low Vitamin D in blood is seen in MANY patients with primary hyperparathyroidism.THEREFORE: IF YOU HAVE HIGH CALCIUM, YOU HAVE A PARATHYROID TUMOR IN YOUR NECK AND YOU NEED AN OPERATION TO REMOVE THE TUMOR. Vitamin D levels have nothing to do with it!  DO NOT AVOID SURGERY BECAUSE YOUR DOCTOR SAYS YOUR VITAMIN D LEVEL IS LOW... AND THE LOW VIT-D IS THE CAUSE OF YOUR PROBLEMS.  THIS IS WRONG!!! This is a myth, and this myth is BUSTED. This is still the case if your calcium goes up and down... high sometimes and back to normal some times..... this is typical for patients with parathyroid tumors. The tumor doesn't regulate the calcium well, and the levels go up and down.

Low Vitamin D is seen in many patients with primary hyperparathyroidism.Why are we discussing Vitamin D and hyperparathyroidism?  Because this has become a HUGE problem in late 2006 and 2007! Now that Vitamin D is easy to measure, many doctors (endocrinologists) will measure Vitamin D levels on all patients with high calcium in the blood. They will also measure the PTH levels... they are trying to prove (correctly) that the high calcium in the body is due to a parathyroid tumor.  Here is where they go wrong... and this is getting very complex.... If the Vitamin D level is low, then they think this is the MAIN PROBLEM. They think that the low vitamin D levels cause too little calcium to be absorbed in the intestines. They think that this low amount of calcium is sensed by normal parathyroid glands which causes the normal parathyroid glands to appropriately increase their production... causing a high PTH level. They further believe that this high PTH level will take calcium out of the bones and increase the calcium in the blood. Thus, they think the PTH levels are high because of the low vitamin D levels... thus they think the high PTH levels are high SECONDARY to the low vitamin D levels... thus they will tell you that you have SECONDARY hyperparathyroidism. THIS IS A MYTH. THIS IS NOT CORRECT. Measuring Vit D levels has nothing to do with making the diagnosis of hyperparathyroidism. Low Vit D levels will NEVER cause high calcium levels. It is not possible!

Update: On July 19, 2007 the New England Journal of Medicine (NEJM) published a review on Vitamin D and these authors report the same results that we do here... that high levels of PTH will decrease Vitamin D-25 in many patient's blood. If your doctors continue to give you Vitamin D when your calcium and/or PTH are high, then you ask them (kindly!) to read this web page and this NEJM article: Holick M. Vitamin D Deficiency. N Engl J Med 2007;357:266-81. Having low vitamin D is CAUSED by hyperparathyroidism, not the other way around!!!

Low Vitamin D is seen in many patients with primary hyperparathyroidism.Getting complex even further... If you are still with us... If the low vitamin D was the starting point... if the low Vitamin D was the main problem... and this caused the parathyroid glands to increase their parathyroid hormone production... then I would be an idiot to operate on these people... and if I did, I would find them to all have normal parathyroid glands... they wouldn't have 3 normal parathyroid glands and one parathyroid tumor! If the low Vitamin D caused the parathyroid glands to get big... they would all get big... but that is NOT what happens! Patients with low Vitamin D levels have parathyroid tumors just like people with normal vitamin D levels. Remember, parathyroid adenomas are tumors. The entire tumor mass is made of cells from one parent cell that went crazy and reproduced itself millions of times. Parathyroid adenomas are TUMORS... (did you see our page showing 80 typical photos of these tumors?). Low Vitamin D does not cause TUMORS to grow. It is the other way around. 

Low Vitamin D is seen in many patients with primary hyperparathyroidism.To defend the endocrinologists (who mean well, but don't see enough patients with hyperparathyroidism to be "expert" at it... we see 3,500 patients per year with this problem!!), it is possible to have LOW vitamin D levels to cause your PTH to go up. BUT... this will NEVER increase the calcium in the blood, and the PTH will only go up slightly. Sometimes your endocrinologist will try to give you Vitamin D as a trial... to see if your parathyroid problem is due to low Vitamin D.  The theory is that giving you Vitamin D will cure the cause of the high PTH... and all your labs will go back to normal... They call this secondary hyperparathyroidism and they will give you a prescription for high doses of Vitamin D.  HOWEVER, this can be dangerous... if your calcium is above 11.5, the additional Vitamin D can make your calcium go above 12 and we have even seen 2 patients have a stroke because of this. We have even seen an endocrinologist get sued for malpractice because he gave a patient with primary hyperparathyroidism high doses of Vitamin D which caused the patients calcium to go high and cause the patient to have a stroke! This is not a smart move.  If your calcium is high, you should NOT take Vitamin D in large doses. If you do, you will find that it almost always makes your symptoms of hyperparathyroidism worse! Is it going to cause you to have a stroke??? nope.... but it will make you feel bad and it will waste your time and money. If your calcium is high, you have a parathyroid tumor (PRIMARY hyperparathyroidism) regardless of what your Vitamin D level is. 

Low Vitamin D is seen in many patients with primary hyperparathyroidism.Remember above when we were discussing Low vitamin D... saying that decreasing the Vit D in your body is the body's way to protect itself from the high calcium?  If this is true, then we should see the low Vitamin D levels in patients with hyperparathyroidism return to NORMAL once the parathyroid tumor is removed.  Well, in January 2007 we began a trial to test this theory scientifically (we had observed it many times, but we decided to test it scientifically so we can publish it in a major medical journal... we publish on parathyroid topics about every other month). Guess what!!!???  95.6% of all patients with LOW vitamin D levels had NORMAL vitamin D levels 1 month after their parathyroid tumor was removed!!  Thus, proving yet another way, the body doesn't like having high calcium which is due to the parathyroid tumor. The body turns off Vit D so we don't absorb as much calcium. When the parathyroid tumor is removed, the body turns the Vitamin D back on and the low vitamin D levels increase back to normal.

The bottom line again:  If your calcium is high, you almost certainly have a parathyroid tumor. If your calcium is high and your Vitamin D is low, you STILL have a parathyroid tumor. If your calcium is high and your Vitamin D is normal, you STILL have a parathyroid tumor.  When you get your parathyroid tumor removed, your Vitamin D level will almost always correct itself within 1 month!

Low Vitamin D is seen in many patients with primary hyperparathyroidism.If your endocrinologist says "you have secondary hyperparathyroidism because your Vitamin D level is low", then you MUST print this page and take it to them! This is not correct. You have PRIMARY hyperparathyroidism... and 1/3 of people with primary hyperparathyroidism have a low Vitamin D level... it is expected. Get the tumor removed and get on with your life! Secondary hyperparathyroidism due to low vitamin D is never associated with a high calcium level in your blood. NEVER. If they put you on Vitamin D and then measure your calcium a month later... and your calcium gets better.... then they are fooling you and themselves... it will be bad again one month later, and you will feel bad. Trust me! This will make you feel bad. Get the tumor removed!

UPDATE.

In May 2008 Dr Norman will be giving a talk to the Endocrine Society's Annual Meeting in San Francisco, CA on Vitamin D in parathyroid disease. Here is an abstract of this talk; the journal article will be published later in 2008. Print this and take it to your doctor who put you on Vitamin-D. Most endocrinologists know this already, but many do not:

Vitamin D -25 is suppressed in patients with primary hyperparathyroidism in linear fashion as calcium levels increase, returning to normal within weeks of tumor removal. A protective mechanism is in play.  

Objective:  Vitamin D-25 is often measured in patients with apparent primary hyperparathyroidism to rule out a possible secondary cause. This study was undertaken to examine if a relationship exists between Vit-D levels and parathyroid pathology in patients with elevated calcium levels.

Methods:  A prospective, single institution study measured preoperative Vitamin D (25OH and 1-25OH) in 1,500 patients undergoing surgery for sporadic primary hyperparathyroidism (PHPT).  All patients underwent curative parathyroidectomy with pathology noted. Blood levels were measured at 1 and 2 months post-op.

Results:  All patients had primary HPT with high serum calcium and PTH preop that normalized at all postop measures indicating cure. The average preop Vit-D25 was 25.8+10 ng/ml (range 4-65). 571 patients (38%) had low Vit-D25 levels preop (mean 14.6, range 4-19), 929 (62%) had normal levels preop (mean 32.4,) and none had high levels. Vit-D25 levels decreased linearly as calcium levels increased such that 63% of those with levels above 12 mg/dl had Vit-D25 <20 (p<0.01, R=0.91).The levels of Vit-D1-25 were low in 1.5%, normal in 63%, and high in 35.5% (mean x 56.2 + 20)(p<0.01).  The findings at surgery were identical (p=0.98) for those with low vs. normal Vit-D25 (single adenoma=92%, double adenoma=6%, 4-gland hyperplasia=3%). 82% of patients with low preop Vit-D25 had normal levels at 1 month postop (mean 41.4+12, range 17-63, p<0.005), increasing to 91% at 2 months. All patients with normal Vit-D25 preop remained normal postop.  Overall 88% showed increased Vit-D25 levels after tumor removal (p<0.05) while 52% showed decreased Vit-D1-25 (p<0.01).

Conclusion:  Vit-D25 levels decrease in a linear fashion as calcium levels rise in patients with primary HPT. Overall, 38% will have low Vit-D25 increasing to 63% of those with calcium levels above 12mg/dl. Vit-D1-25 shows the opposite pattern suggesting a protective mechanism. The pathology found at surgery is identical in PHPT patients with low versus normal Vit-D25 indicating no causal relationship. Low Vit-D25 should NOT be interpreted as signaling secondary HPT in patients with elevated calcium levels. The vast majority of patients will normalize their low Vit-D25 and high Vit-D1-25 levels within weeks of tumor removal.

This page was last updated 01/23/2008

 

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