Caitlin Whyte (Host): This is Community Connect: presented by Tampa General Hospital. I'm Caitlin Whyte. Joining me today are Dr. Jose Lopez, the Co-Director of the TGH Parathyroid and Thyroid Institute at Tampa General Hospital, and Dr. Douglas Politz, the Co-Founder of the TGH Parathyroid and Thyroid Institute. Thank you both for joining us today in this discussion on hyperparathyroidism.

Well, Dr. Lopez, I will start with you today. Could my symptoms like fatigue, aches, or brain fog be caused by hyperparathyroidism?

Dr. Jose Lopez: That's a wonderful question. So, the first thing I want to let everybody know is that most patients actually have symptoms. You just have to ask the right questions. About 95% of our patients are symptomatic and all the questions that you mentioned, you know, like feeling tired, fatigue, brain fog are all likely related to parathyroid disease and hyperparathyroidism.

See, the high calcium delays the nerve impulses and that delays-- it's a minor delay at the micro level-- but those delays is what actually makes you feel tired, fatigue, foggy, because it's just a little bit longer for that nerve impulse to get to the brain and for the answer to come back. So yeah, absolutely, a lot of our patients are symptomatic and most of those patients actually improve after surgery.

Host: Oh wow. Well, Dr. Politz, what tests do we need to confirm whether we have hyperparathyroidism?

Dr. Douglas Politz: You know, actually, Caitlin, I get this question socially all the time. Because people find out what I do and they say, "Oh, well, how would I know if I have that?" And it is a disease of high calcium. That's really the hallmark of this disease is that your blood calcium level is high. It's above 10 basically, is the easiest way to remember it. But I often tell people socially, you don't need to get this checked. You probably already have. If you just look at your patient portal at your primary care doctor's office or whichever doctor you see most regularly, you probably have three or four calcium levels on file already. It's just not always appreciated as being dramatically elevated because most people with this disease only have calcium levels that are above 10, maybe between 10.3 and 11, not 12, 13, 14. Doctors aren't always going to be knocked over by this. That calcium of 10.4 or 10.6 or 10.3 might be as exciting as this ever gets.

And then, you can also measure the parathyroid hormone, and that is also something that's part of a blood test, just not the usual panel. You have to actually order that. But that's something that might have to be asked. If they would order it, if you are clued into this, they may do it on their own.

Host: Well, I'll stick with you for my next question, Dr. Politz, because it's kind of related. So, what is causing those high calcium or abnormal lab tests, even if they're not that high? And what does that mean? Does that mean I have hyperparathyroidism or where do we go from here?

Dr. Douglas Politz: Most people will never meet a person in their whole lives that knows they have one parathyroid gland, much less four of them. It's just a fact. Most people know thyroid. They just don't know parathyroid, but what's causing it? We have four of these glands. They're in your neck and they're normally no bigger than, say, a tic-tac, the little candies, okay? When you get a tumor of one of them-- not cancer, this is almost never cancer--- it swells up basically like a small grape in some instances, and it just overproduces this hormone in these excessive amounts. And that goes to your bones and pulls the calcium out of your bones. That is what is causing the high calcium. That's where that extra calcium came from, is it was stolen from your bones.

Host: All right. Well, Dr. Lopez, what are some treatment options? And does surgery always come with this?

Dr. Jose Lopez: Yeah, that's a great question, too. So, the short answer actually is, yes, surgery always comes with this because there's no other modalities of treating hyperparathyroidism. There's different types, primary, secondary, and tertiary. So for the most part, the primary and the tertiary ones always are always fixed with surgery.

The secondary one can be treated with medication, and those are usually patients that are on dialysis. But for this, you know, I want people to think that surgery's the only way to treat it. With that said, surgery has changed a lot over the last a hundred years. A hundred years ago, you know, this operation was pretty invasive, would take hours, had complications. You know, you fast forward to a hundred years later, it's an outpatient, minimally invasive operation that on average takes 20 some minutes. Patients are able to go home the same-day. Like I mentioned before, symptoms improve in the majority of our patients, and our cure rates are extremely high. So, we do not deny surgery, you know, to anyone. If you have this disease-- and Doug and I talk about this all the time-- if you have this disease and you can walk to the hospital, you can tolerate the operation. The benefits in general outweigh the risk of the operation because the risks are so small.

Dr. Douglas Politz: That's a great point. If I could jump in there, this is one of the things we talk about all the time. Everything we are talking about is an inch, inch and a half maybe, below the surface of the skin of the neck. So, it's not like we're talking about some procedure that's down between your intestines or behind your liver or under your heart or deep in a body cavity. You have to be in pretty bad shape to not be able to tolerate a one-inch incision and have the work done an inch, inch and a half below that. And it takes 20, 25 minutes. Almost anyone is going to be a good risk for this procedure, so to speak.

Host: Well, what complications should I worry about if I don't get this treated, Dr. Politz ?

Dr. Douglas Politz: It is a disease of time. The calcium levels that are elevated, they won't necessarily cause you a problem tonight. But as I always say, it's the time, not the climb, it's how long you have this, not really how high the calcium goes, because as we said earlier, it's probably going to just stay in that 10s range, between 10 and 11. And that over time is going to cost you bone density leading to osteoporosis, kidney function, kidney stones; cardiovascular complications like high blood pressure, atrial fibrillation; and then brain dysfunction that Jose talked about so much earlier: tired, forgetful, achy, depressed, crabby, insomnia, all these different things that are so easy to sort of pawn off on some other condition. "Oh, well, I'm stressed out," "Oh, I have fibromyalgia," "Oh, I have Lyme disease," "I have some other condition causing this." Well, not when your calcium is high. Those are all things that this one little tumor in your neck can cause.

Host: Wow. Well, that leads me into my next question. And I'll turn to Dr. Lopez for this one. How does hyperparathyroidism and kidney stones and bone loss, how are they all interconnected?

Dr. Jose Lopez: Awesome. That's a basic science question. It goes back to the physiology of how the parathyroid glands work. So, I'm going to try to make this quick and easy, but your parathyroid glands are constantly checking your calcium levels throughout the day. And when your calcium levels drop, the parathyroid glands release the parathyroid hormone. And the hormone is, in fact, the one that is in charge of bringing your calcium levels up, the hormone goes to work at the bones and alerts little cells in there like a little PacMan. Those cells get activated, start chewing at the bone, releasing calcium to the bloodstream. If you have excess parathyroid hormone or hormone that is constantly being secreted, you're telling those cells to constantly work so the PacMan never stops. And then, you release a ton of calcium into the bloodstream, but the calcium doesn't get put back, so you end up with bone loss.

Now, that excess calcium, it's going to go somewhere and that's somewhere's the bloodstream. And it's going to get filtered by the kidney. And unlike the filter at home that we can clean out or exchange, the filter in your body doesn't have that ability. So, the kidney starts accumulating a little bit calcium at a time. So, you end up from having some sand to a pebble, to a rock, to calcification of the kidney. So essentially, that's the basic physiology of how parathyroid disease grows slowly, like Doug was saying earlier. But it's not the climb, it's the time. So, the longer you have it, the longer you're exposed to it, the more likely then you're able to develop these problems long-term.

Host: Gotcha. All right. And Dr. Politz, wrap it up for us today. When it comes to having high calcium will changing my diet or calcium intake help at all?

Dr. Douglas Politz: That's actually something that is tried all the time. It's a natural reaction that, you know, you say you go to your primary care physician and they said, "Oh wait, we got your blood test back, Mrs. Jones. And it looks like your calcium's a little high. Let's cut back on any calcium supplements. Don't go crazy drinking the milk or having cheese pizza or whatever it is. And let's get you off vitamin D. And then, let's repeat this down the road and see if that has corrected it." If you have this condition, it won't change anything. Remember the condition is a tumor that won't stop making excess parathyroid hormone.

So, you can try those things. And if that makes it normal, again, your calcium level again, it probably is only temporary if this is what's behind it. Normally functioning parathyroid glands, to kind of put it all together, will sort out this sort of endocrine ballet between your bones, your kidneys, and your intestines to sort out all that extra calcium and put it where it's supposed to go. Whatever needs to go out of the urine goes out of the urine. Whatever needs to go into your bones will go into your bones under normal functioning. But when you get this hijack of the system by a little tumor, well, then all that goes out the window, and that's how you end up with the aberration that we have described here for the last few minutes.

Dr. Jose Lopez: Just to add something really quick to that, because I want people to take this home with them and that was a great explanation, Doug. But one of the things that happens, and we see it a lot is patients end up doing those things, right? Try to manipulate the calcium. And then, the next time they check their calcium levels are normal. And they think, "Well, I don't have parathyroid disease. I'm fixed. I don't have this disease anymore, because they manipulated their diet." What they actually need to do is to go ahead and get their calcium levels checked again. Our body has an amazing ability to get rid of calcium. You're going to urinate it, you're going to sweat it out. But if you have parathyroid disease and you check your calcium levels, again, more than likely, if you do have parathyroid disease, they're going to be elevated, even if you try to change your diet.

Host: That was Dr. Jose Lopez and Dr. Douglas Politz. For more information, please visit tgh.org/parathyroid. If you enjoyed this episode, please share it on your social channels and check out our other episodes. I'm Caitlin Whyte. And this is Community Connect: presented by Tampa General Hospital. Thanks for listening.