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Welcome. Our topic today is parathyroid disease, and my guest is Dr. Herbert Chen. He’s the chairman in the department of surgery at UAB medicine and surgeon in chief. Dr. Chen explain a little bit about the parathyroid. Tell us about the different types of disorders that you see and how they're classified.

Herbert Chen, MD: Sure. Everyone is born with at least four parathyroid glands, which live in your neck. They're called parathyroid because they're near the thyroid, but they really have nothing to do with the thyroid. Their job is to regulate the levels of calcium in your body. What happens in hyperparathyroidism is one or more of the parathyroid glands develops a tumor inside of it which accuses the body to release calcium from your bones into your blood causing you to develop many symptoms from the high levels of calcium in your blood.

There are various types of hyperparathyroidism. By far the most common is primary hyperparathyroidism, which tends to happen in people around somewhere between their 50s and 70s. The other types of hyperparathyroidism called secondary and tertiary typically happen if you have medical problems such as kidney failure, but they're far less common.

Melanie: Are they serious diseases? Has parathyroid disease become milder over the years?

Dr. Chen: Well, I think in our research, in our endocrine surgery area, we've done a lot of research into hyperparathyroidism. We know that one, it’s the third most common endocrine order after diabetes and thyroid disease, but it’s very much unrecognized by most physicians. Hyperparathyroidism is a big cause of fatigue, osteoporosis, difficulty concentrating. There’s so many symptoms, such as kidney stones, that can be caused by this. Really hyperparathyroidism impacts quality of life, how long you live, and a whole bunch of things. I think now we’re trying to get the message out that this is something that doctors should be looking for.

Just in the study done which we've recently published, we found that most patients… The most common way people present with this is that a high calcium level is found on the routine lab. Our research has shown that only about a third of the time is it ever investigated or worked up. So, we feel there are so many people suffering from this, a disorder, that remain undiagnosed.

Melanie: So, tell us a little bit about some conditions that can lead to hyperparathyroidism, and you mentioned calcium. Do they always go together? Do high calcium levels always indicate parathyroid disorders?

Dr. Chen: Well that’s a great question. So, hyperparathyroidism is the most common, or the number one cause of high levels of calcium in the blood. So that’s how it’s often discovered. There are some patients with hyperparathyroidism whose calcium levels are only mildly elevated or intermittently elevated, and that’s one of the reasons why the diagnosis is missed. Sometimes the lab work does not detect it on the first blood test. The disease itself causes can present in a number of ways. Common presentations include kidney stones, abdominal pain. Patients who have frequent urination or constipation. Almost all patients with hyperparathyroidism suffer from fatigue in what they call as brain fog or inability to think. So, if I could get one message out to primary care providers, it’s that when you do have a patient who is complaining of fatigue or difficulty concentrating, hyperparathyroidism should definitely be on the list to look for.

Melanie: Dr. Chen, does how high the calcium level is, does that correlate with how severe symptoms might be in somebody with this condition?

Dr. Chen: So quite ironically, you would think the higher the level, the more symptomatic patients would be. However, our research and research from others have shown it’s actually the patients who have only mild elevated levels actually have more symptoms than those with high levels. In fact, if you measure the quality of life in patients who have mildly high levels versus very high levels, the mildly high patients have a worse quality of life and they have the most improvement after surgery.

Melanie: Wow. So, what would you like providers to know about treatment options, and even which patient selection criteria. There can be some adverse effects of treatment, it can change the quality of life for patients. So, speak about treatment options and patient selection.

Dr. Chen: Sure. So, the only curative treatment for hyperparathyroidism is surgery. Fortunately, the operation that we recommend is called the minimally invasive parathyroidectomy. It’s a very safe, out patient procedure which takes us less than an hour to perform. The patients go home the same day. When they go home, they're eating, drinking, talking, doing their things they normally need to do. Many of them don’t even take any pain medication after the surgery. So, it’s a very, what we call one of those minimally invasive procedures where the patient’s recover very quickly but can have a huge impact on their life. So, what we recommend is once the diagnosis is made, we would like providers just have them meet us. I think as surgeons, we’re in the best position to tell us them what the surgery is like and what the potential risks and benefits and have the discussion with them if it is in their best interest to pursue surgery.

Melanie: Then what is life like the for patient afterwards? What changes before and after the surgery?

Dr. Chen: Well if the patient has a whole host of symptoms, in our research and just from talking to patients everyday that we do this procedure on, they feel better. If they have osteoporosis, there’s improvement on that. Remarkably, people will have the surgery and they will tell me that it has changed their lives. Because of the underdiagnosis, we have so many people that actually self-referred to us because they have these symptoms and they get their primary care providers to check their labs. They find the diagnosis, and they self-refer to us because they hear from other patients how this can drastically improve quality of life, performance, thinking. A whole bunch of other things that we haven’t spoken about is hyperparathyroidism can cause insomnia, reflux and abdominal pain. So, there’s a whole host of things that can get better after the operation.

Melanie: Is there a link between hyperparathyroidism and the risk of developing certain cancers?

Dr. Chen: Well fortunately in most cases, the tumors that form in the parathyroid glands which cause hyperparathyroidism are almost always benign. They're very rarely cancer. So, for most patients with hyperparathyroidism, the cancer word is not even part of the discussion. However, hyperparathyroidism can be associated with other inherited disorders. Such as tumors or cancers of the pancreas, tumors of the pituitary. Those tend to run in families. By far the most common scenario for hyperparathyroidism is a benign tumor.

Melanie: What are some of the long-term monitoring advice that you would like other providers to have after somebody has gone through the procedure for their hyperparathyroidism? What would you like them to know about long term monitoring?

Dr. Chen: So, after the surgery, basically we recommend that the patients, if they’ve had osteoporosis or osteopenia to begin with, we put them on a regiment to take calcium and rebuild some of the calcium that they’ve lost. Ironically what happens is if you have osteoporosis due to hyperparathyroidism, taking extra calcium is not going to help because the hyperparathyroidism is the driving force. Then we recommend after the surgery happens to make sure you take enough calcium in your diet to replace the calcium that your bones have lost. Then we check calcium and parathyroid hormone levels annually because about 5% of patients can have the disease come back.

Melanie: Hm. That’s so interesting. So, if it comes back, how would they know? If they're going to a primary care provider and they're monitoring, what should they be looking for?

Dr. Chen: Well if the disease comes back, generally if they have symptoms to begin with, they usually have the same symptoms. So often the patient’s symptoms come back, and then they go to their doctor and they get tested and it’s back. Occasionally they don’t. It’s the routine lab follow-up that they see the levels go up again and that’s an indication that another tumor has developed. But like I said, this doesn’t happen in most patients. Most patients who have this disorder have one operation to take usually one tumor out and they're good for the rest of their life.

Melanie: Wrap it up for us Dr. Chen with your best information and advice about the comorbidities that can go along with hyperparathyroidism, what you want other providers to know about recognizing those signs and symptoms and monitoring their patients, and when to refer to the specialists at UAB medicine.

Dr. Chen: I think that to reiterate, hyperparathyroidism is the third most common endocrine disorder. It’s the most common of cause of high calcium levels in the blood. We have a very safe outpatient operation which can improve the quality of life in patients. I think if we had a pill that could cure this, people would get treatment for it definitely. They’d be more willing. But because it’s surgery, there’s a little apprehension to consider sending someone for an operation if they're not feeling so bad or they don’t recognize it. But it’s very common for me to hear patients, even if they don’t perceive feeling bad, they have the procedure and they tells us that we've changed their lives. So, I do think you can make a big difference in the functionality of someone, how they feel, how much energy they have with a simple operation.

Melanie: Thank you so much Dr. Chen. As always, you're a wonderful guest, and thank you so much for coming on and sharing your expertise with us today. A community physician can refer a patient to UAB by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole, thanks so much for listening.