Hyperparathyroidism and Tiredness

Dr Francis Hall is Head of the Department of Otolaryngology Head and Neck Surgery at Counties Manukau DHB. He has a private practice in Auckland. He is a New Zealand trained ORL head and neck surgeon with extensive additional overseas training in head and neck surgery in Toronto, Sydney and Melbourne. He worked for five years as a head and neck / thyroid surgeon at Henry Ford Hospital in Detroit. He is an accomplished writer and presenter and loves to share his experiences with fellow specialists and general practitioners.

Primary Hyperparathyroidism Presenting as Tiredness, Fatigue and Poor Concentration. A Curable Condition.

The symptoms of hyperparathyroidism are commonly encountered in general practice and therefore easily overlooked. By reading this article my intention is that you will feel more confident to look out for, and subsequently screen for hyperparathyroidism.

Spare a moment to think about hyperparathyroidism.

In medical school we were taught the rhyme: stones, moans, bones and groans to help us remember the symptoms of hypercalcaemia.

One of the Most Common Causes of Hypercalcaemia is Primary Hyperparathyroidism.

The other common causes of hypercalcaemia are cancer and excessive calcium intake.

The rhyme: stones, moans, bones, groans only applies to about 20% of patients with primary hyperparathyroidism.

However, the most common symptoms of hyperparathyroidism are:

chronic fatigue, body aches, difficulty sleeping, memory loss, poor concentration, depression, and headaches. (Parathyroid.com).

Fortunately, Hyperparathyroidism is Easily Diagnosed with a Simple Blood Test.

In hyperparathyroidism we see a raised PTH level and a raised serum calcium (adjusted calcium) level. It is important to exclude a secondary cause of hyperparathyroidism by checking the vitamin D level, creatinine and EGFR. Secondary causes of hyperparathyroidism include vitamin D deficiency and chronic kidney disease.

Once the diagnosis of hyperparathyroidism is made, I recommend you refer the patient to either a surgeon who performs parathyroidectomy or to an endocrinologist. The endocrinologist is likely to refer the patient to a parathyroid surgeon.

In the 2022 Guidelines for Evaluation and Management of Primary Hyperparathyroidism¹, the Indications for Surgery are:

1. Serum calcium 0.25 mmol/L above the upper limit of normal or
2. Skeletal involvement
3. Renal involvement
4. Kidney stones
5. Hypercalciuria (>250mg/day in women, >300mg/day in men)
6. Age <50

Guidelines indicating which patients with hyperparathyroidism benefit from surgery vary with some groups; the American Association of Endocrine Surgeons² and the German Association of Endocrine Surgeons³ recommending surgery in patients with psychological (chronic fatigue, low mood) or neurocognitive symptoms (poor concentration, poor memory).

This contrasts with the fifth international workshop on primary hyperparathyroidism¹ stating, “surgery cannot be recommended to improve neurocognitive function, quality of life, because the evidence is inconclusive.”

Let’s Look at Some of That Evidence.

In a ten-year prospective study of patients undergoing parathyroidectomy for primary hyperparathyroidism, Paseika JL et al⁴ noted that the quality of life scores improved significantly and this improvement was still evident at 10 years. This study also showed improvement in the tiredness, mood swings, depression, and forgetfulness.

Roman SA et al⁵ in a study of 212 patients with primary hyperparathyroidism concluded that there was a reduction in mood and anxiety symptoms and an improvement in memory in patients who underwent parathyroidectomy.

The problem with the evidence is that most studies looked at relatively low numbers of patients (less than 250 patients per study). Also, the end points (tiredness, poor concentration, fatigue, mood) are difficult to measure and the way the end points are measured varies from study to study. This makes it difficult to perform a metanalysis of the data.

In My Experience and That of Many Parathyroid Surgeons^2,3,

Most patients with psychological and neurocognitive symptoms (tiredness, fatigue, insomnia, depressed mood, poor concentration, poor memory) and primary hyperparathyroidism are substantially better or cured after parathyroidectomy.

Take Home Messages:

1. It is recommended that patients with tiredness, fatigue, insomnia, depressed mood, poor concentration or poor memory be screened for primary hyperparathyroidism.
2. To screen for hyperparathyroidism, request the following blood tests: serum adjusted Ca, PTH, vitamin D, creatinine, EGFR.
3. Refer patients with a high PTH level and a high calcium level to a surgeon who performs parathyroidectomy or an endocrinologist.
4. In my experience and the experience of many other parathyroid surgeons^2,3, operating on patients with primary hyperparathyroidism often improves or cures tiredness, fatigue, insomnia, depressed mood, poor concentration and poor memory.

References:

1. Bilezikian JP, et al. Evaluation and Management of Primary Hyperparathyroidism: Summary Statement and Guidelines from the Fifth International Workshop. J Bone and Mineral Research. 2022; 37: 2293-2314.
2. Wilhelm SM, et al. The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism. JAMA Surg. 2016;151:959-968.
3. Weber T, et al. Management of primary and renal hyperparathyroidism: guidelines from the German Association of Endocrine Surgeons. Lagenbeck’s Archives of Surgery (2021) 406: 571-585.
4. Pasieka JL, et al. The long-term benefit of parathyroidectomy in primary hyperparathyroidism: A 10 year prospective surgical outcome study. Surgery 2009;146:1006-13.
5. Roman SA, et al. The Effects of Serum Calcium and Parathyroid Hormone Changes on Psychological and Cognitive Function in Patients Undergoing Parathyroidectomy for Primary Hyperparathyroidism. Ann Surg 2011; 253:131-137.