Hyperparathyroidism FAQ: Your Questions Answered

These answers follow the 2022 international guidelines for primary hyperparathyroidism from the Fifth International Workshop on the Evaluation and Management of Primary Hyperparathyroidism. They are general information and do not replace advice from your own doctor.

Reviewed by Alexander Shifrin, MD, FACS, FACE, Director of Endocrine Surgery, CentraState Medical Center, Freehold, NJ. Last reviewed: November 2026.

What does a high calcium level mean?

You have four tiny parathyroid glands in your neck. They make parathyroid hormone (PTH), which keeps the calcium in your blood steady. In primary hyperparathyroidism, one or more glands make too much PTH, and your blood calcium rises. In most people (about 85 in 100), one gland has a small, non-cancerous growth called an adenoma. In the rest, more than one gland is overactive. Cancer is very rare, in fewer than 1 in 100 people. The condition is common, and it is more common in women than in men.

Normally, high calcium tells the glands to make less PTH.

In hyperparathyroidism, an overactive gland keeps making PTH anyway.

A high calcium result does not always mean this condition. Some medicines (such as thiazide water pills and lithium), a rare inherited condition, and other illnesses can also raise calcium. The key test is PTH. If calcium is high and PTH is high, or not as low as it should be, primary hyperparathyroidism is likely.

What symptoms does it cause?

Many people have no symptoms. The problem is often found by chance on a routine blood test. When the disease affects the body, the most common problems are in the bones and kidneys:

• Kidney stones, and in some people reduced kidney function
• Bone loss (osteoporosis), bone pain and fractures
• Muscle weakness
• Less often, pancreatitis, stomach pain, constipation, nausea, or very high calcium that affects thinking

Many people also report tiredness, low mood, trouble concentrating or poor sleep. These complaints are common in the general population, and it is not always clear that the parathyroid is the cause (see the question on fatigue and memory below).

How is it diagnosed?

The diagnosis is made with blood tests. Primary hyperparathyroidism is confirmed when your calcium (adjusted for albumin) is high and your PTH is high or inappropriately normal, on two occasions at least 2 weeks apart. Your doctor will also check vitamin D, phosphorus and kidney function. Scans are not used to make the diagnosis. They are used later, to find the gland if you have surgery.

Other causes must be ruled out. These include thiazide water pills and lithium, and familial hypocalciuric hypercalcemia (FHH), a harmless inherited condition in which surgery usually does not help. A 24-hour urine test helps tell FHH apart. If your PTH is low, other causes such as cancer or granulomatous disease are considered. Biotin supplements can falsely lower PTH results on some tests, so the guidelines suggest stopping biotin for at least 48 hours before the blood draw.

What tests are done after the diagnosis?

• Bones: a bone density scan (DXA) of the spine, hip and forearm, plus an X-ray or vertebral fracture assessment (VFA) to look for spine fractures you may not have felt.
• Kidneys: a kidney function test (creatinine clearance or eGFR), a full 24-hour urine collection for calcium, and imaging (X-ray, ultrasound or CT) for kidney stones. If you have stones or high urine calcium, a stone risk profile is recommended.
• Blood: calcium, PTH, phosphorus, vitamin D and creatinine.

The guidelines do not recommend routine memory testing or heart testing for hyperparathyroidism.

Do I need surgery if I have no symptoms?

Surgery is the only treatment that can cure primary hyperparathyroidism. The guidelines clearly recommend it for everyone with symptoms, such as marked high calcium, kidney stones or fractures. They also recommend surgery for people without symptoms. You only need to meet one of the following criteria to be advised to have surgery:

Surgery is also advised if you would rather not be monitored, if monitoring is not possible, or if you choose surgery without meeting any criteria, as long as you have no medical reason to avoid it. In premenopausal women and men under 50, bone density is judged by Z-score instead of T-score, and these patients already qualify by age. If you have only one kidney, surgery may be considered even when your eGFR is above 60.

Will surgery help my fatigue, memory or mood?

Honestly, this is uncertain. Many patients feel better after surgery, but studies have not shown a clear or consistent benefit for tiredness, memory, mood, quality of life or heart health. A 10-year randomized trial could not confirm a link between mild hyperparathyroidism and memory problems. For this reason, the guidelines do not recommend surgery for these reasons alone.

What surgery does do well: it cures the high calcium in about 98 in 100 patients in the trials reviewed, it raises bone density, and it protects kidney function from further decline. Observational studies suggest that kidney stone events fall to the level of people without the disease about 10 years after surgery.

What scans are done before surgery?

Once you and your surgeon decide on surgery, scans are used to find the overactive gland. They are not used to diagnose the condition. The main tests are:

• High-resolution neck ultrasound
• Technetium-99m sestamibi scan
• Contrast-enhanced four-dimensional CT (4D CT)

When a scan clearly shows the gland, the surgeon can often do a focused, targeted operation. Your surgeon will choose the tests that fit your case.

How long does the operation take, and what kind of anesthesia is used?

When tests show which gland is overactive, the operation is often focused: a small incision in the neck to remove only that gland, often with PTH measured during the operation to confirm the overactive tissue is out. The benefits of this approach include a shorter operation, less scarring and less risk to nearby structures. When more than one gland may be involved, the surgeon looks at all four glands. Many operations take about an hour or less, and most patients go home the same day. The operation can be done under general anesthesia or, in some cases, local anesthesia with sedation.

What are the risks and results of surgery?

In the hands of an experienced surgeon, parathyroid surgery is safe and well tolerated, including in older patients. The guidelines report these figures from large series:

A short period of low calcium after surgery can happen while the remaining glands recover. Your surgeon will check your calcium and tell you if you need calcium supplements for a short time.

How do I choose a parathyroid surgeon?

The guidelines say surgery should be done by an experienced parathyroid surgeon. Most endocrine surgeons consider a surgeon who performs at least 50 parathyroid operations a year to be experienced. Good questions to ask are:

• How many parathyroid operations do you do each year?
• What is your cure rate?
• Do you use scans to find the gland, and PTH monitoring during the operation?
• Will I go home the same day?

When can I go back to work?

Recovery is usually straightforward. The guidelines describe mild throat discomfort and a few days of tiredness. Strong pain medicine is rarely needed. The timeline below is typical. Dr. Shifrin will give you instructions that fit your job and your recovery.

Bone density usually keeps improving for a year or more after surgery. Your calcium is rechecked after the operation, and your vitamin D level should be kept above 30 ng/mL.

What if I do not have surgery?

If you do not meet the criteria for surgery, or you choose not to have it, you can be monitored without medicine. The guidelines recommend:

• Calcium and vitamin D blood tests every year
• A kidney function test (creatinine clearance or eGFR) every year
• A three-site bone density scan (DXA) every 1 to 2 years, less often if the results are normal
• A spine X-ray or VFA, a 24-hour urine test or kidney imaging when your doctor thinks it is needed

Surgery is advised later if your calcium stays more than 1 mg/dL above normal, you have a fracture or a kidney stone, your bone density drops significantly to -2.5 or lower, or your kidney function drops significantly.

If surgery is advised but you cannot or will not have it, medicines can help. Cinacalcet lowers the calcium. Alendronate or denosumab raise bone density. These medicines manage the problem, and they do not cure it. Keep your vitamin D above 30 ng/mL. Do not cut out calcium from your diet, since restricting calcium can push PTH higher. Eat and drink the usual recommended amounts, and stay well hydrated.

What if my calcium is normal but my PTH is high?

This can be normocalcemic primary hyperparathyroidism. The diagnosis needs a high PTH with normal albumin-adjusted and ionized calcium on at least two checks over 3 to 6 months, after other causes of a high PTH are ruled out. These include low vitamin D, low calcium intake, kidney disease, certain medicines (for example thiazides, lithium and bone medicines) and gut absorption problems. Your 24-hour urine calcium is usually normal. Some patients have kidney stones or low bone density, and some do not.

The guidelines could not give surgery criteria for this form because there is not enough data. Treatment is decided one patient at a time, based on whether you have bone loss, fractures or kidney stones. Many patients are monitored, and some choose surgery.

Is hyperparathyroidism genetic?

Most cases are not inherited. More than 1 in 10 patients have a gene change linked to the condition. Genetic counseling and testing should be considered if you are under 30, if more than one gland is involved, or if you have a family history of high calcium or related conditions (such as MEN1, MEN2A, MEN4 or hyperparathyroidism-jaw tumor syndrome). The result can change the operation, since these patients usually need all four glands examined. In FHH, surgery is usually not recommended.

What about pregnancy?

Mild cases in pregnancy are managed with good hydration and monitoring of calcium. Surgery in the second trimester is considered when calcium is above 11 mg/dL and there is no reason to avoid it. Bisphosphonates and denosumab should not be used. Imaging is limited to ultrasound. If surgery is delayed, the newborn is watched closely for low calcium, and surgery is done after delivery and before another pregnancy.

Source: Bilezikian JP, et al. Evaluation and management of primary hyperparathyroidism: summary statement and guidelines from the Fifth International Workshop. J Bone Miner Res. 2022;37(11):2293-2314. doi:10.1002/jbmr.4677