Skeletal Effects of Primary Hyperparathyroidism

OBJECTIVE: To review the effect of primary hyperparathyroidism on bone mass and occurrence of fractures as well as the advances in medical management of this relatively common condition. METHODS: We conducted a MEDLINE search of peer-reviewed publications for the period from 1960 to 1999. Studies reviewed were those that evaluated bone mass and fracture risk in primary hyperparathyroidism in both male and female populations. Studies that assessed intervention with hormone replacement therapy, bisphosphonates, calcimimetic agents, and surgical treatment and their effect on bone mass and fracture were also reviewed. Preference was given to prospective studies, but retrospective, cross-sectional, and case-control studies were also evaluated. RESULTS: Most densitometry studies completed to date have been limited by their design. Some cross-sectional studies that used both single-photon absorptiometry and dual-energy x-ray absorptiometry have demonstrated preferential bone loss at cortical skeletal sites. Bone density seems to be relatively well preserved at cancellous bone sites. The absence of large prospective controlled trials makes it difficult to evaluate fracture incidence associated with hyperparathyroidism. Retrospective and case-control studies have found conflicting results relative to fracture incidence in patients with primary hyperparathyroidism. Parathyroidectomy has been shown to be of value in improving bone mineral density at both the lumbar spine and the femoral neck. Hormone replacement therapy in postmenopausal women with primary hyperparathyroidism has also been effective in improving bone mineral density and decreasing bone turnover. Bisphosphonates are currently being evaluated for effectiveness in improving bone mineral density and reducing the risk of fracture. Early results with alendronate treatment have demonstrated improvements in bone mass. Calcimimetic agents are a new treatment option that may become useful in the medical management of primary hyperparathyroidism. CONCLUSION: Although conflicting findings have been reported, bone loss has been noted in patients with primary hyperparathyroidism, especially at cortical skeletal sites. Medical management does not seem to be associated with increased morbidity or mortality in patients with asymptomatic primary hyperparathyroidism. Bone densitometry is advised, particularly for monitoring of bone mass at the midradius or femoral neck, in patients with primary hyperparathyroidism.