Primary Hyperparathyroidism: Evaluation and Current Management Guidelines

Primary hyperparathyroidism (PHPT) is a common disorder of disordered parathyroid function from one or more of the four parathyroid glands. A disease predominantly of postmenopausal women, it is characterized usually by hypercalcemia and elevated or inappropriately “normal” levels of circulating parathyroid hormone (PTH). Another common phenotype in which the serum calcium is consistently normal, but the PTH level is consistently elevated, in the absence of secondary causes for an elevated PTH, is called normocalcemic primary hyperparathyroidism. The majority of patients with PHPT do not demonstrate overt complications of renal and skeletal involvement, but the majority do have evidence of skeletal involvement when noninvasive microarchitectural analyses are conducted. Nevertheless, most people with PHPT are discovered on routine biochemical screening and are therefore called “asymptomatic.” Further analysis of these individuals has given rise to them being designated as with or without target organ involvement. The Fifth International Workshop on the Management of Asymptomatic Primary Hyperparathyroidism was held in 2021 in which new data were reviewed since the time of the previous workshop that was held 8 years before. As a result, the guidelines for parathyroid surgery were revised. In this chapter, we summarize the recent findings that led to a revision of the guidelines for surgery.