When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Primary hyperparathyroidism

Last reviewed: 12 Apr 2025
Last updated: 08 Apr 2024

Summary

Definition

History and exam

Key diagnostic factors

  • incidental finding on biochemical testing
  • history of osteoporosis or osteopenia
  • family history of hyperparathyroidism or features suggestive of hypercalcemia
  • nephrolithiasis
Full details

Other diagnostic factors

  • poor sleep
  • fatigue
  • myalgia
  • anxiety
  • depression
  • memory loss
  • overt neuromuscular dysfunction
  • cardiovascular and metabolic dysfunction
  • gastrointestinal symptoms
Full details

Risk factors

  • female sex
  • age ≥50-60 years
  • multiple endocrine neoplasia (MEN) 1, 2A, or 4
  • current or historical lithium treatment
  • hyperparathyroidism-jaw tumor syndrome
  • family history of PHPT
  • history of head and neck irradiation
Full details

Diagnostic tests

1st tests to order

  • serum calcium
  • serum intact PTH with immunoradiometric or immunochemical assay
Full details

Tests to consider

  • 25-hydroxyvitamin D level
  • serum alkaline phosphatase
  • serum phosphorus
  • 24-hour urinary calcium
  • dual-energy x-ray absorptiometry (DXA) scan
  • trabecular bone score
  • neck ultrasound
  • technetium-99m sestamibi scanning
  • single photon emission CT (SPECT)
  • CT neck
  • 4-Dimensional (4D) CT neck
  • MRI neck
Full details

Emerging tests

  • radiolabeled choline PET
  • machine learning to identify primary hyperparathyroidism

Treatment algorithm

ONGOING

asymptomatic with surgical indications or symptomatic

asymptomatic with no surgical indications

Contributors

Authors

John Ayuk, MD

Consultant Endocrinologist

University Hospitals Birmingham

Birmingham

UK

Disclosures

JA declares that he has no competing interests.

Neil Gittoes, MD, PhD

Consultant Endocrinologist and Honorary Professor of Endocrinology

Associate Medical Director

University Hospitals Birmingham

Birmingham

UK

Disclosures

NG is an author of several references cited in this topic and is a member of the 2021 European Society of Endocrinology Educational Program of Parathyroid Disorders (PARAT) Working Group.

Acknowledgements

Dr John Ayuk and Professor Neil Gittoes would like to gratefully acknowledge Dr Fausto Palazzo, Dr Swaroop Gantela, and Dr Nancy D. Perrier, the previous contributors to this topic. FP, SG, and NDP declare that they have no competing interests.

Peer reviewers

Brendan C. Stack Jr, MD, FACS, FACE

Chairman, Endocrine Surgery Section

American Head and Neck Society

Professor and former inaugural Chairman

Department of Otolaryngology-Head and Neck Surgery

Southern Illinois University School of Medicine

Springfield

IL

Disclosures

BCS declares that he has no competing interests.

Petros Perros, BSc, MBBS, MD, FRCP

Department of Endocrinology

Elliott Building

Royal Victoria Infirmary

Newcastle-upon-Tyne

UK

Disclosures

PP declares that he has no competing interests.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Bilezikian JP, Khan AA, Silverberg SJ, et al. Evaluation and management of primary hyperparathyroidism: summary statement and guidelines from the fifth international workshop. J Bone Miner Res. 2022 Nov;37(11):2293-314.Full text  Abstract

Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. 2016 Oct 1;151(10):959-68.Full text  Abstract

Bollerslev J, Rejnmark L, Zahn A, et al. European expert consensus on practical management of specific aspects of parathyroid disorders in adults and in pregnancy: recommendations of the ESE educational program of parathyroid disorders. Eur J Endocrinol. 2022 Feb 1;186(2):R33-63.Full text  Abstract

Walker MD, Silverberg SJ. Primary hyperparathyroidism. Nat Rev Endocrinol. 2018 Feb;14(2):115-25.Full text  Abstract

Petranović Ovčariček P, Giovanella L, Carrió Gasset I, et al. The EANM practice guidelines for parathyroid imaging. Eur J Nucl Med Mol Imaging. 2021 Aug;48(9):2801-2822.Full text  Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
  • Differentials

    • Familial hypocalciuric hypercalemia (FHH)
    • Humoral hypercalcemia of malignancy
    • Multiple myeloma
    More Differentials
  • Guidelines

    • Practice parameter for the performance and interpretation of diagnostic ultrasound of the thyroid and extracranial head and neck
    • Evaluation and management of primary hyperparathyroidism: summary statement and guidelines from the fifth international workshop
    More Guidelines
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer