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Primary hyperparathyroidism

Last reviewed: 4 Sep 2023
Last updated: 20 Sep 2023



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
More key diagnostic factors

Other diagnostic factors

  • poor sleep
  • fatigue
  • myalgia
  • anxiety
  • depression
  • memory loss
  • overt neuromuscular dysfunction
  • cardiovascular and metabolic dysfunction
  • features suggestive of hypercalcemia
  • hard and dense neck mass
Other diagnostic factors

Risk factors

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

Diagnostic investigations

1st investigations to order

  • serum calcium
  • serum intact PTH with immunoradiometric or immunochemical assay
More 1st investigations to order

Investigations 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
  • Tc-99m sestamibi scanning and ultrasonography
  • single photon emission CT + sestamibi scanning
  • CT neck
  • 4-Dimensional (4D) CT neck
  • MRI neck
More investigations to consider

Emerging tests

  • radiolabeled choline PET

Treatment algorithm


asymptomatic with surgical indications or symptomatic

asymptomatic with no surgical indications



John Ayuk, MD

Consultant Endocrinologist

University Hospitals Birmingham




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




NG has contributed to advisory boards for Takedo and Shire pharmaceuticals.


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

Bridget Sinnott, MD

Clinical Assistant

Professor of Medicine

University of Illinois at Chicago




BS declares that she has no competing interests.

Udaya Kabadi, MD

Professor of Medicine

Department of Internal Medicine

University of Iowa

Iowa City



UK declares that she has no competing interests.

Leonard Egede, MD

Professor of Medicine

Medical University of South Carolina




LE declares that he has no competing interests.

Petros Perros, BSc, MBBS, MD, FRCP

Department of Endocrinology

Elliott Building

Royal Victoria Infirmary




PP declares that he has no competing interests.

  • 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
    • The EANM practice guidelines for parathyroid imaging
    More Guidelines
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