Indications for surgery in primary hyperparathyroidism

Should subjective symptoms, such as fatigue, irritability, and difficulty concentrating, be considered indications for surgery in primary hyperparathyroidism?

Although only a minority of patients with primary HPT manifest the classic symptoms, as many as 90% of patients experience more subtle, subjective symptoms, such as fatigue, weakness, musculoskeletal pains, abdominal discomfort, depression, anxiety, irritability, or memory/cognitive difficulties. In fact, some have argued that there is no such thing as truly “asymptomatic” primary HPT! Although some studies have shown that patients undergoing parathyroidectomy have improvement in these subjective symptoms, the results are inconsistent, and it is not possible to predict in any one patient whether or not these symptoms will improve after surgery. Similarly, some studies have found primary HPT to be associated with an increased risk of cardiovascular disease and early mortality; however, the results of studies investigating whether parathyroidectomy reduces these risks have been conflicting. In contrast to the NIH guidelines, the American Association of Endocrine Surgeons guidelines include neurocognitive and/or neuropsychiatric symptoms as an indication for surgery, and recommend that a history of cardiovascular disease as well as other nontraditional symptoms be considered in the decision for parathyroidectomy.

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