Kidney stones at 45. An osteoporosis diagnosis that seems premature. Fatigue and mental fog that a dozen tests never explained. Years of “slightly high calcium — we’ll keep an eye on it.” These are the calling cards of primary hyperparathyroidism, one of the most underdiagnosed curable diseases in medicine. Dr. Jason S. Cohen, a parathyroid surgery specialist at Cedars-Sinai Medical Towers in Los Angeles, explains the condition that hides in plain sight on routine lab work.
A disease that announces itself in your lab history
Primary hyperparathyroidism is usually caused by a benign tumor — an adenoma — in one of the four rice-sized parathyroid glands behind the thyroid. That gland ignores the body’s signals and pumps out parathyroid hormone continuously, dissolving calcium out of the bones and raising it in the blood, year after year. It is rarely cancerous. It never fixes itself. And it is diagnosable from two blood tests that may already be sitting in your chart: calcium and PTH.
Here is the frustrating part: studies estimate that a large share of people whose labs already show the disease are never referred for evaluation. The elevated calcium is noticed, labeled “mild,” and watched — sometimes for a decade — while bones weaken and stones form.
Symptoms nobody connects
“Moans”: fatigue & fog
Deep tiredness, poor concentration, irritability, low mood, disrupted sleep. Patients often blame age, stress, or menopause — and discover after surgery how much was the calcium.
“Stones”: kidneys
Kidney stones are a classic tip-off; recurrent stones practically demand a parathyroid workup. Frequent urination and thirst belong here too.
“Bones”: silent loss
Osteopenia and osteoporosis — especially when premature or progressing despite treatment — as PTH steadily withdraws calcium from the skeleton.
“Groans”: the rest
Vague abdominal discomfort, constipation, aches, weakness. Individually dismissible; together, a pattern.
Medical students memorize this as “stones, bones, moans, and groans.” What the rhyme undersells is how quiet the disease usually is — many patients insist they feel fine, then report startling improvements in energy and clarity after the cure. Silence, in this disease, is not the same as harmlessness: bone loss proceeds either way.
The diagnosis is simpler than the delay suggests
No scan is needed to make the diagnosis — it is biochemical. High (or repeatedly high-normal) calcium together with a PTH that is elevated, or even “normal” when it should be suppressed, establishes primary hyperparathyroidism in the vast majority of cases. A healthy parathyroid system responds to rising calcium by shutting PTH down; a PTH of, say, 60 alongside a calcium of 10.8 is not normal — it is the fingerprint of an autonomous gland. Vitamin D levels and a urine calcium test complete the picture and exclude mimics.
Imaging — ultrasound, sestamibi, or 4D-CT — comes after the diagnosis, not to make it but to locate the culprit gland and enable a small, focused operation.
The cure is one of surgery’s best-kept secrets
There is no medication that cures this disease. But the operation that does — a focused parathyroidectomy — is brief, elegant, and outpatient. Guided by preoperative localization, Dr. Cohen removes the abnormal gland through an incision of roughly an inch, while intraoperative PTH testing confirms the cure before the incision is closed: because the hormone vanishes from the blood within minutes, a proper drop proves the problem gland is out and its siblings are behaving. Cure rates in specialist hands are excellent, and most patients go home the same day.
What follows is the part patients talk about: bone density stabilizes and rebuilds over the following years, stone risk falls, and — frequently — an energy and mental clarity they had stopped expecting comes back within weeks.
Has your calcium ever been flagged as high?
Pull up your labs and bring them to Dr. Cohen. One paired calcium-and-PTH test may explain years of symptoms — and the cure is often an hour in the operating room.
Who should be evaluated — even without symptoms
Guidelines recommend considering surgery for anyone with symptomatic disease — and for many “asymptomatic” patients too: those under 50, those with calcium meaningfully above normal, reduced kidney function, kidney stones on imaging, or bone density in the osteoporosis range. In practice, the evaluation is worthwhile for nearly anyone with the biochemical pattern, because the operation is small, the disease is progressive, and the alternative is years of surveillance of a problem that surgery simply ends. Dr. Cohen gives an honest recommendation either way — including when monitoring is genuinely reasonable.
The bottom line
Primary hyperparathyroidism is common, quietly destructive, absurdly easy to test for, and curable in under an hour — a combination that should make it rare to miss, yet it remains one of medicine’s most overlooked diagnoses. If your calcium has ever run high, you owe yourself the paired PTH test. If the pattern is there, you owe yourself a conversation with a surgeon who treats this disease every week.
Dr. Jason S. Cohen is a board-certified surgical oncologist whose practice at Cedars-Sinai Medical Towers is dedicated to thyroid and parathyroid surgery, serving patients throughout Los Angeles.
Frequently asked questions
What level of calcium is concerning?
Can hyperparathyroidism exist with a “normal” PTH?
Is the parathyroid tumor cancer?
What does the surgery involve?
I feel fine — do I still need treatment?
This page provides patient-education content and does not replace a medical consultation. Individual recommendations depend on an in-person evaluation with Dr. Cohen.
Recent Comments