Hormonal Influences on Bone Remodeling and Bone Loss: Application to the Management of Primary Hyperparathyroidism

The apparent prevalence and incidence of primary hyperparathyroidism increased about four-fold after routine multichannel biochemical screening began to be widely used [1]. This increase was sustained, and the average patient age at diagnosis also increased. This indicates that screening did not lead to diagnoses of hyperparathyroidism in the same patients at an earlier age (as occurred with screening for cervical cancer) but rather to the discovery of the condition in many persons who otherwise would have remained unburdened by knowledge of their condition [2]. Such persons—it begs several questions to call them patients, a role they did not seek—have, almost by definition, a condition that is mild, does not progress, and lacks traditional manifestations [2, 3]. The problem of what to do with these persons, a problem now almost 30 years old, is still unsolved.

When only the tip of the iceberg was visible, a diagnosis of primary hyperparathyroidism was a sufficient indication for surgical intervention [1]. Many physicians are still most comfortable with this policy, but it has a serious flaw. There are not now, and probably never will be, enough experienced and competent parathyroid surgeons to ensure that operating on all affected persons would do more good than harm [4]. Several authors [1, 2] have suggested that controlled clinical trials be done to determine how persons with fortuitously diagnosed hyperparathyroidism should be treated, but no such trials have yet been completed. Even if a net benefit of surgery in the most expert hands could be shown, recommending surgery would be a reasonable policy only for the few physicians who have ready access to such a surgeon.

Most persons with fortuitously discovered primary hyperparathyroidism accept the role of patient despite uncertainty about how the condition will be managed. Some reasonable indications for surgery in …