Hyperthyroidism (Overactive Thyroid)

Hyperthyroidism means a raised level of thyroid hormone. There are various causes. Graves' disease is the most common cause. Hyperthyroidism can produce various symptoms. Treatment is usually effective. Treatment options to reduce the thyroxine level include: medicines, radioiodine and surgery. Beta-blockers can ease some of the symptoms. Longterm follow-up is important, even after successful treatment.

What is hyperthyroidism?

Thyroxine is a body chemical (hormone) made by the thyroid gland. It is carried around the body in the bloodstream. It helps to keep the body's functions (the metabolism) working at the correct pace. Many cells and tissues in the body need thyroxine to keep them going correctly. Hyperthyroidism means an overactive thyroid gland. When your thyroid gland is overactive it makes too much thyroxine. The extra thyroxine causes many of your body's functions to speed up. (In contrast, if you have hypothyroidism, you make too little thyroxine; this causes many of the body's functions to slow down.) Thyrotoxicosis is a term that may be used by doctors instead of hyperthyroidism. The two terms mean much the same.

What are the symptoms of hyperthyroidism?

The following are symptoms of hyperthyroidism:

Being restless, nervous, emotional, irritable, sleeping poorly and 'always on the go'. Tremor of your hands. Losing weight despite an increased appetite. Palpitations.

Sweating, a dislike of heat and an increased thirst. Diarrhoea or needing to go to the toilet to pass faeces more often than normal. Shortness of breath. Skin problems such as hair thinning and itch. Menstrual changes - your periods may become very light or infrequent. Tiredness and muscle weakness may be a feature. A swelling of your thyroid gland (a goitre) in the neck may occur. Eye problems if you have Graves' disease. (See below under 'What are the causes of hyperthyroidism?'.)

Most people with hyperthyroidism do not have all the symptoms but a combination of two or more is common. Symptoms usually develop slowly over several weeks. All the symptoms can be caused by other problems and so the diagnosis may not be obvious at first. Symptoms may be mild to start with but become worse as the level of thyroxine in the blood gradually rises.

Possible complications
If you have untreated hyperthyroidism: You have an increased risk of developing heart problems such as abnormal heart rhythym (atrial fibrillation), a weak heart (cardiomyopathy), angina and heart failure. If you are pregnant, you have an increased risk of developing some pregnancy complications. You have an increased risk of developing fragile bones (osteoporosis). With treatment, the outlook is good. With successful treatment, most of the symptoms and risks of complications go.

Who gets hyperthyroidism?

It is more common in women. About 8 in 100 women and 1 in 100 men develop hyperthyroidism at some stage of their lives. It can occur at any age.

What are the causes of hyperthyroidism?

There are various causes which include the following:

Graves' disease
This is the most common cause. It can occur at any age but is most common in women aged 20 to 50 years. It can affect anyone but there is often a family history of the condition. There may also be family members with other autoimmune diseases (for example, diabetes, rheumatoid arthritis and myasthenia gravis). Graves' disease is also an autoimmune disease. The immune system normally makes antibodies (tiny proteins that travel in the bloodstream) to attack bacteria, viruses and other germs. In autoimmune diseases, the immune system makes antibodies against tissues of the body. If you have Graves' disease, you make antibodies that attach to the thyroid gland. These stimulate the thyroid to make lots of thyroxine. It is thought that something

triggers the immune system to make these antibodies. The trigger is not known. In Graves' disease the thyroid gland usually enlarges, which causes a swelling (goitre) in the neck. The eyes are also affected in about half of cases. If they are affected, the eyes are pushed forwards and look more prominent (proptosis). This can cause discomfort and watering of the eyes. Problems with eye muscles may also occur and lead to double vision. It is not clear why eye symptoms occur in some people who have Graves' disease. They may be due to the antibodies affecting the tissues around the eye. See separate article called Thyroid Eye Disease for further details.

Thyroid nodules
This is a less common cause of hyperthyroidism. Thyroid nodules are lumps which can develop in the thyroid gland. It is not clear why they develop. They are usually benign (non-cancerous) but contain abnormal thyroid tissue. The abnormal thyroid tissue in the thyroid nodules does not respond to the normal controlling system which ensures that you make just the right amount of thyroxine. Therefore, if you have a thyroid nodule, you may make too much thyroxine.

Sometimes only one nodule forms. This is called a toxic solitary adenoma. This most commonly occurs in people aged between 30 and 50 years. The thyroid may become generally lumpy or nodular. This most commonly occurs in older people and is called a toxic multinodular goitre.

Note: the word toxic above, relating to adenomas or multinodular goitres, does not mean poisonous. It is just one of those medical words which refers to the hyperthyroidism.

Other causes
There are several other rare causes of hyperthyroidism. For example, some people who take the medicines amiodarone and lithium develop hyperthyroidism. There are various other rare conditions that result in excess thyroxine being made.

How is hyperthyroidism diagnosed?

A blood test can diagnose hyperthyroidism. A normal blood test will also rule it out if symptoms suggest that it may be a possible diagnosis. One or both of the following may be measured in a blood sample: Thyroid-stimulating hormone (TSH). This hormone is made in the pituitary gland in the brain. It is released into the bloodstream. It stimulates the thyroid gland to make thyroxine. If the level of thyroxine in the blood is high, then the pituitary releases less TSH. Therefore, a low level of TSH means that your thyroid gland is overactive and is making too much thyroxine. Thyroxine (T4). A high level of T4 confirms hyperthyroidism. Sometimes the results of the tests are borderline. For example, a normal T4 but with a low TSH. Other tests are sometimes done to clarify the situation and the cause. For example, another blood test that measures T3 is sometimes helpful and an ultrasound scan of the thyroid or a thyroid scan may be done if you have a nodular goitre.

Also, if tests are borderline, one option is to repeat the tests a few weeks later, as sometimes borderline tests are due to another illness. Other tests may be done if a rare cause of hyperthyroidism is suspected. In people with Graves' disease a blood test may detect specific autoantibodies which are commonly raised. However, these can also be raised in some people without Graves' disease so this is not a specific test for Graves' disease.

What are the treatments for hyperthyroidism?

The main aim of treatment is to reduce your level of thyroxine to normal. Other problems, such as a large goitre (thyroid swelling) or associated eye problems, may also need treatment. Factors such as the underlying cause of the problem, your age and the size of any goitre are taken into account to decide on the best treatment plan. Treatment options include the following:

Medicines - usually carbimazole

Medicines can reduce the amount of thyroxine made by the overactive thyroid gland. The most common medicine used in the UK is carbimazole. Carbimazole does not affect the thyroxine which is already made and stored but reduces further production. Therefore, it may take 4 to 8 weeks of treatment for your thyroxine level to come down to normal. The dose of carbimazole needed to keep the thyroxine level normal varies from person to person. A high dose is usually given initially which is then reduced as your thyroxine levels come down. Carbimazole is usually taken for 12-18 months at first. After this, in about half of cases, the condition will have settled down and the carbimazole can be stopped. If the condition flares up again some time in the future, a further course may be needed. However, in these cases an alternative treatment (for example, radioactive iodine) is often recommended. In about half of cases, carbimazole needs to be continued long-term to control symptoms. A different treatment may then be a better option if you do not want to take carbimazole long-term. Warning: carbimazole can, rarely, affect your white blood cells which fight infection. If you develop a fever, sore throat, mouth ulcers or other symptoms of infection whilst taking carbimazole, you should stop taking it and see a doctor urgently for a blood test. An alternative medication called propylthiouracil is usually given instead of carbimazole if you are pregnant or breast-feeding.

Radioiodine
This involves taking a drink, or swallowing a capsule, which contains radioactive iodine. The main use of iodine in the body is to make thyroxine. Therefore, the radioactive iodine builds up in the thyroid gland. As the

radioactivity is concentrated in the thyroid gland, it destroys some thyroid tissue which reduces the amount of thyroxine that you make. The dose of radioactivity to the rest of the body is very low and is not dangerous. However, it is not suitable if you are pregnant or breast-feeding. In addition, after treatment, women should not become pregnant for at least six months and men are advised not to father children for at least four months. Also, following radioiodine treatment, you should avoid prolonged contact with others for a specified time. This may be for 2-4 weeks, depending on the amount of radioiodine you receive. The aim is to limit the exposure of radioactivity to others. For the specified period you will be advised to take precautions such as:

Limit close contact with babies, children or pregnant women. Close contact means being within one metre; so, for example, don't cuddle children or allow them to sit on your lap. You may wish to apply similar precautions as above for contact with your pets. If you have children, or have a job where you have contact with children, you should discuss this with the specialist before treatment. Stay more than an arm's length away from other people. Sleep alone. Avoid going to places like cinemas, theatres, pubs and restaurants where you may be in close contact with other people. Take some time off work if your work involves close contact with other people.

Your specialist will give detailed advice regarding these precautions.

Thyroid replacement therapy

It can be difficult for a doctor to judge just the right dose of carbimazole, or just the right amount of radioiodine, to give in each case. Too much treatment may make your thyroxine level go too low. Not enough treatment means your level remains higher than normal. Regular blood tests are needed to check on the thyroxine level. One option is to take a high dose of carbimazole each day deliberately, or to receive a one-off high dose of radioiodine. This stops your thyroid gland making any thyroxine. You will then need to take a daily dose of thyroxine tablets to keep your blood level of thyroxine normal. This over-treatment and then taking replacement thyroxine is also called 'block and replace'.

Surgery
This involves removing part of your thyroid gland. It may be a good option if you have a large thyroid swelling (goitre) which is causing problems in your neck. If too much thyroid tissue is removed then you will be given thyroxine tablets to keep your thyroxine level normal. It is usually a safe operation. But, as with all operations, there is a small risk.

Treatment for eye problems

You may need to see an eye specialist if you develop the eye problems of Graves' disease. Relatively minor symptoms affect the eyes in about half of people with Graves' disease. Measures such as artificial tears, sunglasses and eye protectors whilst you sleep may be sufficient to help. However, about 1 in 20 people with Graves' disease have severe eye changes. Treatment can then be more difficult and may include surgery, radiation treatment or steroid tablets. If you smoke then it is important that you try to stop. Smoking can actually make your eye problems worse.

Beta-blocker medicines
Some people are given a beta-blocker medicine (for example, propranolol, atenolol, etc) for a few weeks whilst the level of thyroxine is reduced gradually by one of the above treatments. Beta-blockers can help to reduce symptoms of tremor, palpitations, sweating, agitation and anxiety.

Follow-up
Regular checks are recommended, even after you finish a successful treatment. It is very important to have a regular blood test (at least every year) to check that you have the right level of thyroid hormone (thyroxine) in your blood. Your GP may do this test. This is because some people become hyperthyroid again at some time in the future. Others who have been treated successfully develop an underactive thyroid in the future. If this occurs, it can usually be treated easily with thyroxine tablets.

Hypothyroidism - Underactive Thyroid

Hypothyroidism (underactive thyroid gland) is the term used to describe a condition in which there is a reduced level of thyroid hormone (thyroxine) in the body. This can cause various symptoms, the most common being: tiredness, weight gain, constipation, aches, dry skin, lifeless hair and feeling cold. Treatment is usually easy by taking a tablet each day to replace the missing thyroxine. Treatment usually works well and symptoms usually go.

What is hypothyroidism?
Thyroxine is a hormone (body chemical) made by the thyroid gland in the neck. It is carried round the body in the bloodstream. It helps to keep the body's functions (the metabolism) working at the correct pace. Many cells and tissues in the body need thyroxine to keep them going correctly. Hypothyroidism results from the thyroid gland being unable to make enough thyroxine, which causes many of the body's functions to slow down. Hypothyroidism may also occur if there is not enough thyroid gland left to make thyroxine, eg after surgical removal or injury. (In contrast, if you have hyperthyroidism, you make too much thyroxine. This causes many of the body's functions to speed up.)

What are the symptoms of hypothyroidism?

Many symptoms can be caused by a low level of thyroxine. Basically, many body functions slow down. Not all symptoms develop in all cases.

Symptoms that commonly occur include: tiredness, weight gain, constipation, aches, feeling cold, dry skin, lifeless hair, fluid retention, mental slowing, and depression.

Less common symptoms include: a hoarse voice, irregular or heavy menstrual periods in women, infertility, loss of sex drive, carpal tunnel syndrome (which causes pains and numbness in the hand), and memory loss or confusion in the elderly.

However, all these symptoms can be caused by other conditions, and sometimes the diagnosis is not obvious. Symptoms usually develop slowly, and gradually become worse over months or years as the level of thyroxine in the body gradually falls.

What are the possible complications of hypothyroidism?

If you have untreated hypothyroidism: You have an increased risk of developing heart disease. This is because a low thyroxine level causes the blood lipids (cholesterol, etc) to rise. If you are pregnant, you have an increased risk of developing some pregnancy complications - for example: pre-eclampsia, anaemia, premature labour, low birth weight, stillbirth, and serious bleeding after the birth. Hypothyroid coma (myxoedema coma) is a very rare complication. However, with treatment, the outlook is excellent. With treatment, symptoms usually go, and you are very unlikely to develop any complications.

Who gets hypothyroidism?

About 1 in 50 women, and about 1 in 1,000 men develop hypothyroidism at some time in their life. It most commonly develops in adult women, and becomes more common with increasing age. However, it can occur at any age and can affect anyone.

What causes hypothyroidism?

Autoimmune thyroiditis - the common cause in the UK
The most common cause is due to an autoimmune disease called autoimmune thyroiditis. The immune system normally makes antibodies to attack bacteria, viruses, and other germs. If you have an autoimmune disease, the immune system makes antibodies against certain tissues of your body. With autoimmune thyroiditis, you make antibodies that attach to your own thyroid gland, which affect the gland's function. The thyroid gland is then not able to make enough thyroxine, and hypothyroidism gradually develops. It is thought that something triggers the immune system to make antibodies against the thyroid. The trigger is not known. Autoimmune thyroiditis is more common than usual in people with:

A family history of hypothyroidism caused by autoimmune thyroiditis.

Down's syndrome. Hypothyroidism develops in 1 in 3 people with Down's syndrome before the age of 25 years. Symptoms of hypothyroidism may be missed more easily in people with Down's syndrome. Therefore, some doctors recommend that all people with Down's syndrome should have an annual blood test to screen for hypothyroidism. Turner syndrome. Again, an annual blood test to screen for hypothyroidism is usually advised for people with this condition. An enlarged thyroid gland (diffuse goitre). A past history of Graves' disease, or thyroiditis following childbirth. A personal or family history of other autoimmune disorders - for example: vitiligo, pernicious anaemia, Addison's disease, type 1 diabetes, premature ovarian failure, coeliac disease, Sjgren's syndrome.

Some people with autoimmune thyroiditis also develop a swollen thyroid gland (goitre). Autoimmune thyroiditis with a goitre is called Hashimoto's disease. Also, people with autoimmune thyroiditis have a small increased risk of developing other autoimmune conditions such as vitiligo, pernicious anaemia, etc.

Surgery or radioactive treatment to the thyroid gland

These are common causes of hypothyroidism in the UK, due to increasing use of these treatments for other thyroid conditions.

Other causes
Other causes of hypothyroidism include:

Worldwide, iodine deficiency is the most common cause of hypothyroidism. (Your body needs iodine to make thyroxine.) This affects some countries more commonly than others, depending on the level of iodine in the diet. A side-effect to some medicines - for example, amiodarone and lithium. Other types of thyroiditis (thyroid inflammation) caused by various rare conditions. A pituitary gland problem is a rare cause. The pituitary gland that lies just under the brain makes a hormone called thyroid-stimulating hormone (TSH). This stimulates the thyroid gland to make thyroxine. If the pituitary does not make TSH then the thyroid cannot make enough thyroxine. Some children are born with an underactive thyroid gland (congenital hypothyroidism).

How is hypothyroidism diagnosed?

A blood test can diagnose hypothyroidism. A normal blood test will also rule it out if symptoms suggest that it may be a possible diagnosis. One or both of the following may be measured:

TSH. This hormone is made in the pituitary gland. It is released into the bloodstream. It stimulates the thyroid gland to make thyroxine. If the level of thyroxine in the blood is low, then the pituitary releases more TSH to try to stimulate the thyroid gland to make more thyroxine. Therefore, a raised level of TSH means the thyroid gland is underactive and is not making enough thyroxine. Thyroxine (T4). A low level of T4 confirms hypothyroidism.

Note: some people have a raised TSH level but have a normal T4 level. This means that you are making enough thyroxine but the thyroid gland is needing extra stimulation from TSH to make the required amount of thyroxine. In this situation you have an increased risk of developing hypothyroidism in the future. Your doctor may advise a repeat blood test every so often to see if you do eventually develop hypothyroidism. Other tests are not usually necessary unless a rare cause of hypothyroidism is suspected. For example, tests of the pituitary gland may be done if both the TSH and T4 levels are low.

How is hypothyroidism treated?

The treatment is to take levothyroxine (thyroxine) tablets each day. This replaces the thyroxine which your thyroid gland is not making. Most people feel much better soon after starting treatment. Ideally, take the tablet on an empty stomach (before breakfast). This is because some foods rich in calcium or iron may interfere with the absorption of levothyroxine from the gut. (For the same reason, don't take levothyroxine tablets at the same time of day as calcium or iron tablets.)

What is the dose of levothyroxine?

Most adults need between 50 and 150 micrograms daily. A low dose is sometimes prescribed at first, especially in those aged over 60 or with heart problems, and is then gradually increased over a period of time. Blood tests are usually taken every 2-3 months, and the dose may be adjusted accordingly. The blood test measures TSH (see above). Once the blood TSH level is normal it means you are taking the correct amount of levothyroxine. It is then common practice to check the TSH blood level once a year. The dose may need adjustment in the early stages of pregnancy. Also, as you get into late middle age and older, you may need a reduced dose of levothyroxine.

Missed a tablet?
Everyone forgets to take their tablets from time to time. Don't worry as it is not dangerous to miss the odd forgotten levothyroxine tablet. If you forget to take a dose, take it as soon as you remember if this is within 2 or 3 hours of your usual time. If you do not remember until after this time, skip the forgotten dose and take the next dose at the usual time. Do not take two doses together to make up for a missed dose. However, you should try to take levothyroxine regularly each morning for maximum benefit.

How long is the treatment for?

For most people, treatment is for life. Occasionally, the disease process reverses. This is uncommon, apart from the following:

Children. Sometimes hypothyroidism is a temporary condition in older children. (This is not so for children who are born with an underactive thyroid.) Pregnancy. Some women develop thyroid imbalance after having a baby. If it occurs, it typically happens about three to six months after the birth. Often this lasts just a few months and corrects itself.

Treatment is needed only in a small number of cases. However, afterwards it is wise to have a yearly blood test, as there is an increased risk of developing autoimmune thyroiditis and long-term hypothyroidism in the future.

Are there any side-effects or problems from treatment?

Usually not. Levothyroxine tablets replace the body's natural hormone, so side-effects are uncommon. However, if you have angina, you may find that your angina pains become worse when you first start levothyroxine. Tell a doctor if this happens. If you take too much levothyroxine it can lead to symptoms and problems of an overactive thyroid - for example, palpitations, diarrhoea, irritability, and sweating - and increase the risk of developing osteoporosis. This is why you need blood tests to check that you are taking the correct dose. Other medicines may interfere with the action of levothyroxine - for example: carbamazepine, iron tablets, phenytoin, and rifampicin. If you start any of these medicines, or change the dose, then you may need to alter the dose of the levothyroxine. Your doctor will advise. Also, if you take warfarin, the dose may need to be altered if you have a change in your dose of levothyroxine.

Free prescriptions
If you have hypothyroidism, you are entitled to free prescriptions. This is for all your medicines, whether related to the hypothyroidism or not. Ask at your GP surgery for a form to fill in (form FP92A) to claim this benefit.

In summary

Hypothyroidism is common. Symptoms develop gradually. They may be confused with other conditions. Treatment with levothyroxine tablets is usually easy and effective. Treatment is usually for life. Have a blood test once a year if you take levothyroxine tablets once your dose has become stabilised.

Hyperparathyroidism
Hyperparathyroidism occurs when an excess of parathyroid hormone is released by the parathyroid glands in the neck. It generally leads to high levels of calcium in the blood. This can cause various symptoms, commonly tiredness, feeling sick (nausea sick), being sick (vomiting), kidney stones and bone pains. It can usually be treated with surgery.

What is hyperparathyroidism?

Your body has four parathyroid glands. They are small, pea-sized glands, located in your neck just behind your butterfly-shaped thyroid gland. Two parathyroid glands lie behind each 'wing' of your thyroid gland. Your parathyroid glands release a hormone called parathyroid hormone. This hormone helps to control the levels of two chemicals in your body: calcium and phosphate. Normally, parathyroid hormone release is triggered when the level of calcium in your blood is low. When the calcium level rises and is back to normal, the release of parathyroid hormone is suppressed. Parathyroid hormone has a number of effects in your body:

It causes the release of calcium from your bones. It causes calcium to be absorbed (taken up into your blood) from your gut (small intestine). It stops your kidneys from excreting (getting rid of) calcium in your urine. It causes your kidneys to excrete phosphate in your urine.

In hyperparathyroidism, your parathyroid glands make and release too much parathyroid hormone. Generally, this means that the calcium level in your blood becomes too high.

Why do we need calcium and phosphate?

Calcium and phosphate combine to make calcium phosphate in your body. This is the chief material that gives hardness and strength to your bones and teeth. Calcium is also needed as part of the complex mechanism that helps your blood to clot after an injury. As well, it is needed for your muscles and nerves to work properly. Phosphate works in conjunction with calcium for these functions. Phosphate is also needed for the production of energy within your body.

What causes hyperparathyroidism?

Hyperparathyroidism is either primary, secondary or tertiary.

Primary hyperparathyroidism
In primary hyperparathyroidism, one or more of your parathyroid glands become enlarged and overactive. The gland, or glands, release too much parathyroid hormone. This results in a high level of calcium in your blood. Causes include:

A single parathyroid adenoma. This is the most common cause of primary hyperparathyroidism. There is a benign (non-cancerous) tumour of one of your parathyroid glands. This causes more parathyroid hormone to be released by the gland. Hyperplasia affecting more than one parathyroid gland. This accounts for most other cases of primary hyperparathyroidism. Hyperplasia means that there is enlargement of a parathyroid gland. It usually affects more than one gland at the same time. As a result of the enlargement, more parathyroid hormone is released. Parathyroid carcinoma. Very rarely, primary hyperparathyroidism is caused by cancer (carcinoma) in one of the parathyroid glands.

It is usually not clear why parathyroid adenoma or hyperplasia occurs. However, if you have had radiotherapy treatment to your head or neck in the past, you seem to have an increased risk of developing a parathyroid adenoma or carcinoma. Primary hyperparathyroidism seems to be more common in women than in men and most commonly affects women after the menopause. Primary hyperparathyroidism does not usually run in families. However, in a small number of people, it can be the result of an inherited condition called familial isolated hyperparathyroidism. Also, rarely, it may be inherited as part of a syndrome (a collection of problems) called multiple endocrine neoplasia (MEN) which affects the parathyroids, the pancreas and the pituitary gland.

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Secondary hyperparathyroidism
Secondary hyperparathyroidism is caused by other diseases or deficiencies that are affecting your body. These other conditions cause a long-standing low level of calcium in your blood. This means that your parathyroid glands are permanently being stimulated to try to raise your blood calcium level. As a result, your parathyroid glands enlarge and their output of parathyroid hormone increases. The raised levels of parathyroid hormone are appropriate due to your low blood calcium level. Some of the causes of secondary hyperparathyroidism include:

Kidney disease. This is the most common cause of secondary hyperparathyroidism. Secondary hyperparathyroidism occurs in nearly all people who are on long-term kidney dialysis because of kidney failure. Because you have kidney failure, your blood calcium level can become low and stay low. Vitamin D deficiency (rickets/osteomalacia). This is another common cause. Vitamin D deficiency causes a long-standing low level of calcium in your blood. Gut (intestinal) malabsorption. There are various diseases that can affect your gut and prevent the calcium that you eat from being taken up (absorbed) into your blood. This can cause your blood calcium level to become low and stay low..

Tertiary hyperparathyroidism
This type of hyperparathyroidism occurs as a result of prolonged secondary hyperparathyroidism. In tertiary hyperparathyroidism, the condition causing your low blood calcium level and the secondary hyperparathyroidism has been treated (or your blood calcium level has been corrected). However, your parathyroid glands continue to produce large amounts of parathyroid hormone. This is because they start to act by themselves (autonomously) and are no longer sensitive to your blood calcium level. They are not 'switched off' when your blood calcium level rises. This results in a high calcium level in your blood. Tertiary hyperparathyroidism is typically seen in people who have chronic kidney failure. It can also persist even after a kidney transplant.

What are the hyperparathyroidism symptoms?

Often people with primary hyperparathyroidism either have no symptoms, or only have mild symptoms. You may only find out that you have hyperparathyroidism because blood tests that are carried out for another reason show a high level of calcium in your blood. If you have primary or tertiary hyperparathyroidism and do develop symptoms, these are due to a high level of calcium in your blood (hypercalcaemia). They can include:

Tiredness Weak and easily tired muscles

Feeling sick (nausea), being sick (vomiting) and feeling off your food Constipation Tummy (abdominal) pain Feeling very thirsty and passing urine frequently Depression/low mood

In extreme cases, if left untreated, a high calcium level can lead to confusion, loss of consciousness, heart rhythm disturbances and, rarely, death. You may also have high blood pressure if you have hyperparathyroidism. It is unclear why this happens. If you have secondary hyperparathyroidism, your calcium level is not high but low, so you do not develop all of the symptoms described above. However, you can develop bone complications (see below) and the symptoms related to that.

Are there any complications of hyperparathyroidism?

Not everyone with hyperparathyroidism gets complications. However, sometimes complications may develop. If you have primary or tertiary hyperparathyroidism, these complications are mostly due to a long-standing high level of calcium in your blood. They can include:

Kidney stones. Small stones may be passed in the urine without you noticing. Larger stones may get stuck, causing pain in your loin area that radiates to your groin. You may also notice blood in your urine. See separate leaflet called Kidney Stones for further details. Corneal calcification. Calcium can collect (be deposited) in the cornea of your eye. This doesn't usually cause any symptoms. Pancreatitis. This is inflammation of your pancreas gland. Rarely, a high level of calcium due to hyperparathyroidism can cause pancreatitis. This can cause upper tummy (abdominal) pain. See separate leaflet called Acute Pancreatitis for further details. Stomach (peptic) ulceration. A high calcium level can stimulate the production of excess acid in your stomach and lead to stomach ulceration. See separate leaflet called Stomach (Gastric) Ulcer for more details. Kidney damage. A prolonged high calcium level in your blood can damage your kidneys and cause kidney failure.

In all types of hyperparathyroidism (including secondary hyperparathyroidism), the increased level of parathyroid hormone circulating in your blood causes high amounts of calcium to be released from your bones. This can cause weakness and thinning of your bones - a condition known as osteopenia. Your bones may become painful and more susceptible to breaks, or fractures.

How is hyperparathyroidism diagnosed?

Hyperparathyroidism is usually diagnosed after blood tests have shown a high level of calcium and a high level of parathyroid hormone. Usually, the level of phosphate in your blood is low.

If you have secondary hyperparathyroidism, your blood calcium level may be low or normal but you will still have a raised parathyroid hormone level. If you also have kidney disease, your blood phosphate level can be high because your kidney cannot get rid of (excrete) phosphate in your urine. Your doctor may have suggested these blood tests because you have one of the complications of hyperparathyroidism, such as kidney stones or pancreatitis. They may also have suggested that your blood calcium level be tested for another reason. For example, if you have symptoms of low mood, tiredness, constipation or feeling thirsty. These may be possible symptoms of a high blood calcium level caused by hyperparathyroidism. However, these symptoms can also occur for a number of other reasons.

Will I need any further investigations?

Once blood tests have shown that you have hyperparathyroidism, you doctor will usually want to confirm which type of hyperparathyroidism you have and to look for any cause. They may also want to look for any complications that you may have. You will usually be referred to a doctor who is a specialist for further tests. Investigations may include:

Further blood tests. These can include blood tests to check your kidney function, your pancreas gland, and your bones. Urine calcium level. You may be asked to collect your urine in a special container over a 24-hour period to measure the amount of calcium in your urine. You usually pass more calcium in your urine in hyperparathyroidism. DEXA scan. Because hyperparathyroidism can cause thinning of your bones (osteopenia), you may be referred for a special scan to assess your bone thickness. This is called a dual-energy X-ray absorptiometry (DEXA) scan. X-rays. These can show changes in your bones due to the increased release of calcium from them. Kidney ultrasound scan. This can show any kidney stones. Ultrasound, CT or technetium scan of your neck. These can show if you have an enlarged parathyroid gland or glands. A scan may be suggested if surgery is being considered as a treatment option (see below). Biopsy of a parathyroid gland. A biopsy of one of your parathyroid glands may be suggested. This is a sample that is taken from the gland, using a needle. It is usually carried out using scanning, such as ultrasound, to guide the doctor who is taking the biopsy. A biopsy may help to exclude parathyroid cancer (carcinoma).

What are the treatment options for hyperparathyroidism?

The treatment that you have depends on the type of hyperparathyroidism.

Primary hyperparathyroidism
There are some different options for treating primary hyperparathyroidism. These include:

Regular monitoring of your symptoms. If you have mild primary hyperparathyroidism, with a mildly raised calcium level and little in the way of symptoms, your doctor may just suggest that you be regularly monitored. The monitoring procedure usually includes blood tests to check your blood calcium level and kidney function, regular blood pressure checks and monitoring for any symptoms that you may have. It may also include dual-energy X-ray absorptiometry (DEXA) bone scanning as described above. This monitoring approach is considered controversial by some. You should discuss the pros and cons with your doctor. Surgery (parathyroidectomy). There are guidelines to help decide when someone with hyperparathyroidism should have surgery to remove the abnormal parathyroid gland or glands (parathyroidectomy). For example, if your hyperparathyroidism is more severe, your bones have become too thin, or you have carcinoma of your parathyroid glands, your doctor may suggest surgery. If you have a single overactive gland then just this is removed. However, if you have more than one overactive parathyroid gland, all abnormal glands need to be removed. If all four parathyroid glands are overactive, usually three and a half of the glands are removed so that you have some remaining parathyroid tissue. Your calcium level will need close monitoring after surgery to ensure that it returns to normal and does not drop too low. Drug treatment. This is used in people with more severe hyperparathyroidism who choose not to have surgery, or who do not meet the guidelines for surgery. Treatment aims to improve bone thickness (density) and correct your high calcium level. Various drugs may be used. These include a group of drugs called bisphosphonates. Another drug called cinacalcet can help to reduce calcium and parathyroid hormone levels and increase the phosphate level in your blood but it does not seem to improve bone density. Sometimes hormone replacement therapy may be suggested in postmenopausal women who also have menopausal symptoms that they wish treatment for.

Secondary hyperparathyroidism
If you develop secondary hyperparathyroidism, it should be treated early to prevent bone complications from developing and also to reduce the chance of tertiary hyperparathyroidism. The underlying condition that is causing secondary hyperparathyroidism needs to be treated; for example, treating vitamin D deficiency with vitamin D supplements. Chronic kidney disease is the most common cause of secondary hyperparathyroidism. Treatment in chronic kidney disease includes:

Treatment to lower your blood phosphate level. You can reduce your intake of phosphate by restricting the amount of milk, cheese, eggs and dairy products that you eat. You may also need some medication such as calcium carbonate. This binds to phosphate and helps to stop it being absorbed from your gut (small intestine) after you have eaten. Treatment to raise your calcium level. You will need to start supplements containing calcium and vitamin D in order to raise your blood calcium level. You need to take an 'active' form of vitamin D to allow calcium to be absorbed successfully from the food that you eat. Normally, vitamin D is converted to this 'active' form by the kidney. However, if you have kidney disease, this conversion cannot happen.

Cinacalet. This drug reduces the release of parathyroid hormone by the parathyroid glands. It is sometimes used if you have secondary hyperparathyroidism due to chronic kidney disease and other treatments have not been effective, and surgery is not an option for some reason.

Surgery to remove abnormal parathyroid glands may be considered if secondary hyperparathyroidism is severe and does not respond to medical treatment.

Tertiary hyperparathyroidism
The ideal situation is that tertiary hyperparathyroidism does not develop because secondary hyperparathyroidism is successfully treated. However, if it does develop, the treatment of tertiary hyperparathyroidism is usually surgery to remove the overactive parathyroid glands. Often, a small amount of one of the glands is transplanted into one of your forearms. This means that some remaining parathyroid gland tissue is left in your body to control calcium levels but it is easily accessible if further surgery is needed.

Possible complications after surgery

Complications after surgery to remove parathyroid glands are not very common. However, in some people, complications may occur. They include:

A low calcium level (hypocalcaemia). Sometimes after surgery, because your bones are 'hungry', calcium and phosphate can be rapidly taken up from your blood and deposited in your bones. This can lead to underactive parathyroid glands (hypoparathyroidism) and a low blood calcium level. The low blood calcium level goes back up to normal when your remaining normal parathyroid glands become sensitive again and can control your blood calcium level. However, sometimes hypoparathyroidism can persist and some people need long-term medication treatment with calcium and vitamin D supplements. Nerve damage in the neck. Damage to one of the nerves in your neck, called the recurrent laryngeal nerve, can sometimes occur during the operation. This can cause a cough and a hoarse voice. Bleeding. This can sometimes occur after surgery. Rarely, the blood can collect in your neck and put pressure on your airway, causing breathing difficulties. This needs quick treatment to remove the blood clot. Infection. After any type of surgery this is a possible complication. Persisting hyperparathyroidism. Occasionally, surgery is unsuccessful and hyperparathyroidism is not adequately treated.

What is the outlook (prognosis) for hyperparathyroidism?

In primary hyperparathyroidism, after successful surgery to remove the parathyroid glands (parathyroidectomy), the outlook is usually excellent and most people are cured. If you do not have symptoms and are followed up without surgery, there is also generally a good prognosis. Significant bone loss and other symptoms may be absent for many years when you are followed up. However, if you have secondary or tertiary hyperparathyroidism, the prognosis tends to be worse. This is because it is usually caused by underlying advanced chronic kidney failure.

Other advice
There are some things that you can do if you have hyperparathyroidism:

Make sure that you drink plenty of fluids and do not become dehydrated. Avoid taking certain medicines such as some 'water tablets' (diuretics). If you are already taking diuretics, you should discuss this with your doctor. If you are confined to your bed (for example, after an accident or illness) or if you have an illness causing you to be sick (vomit) or to have diarrhoea, this can cause your calcium levels to rise further. If you have hyperparathyroidism you should seek medical attention quickly in these situations.

Hypoparathyroidism
Hypoparathyroidism occurs when too little parathyroid hormone is released by the parathyroid glands, or the parathyroid hormone that is released does not work properly. Either leads to low levels of calcium in the blood, which can cause a number of different symptoms. The most common are muscle cramps, pain and twitching. Hypoparathyroidism can be successfully treated with calcium and vitamin D supplements but regular blood test monitoring is needed.

What is hypoparathyroidism?

The four parathyroid glands are small, pea-sized glands, located in the neck just behind the butterfly-shaped thyroid gland. Two parathyroid glands lie behind each wing of the thyroid gland. The parathyroid glands release a hormone called parathyroid hormone. This hormone helps to control the levels of two salts in the body: calcium and phosphorus.

Hypoparathyroidism occurs when either:

The parathyroid glands do not release enough parathyroid hormone, or The parathyroid hormone that is released does not work properly.

The resulting low level of active parathyroid hormone causes the calcium level in the blood to fall and the phosphate level to rise.

Why does the body need calcium and phosphorus?

Calcium and phosphorus combine to make calcium phosphate in the body. This is the main material that gives hardness and strength to bones and teeth. Calcium is also needed as part of the complex mechanism that helps blood to clot after an injury. It is also required for muscles and nerves to work properly. Phosphorus works with calcium to do these jobs. Phosphorus is also needed for the production of energy within the body.

Who gets hypoparathyroidism?

Hypoparathyroidism is rare. Men and women are equally likely to have the problem. The age that someone may develop hypoparathyroidism depends on its cause.

What causes hypoparathyroidism?

Hypoparathyroidism can be:

Acquired (something that develops in childhood or adult life). Transient (short-lived). Congenital (something that someone is born with). Inherited (passed on through your genes, from your relatives). Pseudohypoparathyroidism. Pseudo means false. In these cases, the illness seems to be hypoparathyroidism, but isn't. See below. Pseudopseudohypoparathyroidism. The common cause of acquired hypoparathyroidism is after surgery to the neck. For example, during surgery on the thyroid gland, the parathyroid glands may be accidentally damaged or removed. Sometimes the parathyroid glands are removed because of potential cancer, or as a treatment for overactive parathyroid glands. Radiotherapy treatment (because of a cancer in the neck or the chest) can damage the parathyroid glands and make them underactive. Certain medicines used in the treatment of cancers can do the same. The parathyroid glands can also become replaced and destroyed by cancer cells, spreading from cancer elsewhere in the body. This causes a reduction in parathyroid hormone release and hypoparathyroidism. Acquired hypoparathyroidism can also occur due to an acquired autoimmune condition. Auto-antibodies may start attacking the cells of the parathyroid glands and destroy them, as described below.

Acquired hypoparathyroidism

Transient hypoparathyroidism

This occurs most commonly in babies who are born prematurely (too soon). It can also occur in otherwise healthy babies born at the normal time. Parathyroid hormone is there in the glands but isn't released normally after the baby is born. It is eventually released and all returns to normal. Transient hypoparathyroidism can also affect babies of mothers who have diabetes, or babies born to mothers who have overactive parathyroid glands. DiGeorge's syndrome. This is a congenital condition - you are born with it. The parathyroid glands do not develop properly while the baby is growing in the womb. People with this syndrome have hypoparathyroidism. Also, their immune system does not work properly and they may have heart problems and a cleft palate (problems with the development of the roof of their mouth). Congenital hypoparathyroidism can also be one of a number of problems (a syndrome). One example is hypoparathyroidism that occurs with deafness and problems with kidney development. Most syndromes have unusual names. Hypoparathyroidism may be caused by an inherited autoimmune problem. Normally, our body makes antibodies to fight infections - for example, when we catch a cold or have a sore throat. These antibodies help to kill the cells of the bacteria, viruses or other germs causing the infection. In autoimmune diseases the body makes similar antibodies (auto-antibodies) that attack its normal cells. In autoimmune hypoparathyroidism, these auto-antibodies attack the cells of the parathyroid glands. Autoimmune hypoparathyroidism can exist alone, or as part of a syndrome including diabetes and thyroid gland disease. Inherited hypoparathyroidism can also be caused by inherited problems with the gene that is needed for the body to make parathyroid hormone. This means that the gene does not function properly which leads to a lack of parathyroid hormone.

Congenital hypoparathyroidism

Inherited hypoparathyroidism

Pseudohypoparathyroidism
This is a rare disorder that is inherited. Parathyroid hormone is present in the body but the body is unable to respond to it normally. There is a low calcium level in the blood. Affected people are short and have shortened bones in their feet and hands. They may also have diabetes and an underactive thyroid gland.

Pseudopseudohypoparathyroidism
This is when someone has the features of pseudohypoparathyroidism, as described above, but they have normal calcium and phosphate levels in the blood.

What are the symptoms of hypoparathyroidism?

People experience the different symptoms of hypoparathyroidism in different ways. The symptoms are largely due to the effects of low levels of calcium in the blood. Mild symptoms usually develop slowly and may be fleeting or they may require a small adjustment in medication (see below). Severe symptoms may come on rapidly and need urgent treatment. This may be with calcium given directly into the vein via a drip (intravenously).

Possible symptoms that may occur include:

Muscle pains. Abdominal (stomach) pains. Tingling, vibrating, burning or numbness of the fingers, toes or face. Twitching of the muscles of the face. Carpopedal spasm (contraction, or tightening, of the muscles of the hands and feet). Seizures. Fainting. Confusion. Memory problems. Tiredness. Eyesight problems. Headaches. Brittle nails. Dry skin and hair. Painful periods.

Are there any complications of hypoparathyroidism?

Any complications that may arise are largely due to the low levels of calcium in the body. Complications can include:

Kidney stones. Cataracts. Disturbance of the normal electrical activity of the heart. This can lead to irregularities in the heart rhythm which can in turn lead to collapse. Stunted growth, teeth problems and problems with mental development can occur if low calcium levels are not treated in childhood.

How is hypoparathyroidism diagnosed?

Physical examination
There are a number of things that your doctor may look for when they examine you:

They may tap in front of your ear with your mouth slightly open. If your calcium level is low because of hypoparathyroidism, this can cause repeated contraction (tightening) of the muscles in your face. This is called Chvostek's sign. Your doctor may also inflate a blood pressure cuff around the lower part of your arm. If your calcium level is low because of hypoparathyroidism, this can lead to carpopedal spasm, as described above. They may examine your eyes to look for cataracts which can be a complication of hypoparathyroidism. They may examine your muscle reflexes. This is a painless examination done by tapping the tendons of the muscles - for example, at the knee or the elbow. It is done using a special instrument called a tendon

hammer. If your calcium level is low due to hypoparathyroidism, these reflexes can be much more forceful than normal.

Blood tests
Blood tests can confirm hypoparathyroidism. In hypoparathyroidism, your blood calcium level is low, your blood phosphate level is high, and your parathyroid hormone level is low. If your doctor suspects that your hypoparathyroidism is caused by an autoimmune process, they may suggest some other blood tests. For example, they may want to look at your thyroid gland to check that this is not also affected.

Other possible investigations

Your doctor may suggest some other tests to look for the cause of your hypoparathyroidism. For example:

Hand X-rays - to look for the shortened bones seen in pseudohypoparathyroidism. Echocardiogram (an ultrasound scan of the heart) - to look for heart abnormalities associated with DiGeorge's syndrome. Genetic studies - special blood tests can be performed if your doctor suspects that you have an inherited cause for your hypoparathyroidism.

What are the aims of treatment?

The aims of treatment are to ensure that there is an adequate level of calcium in the bloodstream. This should mean that you will not have symptoms associated with low calcium levels.

What are the treatment options?

Calcium and vitamin D supplements
Hypoparathyroidism is treated with calcium and vitamin D supplements taken by mouth. Vitamin D supplements are needed because vitamin D also helps to regulate calcium levels. It stimulates the release of calcium from bone and helps calcium to be absorbed from the gut and the kidneys. Regular blood tests are needed to ensure that you are taking enough calcium and vitamin D. Closer monitoring is needed during pregnancy, if you are also taking other medicines, or if you also have another illness. Treatment is usually lifelong. These are not dietary supplements that you can buy over-the-counter, but stronger medication requiring careful monitoring by your doctor.

Intravenous calcium
If you have severe symptoms, you may need calcium given directly into your vein via a drip (intravenously).

Diet
A diet rich in calcium and vitamin D is also recommended.

Other treatments
There are other possible treatments for hypoparathyroidism. For example, if you have surgery to remove your thyroid gland, one of the parathyroid glands may be transplanted (or moved) and re-sited in the neck or the arm. This means that it can continue to release parathyroid hormone. There have also been trials carried out where people with hypoparathyroidism have been given parathyroid hormone that has been made synthetically. However, synthetic parathyroid hormone is not currently licensed to treat people with hypoparathyroidism in the UK.

What is the outlook?

If hypoparathyroidism is adequately treated with calcium and vitamin D, the prognosis is good. However, this relies on you taking medication daily for life. You also need to have regular blood tests so that the dose of your medication can be carefully adjusted as needed.

Can hypoparathyroidism be prevented?

During thyroid or neck surgery, the surgeon must identify the parathyroid glands and avoid damaging them if possible. Anybody who is undergoing thyroid or neck surgery, radiotherapy to the neck or the chest, or chemotherapy (a treatment for cancer) should be monitored for symptoms and signs of low calcium levels.

Another point about hypoparathyroidism

You should consider wearing a MedicAlert bracelet (or similar), or carry some kind of ID with you, to identify yourself as having hypoparathyroidism. This is so that if you collapse, are confused or are found unconscious, doctors will know that you need prompt treatment with calcium.

What are the thyroid and parathyroid glands?

Both the thyroid and parathyroid glands are endocrine glands. This means they make and secrete (release) hormones. Hormones are chemicals which can be released into the bloodstream. They act as messengers, affecting cells and tissues in distant parts of your body. Thyroid hormones affect the body's metabolic rate and the levels of certain minerals in the blood. The hormone produced by the parathyroid also helps to control the amount of these essential minerals.

Where is the thyroid found?

The thyroid gland is found in the front part of your neck, just below the large cartilage tissue in your neck (your Adam's apple). It is made up of two lobes - the right and the left lobes. These two lobes are joined by a small bridge of thyroid tissue called the isthmus. The two lobes lie on either side of your trachea (windpipe).

What does the thyroid do?

The thyroid makes three hormones that it secretes into the bloodstream. Two of these hormones, called thyroxine (T4) and triiodothyronine (T3), increase your body's metabolic rate. Essentially, the body's metabolic rate is how quickly the cells in your body use the energy stored within them. Thyroid hormones make cells use more energy. By controlling how much energy our cells use, thyroid hormones also help to regulate our body temperature. Heat is released when energy is used, increasing our body temperature. Thyroid hormones also play a role in making proteins, the building blocks of the body's cells. They also increase the use of the body's fat and glucose stores. In order to make T3 and T4, the thyroid gland needs iodine, a substance found in the food we eat.

T4 is called this because it contains four atoms of iodine. T3 contains three atoms of iodine. In the cells and tissues of the body most T4 is converted to T3. T3 is the more active hormone, it influences the activity of all the cells and tissues of your body. The other hormone that the thyroid makes is called calcitonin. This helps to control the levels of calcium and phosphorus in the blood. These minerals are needed, among other things, to keep bones strong and healthy.

How does the thyroid work?

The main job of the thyroid gland is to produce hormones T4 and T3. To do this the thyroid gland has to take a form of iodine from the bloodstream into the thyroid gland itself. This substance then undergoes a number of different chemical reactions which result in the production of T3 and T4. The activity of the thyroid is controlled by hormones produced by two parts of the brain, the hypothalamus and the pituitary. The hypothalamus receives input from the body about the state of many different bodily functions. When the hypothalamus senses that levels of T3 and T4 are low, or that the body's metabolic rate is low, it releases a hormone called thyrotropin-releasing hormone (TRH). TRH travels to the pituitary via the connecting blood vessels. TRH stimulates the pituitary to secrete thyroid-stimulating hormone (TSH).

TSH is released from the pituitary into the bloodstream and travels to the thyroid gland. Here, TSH causes cells within the thyroid to make more T3 and T4. T3 and T4 are then released into the bloodstream where they increase metabolic activity in the body's cells. High levels of T3 stop the hypothalamus and pituitary from secreting more of their hormones. In turn this stops the thyroid producing T3 and T4. This system ensures that T3 and T4 should only be made when their levels are too low.

Calcitonin is released by the thyroid gland if the amount of calcium in the bloodstream is high. Calcitonin decreases the amount of calcium and phosphorus in the blood. It does this by slowing the activity of cells found in bone, called osteoclasts. These cells cause calcium to be released as they 'clean' bone. Calcitonin also accelerates the amount of calcium and phosphorus taken up by bone. Calcitonin works with parathyroid hormone to regulate calcium levels (see below for full explanation).

Where are the parathyroid glands found?

The body has four parathyroid glands. They are small, pea-sized glands, located in the neck just behind the butterfly-shaped thyroid gland. Two parathyroid glands lie behind each 'wing' of the thyroid gland.

What do the parathyroid glands do?

The parathyroid glands release a hormone called parathyroid hormone. This hormone helps to control the levels of three minerals in the body: calcium, phosphorus and magnesium. Parathyroid hormone has a number of effects in the body:

It causes the release of calcium from bones. It causes calcium to be absorbed (taken up into the blood) from the intestine. It stops the kidneys from excreting (getting rid of) calcium in the urine. It causes the kidneys to excrete phosphate in the urine. It increases blood levels of magnesium.

How do the parathyroids work?

Normally, parathyroid hormone release is triggered when the level of calcium in the blood is low. When the calcium level rises and is back to normal, the release of parathyroid hormone from the parathyroids is suppressed. However, parathyroid hormone and calcitonin work together to control calcium levels in the blood. The blood calcium level is the main stimulus for the release of these hormones, as the release of these hormones is not controlled by the pituitary. When the calcium level is high in the bloodstream, the thyroid gland releases calcitonin. Calcitonin slows down the activity of the osteoclasts found in bone. This decreases blood calcium levels. When calcium levels decrease, this stimulates the parathyroid gland to release parathyroid hormone. Parathyroid hormone encourages the normal process of bone breakdown (essential for maintenance and growth of the bone). This process of bone breakdown releases calcium into the bloodstream. These actions raise calcium levels and counteract the effects of calcitonin. By having two hormones with opposing actions, the level of calcium in the blood can be carefully regulated. Parathyroid hormone also acts on the kidneys. Here it slows down the amount of calcium and magnesium filtered from the blood into the urine. Parathyroid hormone also stimulates the kidneys to make calcitriol, the active form of vitamin D. Calcitriol helps to increase the amount of calcium, magnesium and phosphorus absorbed from your intestines (guts) into the blood.