Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Parathyroid Glands
Parathyroid Glands are small glands located behind the thyroid gland and at the bottom of our neck. They are four in number and are part of the endocrine system. Sometimes they may be located along the food pipe (esophagus) or in the chest, a condition called ectopic parathyroid glands (parathyroid glands located in an abnormal place other than where they need to be).
They produce the hormone ‘parathyroid hormone’. Parathyroid Hormone regulates the levels of calcium and phosphorus in the blood. It also maintains the balance of calcium in the bloodstream and also in the tissues which are dependent on calcium for their proper functioning. It also controls the levels of vitamin D in the blood and bones. This is mainly important for functions of nerves and muscles and also for bone health.
Less production of parathyroid hormone (PTH) causes low amounts of calcium in the blood (hypocalcemia). On the other hand, too much parathyroid hormone causes high amounts of calcium in the bloodstream (hypercalcemia).
Hypoparathyroidism
Hypoparathyroidism is a condition marked by low levels of parathyroid hormones in the blood. This condition causes low levels of calcium in the blood. It is caused by damage to the parathyroid glands. It can also be caused by certain autoimmune and genetic diseases. It is a rare but treatable condition. On the other hand it is a chronic condition but can also be a temporary one.
Hypoparathyroidism also happens when the parathyroid glands are removed surgically or when the body is resistant to PTH (parathyroid hormone). Hypoparathyroidism can also be hereditary.
Events causing hypoparathyroidism (pathogenesis)
Damage to parathyroid glands or effect of certain diseases of autoimmune and genetic origin
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Low levels of parathyroid hormone in the blood
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Low levels of calcium (hypocalcemia) & high levels of phosphorus in the blood
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Hypoparathyroidism
Hypoparathyroidism and Hypocalcemia
Hypocalcemia (low levels of calcium in the bloodstream) is an important event which occurs in hypoparathyroidism and is caused due to low levels of parathyroid hormone in the blood. Hypocalcemia can affect the body’s ability to perform important functions like – nerve functions, muscle contractions leading to movements of your body, clotting of blood (in case of bleeding) and proper functioning of the heart. The human body needs a good and balanced quantity of calcium in the bones to make and keep them strong. Hypocalcemia occurs when there are low levels of calcium in the blood and not in the bones.
Hypoparathyroidism and electrolyte imbalance
Electrolyte imbalance is caused by hypoparathyroidism and is marked by –
– low levels of blood calcium and
– high levels of blood phosphorus
Note – Calcium and Phosphorus are the important body electrolytes.
Therefore the goal of treating hypoparathyroidism will be to bring back the blood calcium and phosphorus levels to normal.
Parathyroid glands need another important electrolyte – magnesium for proper functioning. Therefore low levels of magnesium can also cause hypoparathyroidism.
Whom does hypoparathyroidism affect?
Hypoparathyroidism affects both children and adults. Damage to the parathyroid glands following neck or thyroid surgery is the more likely cause for occurrence of hypoparathyroidism in adults. In children hypoparathyroidism usually occurs due to Di George Syndrome – a genetic condition. It is a rare condition and is found to affect fewer than 2 lakh people in the United States.
Causes of Hypoparathyroidism
Damage to parathyroid glands
Accidental damage to the parathyroid glands from thyroid or neck surgery contributes to about 75% of hypoparathyroidism cases. Though hypoparathyroidism is more likely to develop immediately after surgery, it can also occur years to decades after thyroid or neck surgery. Most of the time these cases are temporary but on the other hand some are chronic in nature.
Extensive cancer radiation treatment
Though rare, radiation therapy can also damage these glands. Radiation treatment of the neck or face can result in destruction of parathyroid glands. In rare cases, treatment for hyperthyroidism with radioactive iodine may lead to hypoparathyroidism.
Genetic conditions
Certain genetic conditions cause hypoparathyroidism. Genetic causes contribute to fewer than 10% of all cases of hypoparathyroidism. A chromosomal genetic condition named ‘Di George Syndrome’ is the most genetic cause for hypoparathyroidism. The parathyroid glands are absent in the babies born with ‘Di Syndrome’. The body cannot make parathyroid hormone without parathyroid glands. So, people with this syndrome will have chronic hypoparathyroidism. Di Syndrome contributes to about 60% of hypoparathyroidism cases occurring in children. Hypoparathyroidism is also caused by other genetic syndromes that are associated with kidney disease and deafness.
Autoimmune diseases
Certain autoimmune diseases also cause hypoparathyroidism. Chronic Hypoparathyroidism occurs when an autoimmune disease called ‘Type 1 autoimmune poly-glandular syndrome’ causes one’s immune system to attack the parathyroid glands. The other diseases which can also cause hypoparathyroidism are Addison’s disease and Pernicious Anemia.
Low levels of Magnesium
As already discussed hypomagnesemia (low magnesium levels) can cause hypoparathyroidism. This type of hypoparathyroidism will go away when magnesium is restored to appropriate levels. Therefore this condition is called ‘functional hypoparathyroidism’.
Infiltrative Disorders
The parathyroid glands can be infiltrated by –
– iron as in hemochromatosis
– copper as in Wilson disease
– certain cancer metastases
Hypoparathyroidism can be caused by either of these situations.
Triggers
Hypothyroidism can be triggered by many things which include
– Injury to the glands during surgery
– Removal of glands during surgery
– Radiation therapy done over your head or neck
– Genetic disorders
– Autoimmune disorders
– Low levels of magnesium
The triggers are also the same as the causes of hypoparathyroidism.
Signs and Symptoms of Hypoparathyroidism
Hypoparathyroidism, in most cases, is a gradually progressing condition and can cause mild symptoms. Many times the diagnosis is late. People would have symptoms of hypoparathyroidism for many years before it is diagnosed. Many times symptoms of hypocalcemia (low blood calcium) are the symptoms of hypoparathyroidism.
Below mentioned are the signs and symptoms of Hypoparathyroidism –
– Muscle cramps
– Tingling in the fingers, toes and lips
– Tetany (muscle spasms), spasms in legs, feet, lower back or face
– Seizures
– Low blood pressure
– Confusion / brain fog
– Anxiety
– Depression
– Arrhythmia (abnormal heart rhythm)
– Heart failure
– Pain in the abdomen
– Dry, scaly skin
– Painful menstrual periods
Long term effects of low calcium include –
– Cataracts
– Dental problems
– Weak tooth enamel
– Bone disease
– Hair loss / dry hairs
– Brittle nails
– Movement disorders like tremors
Risk Factors of Hypoparathyroidism
Below mentioned are the risk factors of hypoparathyroidism –
– having undergone recent neck or thyroid surgery
– having a family history (of parathyroid conditions, hypoparathyroidism)
– having certain autoimmune diseases (like Addison’s disease)
Outlook (prognosis) of Hypoparathyroidism
If hypoparathyroidism is diagnosed early, the prognosis is good. A person having cataracts, brain calcifications and / or dental changes as a part of complications of hypoparathyroidism, cannot be reversed.
Most cases of hypoparathyroidism are chronic. Sometimes it can also be a temporary case.
Complications of Hypoparathyroidism
Below mentioned are the long term complications of hypoparathyroidism –
– kidney stones
– problems in kidney functions
– calcium deposits in the brain
– cataract
Specific complications in children with hypoparathyroidism –
– poor growth
– slow mental development
– dental issues
Complications of untreated hypoparathyroidism (due to sudden and severe hypocalcemia) –
– seizures
– spasms of larynx leading to breathing difficulties
Complications of hypoparathyroidism alert an individual to see the doctor as soon as possible.
Hypoparathyroidism can cause both reversible and irreversible complications.
- Reversible Complications
These are usually the complications caused due to low calcium levels that may improve with treatment. They include –
– Cramp like spasms of hands and fingers
– Muscle pain and twitches / spasms of muscles of face, throat or arms – muscle spasms of throat may cause breathing troubles which might be a possible clinical emergency
– Seizures
– Tingling or burning sensation – the person would experience feeling of pins and needles in the toes, fingers, tongue and lips
– Problems with kidney function (kidney stones, kidney failure)
– Cardiac arrhythmias, heart failure
– Fainting
- Irreversible Complications
– Poor growth
– Hardening of bones
– Changes in the shape of bones
– Delayed mental development in children
– Cataracts leading to clouded vision
– Deposit of calcium in the brain leading to seizures, movement disorders and problems related to balance
– Teeth do not form properly, dental roots and enamel are affected
What is the right time to see the doctor?
You need to see your doctor –
– when you experience symptoms of the disease
– to monitor blood calcium levels and make sure that the treatment is working in a proper way (if you are already diagnosed with hypoparathyroidism)
– in presence of acute hypocalcemia symptoms (painful muscle cramps, seizures etc)
One should see their doctor or healthcare provider immediately for an evaluation if he or she has signs and symptoms associated with hypoparathyroidism especially if seizure or difficulty in breathing is present. These two symptoms can complicate the picture of hypoparathyroidism.
Diagnosis of Hypoparathyroidism
Low levels of calcium and parathyroid hormone in the bloodstream generally help in diagnosing hypoparathyroidism.
Symptoms of hypoparathyroidism too may help the healthcare providers to diagnose this condition but the symptoms are often mild. Hypoparathyroidism, therefore, is most often an ‘accidental diagnosis’ and is done when low levels of calcium are found in the blood during a routine blood screening.
Chronic Hypoparathyroidism is diagnosed when one has low blood levels of calcium and parathyroid hormone at least twice within six months.
Tests recommended for diagnosing hypoparathyroidism
The physician may perform a thorough physical exam along with interrogation to elicit the symptoms following a complete medical history in patients experiencing symptoms of hypoparathyroidism.
One or more of the below mentioned tests may be recommended for diagnosing hypoparathyroidism –
– PTH (parathyroid) blood test
– Blood calcium
– Blood phosphorus
– Blood magnesium
– 24 hour urine test
An ECG or EKG or a CT scan would help to check (identify) more serious side effects of hypoparathyroidism like an abnormal heart rhythm (using ECG or EKG) or calcium deposits in the brain (with the help of CT scan).
Urine test – By its action on kidneys, PTH prevents too much loss of calcium from urine. Urine tests will show if the body is losing too much calcium.
Prevention of Hypoparathyroidism
There are no specific preventive measures for hypoparathyroidism. Below mentioned may be some of the precautionary / preventive measures.
Precautionary tests and supplements – If thyroid or neck surgery is planned for you, your doctor may check for your calcium, vitamin D and parathyroid hormone levels and put you on supplements before surgery, if they are needed.
Auto-transplantation – To minimize the chances of post-operative hypoparathyroidism, parathyroid auto-transplantation may be advised as an option. There is no rule that the transplanted parathyroid tissue (transplanted to another part of the body, like chest muscle, arm etc) should always function.
Watch – The person who has had the surgery or radiation involving the neck or thyroid, he or she should watch out for signs and symptoms of hypoparathyroidism and if they are experienced the physician may recommend treatment including calcium and vitamin D. These measures would minimize the effects of hypoparathyroidism.
Self Care in Hypoparathyroidism
One can manage hypoparathyroidism by making a few simple changes in lifestyle. Similarly one needs to seriously look at foods to include and those which need to be excluded from their food regimen. These also can be considered as tips for prevention of recurrence of the disease and its symptoms. Below mentioned are some effective tips for effective management of hypoparathyroidism.
Hydration – Drinking plenty of water not only keeps one hydrated but will also help in flushing out the extra calcium from the system. One should drink at least 6-8 glasses each day.
Regular exercise – Regular physical exercises / activities help in strengthening the bones and will help in warding off the fractures.
Monitoring the food – Calcium rich and low phosphorus foods should be eaten. Calcium rich foods include dairy products, beans, nuts (mainly almonds), dark leafy vegetables, broccoli, tofu etc. It is better to get the required amount of calcium from foods instead of supplements. Some juices, cereals and breads also have calcium added to them. One should also avoid foods rich (high) in phosphorus. These include processed foods, red meat, poultry, dairy, fish, nuts, hard cheese, fizzy drinks, whole grains like oats, bread and rice and some vegetables. One also needs to know that certain foods are rich in both phosphorus and calcium. One needs to plan the foods with the help of their physician or nutritionist.
Taking supplements – Those having hypoparathyroidism might be recommended with calcium or vitamin D supplements. Vitamin D helps the body to get more calcium from food and also to get rid of phosphorus. If one has low levels of magnesium, magnesium supplements may also be recommended to be taken.
Keep in touch with the doctor – One needs to keep in sync with their doctor or healthcare provider and keep them intimated since hypoparathyroidism might affect the whole body, especially their kidneys and bones. Doctors may recommend regular blood tests and bone density scans to keep an eye on these organs. Calcium deficiency would hurt the teeth and hence it is also essential to keep a dentist in the loop.
If one does not take daily supplements and does not keep a watch on their diet, the condition would become dangerous. Taking enough calcium and vitamin D and getting regular blood checks would keep hypoparathyroidism and its symptoms under control.
Management and Treatment of Hypoparathyroidism
Goals of treatment –
– to minimize the symptoms of the disease
– to correct the amount of calcium and minerals in your body and to bring them back to appropriate levels
Treatment of hypoparathyroidism includes –
Taking calcium carbonate and vitamin D supplements – many times these need to be taken for life. Vitamin D is needed for absorption and utilization of calcium by the body. So patients of hypoparathyroidism should take both supplements. Oral Calcium supplements can be taken in the form of tablets, chews or liquid. High doses are not good and might cause constipation or digestive side effects in some people. Vitamin D when given in high doses can help the body to absorb calcium and eliminate phosphorus. Vitamin D is generally given in the form of calcitriol.
Magnesium supplements – In hypoparathyroidism patients having low levels of magnesium, magnesium supplements are given especially so if symptoms of the disease are evitable.
High calcium and Low phosphorus diet – since regular diet alone would not provide enough calcium, people with hypoparathyroidism may be recommended to eat a diet rich in calcium. High calcium foods such as low fat dairy products, dark green vegetables and foods like some kinds of cereals and orange juices added with calcium shall be consumed. Similarly foods low in phosphorous content should be taken. Phosphate rich foods like soda and fizzy drinks shall be avoided. These foods can pull calcium from the bones.
Parathyroid hormone replacement (injections of PTH) – Parathyroid hormone is prescribed for low blood calcium due to hypoparathyroidism. This is a once-daily injection. It may be recommended to be taken only if taking calcium and vitamin D supplements are not working to treat hypoparathyroidism. This drug is available only through a restricted program since it has potential risk of osteosarcoma.
Thiazide diuretics are prescribed if urine has high levels of calcium or if calcium levels are low in spite of giving proper treatment.
Side effects of treatment – Hypercalcemia is one side effect of hypoparathyroidism treatment caused by too much intake of vitamin D and calcium. This can prove harmful to health. osteosarcoma – a type of bone cancer may be caused by long term use of parathyroid hormone injections.
Diet
Your dietician or doctor might advise you to take foods rich in calcium (dairy products, green leafy vegetables, broccoli, foods fortified with calcium), and low in phosphorus (carbonated soft drinks, processed foods, meats, hard cheese, nuts and whole grains).
Intravenous infusion
Intravenous calcium is given in a hospital set up when immediate symptomatic relief is desired. Along with this oral vitamin D tablets are given. At discharge the patient is advised to continue taking calcium and vitamin D tablets.
Monitoring – the levels of calcium and phosphorus is regularly done through blood checkups. Initially weekly or monthly tests are done. Later one will need blood tests at least twice a year. This will help in adjusting the supplemental calcium doses in case the blood calcium levels fall or rise.
Testing and treatment for hypoparathyroidism is often life long since it is a long lasting disorder.
Research works related to Hypoparathyroidism
Study – If calcium supplementation is always needed in hypoparathyroid patients?
Study – Showing ‘Effects of Parathyroid Hormone Administration on Bone Strength in Hypoparathyroidism”
The HDR Syndrome – “Syndrome of Familial Hypoparathyroidism, Sensorineural Deafness and Renal Dysplasia”
Many such studies about Hypoparathyroidism can be found to read HERE!
Ayurveda Understanding of Hypoparathyroidism
There is no exact explanation of any condition in Ayurveda treatises which can be closely correlated with hypoparathyroidism. But considering all the perspectives of hypoparathyroidism and putting them in line with the basics and concepts of Ayurveda we can draw some theories and hypothetically discuss some conditions in close comparison to the said condition. This will help us to understand hypoparathyroidism from an Ayurveda perspective. This understanding will further help us to formulate proper Ayurveda treatment plans to treat Hypoparathyroidism.
Related Reading – Hypoparathyroidism – Ayurveda Perspective
