Recently, I interviewed Dr. Deva Boone, and we talked about how the parathyroid glands regulate calcium levels in your bloodstream, the role of calcium in the body, and more. If you would prefer to listen to the interview you can access it by Clicking Here.
Dr. Eric Osansky:
I am very excited to chat with Dr. Deva Boone, who is one of the most experienced parathyroid surgeons in the United States. Obviously, we are going to be chatting about the parathyroid glands, and we will talk about Vitamin D.
Dr. Deva was the medical director and senior surgeon at the Norman Parathyroid Center until 2020 when she left to open the Southwest Parathyroid Center, located in Phoenix, Arizona. Thank you so much for joining us, Dr. Deva.
Dr. Deva Boone:
Hi! Yes, thank you for having me.
Dr. Eric:
Really excited to talk with you about the parathyroid glands. Can you give a brief background? How did you decide that you were going to focus on the parathyroid glands? Was it something that you knew when you were in medical school or upon graduating? Did you have a personal experience?
Dr. Deva:
It wasn’t really that. I went to medical school not even knowing I was going to be a surgeon. I thought I was going to be a neurologist. During my rotations in my third year of medical school, I really enjoyed surgery and decided to do general surgery. I didn’t really decide on parathyroids until the end of that residency.
I really liked endocrine surgeons. I did a fellowship in endocrine surgery. Then I went down to Tampa to work with the Norman Parathyroid Center because they do just parathyroid surgery. I was really impressed with the set-up they had and the way they did the operation. I decided to focus on that forever.
It is a really nice operation because you can really help a lot of people. A lot of people feel pretty bad beforehand, and they feel much better afterwards on average. It’s pretty satisfying to be able to help people with this operation.
Dr. Eric:
For those who are not familiar with the parathyroid glands, can you explain the function of them?
Dr. Deva:
Sure. The parathyroid glands are the forgotten cousin of the endocrine glands. A lot of people don’t know about them. They are right next to the thyroid. Your thyroid is this butterfly-shaped gland at the base of the neck. The parathyroid glands sound like thyroid because they have thyroid in the name, but that comes from the fact that they are right next to the thyroid. When they were discovered, we didn’t know what they were, so they were called “para,” next to, the thyroid.
There are four parathyroid glands. They are typically right around the thyroid, two on each side. They exist solely to regulate your calcium. If you think about it, there aren’t any minerals in your body that have a whole organ dedicated to them. They just regulate calcium.
It’s also the only thing that you have four of. They are pretty cool. They are tiny. They are about the size of a grain of rice, each one of them. But they are really important because they regulate your calcium.
Dr. Eric:
Why do you need a separate gland to regulate calcium?
Dr. Deva:
When most people think about calcium, they think about bones. The Got Mlk? billboards. Calcium is really important for your bones. That is the main storage location of calcium in your body. Calcium is what makes your bones hard.
But the reason the parathyroid glands exist is really not to regulate your bone calcium, but the blood calcium. That actually is really important in itself. Your brain, your muscles, all your nerves depend on having a set level of calcium in order to function properly. For your muscles to contract properly, for your brain to have correct signaling, you actually use calcium during all of those processes. Calcium is necessary for that reason.
It’s necessary even in other areas where the electrical signaling is important, like your heart. When your heart beats, there is an electric signal going through it. Calcium is necessary for that. It’s necessary for blood clotting.
For all of these reasons, your calcium in your blood is kept in a very tight range. Sometimes, other things can vary, but your calcium typically doesn’t vary that much because your parathyroids are keeping it in a tight range, so your brain and nervous system can all function properly.
Dr. Eric:
You don’t want calcium to be too low or too high. That goes with any nutrient. When people focus on any mineral or nutrient, they are probably more concerned about deficiencies. They’re concerned about low calcium, which could be a factor in osteoporosis. What you see a lot in your practice is the opposite, elevated calcium levels.
Dr. Deva:
Yes. It’s interesting because low calcium is a problem, but what I see a lot more of is high calcium because I treat primary hyperparathyroidism. When the parathyroids have a problem, typically it’s not a deficiency of PTH, it’s that they have too much parathyroid hormone. The parathyroid glands are pretty simple. They make one hormone called PTH, parathyroid hormone. PTH is just regulating calcium, and phosphorous, but that’s a separate issue. You can think of it as doing one thing with one hormone.
When you have a really low calcium level, and this is important to understand, this thermostat concept. Your parathyroid glands’ job in life is to get that calcium up. They sense that. If you set your thermostat to 68 degrees, and it’s starting to go below that, your thermostat will sense that, and the heat comes on. It brings the temperature back up to 68, and the heating can turn back off.
When that happens in your body, when the calcium level drops too low, the parathyroids turn on, make more hormone. The hormone then raises the calcium by doing a few things, like taking calcium out of your bones to put it in the blood. As the calcium rises and goes back up to the normal range, the parathyroids can turn off and make less hormone.
If the calcium level goes too high for any reason, the parathyroids turn off. Just like if your temperature went up to 90, your heating should turn off. Your parathyroids are regulating things throughout the day.
I do sometimes see people with low calcium because for whatever reason, they have a problem getting calcium. If they have issues with chronic diarrhea or any problem with absorption from a gastric bypass, that kind of thing, they can have problems keeping their calcium up.
When you have a problem with the parathyroids, typically you see a high calcium level. That is because when you have a parathyroid problem, most of the time, it’s due to a small, benign tumor in the gland. That tumor is acting inappropriately, meaning it’s making hormone even though it shouldn’t. That means that PTH continues to dump out and raise the calcium level. You end up with these high calcium levels.
Most people, when they see that, they actually think it’s a good thing. They look at their labs and are looking for deficiencies. If they see their potassium is low, they clue into that. If they see their Vitamin D is low, they clue into that. If they see their calcium is low, they might worry about that. If they see it’s a little high, they think that’s probably good for their bones to have more calcium because they have been taught that they should take calcium for their bones. If their calcium is on the high side, that must be a great thing. They don’t realize that’s as much a problem as having low calcium, possibly more.
You really want to pay attention to keeping that calcium in range, not letting it get too low or too high. Your brain, nerves, muscles all want that calcium to be in a certain range. Anywhere outside of that range will cause problems.
Dr. Eric:
It’s a negative feedback mechanism, similar to thyroid. If you have low thyroid hormone, you have TSH, thyroid stimulating hormone, signaling to the thyroid to produce more thyroid hormone. Under normal circumstances, if serum calcium was low, you’d want to see the PTH high, signaling for the parathyroids to increase the calcium levels, correct?
Dr. Deva:
Right. The parathyroids do that through a couple of ways. One of the ways they get the calcium up is PTH actually stimulates the bones to release calcium. That is how patients with these parathyroid tumors get osteoporosis. You see that your calcium is high, but actually, your bones don’t have enough calcium. You see your bone density dropping. That is connected. The reason your calcium in your blood is high because it’s coming out of your bones. It wants to go back in. That is part of primary hyperparathyroidism, or having too much PTH.
Dr. Eric:
How common is primary hyperparathyroidism?
Dr. Deva:
Unfortunately, it’s more common than most people realize. A lot of people don’t even know what the parathyroids are. They don’t know what they do.
Just to get to exactly how many, it’s hard to say. It does increase as you get older. It is more common in women. Probably even up to 1% of women over the age of 50 will get this. It’s most common in post-menopausal women. Having said that, I have had teenage boys with this, so it doesn’t mean that you can’t get it if you’re younger. There are a lot of people who get it younger and as men. About 75% of the patients are women, and the average age is probably about 60.
I think that gets into why the disease is underdiagnosed. If you think about it, it tends to happen in women who are around the age of menopause. A lot of the symptoms tend to get blamed on that. If you’ve gone through menopause in the last 10 years, and you start to tell your doctor that you’re tired and can’t sleep at night, the immediate thing is not to check your calcium, but to respond with, “This is probably menopause.” That is partly why the disease gets overlooked a little bit.
Another reason is that our labs give a very broad range for calcium. If you get your labs, and I encourage everybody to get their own labs, get the results, keep them for yourself in a file, so you have them and can review them. If you look at your labs, a lot of times, what you’re doing and what your doctor is doing is scanning down for anything that’s abnormal. They put an abnormal note or make it red. Often, you get so many labs that you’re just looking for that.
With calcium unfortunately, a lot of the labs give a range that is both too far on the low end and on the high end. It will say 8.5-10.5 is normal. Really, it’s more like 9.2-9.9 is the normal range. 10.0 can be normal. Once you get further in age, your calcium level shouldn’t be in the 10s. The labs don’t adjust for that. You end up sometimes with people who have had high calcium for years, but it didn’t register until the calcium went to 11. That’s part of the reason why.
I also think a big part is that a lot of patients are having these symptoms that are non-specific, and they go to their doctor, and it’s blamed on age or menopause.
Dr. Eric:
Can you talk more about the ranges? You mentioned that as we get older, you shouldn’t have a calcium level that’s higher. The serum calcium should decrease as you get older?
Dr. Deva:
Yeah. Children actually can have pretty high calcium levels. Their calcium levels, and this is in U.S. ranges, mg/dl. Their calcium levels are often in the 10s, even up to 11. Then it drops as you get older. In your 20s, a lot of people will have calcium levels in their 9s or 10s. In your 30s, maybe you can have some calcium levels in the low 10s, but it drops with time. By the time you get to age 40, most of your calcium levels should be in that 9s range. As I said, mid- to high 9s. 9.2/9.3-10.0. If you’re outside that range, usually it indicates a problem.
Dr. Eric:
If it’s above 10, especially above age 40-
Dr. Deva:
Or 10.0. It does get tighter as you get older. If I see a 40-year-old with a 10.1, I want to check things out. That’s not definitive yet. If I see an 80-year-old with a 10.1, and they have a PTH that is either normal or high, that is primary hyperparathyroidism.
There is no clear cutoff with the age thing. It’s not like you wake up at 40 with a different calcium level. It slowly happens over time, and everybody is a little different. In general, if you’re 60 years old, all your calcium levels should be 10.0 or under. You don’t want it too low, but you don’t want it to go above 10.0.
Dr. Eric:
If you see it above 10.0, as you mentioned, then you order a PTH test to see if that is elevated. If that’s elevated, then that’s typically indicating hyperparathyroidism.
Dr. Deva:
That’s the most common scenario, high calcium and high PTH. Interestingly, you don’t need the high PTH. That is why I went over the thermostat analogy. Think for a second: If your house is 90 degrees, and your heating is on low, but it’s still on, that’s a problem. Your thermostat clearly is not sensing that it’s 90 degrees. It should have kicked in, and the heating should be off.
It’s like that with parathyroid glands. If you have a calcium of 11, and your PTH is in the normal range, that’s an inappropriate response. Your parathyroid glands should turn off. All of your normal parathyroid glands are turning off. You’ll have a very low PTH level if something else is causing the high calcium. If you have a PTH that is normal range with a high calcium, that is usually primary hyperparathyroidism.
Dr. Eric:
We were chatting a little bit before. A lot of people who are listening to this have hyperthyroidism, be it Graves’ or toxic multinodular goiter. Some people with hyperthyroidism will have an elevated serum calcium as well. The way to know if it’s related to the thyroid or if it’s hyperparathyroidism is what you just said. If someone has hyperthyroidism, their serum calcium is 10.2, so you look at PTH and see if it’s elevated or normal. It should be on the lower side normally.
Dr. Deva:
Exactly. You look at the overall picture. There aren’t that many things that can cause high calcium first of all. Most of the time, if you’re going to place a bet on someone with high calcium, you will bet they have primary hyperparathyroidism. That by far is the most common thing.
There are these scenarios with hyperthyroidism where you do get high calcium levels. With all of these issues, I want to see the history. Some of these patients had high calcium before they developed hyperthyroidism. Doesn’t seem like that was probably it. When some people’s thyroid disease is particularly active, their calcium can rise. That can be true of something like sarcoidosis, too. If they have very active sarcoidosis, they will see the calcium rise. Once it’s treated, the calcium goes back to normal.
That is true of the thyroid as well. If you are under in control, if you haven’t had many issues, your labs will typically go back to normal. Tracking those over time—the calcium, PTH, and Vitamin D levels all together—is the best way to figure it out.
Dr. Eric:
You mentioned Vitamin D. Vitamin D also in some cases can cause elevated serum calcium, correct?
Dr. Deva:
Yes. Vitamin D is one of my favorite topics because it is intimately related to calcium and parathyroid hormone. A lot of people really like Vitamin D. A lot of people take Vitamin D. I take Vitamin D. But there are things you need to know about Vitamin D.
First, it’s not really a vitamin. Your body does produce it. Second, it’s a hormone. You have to treat it like any other hormone. We know when we’re talking about sex hormones or steroids which are hormones, we know you have to treat those carefully because they can have these systemic effects. But Vitamin D doesn’t always have that reputation because it’s a supplement people can buy over the counter. It’s sometimes not treated with the same respect.
Vitamin D is essential. It is really essential for calcium metabolism. One of the main things that active Vitamin D does is help your intestines absorb calcium. If you have a severe Vitamin D deficiency, you won’t be able to absorb calcium appropriately. This can lead to things like Ricketts. This is how low Vitamin D causes issues. You’re not absorbing the calcium or properly handling the calcium.
The way that it’s involved with the parathyroid is part of the way they get your calcium level up. Remember I said they sense that low calcium and turn on. They make more hormone. Part of what that hormone does is stimulate the activation of Vitamin D that happens in your kidneys.
Your Vitamin D exists in multiple forms in your body. This is really confusing, too, but we’ll keep it simple and just talk about the inactive form and active form of Vitamin D. To activate that form, you need PTH and an enzyme, which is just directly stimulated by PTH. PTH ramps up the conversion of inactive Vitamin D to the active Vitamin D, which then goes to the intestines and helps your intestines absorb calcium. That is one way it will raise your calcium level.
The way this gets confusing, even for doctors as well. I have to explain this to doctors all the time. When you have a parathyroid tumor, you will end up with a low Vitamin D level and a high calcium level. You should not treat that. That Vitamin D is not real exactly. What they’re measuring is the inactive form. That is the form that we measure on people. If I say, “I want you to get Vitamin D checked,” and I check off Vitamin D at the lab, they will draw the inactive form, Vitamin D 25 hydroxy. That is the form that is really accurate for most people. It indicates your overall Vitamin D status better than the other forms. The other forms tend to break down more easily, and they are not as easy to measure.
Now we can measure the active form. We do sometimes. But in most cases, we don’t because it tends to break down quickly. It’s not a good assessment of your overall Vitamin D status.
Inactive Vitamin D is accurate for almost everyone. But it is not accurate for people with primary hyperparathyroidism. Go back to what I said about PTH. It activates the Vitamin D. Your inactive form drops because it’s getting converted to the active form. If I measure the active form in primary hyperparathyroidism, you will see it’s actually high. Your inactive form is low.
We only measure the inactive form. Because of that, most patients with parathyroid disease will get diagnosed with Vitamin D deficiency, and they will automatically be prescribed Vitamin D.
Why is that a problem? If your calcium is already high, and you start taking more Vitamin D, you can raise your calcium into a dangerous level by taking more Vitamin D. It is a little bit complicated.
Basically, if you see a low Vitamin D, don’t immediately treat it. You want to know your calcium level as well. If your calcium level is high, you don’t want to take it.
The thing that is really confusing—stop me if I am talking too much because I love talking about Vitamin D—is that when you’re deficient in Vitamin D, that causes your calcium level to be low. That low calcium will then stimulate your parathyroids and raise your PTH. This is as separate condition called secondary hyperparathyroidism. Your parathyroids are active but only because they have to be because you’re not getting enough calcium. They get activated and make more PTH to try to get the calcium up if you have a severe Vitamin D deficiency. In that case, you want to treat that with Vitamin D. That will help get your calcium up and bring your PTH down.
The place where doctors get confused is they see the high PTH and low Vitamin D. They ignore the calcium and give you more Vitamin D. That’s not going to solve the underlying problem. The underlying problem is a parathyroid tumor.
Dr. Eric:
Just to clarify, with someone who does not have primary hyperparathyroidism, you do recommend the 25 hydroxy Vitamin D test, like the inactive form, as far as testing.
Dr. Deva:
I do. For most people, that form is the most accurate and the easiest to get. If you just order it from the lab, if you just check off Vitamin D, that’s the one you’re going to get. I do recommend that.
There are two populations where it’s not accurate: primary hyperparathyroidism and sarcoidosis. They also have an abnormal conversion to the active form. There are those two scenarios where it’s not going to be as accurate. But for almost everybody else, I would track the inactive form.
Also, all of our recommendations and studies are done on the inactive form. We don’t have a lot of data on how to interpret or what to do with the active form and where to adjust it. When we are talking about guidelines, we are talking about the inactive form.
Dr. Eric:
I agree. I test the inactive form, 25 OH Vitamin D.
Taking too much Vitamin D can increase serum calcium. What do you like to see Vitamin D levels at? Some will say at least 50 ng/ml. Some will say between 60-80. Every now and then, someone will say greater than 80.
Dr. Deva:
Yeah, this is really controversial. I do love this topic. First, remember that I have a selected patient base. The people who come to me are people generally who are worried about their parathyroids and typically have high calcium levels.
I will just say that when I see the high calcium level, I always check the PTH and Vitamin D levels. If the Vitamin D level is very high, there is a pretty good chance that is causing the high calcium, as long as the PTH is in the normal to low range.
What I have them do first is stop the Vitamin D. Now you’re wondering what level of Vitamin D do I see it? I see it happen over 50 ng/ml. Now, lots of people can tolerate a Vitamin D of 60 and not get high calcium. Those aren’t the patients I tend to see. I tend to see patients where when it’s over 50, they end up with calcium levels pushing into the 10s. It’s not always recognized by their doctors as high calcium, but I know that’s a high calcium, and it will cause symptoms of high calcium.
I typically recommend people keep it in the 30-50 range, unless they’re using Vitamin D to treat something else. I always encourage people to treat any supplements as a medication. Have a reason why you’re taking it. There are people who are taking higher doses of certain vitamins in order to treat a condition or try to mitigate a condition or alleviate a condition. That is okay. As long as you know what you’re taking and what the risks are.
With Vitamin D, the thing you have to know is there is a risk that your calcium will go too high. If you’re on high doses of Vitamin D, if your Vitamin D level is 70, there is not a lot of evidence that it really is beneficial to be 70 versus 50. But if you wanted to do that and keep it there, all I would say is watch your calcium level and make sure it’s not going into the high range.
There are people who can tolerate Vitamin D levels of 80, and their calcium level is normal. Then there are people who have a Vitamin D level of 60, and their calcium level is 10.5 as a result of it. They’re going to get the symptoms of high calcium. You have to tailor it. There isn’t one amount for everybody.
In general, I encourage people to keep it in the 30-50 range because we have a lot of evidence that Vitamin D deficiency, meaning true deficiency, like under 15, does cause problems. We likely have problems with under 30. That’s not as clear; the evidence is not as good. I think it’s reasonable enough to say there may be issues with under 30.
Keeping it in the 30-50 range is a nice medium for me. I don’t see it causing high calcium. I think you’re probably getting most of the benefits from Vitamin D in that range. That’s where I stand on it. I know I’m going against a lot of other people. That’s because I see these effects. I see a lot of patients come to me with high calcium, and I do have to caution them to keep it in the range. If you don’t want to keep an eye on your calcium all the time, 30-50 for Vitamin D is a good range.
Dr. Eric:
30-50 is where you like to see it.
Dr. Deva:
That’s my opinion.
Dr. Eric:
If someone insists on having it where the level is 50 or greater, you would say to monitor the serum calcium to make sure that it’s not elevated. If it’s elevated, it very well might be due to Vitamin D. There is a chance someone could have hyperparathyroidism if someone is taking too much Vitamin D. It could be a combination of both. The first thing is to look at serum calcium.
Dr. Deva:
Exactly. Sometimes, it is. Sometimes, Vitamin D will uncover parathyroid disease. Maybe the tumor was growing. As you take more Vitamin D, it easily slips into the 10s. That can be early parathyroid disease. I do see it where it starts going into the 10s.
I also see it happen over time. Remember Vitamin D is a fat-soluble vitamin. The longer you take these high doses, the more it’s collecting up in your body. It can take a while for it to drop even if you stopped entirely taking any.
I see these people who will be on these very high doses. What I consider a high dose is 5,000 units a day, which is what a lot of people are on. If you take that for a short period of time, it is unlikely you will see bad effects from it. if someone is on it for 10 years, and then they didn’t get a high calcium level for the first few years, and it took a few years for the calcium level to start rising. They are thinking they have been on this for so long that this can’t be the problem. But it could be. You see those effects add up over the years.
Dr. Eric:
Based on what you just said: Let’s say someone is taking Vitamin D, and their Vitamin D levels are 60 or 70. Then their serum calcium is over 10. Would you recommend for them just to go ahead and test PTH just to make sure it’s not high? You would say probably stop the Vitamin D anyway. Is another option to stop the Vitamin D and wait a few months because it could take quite a while for that to drop significantly to impact the serum calcium, if that is indeed the cause of the elevated serum calcium?
Dr. Deva:
I don’t want to miss a parathyroid tumor. I will have them recheck labs with calcium, PTH, and Vitamin D. Typically, when the Vitamin D is causing it, the PTH will be on that low end of normal. I do have patients where their calcium is 10.5, their Vitamin D is 70, but their PTH is 100. That’s primary hyperparathyroidism. The PTH level is not responding appropriately to that calcium. I know that’s a parathyroid problem.
If on the other hand, the PTH level is 25, on that lower end of normal, that is more consistent with Vitamin D. I do have them stop Vitamin D regardless, whether it’s primary hyperparathyroidism or not because your calcium is high. The high calcium is what is causing most of the symptoms with parathyroid disease. You want to stop the Vitamin D. You want to stop it and repeat labs.
Three months is the earliest I will recheck. If it’s that high because you have been on high doses for many years, it may take six months for it to drop below 50. That’s what I’m looking for. Once it gets below 50, that’s when I see the calcium drop back to normal. That’s what I have people do. Sometimes, it takes six months, but it will happen.
Dr. Eric:
Talking about primary hyperparathyroidism, if someone has a benign adenoma, is there any natural options out there? When it comes to hyperthyroidism and hypothyroidism, I’m all about trying to improve the health of the immune system, address the cause of the problem, as are many other functional medicine and natural health care practitioners. Any other options besides surgery when it comes to benign adenomas?
Dr. Deva:
Sure. I will first say I am a huge proponent of lifestyle medicine and modifying your lifestyle, your diet, in order to treat and prevent disease. For the thyroid, that makes a lot of sense. As I mentioned earlier, I am not a huge fan of surgery for Graves’. I think that should be the last resort option after you’ve tried other things to control your thyroid.
Having said that, there are some things where surgery is just necessary. For parathyroid tumors, there really isn’t any lifestyle modification that you can make that will affect it. It is a small tumor. It’s benign; it’s not a cancer. It’s a small tumor growing inside the parathyroid gland. There is nothing that will get rid of it or cause it to go away without taking it out, at least anything we have right now. The only treatment is removing this.
In that case, it makes sense to have the operation because it does have such a huge effect. You can cure it. For most people, once you take the parathyroid gland disease out, your other glands react normally. Then you prevent all of the potential medications you might need to take later on down the road if you had left it in place. A lot of people with parathyroid disease get high blood pressure, cardiac arrythmias, fatigue, constipation, reflux. They end up on all of these other medications to try to treat the symptoms of this when really a simple operation can cure it and prevent these complications.
Dr. Eric:
Prior to going live, as you mentioned, we were talking about Graves’ and how you recommend not having surgery as a last resort. There is a time and place. One thing you mentioned with surgery of the thyroid is complications are common. With parathyroid surgery, it all comes down to choosing the right surgeon, too.
Same thing with thyroid. You wouldn’t want to get thyroid surgery from someone who just did 10 thyroid surgeries. At least I wouldn’t want to go to someone who was not experienced. Obviously, you focus on that. Can you talk more about potential complications, like the risk factors of this surgery?
Dr. Deva:
Especially with something like Graves’, that is my main reason for not wanting to push for surgery because the complication rate is high. Actually, one of the big complications with surgery for Graves’ is hypoparathyroidism, meaning all the parathyroid glands can be injured during the operation. That is a serious, can be lifelong complication that can be very hard to manage if you don’t have any parathyroids.
The reason it’s more of an issue than with other thyroid operations, because not all thyroid operations are equal. Surgery for Graves’ is one of the riskier ones because of all that inflammation around the thyroid. It makes it very difficult. I have operated on Graves’ thyroids. They are hard to deal with. They are very temperamental, they bleed easily, and they’re stiff. It’s hard to get around them.
For all those reasons, when you do a Graves’ thyroid and take it out, it is very easy to injure the parathyroid glands around it and not even realize it. And also injure the nerve that controls your voice. For all those reasons, I say try to treat it medically or with lifestyle medicine, even radioactive iodine, before I would recommend surgery.
There are patients who need surgery for Graves’, and they should get it. If you do that, go to a surgeon who just does thyroid operations. There are people who really specialize in this and are mostly doing thyroid operations or solely doing thyroid operations. That’s who I would want doing my operation.
Parathyroid surgery tends to be a very safe operation. It has some of the same risks as with thyroid surgery and with any other operation. Any time someone takes a knife to any part of your body, there is a risk of bleeding. That is true for parathyroid disease, like any other operation. But it’s pretty low. There is always a risk to those nerves that control your voice. Again, pretty low risk. Finally, there is a risk that you would injure or remove all the parathyroid glands. Typically, you’re trying not to do that. In general, it is a very safe operation. It lasts under an hour. It’s usually about half an hour to see all the glands.
With this as with other operations, you do want to get someone who is experienced in this. A lot of general surgeons are credentialed to perform thyroid surgery and parathyroid surgery. It doesn’t mean that you would want them doing your parathyroid or thyroid operation.
Parathyroid surgery can be pretty hard if you’re not experienced in it. Those glands are a grain of rice. It could be a grain of rice that is stuck to the nerve that controls your voice. You really don’t want someone inexperienced digging around in there. You want someone who is going to be able to evaluate it and remove the tumor safely and quickly in order to reduce those complications, get you out of the hospital. It’s a same-day procedure. It’s a very safe operation in general, as long as you have someone experienced doing it.
Dr. Eric:
If you had to take a guess, how many surgeries have you done?
Dr. Deva:
I’ve done at least 4,000, which makes me the most experienced person in the western U.S., I think. I’ve only done parathyroid operations for the last 10 years. That’s all I focus on.
To me, I wouldn’t want a surgeon who just did this operation once a week to do my operation. A lot of the guidelines will say that you’re an expert if you do 50 a year, which is about one a week. That is not very many. To get good at this, you have to do a lot of operations. That means specializing in the area, which a lot of surgeons aren’t doing.
I will say the thing I do differently is I look at all four parathyroid glands in the operating room. It’s the most accurate and reliable way to actually assess the parathyroid glands. Scans and imaging studies are so often wrong with the parathyroids because they are so tiny to begin with. You can’t see normal glands. You can’t even see small tumors.
I have a lot of patients who have completely negative scans. This is weird to think about because when I say you have a small tumor, most people are thinking, “Okay, you know that because either you see a lump or feel a lump or see it on the scan.” If I say you have a tumor, you are thinking about a scan or a lump you have on your arm.
With parathyroid disease, it’s not like that. I can’t feel it on your neck. We can’t see it on imaging studies, even with the most advanced imaging studies we have. They may not show up. You have to base it on the labs. I know from your labs, you have a parathyroid tumor. It’s a little weird. “I don’t see anything on the scans, but I know you have a parathyroid tumor. If I look at your parathyroid glands, I will be able to figure it out.” That means going in there and being able to find all four safely and quickly.
For most surgeons, they often won’t do that. They will rely solely on imaging, so they will only operate if they have a positive scan. They will only go after that gland. That does lead to a lot of patients needing further surgery in the future. I avoid that by looking at all four parathyroid glands during that one operation, so it’s a one and done procedure.
Dr. Eric:
Thanks for bringing that up. That’s really important to know. If a surgeon relies on finding it on a scan, and it’s there, but it just doesn’t show up on the scan, then that person will be continuing to have the symptoms associated with elevated calcium levels, hypercalcemia. Eventually, they will probably get the surgery when they get a second or third opinion.
Dr. Deva:
They find another surgeon, yeah.
Dr. Eric:
Exactly. You shared a lot of information, Dr. Deva. Is there anything else I should have asked you that I didn’t ask you? Any last words that you have for those who might be suspecting that they might have an issue with the parathyroid glands?
Dr. Deva:
I think that’s covering a lot of it. It’s a lot of information in a short period of time. If your fans don’t know much about the parathyroids, it’s overwhelming.
My advice to all people is to get your own medical records. Get your lab results. Look at them yourself. If you’re having symptoms, get a second opinion. Read through your results yourself. Do your research.
Some doctors don’t like patients looking up their illnesses on Google. I’m fine with it. I think that’s great. You can learn a lot online and through reading. A lot of my patients figure this out themselves because they’re really tired and have headaches every day and can’t figure out why. They finally get their lab reports themselves and see that their calcium is high, and it has been high, but nobody has mentioned it. Then they finally find me online and get treated for it and feel better.
It’s one of those things where your doctors may miss it. This is one where they often don’t take it as seriously, or they will give a “wait and see” attitude, to just watch it over time. You really need to take control of your health. Remember that nobody is going to care about your health as much as you do. You need to advocate for yourself.
That is definitely true with Graves’ as well. There are some things we learn for Graves’ that I have learned are not true and disagree with and have changed my practice based on that.
Take control of your own health.
Dr. Eric:
Thank you so much. Where can people find out more about you?
Dr. Deva:
My center is Southwest Parathyroid Center. Go to SouthwestParathyroid.com to find me.
Also, I have my own Facebook page and answer a bunch of questions there.
You can go to ParathyroidQAndA.com, where I answer a lot of questions, too. Any question about parathyroid disease.
Dr. Eric:
Wonderful. Thank you so much, Dr. Deva. Really appreciate you taking the time to talk about the parathyroid glands, hyperparathyroidism, and Vitamin D.
Dr. Deva:
Sure. Thank you for having me. If people have questions, they can always reach out to me through my website.
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