Primary hyperparathyroidism (PHP) is one of the most common endocrine diseases; it is frequently found in asymptomatic patients when there is some doubt as to the appropriate choice of surgery (PTX), medical therapy or watchful waiting. These decisions are generally based on the consensus guidelines produced by the NIH however there is concern that these reflect established medical/surgical practice in the USA as much as clinical evidence. What evidence that does exist is frequently scanty and where present contradictory. In order to develop evidence based guidance it is necessary to understand the effects of PHP:
Renal stones were once seen as the hallmark of primary hyperparathyroidism but are now seen less frequently; meta-analysis of reports of the effect of primary hyperparathyroidism indicates that although their frequency is reduced by surgery this still remains above that expected for the population suggesting that these may occur in patients with PHP who also have other predisposing conditions for stone disease.
Reduced bone density is generally accepted to occur in patients with PHP. The effect of this on fractures is less clearly demonstrated as is the effect of PTX on fracture rates.
Although there is reasonable consensus on the associating between PHP and hypertension there is little consistency in the association between other manifestations of vascular disease and PHP.
Neuropsychiatric and other non-specific symptoms are frequently associated with PHP but are common in the general population and no definite association has been demonstrated. The effect of PTX on these symptoms is contradictory.
If evidence based guidance for the management of PHP is to be developed it is important to both understand the natural history of the condition and to the effects of treatment, both medical and surgical. This will require an adequately powered RCT comparing PTX to medical therapy to placebo. Such a study has frequently been discussed but still needs to be undertaken.