Online Health Chat with Krupa Doshi, MD

September 13, 2012


Cleveland_Clinic_Host: The four parathyroid glands are located on the thyroid gland in the neck. Parathyroid glands make parathyroid hormone (PTH), which regulates the balance of calcium and phosphorous levels in the body. Hyperparathyroidism is caused by too much PTH, which causes excess calcium in the body. Hypoparathyroidism is the result of too little PTH, causing a deficiency of calcium in the body. Parathyroid disorders may cause a loss of energy, bone density loss, depression, and many other symptoms. Parathyroid disorders may be genetic or due to genetics or other illnesses. Diseases of the thyroid are also associated with osteoporosis and kidney stones, among other medical conditions. Diagnosis and treatment are essential to managing a parathyroid problem, and will help to control the related symptoms.

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The departments and centers of the Endocrinology & Metabolism Institute at Cleveland Clinic include endocrine surgery; endocrinology, diabetes and metabolism; and the Bariatric and Metabolic Institute. We treat various disease and conditions of the endocrine system, including diabetes (types 1 and 2), obesity, hyper- and hypothyroidism, Cushing’s disease, and Addison’s disease among other illnesses.

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About the Speakers

Kupra Doshi, MD, is a specialist in the Endocrine Calcium Clinic, and a staff physician in the Endocrinology & Metabolism Institute. She is board certified in Internal Medicine and Endocrinology, Diabetes & Metabolism. A graduate of the University of Bombay, Seth G.S. Medical College, she completed her residency at Saint Luke’s/Roosevelt Hospital Center in New York and her fellowship in endocrinology at Cleveland Clinic. Dr. Doshi’s specialty interests include parathyroid and calcium disorders, osteoporosis, metabolic bone and skeletal problems, thyroid cancers and disorders, and diabetes.

Let’s Chat About Calcium Disorders and Parathyroid Disease: What You Should Know About Your Parathyroid

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic expert Dr. Krupa Doshi, MD. We are thrilled to have her here today for this chat. Let’s begin with some of your questions.

Hypoparathyroid and Hyperparathyroid Diagnoses

generally_weston: An endocrinologist is now seeing me at the University of Michigan, and I have a few questions: Why is my PTH (parathyroid hormone) high if I don't have hyperparathyroidism? Should I have another sestamibi scan? What are the diagnostic problems here? I am a 51-year-old female. My PTH is 141. My calcium is now 10.2, but was 10.4 nine months ago. My calcium has been in the high 9s and up to 10.2 for six years. My vitamin D is now 35, but was 18 nine months ago. (I took 50,00 IU for the first 6 months). Recently, I had a 24-hour urine test with a calcium level of 444. Most recently, I had normal sestamibi and CT scans. My endocrinologist is saying to take more calcium and vitamin D. He said since my scan was normal, I do not have parathyroid disease. I have nearly every symptom and I have been telling my family doctor this for 10 years! I have been taking water pills (due to bloating) for five years, so he just switched me from the thiazide to a non-thiazide.
Dr_Doshi: I do believe that you may have a primary parathyroid disease based on your laboratory tests. Sestamibi scans and CT scans may occasionally be normal. It may be time for you to get a second opinion, and it may be worthwhile for you to come to Cleveland Clinic.

Burkamore:I had two of my four parathyroid glands removed over 15 years ago as well having multinodular goiter for many years. My original endocrinologist retired and I have not been followed by one for several years. I'm really not clear on what kind of monitoring of either condition is appropriate or necessary. Is parathyroid disease an ongoing concern for me?
Dr_Doshi: Youmay not have parathyroid disease, if your calcium levels are fine. You should still have other working parathyroid glands, which can produce enough hormone to maintain a normal state. Did you have your thyroid removed completely? If not, you may need a thyroid ultrasound to make sure you have not developed new nodules in the remainder of your thyroid gland.

lisa_lycon:My husband is starting to display some serious symptoms. He has an enlarged spleen, and he has had multiple episodes of kidney stones. This week he is having his gallstones removed and soon the gallbladder. He has heartburn, and is tired and depressed. He shows all the signs of parathyroid disease and we just made an appointment with Cleveland Clinic’s Department of Endocrinology. I was wondering what time of timeline we are looking at and how urgent this situation is? Is this something hereditary? What is a DEXA scan?
Dr_Doshi: Your husband’s symptoms may or may not be all related. For example,an enlarged spleen is not a symptom of a parathyroid problem. It is relatively easy to assess for parathyroid problems by checking PTH, calcium and vitamin D levels. Your primary care physician should be able todo this to help asses the urgency of the situation and to triage the appropriate consults for your husband. Regarding your question about heredity, this would depend on the condition he has. Lastly, DEXA (dual-energy X-ray absorptiometry) scan is a technique of measuring bone mineral density to assess for osteopenia and osteoporosis.

Faskeg: My first endocrinologist said I have hypoparathyroidism. After I changed physicians due to my insurance plan, another doctor said I have hypothyroidism with no mention of parathyroid malfunction. I often have severe muscle spasms when my calcium level is low, plus I have high cholesterol.
Dr_Doshi: Low calcium levels are not from a thyroid problem. They could be from a calcium deficiency, vitamin D deficiency or a primary parathyroid problem. You may benefit from seeing a bone or calcium metabolism specialist. I invite you to come to Cleveland Clinic’s Endocrine Calcium Clinic.

CherW76: Could you introduce the parathyroid to me? I am not exactly sure how a healthy one functions
Dr_Doshi: For some general information about the parathyroid gland, please link to the following document.

Kailee: I have osteoporosis and will be seeing a Cleveland Clinic endocrinologist next week. I’m not sure what questions I should ask. My serum calcium is 10.4 and my 24-hour urine calcium is 273. My urine creatinine was 76.5 and my 24-hour urine creatinine was 956. Could this be due to a parathyroid problem? What do they do in this case?
Dr_Doshi: I am glad you are being seen next week. Your physician will probably need some more blood and urine tests, such as testing PTH,  vitamin D, creatinine (in blood) and phosphorus levels, before he or she can confirm that you have a parathyroid problem,.

Once your doctor confirms that you have a parathyroid problem, he or she will try to confirm if this is from a growth on one or more parathyroid glands. Sometimes having surgical removal of the growths on the parathyroid gland can cure the problem.

Don't worry about the questions. It seems that more work may be needed anyway to find out if your parathyroid glands are the problem and, if so, if they are related to your osteoporosis.

robtoby: I have had a few kidney stones. My nephrologist did some tests and found I had high PTH and low vitamin D levels possibly producing calcium oxalate stones. I am now taking 2000 IU of vitamin D daily. My levels are now 38 for vitamin D and 64 for PTH. I haven't produced any new stones over the past few years. Are these levels 'good enough' for now? Is there anything else you suggest I do?
Dr_Doshi: The third piece of the puzzle is calcium. I suggest that you should have a 24-hour urine calcium test to see if you have a dietary calcium deficiency. Your parathyroid levels are still a bit generous, and it could be from a lack of sufficient dietary calcium. Also make sure to avoid getting dehydrated.

burk525: I had two parathyroid glands removed about 15 years ago. Since then I was also diagnosed with multinodular goiter. What concerns remain for ongoing parathyroid disease, and what type of monitoring is recommended?
Dr_Doshi: Multinodular goiter is a thyroid problem and may be monitored via thyroid ultrasound. Calcium, PTH and vitamin D levels in the blood may be checked to screen for residual or recurrent parathyroid disease.

burk525:How likely is residual or recurrent parathyroid disease given that only two of the four glands were removed, and is that typical?
Dr_Doshi: It is not very typical, but it is certainly possible,

Reximus: On July 19, my calcium was 12.5, PTH 70, and vitamin D was 1.25. (It was 48.) On July 31, my calcium was 11.3, PTH 76 and vitamin D 1.25 (it was 114). My vitamin D 25 was 40. On August 9, my calcium was 11.0, and PTH 76 (after one week of 20 mg Lasix® per day). On August 16, my calcium was 10.4, and PTH 75 (after two weeks on Lasix®). 1n 2010, when I was 46 years old, I had a DEXA (dual-energy X-ray absorptiometry)scan that showed: -2.8 AP spine, -2.8 total left, and -2.5 total right. I had already been on hormone replacement therapy for three years. I cannot see an endocrinologist until October 3. Will normal calcium due to the Lasix® muddy the waters at all? I still have many significant symptoms, including constant nausea, vomiting, extreme fatigue and increased cognitive problems. (I have multiple sclerosis [MS], and these symptoms are much worse than normal right now). I have episodes of heart pounding, chest pressure and difficulty breathing. Is this still related to the calcium, since the PTH is still high while the calcium is ‘normal’?
Dr_Doshi: Just tell your physicians which tests were done under the influence of Lasix®, and they will interpret the lab results in the context of that information. They may have you come off of Lasix® (if this is safe), and have you repeat some of the laboratory tests in a few weeks. You can still have a primary parathyroid problem, even if your calcium levels are normal. However, the symptoms that you mention are not all explainable with the blood tests here. There may be something else going on, perhaps an MS flare?

Pambb:I have secondary hyperparathyroidism due to a gastric bypass. In May, my PTH was 131, vitamin D was around 50, and calcium was 8.8. I have been taking calcium with a dosage of 1500 to1800 mg per day, and vitamin D3 with a dosage of 50,000 units every other day. My 24-hour urine test was abnormal at about 2. Is there anything else I can do to lower my PTH? Does an abnormal PTH in this case have the same symptoms as a primary hyperparathyroidism, such as depression, low energy etc? Some of my doctors say they have patients with PTH in the 1000s, and do not have the same symptoms. All my other tests are normal.
Dr_Doshi: I did not understand your 24-hour urine test results. What was measured?It is likely that you are not absorbing calcium, which is a common problem after gastric bypass. The best way to assess for low calcium is to obtain 24-hour urine calcium levels. Low calcium levels can make you feel tired. This should be addressed first before looking for other causes of elevated PTH.

Pambb:Does secondary hyperparathyroidism cause the same symptoms as primary hyperparathyroidism with depression, loss of energy, etc.?
Dr_Doshi: Yes, it may.

giblet2u: I was made hypoparathyroid in June 2008. Since that time I have developed diabetes, Parkinson’s with tremor and gait issues, depression, body and muscle cramps and bone pain, carpal tunnel syndrome, stuttering and word finding issues, and mental confusion. Neurologists tell me it is all in my head (psychogenic). I believe it's the hypoparathyroid. What do you think?
Dr_Doshi: Extremely unlikely. Pure hypoparathyroidism cannot physiologically explain all of your symptoms. I would like to know how you were 'made hypothyroid.'

giblet2u:I was made hypoparathyroid by a surgery to remove my thyroid. When they got in to do the procedure, my thyroid had ‘melted’ and everything in my neck was a mess. The minor two-hour surgery turned into eight hours. The surgeon believes he destroyed my parathyroid in the process. I have been at less than three since the procedure in June 2008.

Osteoporosis Diagnosis

clara: My parathyroid was 79.3 and calcium was 9.5 . It has been 10 before. I do have osteoporosis. I read that it can show normal, but can be missed (i.e., calcium can appear to return to normal, but not be normal). I also read that calcium does not have to be high. I was told that one always has osteoporosis if parathyroid disease is present. I have been on Fosamax® for 15 years, and went off of it two years ago after the latest findings. I was told that I could go on Forteo® now, but I really worry about having parathyroid disease. I also have very aggressive heart disease that I read can be connected to thyroid disease. I believe that Dr. Hatipoglu at Cleveland Clinic wrote about it. I am also losing hair. Is that connected to the parathyroid?
Dr_Doshi: It is true that PTH (parathyroid hormone) levels can be high with normal calcium levels. It may be a good idea to have your Vitamin D levels tested, which can drive the PTH levels up independent of a primary parathyroid problem.

It is not necessarily so that you will always have osteoporosis once parathyroid disease is present. However, having hyperparathyroidism certainly increases the chances of having osteopenia or osteoporosis. If you truly have parathyroid disease, using Forteo® is not a good idea until the cause of your increased PTH levels is resolved. Hair loss may be caused by many, many diseases, one of which could be the parathyroid glands.

Parathyroid vs. Thyroid Diagnosis

rmullet33: I have a hypothyroid. Is the parathyroid tested by blood tests too, and how can they be differentiated? My thyroid was OK with no medicine, and then the TSH (thyroid-stimulating hormone) levels were elevated.  I went back on the thyroid medicine of 50 mcg, had routine blood work that showed elevated TSH levels even on 50 mcg (which has been my dose for about 12 years). One doctor thought I did not have a thyroid problem at all, but did not explain why. I had other health problems, so I didn't really ask any questions. But what are other underlying reasons for the TSH levels to be elevated, and then not elevated that doctors are not relating to me as a patient? Could it be the parathyroid, if this is different then thyroid? I only have been treated with medicine, and my blood levels were checked as needed. No other testing has been done to determine if there were other causes then, unless my doctors ordered the tests without verbally telling me?
Dr_Doshi: Thyroid and parathyroid are located close together, hence the similar names, but they do completely different things. It seems like you have a thyroid problem. Parathyroid problems can also be tested by a series of blood work, but is a different test than the TSH.

pamt: What is the relationship between hypothyroidism and hypoparathyroidism?
Dr_Doshi: The parathyroid glands are located very close to the thyroid glands, hence the similar sounding names. Otherwise, both these conditions usually have different symptoms and are managed quite differently.

jzt: What are the symptoms of a thyroid disorder?
Dr_Doshi: Please refer to the following document from our website:

Jocelyn:My sister has lost a lot of weight recently and is very tired all the time. Her doctor suggested possible thyroid issues. Her initial tests came up negative. Is it possible that she can still have a thyroid problem that further testing might reveal? Or does her doctor need to look in a different direction? She is still convinced that her problems are thyroid related.
Dr_Doshi: Thyroid problems can be easily checked via blood tests which have become very reliable as they can pickup thyroid disease early on—thanks to very good laboratory assays. If her thyroid function tests have been repeatedly fine, she may not have a thyroid problem, and it may be a good idea to look in a different direction.


Hypoparathyroid Treatment

Pamt: Is it important to keep track of your calcium intake, calcium levels, etc. if you have hypoparathyroidism? Is there anything else you should track about diet and supplements to be careful?
Dr_Doshi: Yes, it is important to keep track of your calcium intake and calcium levels if you have hypoparathyroidism. You also need to take vitamin D. It is very important to work with a physician familiar with the management of hypoparathyroidism, because both over-replacement and under-replacement of calcium may be harmful.

Pamelaat: If you have hypoparathyroidism, is it important to track calcium and other supplements you are taking? What is the best way to do that? Should you keep track of your symptoms, too, to see if there is any connection?
Dr_Doshi: Tracking can be done by assessing blood and urine levels of calcium and other mineral and vitamins.Keeping a track of symptoms is always a good idea.

Faskeg: How often should I take calcium pills per day? What's the maximum I can take? Is there a side effect? What type of calcium is recommended for hypoparathyroid?
Dr_Doshi: It depends on your age and if you do have a bona fide hypoparathyroid problem. If you do, you need much more calcium than someone who does not have hypoparathyroidism.
If you don't, I would encourage you to check -out the National Osteoporosis foundation website for calculating your daily calcium needs. Here is the link to the website:

Faskeg: Are there any other alternatives to taking calcium pills?
Dr_Doshi: Yes! For more info, please check out this link from the National Osteoporosis foundation:

Faskeg: Are there any other medicines prescribed for hypoparathyroid?
Dr_Doshi: No, just calcium and Vitamin. D.

Faskeg: What is the treatment for hypoparathyroid?
Dr_Doshi: This a condition in which secretion of PTH is diminished. This is most commonly caused by the removal of parathyroid glands during neck surgeries, or after radiation treatment in this area. This causes hypocalcemia (low blood levels of calcium). These patients are treated with vitamin D and calcium.

Faskeg: What I meant is, for a hypoparathyroidism, are there alternatives to calcium pills? I have low blood calcium that tested negative in bone density.
Dr_Doshi: No, not yet. Some new drugs are being developed, but calcium pills still need to be taken.

Medical Identification of Hypoparathyroidism

pamt: Since doctors are often uninformed about a rare disease like hypoparathyroidism, can you suggest how best to communicate key facts about your condition in an emergency situation—to the emergency room doctor or emergency personnel?
Dr_Doshi: Emergency department physicians should certainly be familiar with the diagnosis and management of hypoparathyroidism. However, it is always best to wear a medical alert tag stating one has this illness, in case one gets sick enough to not be able to give a history (such as an automobile accident). This would be extremely helpful to emergency room and EMS personnel.

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic expert Dr. Krupa Doshi is now over. Thank you Dr. Doshi for taking your time to answer our questions today about Calcium Disorders and Parathyroid Disease: What You Should Know About Your Parathyroid.
Dr_Doshi: Good bye folks! Many thanks for chatting with me. Again, we have developed an Endocrine Calcium Clinic for people with common and not-so-common calcium and metabolic bone diseases and symptoms. So, I invite you to visit me and my colleagues !


Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic expert Kupra Doshi, MD, is now over. Thank you Dr. Doshi for taking your time to answer our questions today about Calcium Disorders and Parathyroid Disease: What You Should Know About Your Parathyroid.
Dr_Doshi: Good bye folks! Many thanks for chatting with me. Again, we have developed an Endocrine Calcium Clinic for people with common and not-so-common calcium and metabolic bone diseases and symptoms. So, I invite you to visit me and my colleagues !

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