Parathyroid.com discusses hyperparathyroidism, parathyroid disease, parathyroid surgery, parathyroid hormone, parathyroid cancer, parathyroid operations and mini-parathyroid surgery.

"The 10 Parathyroid Rules of Norman"

Hyperparathyroidism (parathyroid disease caused by a parathyroid tumor resulting in high blood calcium) is easy if you can understand these 10 simple rules. Dr Norman has written extensively about the facts and the myths of parathyroid disease and hyperparathyroidism. These are the parathyroid facts--widely know as:

"The 10 Parathyroid Rules of Norman".

hyperparathyroidism, high calcium, surgery, operation, parathyroid surgery, parathyroidism.

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Dr. Norman has written many scientific articles about parathyroid disease, and the proper way to treat it. He has also written or participated in the preparation of numerous articles in the lay-press (print and television) on hyperparathyroidism. One of his most famous articles was written to explain the 10 most important facts about parathyroid disease...and the myths that are laid to rest with these facts.
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"The 10 Parathyroid Rules of Norman"

  1. There are no drugs that will make parathyroid disease better….None.
    --Read More--
  2. Nearly all parathyroid patients have symptoms; 95% know it--and feel bad. Most of the rest just don’t know it until the disease is fixed.
    --Read More--
  3. Symptoms of parathyroid disease do NOT correlate with the level of calcium in the blood. Many patients with only slightly elevated calcium and parathyroid hormone will have BAD symptoms and develop severe osteoporosis.
    --Read More--
  4. All patients with parathyroid disease have calcium levels and PTH levels that go up and down. Fluctuating levels of calcium are typical of parathyroid disease.
    --Read More--
  5. All patients with hyperparathyroidism will develop osteoporosis.  ALL.
    --Read more--
  6. Taking Fosamax, Actonel, Boniva, or Reclast (etc) will NOT help bones that are being attacked by a bad parathyroid. These osteoporosis drugs have no place in the treatment of parathyroid disease.
    --Read More--
  7. Parathyroid disease will get worse with time in all patients. It will not stay the same, nor will it get better on its own.
    --Read More--
  8. There is only one treatment for parathyroid disease (hyperparathyroidism):  Surgery
    --Read More--  
  9. Nearly all parathyroid patients can be cured with a minimal operation. The days of big dangerous parathyroid surgery are gone (so don't let your surgeon perform one on you!).
    --Read More--
  10. The success rate and complication rate for parathyroid surgery is VERY dependent upon the surgeon’s experience.
    --Read More--

Explanations and Details Regarding the "10 Parathyroid Rules of Norman "

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1. There are no drugs that will make parathyroid disease better….None.  Parathyroid disease is caused by a parathyroid tumor that makes too much parathyroid hormone. There is no way to take a drug to dissolve the tumor. Fosamax (and other osteoporosis drugs such as Actenol, Boniva, Evista, etc) will NOT counteract the effects of the hormone. Your osteoporosis will continue to get worse as long as the tumor is in place--the parathyroid tumor and the hormone it makes is too powerful for a drug to overcome.

Sensipar is a drug that is used to treat patients on kidney dialysis who have large parathyroid glands due to the kidney failure. Beginning in 2007 some doctors began trying to use Sensipar for patients with primary hyperparathyroidism (high calcium and NOT because they are on kidney dialysis). It turns out that this can be very detrimental to the patient. In fact, the use of Sensipar (cinacalcet) appears to us to be so dangerous to patients with primary hyperparathyroidism that we have made a new web page just about this drug. Note that using Sensipar for primary hyperparathyroidism is NOT approved by the FDA... for good reason! Remember... there is a tumor in your neck that needs to come out. Taking a drug will not make the tumor go away.
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2. Almost all parathyroid patients have symptoms. This is a VERY important point. Read more about parathyroid symptoms on another page of this Website, but realize 90-95% of all patients with this disease have some symptoms (feeling bad, low energy, etc, etc). HOWEVER, almost all of the remaining 10% that think they don't have symptoms will feel better once the parathyroid tumor is removed! UPDATED April, 2004... It is very rare for somebody with parathyroid disease to not have symptoms. The symptoms may be osteoporosis or high blood pressure that the patient can't "feel"... but without a doubt, this disease will take its toll on you mentally and physically. A recent study from the MD Anderson Hospital that looked at thousands of patients from many different doctors showed that virtually 100% of parathyroid patients have symptoms. Sometimes they can't feel it (high blood pressure, osteoporosis), but they all have it. When you get it fixed, it will change your life! So when your doctor says "lets just watch it for a while"... you know that this may not be the best advice. It will only get worse, and WILL make you sick (sicker??).
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3. Symptoms of parathyroid disease do NOT correlate with the level of calcium in the blood. This is one of the most important points, and a point that MANY physicians don't understand. Having calcium levels that are only "mildly" or "slightly" elevated does NOT mean that the patient doesn't have symptoms. It does NOT mean that they won't get osteoporosis. It does NOT mean that they won't get kidney stones. It does NOT mean that they can't have a MIRP mini-operation. It does NOT mean that they shouldn't get the tumor removed until the calcium goes higher. THIS IS DUMB! Many people with very mild or only slightly elevated calcium levels will have symptoms that are WORSE than people with very high levels of calcium.  Different people's nervous system will respond differently to elevated calcium. It is almost always inappropriate to "wait and see if the calcium gets higher".  It may never go higher, but your bones are being destroyed and the symptoms are causing you to lose some of the pleasures of life! Also, a lower calcium level one time does not mean that the parathyroid problem is not getting worse... it just means that the levels fluctuate from day to day... keep reading... It cannot be over emphasized that the degree of destruction of your bones, blood vessels, and mental health is NOT related to how high your calcium is. If your doctor says "your calcium is not that high, so lets wait and see", then you may want to check with a different doctor... They are not doing you any favors and this disease may be slowly killing you!  Again, we cannot over state this: Waiting for your calcium to reach some "magical" number for you to become a "candidate" for parathyroid surgery does not make sense and is outdated. If you haven't looked at the page of parathyroid tumors yet... please do so... you can see some large tumors removed from people with very modest elevations in their calcium (some with normal calcium). Waiting until your calcium gets to some number does not make sense and in our opinion this is silly.
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4. All patients with parathyroid disease have calcium levels and PTH levels that go up and down. We operate on over 400 patients per year that have been waiting for parathyroid surgery for several years because of a misunderstanding of this one parathyroid fact alone. Their doctor will see a high calcium and then re-check it a few weeks later. The second one is lower, and sometimes inside the normal range. They then wait for a few months and check the calcium again, this time it is up again, but not as much. The parathyroid hormone is checked, and it is up, but the calcium is not that high... This routine can go on for YEARS.  These patients have hyperparathyroidism. This is exactly what this disease does... it is expected that they calcium levels vary from week to week! MOST patients with this disease have calcium levels that fluctuate from "high normal range" to "high". This is expected, and it may stay this way for years...during which time the patient has symptoms which prevent them from enjoying life... and their bones are getting ruined.
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5. All patients with hyperparathyroidism will develop osteoporosis. The parathyroid glands have one job to do... maintain the blood calcium in the normal range. They do this by making parathyroid hormone (PTH). When you have hyperparathyroidism, you have TOO MUCH PTH. The way PTH works is by going to your bones and removing calcium out of the bones and putting it into the blood. Thus, ALL PATIENTS with hyperparathyroidism will continue to lose calcium from their bones every day that the parathyroid hormone is high. Over time, ALL parathyroid patients will get osteoporosis. So, don't fall into this common trap: "Lets check your bones and see if you have osteoporosis--if you do then you will need an operation--if you don't, we can wait and see what happens".  Trust me... it WILL happen if you wait long enough. So you will probably be better off by getting the problem fixed before your bones go south!
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6. Taking Fosamax, Actonel, Boniva, Reclast, or any of the other drugs made for osteoporosis will NOT help bones that are being attacked by a bad parathyroid. I wish I had a $dollar$ for every time I saw this problem. There are two important issues here. First, Fosamax, Actonel and all the other osteoporosis drugs do not work on bones in the same way that parathyroid hormone does. It does not block the effects of parathyroid hormone (PTH). It is not approved by the FDA for this purpose, and it has NEVER been shown in any clinical trial to help increase bone density in patients with parathyroid disease. The makers of these drugs do not recommend using them for this purpose! Parathyroid hormone is much too powerful for Fosamax to overcome. Parathyroid patients can take these drugs for years and their bones will continue to get thinner! Don't make this mistake! The second issue is that most endocrinologists don't want to send their patients for the big "old-fashioned" parathyroid operation... so rather than do that, they feel Fosamax "may be worth a try rather than send you for that big operation".  Of course, now that Minimally Invasive Radioguided Parathyroid (MIRP) surgery is available, endocrinologists are rapidly changing their management (read more about how 96% of endocrinologists would have a MIRP for themselves!). Bottom line, these drugs are designed and approved to help post-menopausal women who have osteoporosis, or men that have osteoporosis due to long-term steroid use. They are quite good in treating osteoporosis in these settings. However, the manufacturers don't even claim to have a use in patients with parathyroid problems. If you have a parathyroid problem, then you need to get the parathyroid TUMOR removed.
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7. Parathyroid disease will get worse with time in all patients. It will not stay the same, nor will it get better on its own. This rule is quite simple...but still not understood very well. There has never been a report of a person with hyperparathyroidism who waited for some period of time and the disease went away. It doesn't happen. And since the disease is caused by one (or more) of the parathyroid glands becoming an over-grown tumor, the tumor will continue to grow with time, only to make more parathyroid hormone and making the patient feel bad (read the symptoms page). "Waiting and seeing" is wishful thinking! This disease is caused by a tumor that has grown in a person's neck. Did you see the pictures of the tumors?
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8. There is only one treatment for parathyroid disease (hyperparathyroidism):  Surgery. As discussed above and throughout this large Website, parathyroid disease is caused by a tumor in one or more of the parathyroid glands. The tumor is almost always benign (it is not cancerous!), so simply removing the tumor will cure the disease. Realize that at some very specialized centers, almost all patients can have their parathyroid problem cured in 20 minutes or less, with most mini operations taking 17 minutes or less. 

Sensipar is BAD for primary hyperparathyroidism.NOTE: we have a page on the drug Sensipar... this drug should NOT be used in patients with hyperparathyroidism unless they are on kidney dialysis. This can be dangerous to take if you have a parathyroid problem and do not have kidney failure that requires you to have dialysis. If your doctor said "there is a new drug that will be coming out soon that we may be able to give you so you don't have to have surgery" then you MUST read our page on Sensipar... and take it to them! Your doctor is WAY behind the times. This drug does not work in primary hyperparathyroidism and there is good evidence that it will make you WORSE! The maker of this drug says "NO".  The FDA says "NO".  We say "NO"!"
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9. Nearly all parathyroid patients can be cured with a minimal operation. The days of big dangerous operations are gone. New techniques, tests, and tools have dramatically changed the way parathyroid operations should be done. The days of making a big incision and having the surgeon explore all parts of the neck for the parathyroid glands are gone. These new tools allow ALMOST ALL parathyroid patients to have a MINI parathyroid operation, and ALL patients will benefit from the new tools even if they are one of the 5% or so that require a more extensive operation.  Thus even for them, the new tools make the big operation LESS BIG! Note, a few surgeons have done so many parathyroid operations that they can do mini-parathyroid surgery on ALL patients. This is something that you must discuss with your doctor. Experience matters here... be an informed consumer, discuss options with your surgeon and see what options he/she can offer you. We do mini parathyroid operations on virtually all patients, even when they don't have a positive scan. NOTE: Whether you have a mini-operation or not is dependent upon your SURGEON... NOT your scan.  We do mini parathyroid surgery on essentially 100% of patients... regardless of the scan... and actually prefer that you don't get a scan. The operation you get is dependent upon your surgeon's experience and skill... nothing else.
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10. The success rate and complication rate for parathyroid surgery is VERY dependent upon the surgeon’s experience. Most surgeons don't see more than 1 parathyroid patient every year or two, so they have not had the opportunity to learn the new mini-parathyroid operations. Similarly, the "probe" used for radioguided parathyroidectomy (MIRP) costs approximately $75,000 to $100,000 and most hospitals won't spend the money to buy one of these probes (or some of the other tools available) if only a couple of parathyroid operations are being performed at their hospital every year. Doctors who rarely treat a disease have little or no opportunity to 'practice' or learn the new operative skills, thus they rely on the skills that they use when they take out gallbladders and fix hernias. The differences in CURE RATE, COMPLICATION RATE, and NEED FOR ANOTHER OPERATION between expert parathyroid surgeons and general surgeons is DRAMATIC, and has been published in several medical journal articles. Even the New York Times (Feb, 2003) has written about the difference in outcomes between experts and those who do an operation only a few times per year.  We have an entire page on this topic... click here to read more about this very important topic. Let us state the obvious here... we cannot operate on every patient with parathyroid disease... nor do we want to. However, we are frustrated and saddened EVERY DAY when we get calls and emails from people who went to a general or ENT surgeon for their parathyroid operation and they didn't ask the surgeon important questions like "how many of these operations do you do annually?", or "What is the cure rate?", or "what are the potential complications?". After the operation they call us to say they can't talk, spent 3 days in the hospital, and the surgeon couldn't find the tumor. It is not debatable, surgeons who perform parathyroid operations regularly (at least 1 every week) have better outcomes than surgeons who do fewer than this number. Please become an informed patient and ask the correct questions of your surgeon. There are medical journal articles posted on several other areas of this web site that have the statistics for parathyroid surgery outcomes.

NOTE: the "10 parathyroid rules of Norman" first appeared in the New York Times in 1998.

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