Individualized management of primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common endocrine disease that typically presents in peri- and postmenopausal women. PHPT is due to a single parathyroid adenoma in most cases, which leads to stable hypercalcemia over years. Nowadays, the diagnosis is often coincidental, reached by chance in subjects without specific symptoms-asymptomatic PHPT. However, the patients might have subtle disease-related manifestations. Management standards have been reviewed through international workshops over more than three decades, leading to absolute and relative indications for parathyroidectomy (PTX), the only curative treatment. The alternative to PTX is observation without intervention in asymptomatic patients without organ manifestations and only mildly elevated calcium levels (mild PHPT). On the basis of recent literature, our aim is to challenge current recommendations for managing PHPT with focus on mild asymptomatic disease, integrating informed patient preferences. Considering the changing patient demography with increasing life expectancy, more sensitive visualization procedures, improved surgical techniques, and new data on PHPT-related morbidity, we test some of the established indications for PTX, particularly age as an isolated criterion, and the validity of a circulating calcium "threshold" for considering PTX. Additionally, bone mineral density (BMD) decreases for at least a decade with observation in contrast to PTX, where BMD normalizes after surgery and remains stable in the axial compartments for years. Therefore, skeletal-related thresholds for PTX also deserve review. In conclusion, we suggest integrating more clinical outcomes and wider perspectives in decision-making for the management of mild PHPT, taking patient preferences into consideration, and focusing on informed and shared decision-making.