Five Things to Know About Intraoperative PTH Monitoring

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1. Intraoperative PTH monitoring is a tool, not the whole operation.
Patients may hear a lot about intraoperative PTH monitoring and assume it is the main thing that makes parathyroid surgery successful. It is better thought of as one useful tool. The real goal of surgery is to identify and remove the overactive parathyroid gland or glands safely and effectively. Intraoperative PTH monitoring can help confirm that the right tissue has been removed, but it does not replace sound judgment and experience.

2. Some surgeons use it routinely, and some use it selectively.
This is one reason patients see so many different opinions online. Some surgeons check intraoperative PTH in nearly every case. Others use it in selected patients, such as when imaging is not clear, when more than one gland may be abnormal, or when the findings in the operating room are not straightforward. A surgeon’s approach often reflects training, experience, and how they structure their operation.

3. One advantage is that it gives real-time feedback.
Parathyroid hormone levels usually fall within 10-15 minutes after the overactive gland is removed. That means the surgeon can often get biochemical confirmation during the operation that the hyperparathyroidism has been corrected. This can be reassuring, especially in a focused operation where the surgeon is not planning to explore the entire neck.  It does take time to get the result back from the lab, typically 20-30 minutes after each blood sample is drawn. 

4. It also has limits.
Intraoperative PTH monitoring is not perfect. It adds steps to the procedure, will increase the time in the operating room, and sometimes the results are not completely straightforward. A falling PTH is helpful, but it still has to be interpreted in the context of the patient’s lab values, imaging, anatomy, and operative findings. It is an aid, not a guarantee. 

5. The important question is not simply whether it is used, but why.
Patients often ask whether intraoperative PTH monitoring is “the best way.” A better question is whether the surgeon has a clear plan and can explain why this tool is or is not being used in that particular case. Good parathyroid surgery is not defined by one single technique. It is defined by accurate diagnosis, thoughtful planning, careful surgery, and a high likelihood of cure.

Closing paragraph:
If you are talking with a surgeon about parathyroid surgery, it is reasonable to ask whether intraoperative PTH monitoring will be used and how it fits into the plan. The answer should make sense in the context of your case. Different surgeons may use different methods, but the goal is always the same: to treat the hyperparathyroidism safely and effectively.

Disclaimer:
This article is for general education only and is not personal medical advice. Individual recommendations depend on a patient’s full history, laboratory findings, imaging, and overall clinical situation.

How Do You Know If High Calcium Is Coming From a Parathyroid Problem?

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When a blood test shows a high calcium level, one of the first questions is what is causing it. In many cases, the answer is a parathyroid problem, specifically primary hyperparathyroidism. But not every case of high calcium comes from the parathyroid glands, so the lab results have to be interpreted carefully.

The key test is the parathyroid hormone level, usually called the PTH.

If your calcium is high, your parathyroid glands should normally respond by making very little PTH. In other words, a high calcium level should suppress the parathyroid glands. So if the calcium is elevated and the PTH is also elevated, that strongly supports a diagnosis of primary hyperparathyroidism.

In fact, the diagnosis can also be made when the PTH is technically in the normal range. That may sound confusing, but it is actually very important. If the calcium is high, then a “normal” PTH is not really normal. It is inappropriately normal, because it should be low. A non-suppressed PTH in the setting of high calcium points to a parathyroid source.

On the other hand, if the calcium is high and the PTH is clearly low, that usually means the parathyroid glands are behaving normally. They are being turned off, just as they should be. In that situation, the high calcium is probably coming from some other cause, and the evaluation should move in a different direction.

This is why the combination of the two numbers matters more than either one alone. A calcium level by itself does not tell the whole story. A PTH level by itself does not either. The answer comes from looking at them together.

Other tests may also be helpful. Depending on the situation, the workup may include vitamin D measurement, kidney function, urine calcium testing, and sometimes bone density evaluation. These tests help confirm the diagnosis and show whether the condition may already be affecting bones or kidneys.

It is also important to understand what imaging can and cannot do. A sestamibi scan, ultrasound, or CT scan does not make the diagnosis of hyperparathyroidism. The diagnosis is made from the laboratory findings. Imaging is used later, mainly to help plan surgery if surgery is being considered.

The bottom line is this: if your calcium is high, the way to tell whether it is coming from a parathyroid problem is to check the PTH and interpret the two results together. If the calcium is high and the PTH is not suppressed, primary hyperparathyroidism is usually the reason.

This article is for general education only and is not personal medical advice. Individual recommendations depend on a patient’s full history, laboratory findings, and overall clinical situation.

High Calcium on a Routine Blood Test: What Should Happen Next?

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Many people are surprised when a routine blood test shows a high calcium level. They may feel fine, or they may have symptoms they never connected to calcium at all. Either way, it is not something to ignore. Persistent hypercalcemia deserves a careful evaluation, and one of the most common causes is primary hyperparathyroidism.

A single mildly high calcium level does not always mean there is a serious problem. Lab error, dehydration, medications, and other conditions can sometimes play a role. But if the calcium stays elevated on repeat testing, the next step is usually to look at the parathyroid hormone (PTH) level at the same time. If the PTH is also high, or “inappropriately normal” when it should be suppressed, then with just that information a diagnosis of primary hyperparathyroidism is established. If your parathyroid glands are all functioning normally, then they will not be producing much PTH at all if your calcium is high. There is no other explanation for a non-suppressed PTH with a high calcium other than a diagnosis of primary hyperparathyroidism. If you have a high calcium and a low PTH, that means your parathyroid glands are responding appropriately. In this situation other explanations for high calcium should be considered.

Age does matter though. In younger adults, especially patients in their twenties, normal calcium levels may run a little higher. By contrast, in patients who are middle-aged or older, a calcium level that is consistently above about 10 mg/dL deserves closer attention. Calcium reference ranges vary by laboratory, but normal upper limits tend to be higher in younger people and decline with age.

If repeat testing confirms hyperparathyroidism, the workup may include kidney function, vitamin D measurement, and sometimes urine calcium testing or bone density evaluation. The goal is not just to explain the lab value, but to understand whether the condition may already be affecting bones, kidneys, energy level, or quality of life.

The important point is simple: if your calcium is repeatedly high, do not just file that result away. It is worth finding out why. In many cases, the answer is treatable.

This article is for general education only and is not personal medical advice. Individual recommendations depend on a patient’s full history, laboratory findings, and overall clinical situation.

Is There a “Magic Number” for High Calcium?

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One of the most common misunderstandings about high calcium is the idea that a slightly elevated calcium level means a patient has only a mild problem.

That is not a reliable way to think about primary hyperparathyroidism.

But first let’s clarify that we are talking about someone who has a PTH level that is inappropriately high for a given calcium level. This is what establishes a diagnosis of hyperparathyroidism. Many patients are told to simply “watch it for a while” when calcium is only modestly elevated on routine blood work. In some situations, careful follow-up may be part of the discussion. But a mildly elevated calcium level should not automatically be dismissed as unimportant.

When primary hyperparathyroidism is present, the calcium number by itself does not tell the whole story.

There Is No Single “Magic Number”

A common myth is that patients only need to worry when calcium rises above a certain number.

There is no single calcium level that defines how serious a patient’s hyperparathyroidism is. Calcium levels and parathyroid hormone levels can fluctuate. Some patients with proven parathyroid disease never have dramatically elevated calcium levels.

That matters because patients sometimes assume that if the number is not very high, the condition must not be significant. That is not always true.

Why “Mild” High Calcium Can Still Matter

Primary hyperparathyroidism should be evaluated based on the overall clinical picture, not just one lab value.

The evaluation and treatment decision depend on more than the highest calcium level. They depend on the pattern over time, the parathyroid hormone level, bone health, kidney stone history, symptoms, age, and other individual factors.

In other words, a lower calcium level does not necessarily mean a trivial problem.

What If You Do Not Notice Symptoms?

This is another area where patients can be misled.

Some people with hyperparathyroidism have obvious symptoms such as fatigue, poor sleep, body aches, bone pain, poor concentration, headaches, or depression. Others feel relatively well, or they attribute their symptoms to aging, stress, or another condition.

Some patients considered “asymptomatic” may actually have subtler symptoms that are easy to overlook.

That is one reason the absence of dramatic symptoms does not automatically rule out a meaningful problem.

Why Proper Evaluation Matters

The real concern is not whether a calcium level crosses some arbitrary line. The more important issue is whether a patient with persistent high calcium is being evaluated appropriately.

Over time, untreated primary hyperparathyroidism may contribute to problems such as:

  • osteoporosis
  • kidney stones
  • declining kidney function
  • hypertension
  • other long-term health effects

That does not mean every patient with a mildly elevated calcium level needs immediate surgery. It does mean the finding deserves thoughtful attention rather than casual dismissal.

The Bottom Line

If your calcium is high, the most important question is not whether it has reached a “magic number.”

The more important question is whether the finding could represent primary hyperparathyroidism and whether it has been evaluated carefully.

A calcium level that is only slightly elevated can still matter. The right next step is not to focus on one number alone, but to look at the whole picture.

This article is for general education only and is not personal medical advice. Individual recommendations depend on a patient’s full history, laboratory findings, and overall clinical situation.

What’s All the Hype About Vitamin K2?

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Vitamin K2 has been getting more attention lately in relation to hyperparathyroidism, calcium, and vitamin D supplements, especially in conversations about bone health and calcium metabolism. Interestingly, despite a growing amount of information available online, vitamin K2 still lives mostly in the background when it comes to mainstream, peer-reviewed medical literature.

There are a few reasons for that. One is practical: vitamin K2 is not patentable in any meaningful way, which means there is very little financial incentive for large pharmaceutical companies to fund expensive clinical trials. As a result, you won’t see vitamin K2 featured prominently in the major journals the way you might see a new drug or device.

Another issue is that we don’t have a clearly established recommended daily allowance (RDA) for vitamin K2. Different populations consume very different amounts through diet, and the research hasn’t yet settled on a single “correct” dose. Complicating matters further, there is no widely available, reliable blood test to measure vitamin K2 levels. That makes large-scale studies harder to design and interpret.

It’s also important to clarify a common point of confusion: vitamin K2 is not the same as vitamin K1. Vitamin K1 is primarily involved in blood clotting and is what most people think of when they hear “vitamin K.” Vitamin K2, on the other hand, plays a different role—helping direct calcium to where it belongs, particularly into bones and away from soft tissues. Because they share a name, the two are often lumped together, but functionally they are quite distinct.

In my own practice, I have been recommending the addition of vitamin K2 alongside calcium and vitamin D for many years, particularly in patients concerned about bone health and calcium balance. Only more recently have other parathyroid experts begun to publicly emphasize the same approach.

Based on the available evidence and clinical experience, my personal recommendation for vitamin K2 (MK-7) supplementation is 200–300 micrograms daily. While this is not an official guideline, it reflects what I believe to be a reasonable and safe range for most adults.

As with many nutritional supplements, vitamin K2 sits at the intersection of emerging science and clinical judgment. The absence of large trials does not mean it lacks value—it often means the system has little incentive to study it.

This information is educational and not a substitute for medical advice. Talk with your own clinician about your specific situation before starting any new supplement.

What if my scans are normal?

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It is quite common for an endocrinologist to confirm a diagnosis of primary hyperparathyroidism with lab work and then order one or more scans to look for an abnormal gland. It is important to understand that it is not necessary to see an abnormal gland on imaging before an operation to know that you have primary hyperparathyroidism. But it seems that endocrinologists tend to want to “hedge their bets” before referring a patient for surgery. In addition, there are many surgeons who don’t feel comfortable considering surgery without having a scan that shows a single abnormal gland.

The most experienced parathyroid surgeons feel quite comfortable proceeding with surgery even if scans are normal. They know that if the lab work confirms the diagnosis, then they will be able to identify the abnormal gland or glands at surgery, regardless of the scan findings. The scans are quite helpful as a roadmap in preparation for surgery. But the imaging should not be the determining factor.

Why do scans sometimes look normal? Parathyroid glands are tiny and sit close to the thyroid. Normal glands are almost never seen, and a small overactive gland may blend in, or it may sit behind the thyroid or lower in the neck where it’s hard to see. Ultrasound is also operator-dependent: subtle findings can be missed by people who do not perform or read these tests often. An expert review can sometimes spot clues that others overlook. Although an abnormal parathyroid gland might not be seen on a sestamibi scan if it sits behind the thyroid (its usual location), it is hard to miss if it sits somewhere else. It is important for the surgeon to know if an abnormal gland is in an ectopic location, because those are the ones that might not be found even by an experienced surgeon. As long as the sestamibi scan doesn’t show an abnormal location for the parathyroid gland, the surgeon can confidently go ahead with surgery, even if the scan is read as normal.

Bottom line: Don’t delay treatment you need while waiting for a scan to “light up.” If your labs confirm primary hyperparathyroidism, talk with a surgeon who treats this every week and can walk you through cure rates, risks, and next steps for you.

This information is educational and not a substitute for medical advice. Talk with your own clinician about your situation.

“My Endocrinologist says I have primary hyperparathyroidism, but he wants to watch it and not refer me for surgery. Why is that?”

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The history of parathyroid surgery is pretty interesting. It started over a century ago, long before we had the advanced testing we use today. Back then, there was no way to measure parathyroid hormone (PTH) levels—only serum calcium could be tested. Patients often showed up with severe bone disease or kidney stones. Without a PTH test, doctors had to rule out every other possible cause of high calcium before suspecting a parathyroid problem. Endocrinologists became the go-to specialists for sorting through all those possibilities. Only when every other cause was eliminated would they conclude an overactive parathyroid gland was to blame, and that’s when a surgeon got involved.

Fast forward to today, and things are much simpler. We have a quick blood test to check intact PTH levels. If you have four normal parathyroid glands, they won’t overproduce PTH just because your calcium is high for another reason. Now, the first step when calcium is elevated is to check PTH. If it’s not suppressed, the diagnosis of primary hyperparathyroidism can be made right away. In fact, if you’re generally healthy and your calcium is consistently high, chances are good that’s the issue—so it’s smart to check this first.

Still, many primary care doctors send patients with high calcium to an endocrinologist, and some endocrinologists keep running through all the old possible causes even when it’s unnecessary if the PTH is already too high. They might diagnose primary hyperparathyroidism but downplay it, telling the patient, “It’s not that bad, let’s just follow it”.

This likely comes from a time when parathyroid surgery wasn’t as safe or routine as it is today in skilled hands. They may not realize how symptomatic these patients can be, even when calcium and PTH levels aren’t “that high.” The truth is, parathyroid surgery is highly effective and very safe when performed by experienced surgeons. Most people with primary hyperparathyroidism have symptoms that can improve, often significantly, after a straightforward operation.

Maybe your endocrinologist ordered scans to locate an abnormal parathyroid gland, but they came back negative. So, what happens next? Stay tuned.

Too Much of a Good Thing: The Truth About High Blood Calcium

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Understanding Hypercalcemia: Causes, Symptoms, and Treatment

Hypercalcemia occurs when the level of calcium in the blood is too high—usually above 10.0 mg/dL. Calcium plays a key role in keeping bones strong, helping muscles work, and supporting nerve function. However, too much calcium in the bloodstream can interfere with these systems and lead to serious health problems.

The most common cause of hypercalcemia is a condition called primary hyperparathyroidism (PHPT). This happens when one or more of the parathyroid glands become overactive and produce too much parathyroid hormone (PTH). These small glands are located in the neck near the thyroid and help regulate calcium levels. When they produce too much PTH, calcium is pulled from the bones, absorbed more in the intestines, and lost less through urine—leading to high blood calcium levels.

Symptoms of Hypercalcemia:

  • Constant fatigue or muscle weakness
  • Kidney stones due to excess calcium being filtered
  • Bone pain or weakened bones, increasing fracture risk
  • Nausea, constipation, or appetite loss
  • Trouble with memory, focus, or mood

Best Treatment: Parathyroid Surgery

For most people with PHPT, parathyroid surgery is the only long-lasting solution. The procedure involves removing the overactive gland, which allows calcium levels to return to normal. At ParathyroidAtlanta, a minimally invasive surgery called MIRP (Minimally Invasive Radioguided Parathyroidectomy) is used to precisely remove the affected gland with a small incision, resulting in quicker recovery and fewer complications.

Life After Treatment

Patients usually feel better within days—less tired, fewer digestive problems, and improved focus. Most go home the same day and return to regular activities in less than a week.

Treating hypercalcemia early helps prevent long-term damage to bones, kidneys, and mental health.

How Parathyroid Problems Can Cause Weak Bones

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Your parathyroid glands help control how much calcium is in your blood and bones. If one or more of these glands makes too much hormone, it’s called hyperparathyroidism.

This hormone tells your bones to release calcium into your blood. Over time, your bones can lose too much calcium and become weak. This can lead to osteoporosis, which means your bones are more likely to break.

The hormone also makes your body lose calcium through urine. It can also stop your body from using vitamin D the right way. Without enough calcium and vitamin D, your bones can get even weaker.

The only way to fix this problem of excess parathyroid hormone is with parathyroid surgery. A doctor removes the gland or glands that are making too much hormone. This helps your calcium levels go back to normal and helps your bones stay strong. Bones can even regain strength over time after surgery.

But this surgery can be tricky. If the doctor doesn’t check all four parathyroid glands, the problem might not be fully fixed. And if too much is removed, you can get another problem called hypoparathyroidism, which is very hard to treat. That’s why it’s important to go to a doctor who does this surgery often.

Dr. Kennedy has decades of experience in parathyroid surgery, and routinely looks for all four glands, to be certain that all abnormal glands are found. The surgery is done as an outpatient, with a 98% success rate.

If you are diagnosed with hyperparathyroidism, there’s a sure and simple cure. With minimally invasive outpatient surgery  — one precise and tiny little incision — we can remove the overactive parathyroid gland, leaving behind the three healthy remaining glands.
The cure is almost always immediate.

Contact Us Today to Get Started on Your Diagnosis and Cure

The Review of Patient Records is Included in the Consult Fee; There is no Additional Charge

Even a slightly elevated calcium can have a major impact on your health!

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Here is a letter I recently received from a patient who had been suffering with typical symptoms of high calcium for about 4 years, with a calcium level that was “only” in the low 10’s. She recently underwent a simple outpatient operation to remove the overactive parathyroid gland and get her calcium and PTH back to normal.

“Dear Dr Kennedy,

I wanted to thank you again, for all of your help! I also wanted to give you a quick update on my progress!

My body seems to be healing by leaps and bounds since parathyroid surgery on xx/xx/23! I’m now OFF all 4 of my BP meds (I met with cardiologist yesterday).

My BP used to be in the 220/117 range (even with all the BP meds), and yesterday in his office it was 120/78 without taking any BP meds since November.

I’ve been able to stop my daily muscle relaxer /AND I’ve also cut back on pain meds for my lumbar spinal pain.

Chronic fatigue is improving daily!! A “normal day” for me before surgery was to struggle to get to work (and I work from home) by 9AM, and then I’d go right back to bed whenever I finished work. No hobbies, and I’d have to rest on all days off.Since surgery, now I have no problem getting to (and thru) my work days, I’m also studying Japanese again AND planning a ski trip to Japan in Winter 2025 plus I hope to make it to the Philippines to visit friends on the same trip! (I used to live in Japan, that’s where I learned to ski). I’ve also started hiking again and will try light mountain biking again this weekend. I’m also doing weights again on the days I’m not hiking! This is all just after 6 weeks or so….

I can’t wait to see the changes after 6 months! Mood problems (extreme anxiety and depression) haven’t been a problem since I healed from surgery.

I wanted to wish you and all of your loved ones a Merry Christmas, Happy New Year, and a wonderful holiday season!

Thank you again!

SD”