Primary hyperparathyroidism. When to observe and when to operate.

The decision to recommend parathyroid surgery in patients with symptomatic primary hyperparathyroidism is clear. The decision to recommend parathyroid surgery in patients with asymptomatic primary hyperparathyroidism is clearer than it was 10 years ago. In addition to the NIH guidelines, the author believes that patients who have vertebral osteopenia, patients who have vitamin D deficiency, and patients who are in their perimenopausal years should undergo surgery. Although surgery may be an acceptable option even for patients who do not meet these guidelines, many patients can be safely managed without surgery. For these patients, monitoring is essential because a small number will show progression of disease over time.