Journal of Clinical Epidemiology 53 (2000) 11641169

Primary hyperparathyroidism detected in a health screening:

The Troms Study
Rolf Jordea,b,*, Kaare H. Bnaac, Johan Sundsfjordd
a
Department of Internal Medicine, University Hospital of Troms, 9038 Troms, Norway
Centre for Clinical Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, University of Newcastle, Newcastle, Australia
c
Institute of Community Medicine, University Hospital of Troms, Troms, Norway
d
Department of Clinical Chemistry, University Hospital of Troms, Troms, Norway
Received 20 January 1999; received in revised form 29 February 2000; accepted 4 March 2000

Abstract
Serum calcium was measured in 12,339 men and 13,394 women ages 25 to 75. Primary hyperparathyroidism, defined as a combination
of serum calcium and parathyroid hormone (PTH) levels within the extreme or upper normal range, was diagnosed in 17 men and 47
women. The prevalence in both sexes increased with age. When 42 subjects with asymptomatic primary hyperparathyroidism were followed for 3 years, no significant increase in serum calcium or PTH was seen. In a subgroup of 473 men and 517 women ages 50 to 75, serum PTH was measured along with serum calcium. Depending on the criteria used to define primary hyperparathyroidism, the prevalence
in older women within this subgroup ranged from 3.6% to 13.9%. The study concluded that a high prevalence of primary hyperparathyroidism exists in older women, although the progression of the disease, judging by serum calcium and PTH measurements, appears to be
very slow. 2000 Elsevier Science Inc. All rights reserved.
Keywords: Hypercalcaemia; Parathyroid hormone (PTH); Primary hyperparathyroidism (PHPT); Serum albumin; Serum calcium; PTH screening

1. Introduction
Primary hyperparathyroidism is diagnosed by demonstrating an inappropriately increased level of parathyroid
hormone (PTH) in relation to that of serum calcium [1].
However, in larger population-based health surveys which
included screening for primary hyperparathyroidism, the diagnosis has mainly been based on serum calcium measurements alone, since reliable assays for PTH were not available. Thus, for example, in a health screening from 1969 in
Gvle, Sweden, which included more than 16,000 subjects,
the prevalence of hypercalcaemia in the total population
was found to be 0.7%, increasing to over 3% in women
above the age of 60 [2]. Similarly, in a study from Stockholm in 1973 where some 21,000 subjects were screened,
the prevalence was found to be 0.3% of the total population,
increasing to 1.3% in older women [3]. This pattern has
been confirmed in several hospital-based studies; there is
now general agreement that the incidence of primary hyperparathyroidism is higher in women than men, and that it increases with age [4,5].

* Corresponding author. Tel.: 47 776 26000; fax: 47 776 26863.

E-mail address: medrj@rito.no (R. Jorde).

In Troms, Norway, a large health survey was performed

on more than 27,000 inhabitants during 19941995. Serum
calcium was measured in all subjects, and those with levels
above 2.59 mmol/L were re-examined. PTH was also measured in a subgroup of 990 subjects, thus affording an opportunity of determining the prevalence of primary hyperparathyroidism by a variety of criteria for its definition.
2. Materials and methods
2.1. Subjects and definitions
The Troms study is a broad health survey first instituted
in Norway in 1974. It is carried out by the National Health
Screening Service in co-operation with the University of
Troms and local health authorities. The present study is
based on the fourth survey (19941995). A total of 12,866
men and 14,293 women participated, representing 74.2%
and 79.0% of the eligible population, respectively. All subjects had blood samples drawn for serum calcium measurements. If serum calcium was 2.60 mmol/L in the case of
an individual under the age of 76 who lived within a reasonable distance of the city center, that person was asked to return for testing in order that levels of serum calcium, creatinine, albumin, phosphate, and PTH could be ascertained. To

0895-4356/00/$ see front matter 2000 Elsevier Science Inc. All rights reserved.
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R. Jorde et al. / Journal of Clinical Epidemiology 53 (2000) 11641169

1165

insure the inclusion of patients with mild cases of the disease, we used a set of combinations of serum calcium and
PTH similar to that reported by Lundgren et al. in their diagnosis of primary hyperparathyroidism [6]. Thus, if serum
calcium was still 2.50 mmol/L and serum PTH 6.0
pmol/L; or serum calcium 2.55 mmol/L and serum PTH
5.5 pmol/L; or serum calcium 2.60 mmol/L and serum
PTH 5.0 pmol/L, the subject was considered to have primary hyperparathyroidism (provided the serum creatinine
level was below 150 mol/L). Such individuals were then
examined in the outpatient clinic of the Medical Department, University Hospital of Troms, at intervals of 6, 18,
and 36 months. Where serum calcium rose above 2.80
mmol/L or the patient had symptoms that could be ascribed
to hypercalcaemia, an operation was advised.
Additionally, a subgroup of 473 men and 517 women between the ages of 50 to 75 had blood samples drawn for serum PTH measurements.

in our laboratory, had a CV of 68% in the actual range.

The reference range used in the laboratory was 1.16.8
pmol/L for those below the age of 50, and 1.17.5 pmol/L
for those 50 and above.

2.2. Analyses

3.1. Main study group: serum calcium measured

during screening

The subjects were not requested to fast. Blood samples

were drawn, as previously described, and were analyzed at
the Department of Clinical Chemistry, University Hospital
of Troms [7]. Serum concentrations of calcium, creatinine,
albumin, and phosphate were determined on a Hitachi
Model 917 analyzer with reagents from Boehringer Mannheim (Mannheim, FRG). The respective reference ranges in
our laboratory were: serum calcium 2.202.60 mmol/L; serum creatinine 70100 mol/L for men and 55100 mol/L
for women; serum albumin 35.050.0 g/L; and serum phosphate 0.751.55 mmol/L. After the initial screening, serum
calcium was also normalized against serum albumin using
the following formula: serum calcium (adjusted value)
serum calcium (analyzed value) (serum albumin 40)
0.02. Intact PTH was measured on an Immulite analyzer
(Diagnostic Products, Los Angeles, CA, USA) on the basis
of a two-site chemiluminescent immunometric assay which,

2.3. Statistics
Comparisons between the prevalence of primary hyperparathyroidism in men and women were done using
Fishers Exact Test. Differences between mean PTH levels
at the four re-examinations were evaluated employing
ANOVA with least-significant difference (LSD) as a post
hoc multiple comparison test. The aforementioned tests
were all done two-sided, P 0.05 being considered statistically significant. The data was analyzed with the SPSS statistical package for Windows 8.0 (SPSS, Chicago, IL, USA).

3. Results

Because only individuals below the age of 76 were included in the follow-up study, those above that age do not
appear in the presentation below. The total number of subjects, therefore, comprised 12,339 men and 13,394 women.
3.1.1. Unadjusted serum calcium
The distribution of serum calcium is shown in Table 1
and Fig. 1. In men, serum calcium decreased with advancing age, whereas in women an increase was seen after the
age of 50.
A total of 366 subjects were identified as having serum
calcium levels above 2.59 mmol/L. The hospital records of
all these individuals were reviewed. Eighteen subjects with
chronic diseases (stroke, heart disease, cancer) were considered too ill to justify a re-examination for research purposes; 34 more were living outside central Troms; and 32

Table 1
Distribution of serum calcium (mmol/L) and albumin (g/L), and prevalence of PHPT

Sex/age
Men
2529
3039
4049
5059
6069
7075
Women
2529
3039
4049
5059
6069
7075

PHPT found

No. of
subjects

Mean serum
calcium (mmol/L)

Serum
calcium
2.59
(n)

1285
3213
3330
2304
1500
707

2.41 (0.10)
2.40 (0.10)
2.39 (0.10)
2.38 (0.09)
2.37 (0.10)
2.37 (0.10)

21
54
40
17
22
10

13
40
27
13
19
9

45.2 (1.7)
44.4 (2.3)
43.6 (2.7)
41.8 (2.5)
42.0 (2.2)
39.6 (4.0)

1
1
2
5
2
6

1532
3653
3416
2296
1638
859

2.35 (0.10)
2.35 (0.10)
2.36 (0.10)
2.39 (0.11)
2.40 (0.11)
2.40 (0.11)

11
22
28
57
58
26

10
20
21
44
47
19

42.5 (3.7)
41.3 (4.3)
41.9 (3.4)
41.7 (2.6)
41.6 (2.0)
40.7 (1.9)

0
3
5
10
18
11

No.
re-examined

Mean serum
albumin

Calcium
unadjusted

Prevalence PHPT (%)

Calcium
albuminadjusted

Calcium
unadjusted

Calcium
albuminadjusted

1
2
1
3
2
6

0.12
0.04
0.09
0.28
0.15
0.95

0.12
0.08
0.05
0.17
0.15
0.95

0
2
3
9
18
11

0
0.09
0.20
0.57
1.36
1.75

0
0.06
0.12
0.51
1.36
1.75

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R. Jorde et al. / Journal of Clinical Epidemiology 53 (2000) 11641169

Fig. 1. Distribution of serum calcium in men and women studied.

did not respond when contacted. Thus, 282 subjects (121

males and 161 females) had a second set of blood samples
drawn. The testing showed serum calcium levels as follows:
178 (63.1%) 2.50 mmol/L; 41 (14.5%) 2.50 to 2.55
mmol/L; 22 (7.8%) 2.55 to 2.60 mmol/L; and 41 (14.5%)
2.60 mmol/L. In the last three serum calcium groups, primary hyperparathyroidism was confirmed in the case of 22
(53.6%), 11 (50.0%), and 31 (75.6%) subjects, respectively.
Thus, the total number of individuals with primary hyperparathyroidism was 64 (17 men and 47 women). Assuming
the age-adjusted prevalence of primary hyperparathyroidism to be equally high in the 84 subjects who were not reexamined, the prevalence in the total population can be estimated at 0.17% for men and 0.45% for women (P 0.001).
Both sexes showed an increase with age (Table 1).
3.1.2. Adjusted serum calcium
The prevalence of primary hyperparathyroidism when
adjusting serum calcium for albumin concentration is given
in Table 1. Because the mean serum albumin level was
higher than 40 g/L (particularly in young men), correcting
for serum albumin caused a slight reduction in mean serum
calcium levels, and thus a slight decrease in serum calcium
in the younger age groups. In our study, correcting for serum albumin had no effect on the prevalence of primary hyperparathyroidism in the older age groups.
3.2. Follow-up study
Surgery was recommended and performed in 8 of the 64
subjects with primary hyperparathyroidism. Of the remain-

der, three died, one moved, and one declined further contact. Nine subjects attended some of the follow-ups. Thus,
complete follow-up data is available in the case of 42 subjects. Furthermore, 39 of those with serum calcium above
2.59 mmol/L at the screening, but with normal serum calcium and PTH at the first re-examination, attended the follow-ups and thereby served as a control group.
As appears from Table 2, there was an insignificant increase in PTH values in the primary hyperparathyroidism
group when they were examined for the last time. However,
a similar increase was also seen in the control group. No
corresponding increase was noted in the case of other parameters.
3.3. Subgroup: serum calcium (unadjusted) and
PTH measured at the screening
The 990 subjects were grouped by PTH levels in steps of
0.5 pmol/L from 5.0 to 6.9 pmol/L, and serum calcium
levels in steps of 0.05 mmol/L from 2.45 to 2.59 mmol/L.
The interrelations between these groups are shown in Table 3.
Using the definition of primary hyperparathyroidism employed in the larger study, we determined a prevalence of
8.8% in the older women. As can be seen from Table 3,
slight changes in the definition would yield great changes in
the prevalence. Thus, if one sought both a serum calcium
level above 2.59 mmol/L and a PTH above 6.9 pmol/L, the
prevalence in women 70 to 75 years old would fall to 3.6%.
On the other hand, if one applied the criteria used by
Lundgren et al. in their re-examination of women whose se-

R. Jorde et al. / Journal of Clinical Epidemiology 53 (2000) 11641169

1167

Table 2
Serum calcium (mmol/L), PTH (pmol/L), Phosphate (mmol/L), and creatinine (mol/L) at initial screening and follow-up
Initial screening
PHPT (n 42)
Calcium
Calcium (adjusted)
PTH
P-valuea
Phosphate
Creatinine
Controls (n 39)
Calcium
Calcium (adjusted)
PTH
P-valuea
Phosphate
Creatinine
a

2.71 (0.09)

First follow-up
2.57 (0.08)
2.54 (0.09)
9.1 (2.7)
0.94 (0.19)
74.2 (12.7)

2.64 (0.05)

2.49 (0.09)
2.41 (0.08)
4.0 (1.4)
0.99 (0.18)
72.3 (13.0)

After 6 months

After 18 months

After 36 months

2.63 (0.10)
2.57 (0.10)
9.4 (3.4)
0.94
0.90 (0.18)
76.1 (13.0)

2.62 (0.11)
2.56 (0.12)
9.6 (3.2)
0.63
0.91 (0.15)
72.7 (13.7)

2.54 (0.10)
2.50 (0.12)
10.8 (4.8)
0.22
0.91 (0.18)
78.6 (16.4)

2.50 (0.11)
2.43 (0.10)
4.0 (1.5)
0.81
0.98 (0.15)
74.5 (13.1)

2.51 (0.09)
2.43 (0.10)
3.9 (1.6)
0.82
1.05 (0.19)
72.6 (12.5)

2.38 (0.08)
2.32 (0.09)
4.8 (2.0)
0.12
1.01 (0.18)
76.4 (12.9)

Versus PTH at first follow-up.

rum calcium was above 2.55 mmol/L, the prevalence would

be as high as 13.9% [6].
4. Discussion
The present study indicates the increased prevalence of
primary hyperparathyroidism in women, particularly those
above the age of 70. Depending on the screening method
and definition of primary hyperparathyroidism employed,
the prevalence in this group ranged from 1.75% to 13.9%,
underscoring the role consensus plays in the identification
of this disease.
In attempting to diagnose primary hyperparathyroidism,
it will be recalled that about 50% of total serum calcium exists in a free or ionized form, and approximately 40% is
bound to serum albumin. The ionized form is biologically
active, and thus it is the most relevant element in the diagnosis of primary hyperparathyroidism. Serum ionized cal-

cium values were not available to us during the present

study. As an alternative measure, serum calcium was corrected for serum albumin level after the initial screening.
However, this adjustment had only a marginal effect on the
prevalence of primary hyperparathyroidism in our findings.
Previous research into the prevalence or incidence of primary hyperparathyroidism has utilized definitions which
have varied widely. Thus, in a study by Palmr et al., hypercalcaemia (presumably caused by primary hyperparathyroidism) was diagnosed on the basis of a subject having a serum
calcium level above 2.60 mmol/L on two occasions [2];
whereas in a study by Christensson et al., the cutoff point
was set as high as 2.78 mmol/L [3]. In more recent studies,
serum PTH and ionized calcium have been taken into account, but definitions are still not uniform. Thus, Sorva et al.,
looking at 610 subjects ranging from 75 to 85 years old,
found primary hyperparathyroidism in 3% of the women, but
in less than 1% of the men; these results were based on find-

Table 3
Distribution by age according to serum PTH (pmol/L) and unadjusted serum calcium (mmol/L) levels in subgroup of 990 subjects screened for both variablesa
Age
group

Serum
calcium

Serum PTH
5.0

5.05.4

5.55.9

6.06.4

6.56.9

5059

2.45
2.452.49
2.502.54
2.552.59
2.59
2.45
2.452.49
2.502.54
2.552.59
2.59
2.45
2.452.49
2.502.54
2.552.59
2.59

75 (53)
11 (14)
13 (7)
4 (4)
1 (2)
119 (122)
22 (41)
19 (18)
5 (6)
1 (4)
47 (54)
8 (19)
9 (10)
3 (5)
2 (5)

10 (5)
1
1
(1)

6 (2)
2

3 (3)
(1)
1
1

3 (1)
1

7 (15)
(5)
(5)

5 (5)
2 (1)

3 (4)
(1)
1

7 (4)
2
(1)
(1)

5 (2)
3 (1)
(2)
(1)

4 (1)
(1)

6069

7075

6 (15)
1 (2)

(1)

(1)
7 (5)
3
(2)
(1)

Figures without parentheses, men; figures within parentheses, women.

6.9
8 (7)
(1)
(1)
(1)
16 (26)
3 (2)
1 (1)
(2)
12 (11)
3 (4)
3 (1)
(1)
3 (5)

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R. Jorde et al. / Journal of Clinical Epidemiology 53 (2000) 11641169

ing serum ionized calcium 2 SD above the population mean,

together with an elevated serum PTH [8]. Similarly, Lindstedt et al. ascertained primary hyperparathyroidism in 2%
of a group 75 years of age and older on the basis of finding
ionized serum calcium 3 SD above the population mean, together with serum PTH in the upper range [9]. Finally,
Lundgren et al. measured serum calcium in more than 5000
women 55 to 75 years old who had presented themselves for
mammograms, re-examining those with a serum calcium
level of 2.55 mmol/L or above. Using criteria similar to
those we employed, the prevalence of primary hyperparathyroidism was found to be 2.1% in their study population [6].
How, then, is primary hyperparathyroidism to be defined
and diagnosed? An NIH consensus development statement
from 1991 concludes that the diagnosis of primary hyperparathyroidism is established by demonstrating persistent
hypercalcaemia together with an elevated parathyroid hormone concentration [1]. Today such a procedure is not difficult. Modern PTH assays are both reliable and sensitive;
the combination of an increased serum PTH and increased
serum calcium is seen only in patients with primary hyperparathyroidism, with the possible exception of patients on
lithium therapy, or those with familial hypocalcuric hypercalcaemia [10]. In northern Norway, familial hypocalcuric
hypercalcaemia is very rare. However, as this was not specifically tested for in our study, we cannot discount the possibility that a few such patients were included in the primary
hyperparathyroidism group. In other individuals, hypercalcaemia causes a suppression of PTH secretion; these subjects would ordinarily be identified by the screening and excluded, as was the case in our study.
Such a definition of primary hyperparathyroidism, however, although it has a high specificity, is lacking in sensitivity. Thus, subjects with a combination of serum calcium
and PTH in the upper normal range most likely have the disease in a mild form. There are also several reports of normocalcaemic primary hyperparathyroidism [11,12]. However, as pointed out by Ljunghall et al., there is seldom the
need to rush the diagnosis in such mild cases, as the disease
usually progresses very slowly [13].
This slow progression of primary hyperparathyroidism
was demonstrated in our follow-up study. Although a slight
elevation of serum PTH was detected at the concluding reexamination, such an increase was also seen in the control
group. One possible explanation for this could be analytic
driftan unlikely conjecture since the PTH assay was performed on the same instrument as the initial screening, with
the same analytic tools, and without deviation or loss of accuracy, as judged by pooled serum controls at the beginning
and end of each series. On the other hand, one could argue
that our control group was not a properly constituted one,
since a prerequisite for inclusion was evidence of hypercalcaemia on at least one occasion. Accordingly, the slight increase in PTH in the controls could reflect slowly evolving
disease in that group as well. However, the increase in PTH
in the primary hyperparathyroidism group was very small

and not statistically significant. Nevertheless, this should be

interpreted with caution, as we followed only 42 subjects.
A similar observation was made by Sudhaker et al. in a
study where 174 patients with primary hyperparathyroidism
were tracked from 1 to 11 years, but showed no progression
in their disease or in its biochemical effects [14]. Similarly,
Corlew et al. followed 47 patients for 5 years and found no
further increase in serum calcium [15]. The same overall conclusion was reached by Palmr et al. in studying 176 hypercalcaemic patients for 14 years and finding little risk of a progressive rise in serum calcium [2]. On the other hand,
Rudnicki and Transbl detected a clear increase in serum
PTH during an observation period of two and a half years
[16]. It should be noted, however, that most of their 24 patients already had relatively advanced disease; only six were
considered asymptomatic. In sharp contrast, all of those in
our group were without obvious symptoms of disease. Thus,
it may be assumed that the course of mild primary hyperparathyroidism is most likely to be quite gradual, with only a few
patients progressing to symptomatic disease. Still, it must be
emphasized that the progression of the disease, as well as the
need for surgery, is dependent upon several other factors,
such as reduction in bone mass and hypertension, and cannot
be assessed by following serum calcium and PTH alone.
The Mayo Clinic has recently issued a report suggesting
that the incidence of primary hyperparathyroidism is declining [17]. Their findings showed, as expected, an increase in
patients diagnosed with primary hyperparathyroidism when
routine measurements of serum calcium by automated technology was introduced. Thereafter, a persistent decline was
seen, suggesting a change in the epidemiology of the disease.
However, our estimation of the prevalence of primary hyperparathyroidism, based on serum calcium screening, was fairly
similar to that reported 30 years ago in two large Swedish
studies [2,3]. Although these studies are not directly comparable to ours, they do still caution against proposing major
changes in the epidemiology of primary hyperparathyroidism.
In the main study, we established a serum calcium level
of 2.60 mmol/L or above at the first screening as the threshold for re-examination. Fig. 1 indicates that most subjects
had a slightly increased calcium level, with only 14.5%
showing evidence of hypercalcaemia at the second testing.
However, in those subjects in whom a serum calcium level
2.60 mmol/L could be confirmed, a diagnosis of primary
hyperparathyroidism was made in 75.6% of the cases. Furthermore, among 26 subjects with serum calcium 2.65
mmol/L at the re-examination, primary hyperparathyroidism
was confirmed in 23 of them (88.5%). In the remaining
three subjects, serum PTH levels were between 4.0 and 4.9
pmol/L, making a diagnosis of primary hyperparathyroidism
plausible. Accordingly, it may safely be conjectured that, in
otherwise healthy subjects, a persistently elevated serum
calcium level is most likely to be caused by primary hyperparathyroidism. In the presence of moderate hypercalcaemia, the likelihood of this diagnosis grows as serum calcium
levels increase. Unfortunately, we did not follow systemati-

R. Jorde et al. / Journal of Clinical Epidemiology 53 (2000) 11641169

cally those with transient hypercalcaemia, nor those with

persistent hypercalcaemia in the absence of primary hyperparathyroidism. None of these individuals, however, had
suppressed serum PTH values and none were clinically ill.
Our study found a remarkably high prevalence of primary
hyperparathyroidism in elderly women, regardless of inclusion criteria. It also seems certain that, in mild cases, the
progress of the disease is very slow, if one judges by measurements of serum calcium and PTH. Finally, we conclude that,
where hypercalcaemia can be confirmed by a second test, the
most likely diagnosis is primary hyperparathyroidism.

[7]

[8]

[9]

[10]
[11]

Acknowledgment
The present study was supported by a grant from the
Norwegian Research Council.

[12]

[13]

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