Primary hyperparathyroidism across the care continuum: gaps in diagnosis, access to surgery, and post-operative care

Abstract Background PHPT (primary hyperparathyroidism) is a common endocrine disorder characterised by inappropriate elevation of parathyroid hormone (PTH) and hypercalcaemia, leading to multisystem complications, including skeletal fragility, nephrolithiasis, neurocognitive impairment, and cardiovascular risks. Despite the availability of curative parathyroidectomy (surgical removal of overactive parathyroid gland(s)), many patients experience delayed diagnosis and inequitable access to surgery. Main text Diagnostic delay in PHPT is driven by inconsistent application of testing guidelines, limited use of ionised calcium, biochemical masking by vitamin D deficiency, age-related diagnostic ambiguity, patient and clinician unawareness of the condition, and reliance on fixed calcium thresholds, resulting in frequent incidental diagnosis and a substantial proportion of patients remaining undiagnosed despite biochemical evidence. Surgical referral is often restricted by arbitrary serum calcium cut-offs and age-based differential criteria, even though evidence demonstrates that timely surgery improves outcomes across age groups. Recognition of PHPT as a systemic disorder extending beyond classical skeletal and renal manifestations highlights the need to consider its broader clinical spectrum, including neurocognitive symptoms and other potential systemic manifestations. Postoperative care remains insufficiently addressed, yet persistent and recurrent PHP require long-term biochemical monitoring, and skeletal recovery require structured follow-up. Conclusions Timely recognition of PHPT and equitable access to curative parathyroidectomy are essential to reduce disease burden and prevent avoidable morbidity. Greater clinical awareness of the broader clinical spectrum of PHPT, improved diagnostic and referral pathways, and stronger evidence on disease trajectories, treatment response, and long-term follow-up are needed to address persistent gaps across the PHPT care continuum.