Parathyroid hormone deficiency and excess: Similar effects on trabecular bone but differing effects on cortical bone

Parathyroid hormone (PTH) may be anabolic at trabecular bone and catabolic in cortical bone. As many regions of the skeleton contain both types of bon e, the effects of PTH deficiency or excess may be difficult to evaluate usi ng bone densitometry, a technique that integrates the cortical and trabecul ar compartments of bone. We asked the following questions: 1) Is the higher bone mineral density (BMD) in postsurgical hypoparathyroidism due to highe r cortical, not trabecular, bone? 2) Is age-related bone loss slowed in pat ients with postsurgical hypoparathyroidism? 3) Is lower BMD in primary hype rparathyroidism the result of deficits in cortical, not trabecular, bone? BMD of the lumbar spine, proximal femur, distal radius, and femoral midshaf t was measured by postero-anterior (PA) scanning, while bone mineral conten t (BMC) of the third lumbar vertebra was measured by lateral scanning using dual x-ray absorptiometry in 10 women, ages 64.6 +/- 3.2 yr, with postsurg ical hypoparathyroidism and in 25 women, ages 68.7 +/- 1.6 yr, with primary hyperparathyroidism. Measurements were repeated 4.7 +/- 0.6 yr later in 8 patients with hypoparathyroidism and 4.0 +/- 0.4 yr later in 20 age-matched controls. Data were expressed as z scores (SD, mean +/- sem) derived from 405 postmenopausal women. In patients with hypoparathyroidism, bone mass z score of the third lumbar vertebra (vertebral body plus posterior processes) was higher than zero by PA scanning (1.26 +/- 0.58 so, P < 0.05) and lateral scanning (1.04 +/- 0.6 0 so, P = 0.1), and higher at the trabecular-rich vertebral body(1.02 +/- 0 .47 SD, P = 0.07) and predominantly cortical posterior processes (0.98 +/- 0.66 so, P = 0.1) determined by lateral scanning. The BMD z scores were hig her than zero at the femoral neck (0.89 +/- 0.48 so, P = 0.09), but not at the femoral midshaft(0.45 +/- 0.60, NS) and distal radius (0.04 +/- 0.51, N S). During follow-up, femoral neck BMD decreased in controls but not in pat ients with hypoparathyroidism (slope, -0.00818 +/- 0.00496 g/cm(2)/year us. 0.00907 +/- 0.00583 g/cm(2)/year, respectively, P = 0.06). There was no ch ange in lumbar spine BMD in either group. In 25 women with primary hyperpar athyroidism, there were no deficits in BMD at the third lumbar vertebra (ve rtebral body plus posterior processes) by PA or lateral scanning. By latera l scanning, BMC was increased at the vertebral body (0.64 +/- 0.31 SD, P < 0.01) and reduced at the posterior processes (- 0.65 +/- 0.26 SD, P < 0.05) . BMD was lower at the midshaft of the femur (- 0.82 +/- 0.37 sn, P < 0.05) and at the distal radius (-0.68 +/- 0.20 sn, P < 0.01), but not at the fem oral neck. (- 0.08 +/- 0.20 so, NS). Longitudinal data were unavailable in hyperparathyroid patients. In summary, trabecular bone is increased by both PTH deficiency and excess. Cortical bone loss is slowed by PTH deficiency and accelerated by PTH exce ss so that suppression of PTH may reduce age-related bone loss and the risk of fracture. Assessment of BMD in PTH deficiency and excess requires the s eparate study of cortical and trabecular bone.