**7. Conclusion**

Despite of the fact that many patients with hyperparathyroidism do not show symptoms of skeletal affection, clinicians always need to keep an eye on the catabolic effect of hyperparathyroidism on the skeletal system. Better understanding of the mechanism of action of PTH of bone showed that many cells and mediators can influence the RANK/RANKL/OPG system, namely, T lymphocytes. Newer imaging modalities as TBS and HR-pQCT can be useful for detecting subtle bony changes. While parathyroidectomy is proven to reverse the skeletal effects of hyperparathyroidism, many patients may not be indicated for surgery, yet they should receive medical treatment that will protect them from the catabolic effect on the bone. Alendronate was extensively studied and showed to decrease bone turnover and increase BMD. Vitamin D supplementation for patients with vitamin D deficiency has a protective effect on the bone. Denosumab also has a protective effect, but clinical data about its use for patients with hyperparathyroidism is still limited.
