Last reviewed: 24 Feb 2023
Last updated: 27 Jul 2022



History and exam

Key diagnostic factors

  • history of thyroid, parathyroid, or laryngeal surgery
  • chronic alcoholism
  • malnutrition, malabsorption, diarrhoea
  • muscle twitches, spasms, cramps
  • paraesthesias, numbness, tingling
  • poor memory, slowed thinking
  • Chvostek’s sign
  • convulsions
  • irregular heart beat, tachycardia
  • Trousseau sign
More key diagnostic factors

Other diagnostic factors

  • anxiety
  • dry hair, brittle nails
  • cataracts
  • history of mucocutaneous candidiasis
  • history of chronic transfusions in patients with thalassaemia
  • dyspnoea
  • laryngeal spasm
Other diagnostic factors

Risk factors

  • thyroid surgery
  • parathyroid surgery
  • hypomagnesaemia
  • moderate and chronic maternal hypercalcaemia (neonatal hypocalcaemia)
  • autosomal dominant conditions (e.g., mutations in CASR, GATA3)
  • hereditary haemochromatosis
  • transfusional iron overload in thalassaemia
  • Wilson's disease
  • metastatic cancer
More risk factors

Diagnostic investigations

1st investigations to order

  • serum calcium
  • serum albumin
  • ECG
  • plasma intact PTH
  • serum magnesium
  • serum 25-hydroxyvitamin D
  • serum phosphorus
  • serum creatinine
More 1st investigations to order

Investigations to consider

  • 24-hour urine calcium, creatinine
  • 24-hour magnesium, creatinine
  • liver function tests
  • arterial blood gases (ABGs)
  • serum free thyroxine, thyrotropin
  • morning cortisol and adrenocorticotropin (ACTH) stimulation testing
  • full blood count
  • serum iron, transferrin, ferritin
  • serum copper
  • ophthalmological examination
  • audiology
  • renal imaging
  • gene sequencing
More investigations to consider

Emerging tests

  • autoantibodies to 21-hydroxylase or type 1 interferons

Treatment algorithm


severe symptomatic hypocalcaemia (albumin-corrected serum total calcium <1.88 mmol [<7.5 mg/dL])


asymptomatic temporary postoperative hypocalcaemia


chronic hypoparathyroidism



Dolores Shoback, MD

Professor of Medicine

University of California San Francisco

Endocrine Research Unit

San Francisco VA Medical Center

San Francisco



DS worked as a consultant for Takeda Pharmaceuticals, Ascendis, and Bridge Bio. She has received honorarium from Neopharma, and served as an expert witness for a patient-based malpractice case. For the past 5 years, DS was a speaker for the annual patients and caregivers conference on hypoparathyroidism for the US-based Hypoparathyroidism Association, and is an unpaid member of their medical advisory board. DS has given many CME lectures on hypoparathyroidism and calcium and bone and mineral disorders.

Quan-Yang Duh, MD

Professor of Surgery

Section of Endocrine Surgery

University of California San Francisco

San Francisco



QYD declares that he has no competing interests.


Professors Dolores Shoback and Quan-Yang Duh would like to gratefully acknowledge Professor Ronald Merrell, a previous contributor to this topic. RM declares that he has no competing interests.

Peer reviewers

Wail Malaty, MD

Adjunct Clinical Professor

Department of Family Medicine

University of North Carolina

Chapel Hill



WM declares that he has no competing interests.

  • Hypoparathyroidism images
  • Differentials

    • Hypovitaminosis D
    • Hypomagnesaemia
    • Hypoalbuminemia
    More Differentials
  • Guidelines

    • Standards of care for hypoparathyroidism in adults: a Canadian and international consensus
    • Postoperative hypoparathyroidism: diagnosis, prevention, and management in adults
    More Guidelines
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