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BRS Endocrinology > 1b// Hypopituitarism > Flashcards

1b// Hypopituitarism Flashcards

1
Q

What are the hormones secreted from the anterior pituitary?

A

Growth hormone (somatotrophin)
Prolactin
Thyroid stimulating hormone (TSH, thyrotropin)
Luteinising hormone (LH) and follicle stimulating hormone (FSH)
Adrenocorticotropic hormone (ACTH, corticotrophin)

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2
Q

What cells do the hormones of the anterior pituitary come from?

A

somatotrophs
lactotrophs
thyrotrophs
gonadotrophs
corticotrophs

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3
Q

What is the intermediate between growth hormone and growth?

A

IGF1

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4
Q

What is IGF-1 role?

A

IGF1 in children causes cell differentiation and growth

IGF1 in adults is anabolic e.g., building muscle

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5
Q

What does prolactin do? (basic)

A

causes milk production

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6
Q

What happens to prolactin when the pituitary is damaged and why? (basic)

A

since it is negatively regulated, when the pituitary is damaged it goes up, because there is less dopamine to suppress it.

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7
Q

What type of circulation does the anterior pituitary have?

A

portal circulation

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8
Q

What does portal circulation mean?

A

it has capillaries at both ends and doesn’t go to the heart

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9
Q

What is primary and secondary disease?

A

primary disease= the gland itself fails

secondary disease= no signals from hypothalamus or anterior pituitary, their failure

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10
Q

What are the hormones involved with thyroidism and where do they come from?

A

TRH= hypothalamus
TSH= pituitary
T3 and T4= thyroid

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11
Q

What is primary hypothyroidism?

A

Autoimmune destruction of thyroid gland
T3 and T4 can no longer be produced
So T3/4 decrease
TSH and TRH increase (but usually only TSH is measured)

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12
Q

What is secondary hypothyroidism?

A

pituitary tumour damages thyrotrophs
They no longer make TSH
TSH falls
Therefore so does T3/4

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13
Q

What are the hormones involved with adrenals and where do they come from?

A

CRH= hypothalamus
ACTH= pituitary
cortisol= adrenal cortex

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14
Q

What is aldosterone and cortisol regulated by?

A

cortisol is regulated by ACTH

aldosterone is regulated by the renin-angiotensin system

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15
Q

What is primary hypoadrenalism?

A

Destruction of adrenal cortex (e.g., autoimmune)
Therefore cortisol falls and CRH and ACTH increase
CRH is not normally measured
Aldosterone decreases

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16
Q

What is secondary hypoadrenalism?

A

pituitary tumour damaging corticotrophs
No ACTH/ less
ACTH and cortisol falls
Aldosterone secretion is fine

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17
Q

What are the hormones involved in gonadism and where do they come from?

A

GnRH (gonadotrophin releasing hormone)= hypothalamus

LH and FSH= pituitary

testosterone= Testosterone is produced by the gonads (by the Leydig cells in testes in men and by the ovaries in women)

oestrogen= the ovaries

progesterone

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18
Q

What is primary hypogonadism?

A

e.g., destruction of testes (e.g., mumps) or ovaries (e.g., chemotherapy)

testosterone in men or oestrogen in women fall, LH and FSH increase

GnRH is not measured but would be high

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19
Q

What is secondary hypogonadism?

A

e.g., pituitary tumour damages gonadotrophs

can’t make LH/ FSH

LH, FSH, oestrogen, testosterone fall

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20
Q

What are the causes of hypopituitarism?

A

Congenital
- rare
- usually due to mutations of transcription factor genes needed for normal anterior pituitary development
- I.e., the pituitary is not made

Deficient in GH and at least 1 moe anterior pituitary hormone
- so the pituitary is underdeveloped and small
- short stature
- hypoplastic (underdeveloped) anterior pituitary on MRI

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21
Q

How many axes does hypopituitarism effect?

A

1, some or all

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22
Q

Is hypopituitarism only affecting the anterior pituitary?

A

Hypopituitarism often describes anterior pituitary disfunction, but certain processes- especially inflammation or surgery- may cause posterior pituitary dysfunction too

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23
Q

What is pituitary inflammation?

A

hypophytis

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24
Q

What is total loss of both anterior and posterior pituitary?

A

panhypopituitarism

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25
Q

What are the hypothalamus and pituitary sensitive to?

A

radiation

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26
Q

What can radiation cause in the pituitary?

A

hypopituitarism

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27
Q

Give an example for how radiation can be direct or indirect to the pituitary?

A

direct= hormone producing pituitary tumour

indirect= CNS tumour nearby

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28
Q

How is radiotherapy dose (Gy) linked to risk of HPA axis damage?

A

higher total dose= higher risk of HPA axis damage

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29
Q

What cells in the pituitary are most sensitive to radiotherapy?

A

somatotrophs and gonadotrophs (growth hormone and LH and FSH) aka they are the first to decrease

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30
Q

The sensitivity of gonadotrophs and somatotrophs to radiotherapy cause what issue?

A

infertility

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31
Q

For how long can the risk persist after radiotherapy last, and what do you therefore need to do?

A

up to 10 years
therefore annual assessments

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32
Q

What is a haemorrhage?

A

acute blood loss from a damaged blood vessel

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33
Q

What is an infarction?

A

death of tissue due to blockage in a vessel

34
Q

Do anterior and posterior pituitary have the same circulation?

A

No

35
Q

What does a patient suffering with hypopituitarism with decreased FSH/ LH say?

A

reduced libido
secondary amenorrhea
erectile dysfunction
reduced pubic hair

36
Q

What does a patient suffering with hypopituitarism with decreased ACTH say?

A

Fatigue
NB not a salt losing crisis (renin-angiotensin is fine)

37
Q

What does a patient suffering with hypopituitarism with decreased TSH say?

A

Fatigue

38
Q

What does a patient suffering with hypopituitarism with decreased GH say?

A

reduced quality of life
NB short stature only in children

39
Q

What does a patient suffering with hypopituitarism with decreased prolactin say?

A

inability to breastfeed

40
Q

What is Sheehan’s syndrome?

A

post-partum hypopituitarism

41
Q

What is Sheehan’s syndrome secondary to and why?

A

hypotension (PPH= postpartum hemorrhage)

42
Q

Where is Sheehan’s syndrome more common in the world?

A

developing countries

43
Q

What happens to the pituitary during Sheehan’s syndrome?

A

anterior pituitary enlarges in pregnancy (lactotroph hyperplasia)

44
Q

What does PPH cause?

A

leads to pituitary infarction

45
Q

What are the symptoms of Sheehan’s syndrome and why

A

lethargy (TSH)
anorexia (ACTH)
weight loss (GH- in adults GH decrease leads to weight loss)
failure of lactation (prolactin)

failure to resume menses post-delivery

  • TSH, ACTH, GH deficiency
46
Q

Does Sheehan’s syndrome affect the posterior pituitary?

A

No

47
Q

What is postpartum hypopituitarism?

A

Sheehan’s syndrome

48
Q

What is the best imaging to visualise the pituitary?

A

MRI

49
Q

What type of imaging do you use to see haemorrhages and fractures?

A

CT scan

50
Q

What is bleeding (haemorrhage) into the pituitary called?

A

Pituitary Apoplexy

51
Q

How would you describe the presentation of pituitary apoplexy in someone with pre-existing pituitary tumours (adenomas)?

A

dramatic presentation

52
Q

How may the presentation of pituitary apoplexy first present?

A

as a pituitary adenoma

53
Q

What precipitates pituitary apoplexy?

A

anti-coagulants (blood thinners)

54
Q

What does pituitary apoplexy cause immediately?

A

severe sudden onset headache
and

visual field defect- compressed optic chiasm= bitemporal hemianopia

55
Q

What can cavernous sinus involvement in pituitary apoplexy cause?

A

diplopia and ptosis

56
Q

What is diplopia?

A

double vision

57
Q

What is ptosis?

A

upper eyelid of one or both eyes droops over your eye

58
Q

What cranial nerves are involved with diplopia?

A

IV, VI

59
Q

What cranial nerves are involved in ptosis?

A

III

60
Q

If the tumour of the pituitary gland presses, what can it cause?

A

cranial nerve palsy (lack of function of the cranial nerves)

61
Q

What cautions do you have to have while measuring the various hormones involved with the pituitary gland?

A

Cortisol- what time of day?
T4- circulating half life is 6 days
FSH/ LH- cyclical in women
GH/ ACTH- pulsatile (not always high)

62
Q

When is interpretation of pituitary hormones especially hard due to their variation?

A

right after injury

63
Q

What can you do to make it easier to measure the various hormones involved with the pituitary gland?

A

dynamic pituitary function tests, they stimulate the anterior pituitary

64
Q

What are the “stress” hormones from the pituitary?

A

GH and ACTH

65
Q

How can you measure ACTH and GH?

A

the patient is deliberately put under “stress” to increase ACTH and GH

they are put into hypoglycaemia (<2.2mM)= stress

Insulin induced hypoglycaemia stimulates GH release and ACTH release (cortisol is measured)

66
Q

How do you measure TSH and FSH and LH?

A

TRH stimulates TSH release
GnRH stimulates FSH and LH

these are both dynamic tests

67
Q

What is empty sella?

A

thin rim of pituitary tissue

68
Q

What is empty sella syndrome?

A

the person had a tumour before, but it was ok to live with
and then it infarcted and the body got rid of the dead cells
leaving empty space

69
Q

How do you treat hypopituitarism (basic)?

A

GH, TSH, FSH, LH, ACTH= replace
prolactin= no need to replace

70
Q

How do you treat GH deficiency?

A
  • NICE guidelines
  • First confirm GH deficiency on dynamic pituitary function test
  • Asses quality of life (QoL) using specific questionnaire
  • Daily injection (no oral option)

Measure response by…
- Improvement in QoL
- Plasma IGF-1

71
Q

How do you treat TSH deficiency?

A
  • Replace once daily with levothyroxine
  • TSH will be low, so you can’t use this to adjust dose as you do in primary hypothyroidism

Therefore, aim for a fT4 above the middle of the reference range

72
Q

How do you treat ACTH deficiency?

A
  • Replace cortisol rather than ACTH
  • It’s difficult to mimic diurnal variation of cortisol
  • 2 main options in the UK using synthetic glucocorticoids…
  1. PREDNISOLONE
    - Once daily AM e.g., 3mg
    - Better but only a little bit, it can’t do the steady rise at night
  2. HYDROCORTISONE
    - 3x per day
    - E.g., 10mg, 5mg, 5,mg
73
Q

Do hormones generally have a long or short half life?

A

short

74
Q

What are the sick day rules for patients with ACTH deficiency?

A
  • Patients with primary adrenal failure (Addison’s) or secondary adrenal failure (ACTH deficiency) are at risk of ‘adrenal crisis’ triggered by intercurrent illness
  • Patients who take replacement steroid e.g., prednisolone, hydrocortisone must be told the sick day rules
    1. Steroid alert pendant/ bracelet
    2. Double steroid dose (glucocorticoid not mineralocorticoid) if fever/ intercurrent illness
    3. Unable to take tablets (e.g., vomiting), inject IM or come straight to A and E
75
Q

What are adrenal crisis features (5)?

A

dizziness, hypotension, vomiting, weakness, can result in collapse and death

76
Q

How do you treat FSH/ LH deficiency in males with no fertility required?

A

replace testosterone- topical or intramuscular (most popular)

measure plasma testosterone

replace testosterone does not mean replaced fertility (this requires FSH)

77
Q

How do you treat FSH/ LH deficiency in males with fertility required?

A

induction of spermatogenesis by gonadotrophin injections

best response is secondary hypogonadism has developed after puberty

measure testosterone and semen analysis

sperm production may take 6-12 months

FSH and LH x2 a week

78
Q

How do you treat FSH/ LH deficiency in females with no fertility required?

A

replace oestrogen
- oral or topical

will need additional progesterone if intact uterus to prevent endometrial hyperplasia

79
Q

How do you treat FSH/ LH deficiency in females with fertility required?

A

can induce ovulation by carefully timed gonadotrophin injections (IVF)

80
Q

What usually causes pituitary apoplexy?

A

sudden haemorrhage or infarction of anterior pituitary, usually due to pre-existing adenoma

BRS Endocrinology (12 decks)

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