Clinical Aspects of Pituitary Disease

Question 1

What disease come from hypersecretion of the pit.gland? Causes?

Answer 1

Acromegaly - GH
Cushing’s - ACTH
Hyperprolactinaemia - Prolactin

Tumours

Question 2

Hormones affected by hyposecretion? Cause?

Answer 2

AG - FSH/LH, GH, ACTH and TSH

PG - vasopressin

Mostly due to tumours too

Question 3

What is FSH and LH?

Answer 3

Follicle stimulating hormone

Luteinizing hormone

Question 4

What is another common presentation of a pit. tumour?

Answer 4

Bitemporal hemianopsia due to optic chiasmal compression

Question 5

Clinical features of acromegaly?

Answer 5

Soft tissue like overgrowth =

Spade like hands
Wide feet
Thick lips and tounge
Space between teeth
Sweating
Carpal tunnel syndrome

Question 6

Complications form acromegaly?

Answer 6

Diabetes 
Hypertension 
Cardiomyopathy
Sleep apnoea
Headaches
Chaismal compression = bitemporal hemianopsia

Question 7

Diagnosis of acromegaly?

Answer 7

Test to see if GH can be supressed via a OGTT

Is IGF-1 elevated?

Glucose will also be elevated

Is the rest of pit. gland function normal?

Is vision normal?

tumour on MRI?

Question 8

What is cushings?

Answer 8

Excess cortisol

Question 9

What does cortisol do?

Answer 9

A catabolic hormone

Tissue breakdown causing weakening of skin, muscle and bone

Na retention - causing hypertension and heart failure

Insulin antagonism - causing DM

Question 10

Symptoms that give high suspicion of cushings?

Answer 10

Moon face with central adiposity but skinny arms and legs, also pink striae 
Oedema
Skin atrophy
Spontaneous purpura
Proximal myopathy
Osteoporosis
Growth arrest in kids

Question 11

Other causes of cushing’s besides a pit. tumour?

Answer 11

ACTH dependant = Ectopic ACTH secretion like a lung carcinoid

ACTH independent = Adrenal tumour - adenoma/carcinoma

Corticosteropid therapy

Question 12

Cushings disease vs syndrome?

Answer 12

Cushing’s disease is a medical cause of Cushing’s syndrome. Cushing’s disease occurs when a tumor on the pituitary gland causes the gland to produce too much ACTH

Question 13

What are the clinical manifestations of hyperprolactinaemia in women?

Answer 13

Galactorrhoea in 30-80%
Menstual irregularity
Infertility

Question 14

What are the clinical manifestations of hyperprolactinaemia in men?

Answer 14

Galactorrhoea - 5%
Impotence
Visual field abnormalities
Heachache
Extraocular muscle weakness
Anterior pituitary malfunction

Question 15

What is purpura ?

Answer 15

a condition of red or purple discolored spots on the skin that do not blanch on applying pressure

Question 16

What is galactorrhoea?

Answer 16

Production of milk when you shouldn’t be making milk

Question 17

Causes of hyperprolactinaemia?

Answer 17

Physiological - pregnancy, stress, lactation

Pharmacological - Dopamine depleting and dopamine antagonistic drugs

Pathological - 1y hypothyroidism, pit. lesions like prolactinoma or pit. stalk pressure

Question 18

Drugs that may cause hyperprolactinaemia?

Answer 18

Dopamine antagonists - neuroleptics, anti-emetics
Dopamine depleting drugs
Oestrogens
Some antidepressants
Homeopathic or herbal remedies

Question 19

Clinical features of hypo-pituitarism in adults?

Answer 19

Tiredness
Weight gain
Depression
Reduced libido and impotence
Menstrual problems
Skin pallor
Reduced body hair

Question 20

Clinical features of hypopituitarism in kids?

Answer 20

Reduced linear growth

Delayed puberty

Question 21

What is cranial diabetes insipidus?

Answer 21

The hypothalamus/pit gland does not produce enough anti-diuretic hormone/vasopressin

Question 22

Symptoms of DI?

Answer 22

Polyuria/nocturia

Extreme thirst

Question 23

DI differentials/causes?

Answer 23

Idiopthic
Post-trauma
Carcinoma mets
Cranio-pharyngioma
Other brain tumours
Rarer causes like Sarcoidosis

Question 24

Management of prolactinoma?

Answer 24

Dopamine agonists for

Question 25

Management for acromegaly?

Answer 25

Somatostatin analogues | GH receptor antagonist

Question 26

Management for hyposecretion of normal pit. gland?

Answer 26

``` Cortisol T4 Sex steroids GH Desmopressin ```

Question 27

Management for pituitary tumours?

Answer 27

Trans-sphenoidal surgery most common Radiotherapy

Question 28

What are the beneficial effects of somatostatin analogues in acromegaly?

Answer 28

Improves soft tissue overgrowth, sweating, headache and sleep apnoea symptoms Normalise GH and IGF-1 in over 50% of patients Induce tumour to shrink in the majority Reduces morbidity and mortality

Question 29

Name somatostatin analogues?

Answer 29

Octreotide LAR | Lanreotide autogel

Question 30

Adverse side effects of somatostatin analogues?

Answer 30

Nausea Cramps Diarrhoea Flatulence Cholesterol gallstones - often asymptomatic

Question 31

Disadvantages of SS analogues?

Answer 31

Expensive | Slow release preparations need monlthy IM or s/c injections

Question 32

Is pituitary radiotherapy used often?

Answer 32

No, use is declining as it acts slowly and causes hypopituitarism

Question 33

When is pituitary surgery carried out?

Answer 33

Mainly for non-functioning pit. tumours and cushing's

Question 34

What hormones control the release of prolactin?

Answer 34

Thyrotrophin releasing hormone increases release of prolactin Dopamine (prolactin inhibiting factor) inhibits the release of prolactin and cancels the effects of thyrotrophin releasing hormone Dopamine is constantly released in anyone that is not pregnant to stop the effects

Question 35

Neg. feedback loops that stop high levels of prolactin?

Answer 35

Dopamine released to inhibit it | Gonadotrophin releasing hormone levels are reduced

Question 36

What is a prolactinoma and what makes it micro/macro?

Answer 36

A functional tumour that divides uncontrollably and makes prolactin Can compress optic chiasm Over 10mm is macro and under is micro

Question 37

Features of micro-prolactinoma

Answer 37

Usually women with galactorrhoea Amenorrhoea Infertility Serum prolactin less than 5000 mU/I

Question 38

What is amenorrhoea?

Answer 38

Absence of a menstrual period

Question 39

Treatment of microprolactinoma?

Answer 39

Cabergoline (dopamine receptor agonist) Ovulatory cycles, fertility and normoprolactinaemia is restored in 70-90%

Question 40

Dopamine agonist effects on macroprolactinoma?

Answer 40

Rapid fall in serum PRL (hours) Tumour shrinkage (days/weeks) Visual improvement (often within days) Often recovery of pituitary function 80-90% tumours show these responses & most will shrink by at least one half