Endo check Flashcards

Question

Causes of precocious puberty?

Answer 1

**Central precocious puberty** Early activation of the HPG axis, with initiation of pulsatile GnRH secretion resulting in pituitary LH and FSH release with resultant development of secondary sexual characteristics. Can be idiopathic, or due to any CNS disruption, including tumour and irradiation. This leads to an early onset of puberty with a normal pattern of development. **Peripheral precocious puberty,** also termed gonadotrophin-independent precocious puberty Increased levels of sex hormones, in the absence of HPG axis activation May be due to gonadal hormone release (such as ovarian cyst or tumour), ectopic hormone release (tumour), or exogenous hormones. This can lead to atypical patterns of sexual development due to the aberrant hormone exposure.

Answer 2

FSH LH Oestradiol (Total testosterone in boys) Bone age Xray TFT (If CNS symptoms MRI brain)

Answer 3

Urgent endo referral. Treatment is determined by psychologically ready for particular stage of pubertal growth and maximisation of adult height.

Answer 4

**GnRH agonist (GnRHa) therapy can be used to suppress puberty in CPP.** GnRHa treatment provides continuous stimulation of the pituitary gland, which disrupts the secretion of gonadotrophins and accordingly halts CPP. In Australia, two preparations are readily available; **leuprorelin depot and goserelin.** Leuprorelin is available on the Pharmaceutical Benefits Scheme (PBS) so is most commonly used for CPP. In some specific situations, goserelin may be preferred. Treatment must be **initiated by a paediatric endocrinologist and will be closely monitored.** GPs may be asked to prescribe subsequent doses or administer GnRHa under the direction of the paediatric endocrinologist.[52] **Cyproterone acetate** is a steroid that acts directly to suppress the gonad and centrally to suppress GnRH. This medication may sometimes be used as an adjunct to GnRHa treatment. It is effective in suppressing puberty but does not change final adult height so is not often used on its own.[42] _Hannah should be treated by a paediatric endocrinologist with GnRHa. Given that leuprorelin is available on the PBS, this is the most suitable choice of medication._

Answer 5

**Local reactions at the site of injection**, including sterile abscess or implant-site reaction, are common. Most children report that the injections are quite **painful.** After the first dose of GnRHa, **a slight progression of puberty can be seen because the medication initially will increase gonadotropin secretion.** **Hormone withdrawal symptoms**, akin to those seen in menopause, may also be seen at the start of treatment. A **transient decrease in bone mineral density i**s seen, but this normalises after the child has gone through puberty following treatment cessation.[53,54] There is **no clear evidence that GnRHa impairs fertility** in later life.

Answer 6

Given as a fixed dose depot but may be given more frequently Usually given every 3 months but can be given every 2 months instead Stopped according to clinical context - psychogically ready for a particular height and maturation level AND maximising adult height Usually, GnRHa is stopped at approximately 10–12 years of age.[51] Pubertal signs usually progress or reappear within 2–16 months following cessation of GnRHa.[57]

Answer 7

What is the **quantity and quality of her sleep**? Is she known to snore, and has anyone raised concerns about her stopping breathing in her sleep? Does she have a low mood? Has she had any post-menopausal bleeding? Has she experienced any weight loss or gain? Has she noticed any change in bowel habits? Were there any viral illnesses at the onset of symptoms? Is there any shortness of breath? What is her social history? Are there new psychosocial stressors, alcohol or other drugs? Are there risk factors for blood-borne virus infections? What is her past medical and surgical history? Conduct a review of the systems, looking for the following symptoms: haem – night sweats, fevers, bone pains, bruising, bleeding, recent infections, lymphadenopathy endocrine – increased thirst, polyuria cardiovascular – palpitations, ankle swelling, chest pain respiratory – shortness of breath, cough, wheeze, hoarseness gastrointestinal – change in bowel habits, rectal bleeding, indigestion, abdominal pain genitourinary – frequency, dysuria, haematuria musculoskeletal – inflamed joint, myalgia neurological – headaches, paraesthesia, power loss.

Answer 8

hypothyroidism depression ovarian cancer anaemia diabetes obstructive sleep apnoea chronic kidney disease.

Answer 9

1. Triiodothyronine (T3) is required to upregulate LDL-C receptors. 2. Thyroid hormones also increase cholesteryl ester transfer protein activity, which is important for HDL-C metabolism.[63]

Answer 10

There is an increased prevalence of anaemia among individuals with hypothyroidism.[64] Macrocytosis is found in up to 55% of patients with hypothyroidism and may be the result of insufficiency of the thyroid hormones themselves without nutritive deficit. T3 is known to enter cells and promotes cellular activity and metabolism. A lack of T3 is thought to lead to adaptive changes in metabolism at a cellular level. Nutritional deficiencies such as vitamin B12 deficiency are seen in up to 10% of individuals with autoimmune hypothyroidism.[65] It is important to consider the possibility of pernicious anaemia here. Further investigations would include haematinics, as well as intrinsic factor antibodies and parietal cell antibodies if vitamin B12 is found to be low.

Answer 11

For well individuals under 60 years of age, suggested initial dosing is 50–100 mcg thyroxine daily, with titrations of 25–50 mcg at no less than four weekly intervals according to thyroid function tests. The target TSH range in this group is 0.5–2 mU/L, the population average. For individuals over 60 years of age or with ischaemic heart disease, a slower titration is suggested. This is to avoid precipitating arrhythmia or myocardial ischaemia. An initial dose of 25–50 mcg is recommended, with titrations of 25 mcg at no less than four weekly intervals as required. A broader target TSH range of 0.5–5 mU/L is advised. In the long term, monitoring of Mabel’s thyroid function for both under-treatment and over-treatment is important.[67] Monitoring should take place at 6–8 week intervals until a steady state is achieved. Once thyroid function has normalised, reviews are recommended at three and six months, and thereafter annually if thyroid function remains stable and asymptomatic.[61] Thyroxine should be stored in the fridge, and patients should be informed that absorption can be impaired by food so it is best taken on an empty stomach. Likewise, certain drugs can impair absorption or alter the metabolism of thyroxine, so instructions regarding separate and consistent dosing is recommended for patients on concomitant therapy with: phenytoin carbamazepine frusemide heparin aspirin ferrous sulphate

Endo check Flashcards

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