Hypopituitarism

Question 1

What hormones are made by the anterior pituitary?

Answer 1

1. Growth hormone
   - Somatotrophin
2. Prolactin
3. Thyroid stimulating hormone (TSH)
   - Thyrotrophin
4. Luteinising hormone (LH)
5. Follicle stimulating hormone (FSH)
6. Adrenocorticotrophic hormone
   - ACTH, corticotrophin

Question 2

How is anterior pituitary hormone production regulated?

Answer 2

Hypothalamic releasing or inhibitory facotrs

Travel in portal circulation

Question 3

What is the function of growth hormone?

Answer 3

Growth

Question 4

What is the function of prolactin?

Answer 4

Milk production

Question 5

What does LH and FSH produce?

Answer 5

Oestrogen and Progesterone

Testosterone

Question 6

What does TSH produce?

Answer 6

1. T3 - Triiodothyronine

2. T4 - Thyroxine

Question 7

What does ACTH produce?

Answer 7

Cortisol

Question 8

What is a primary disease?

Answer 8

The gland (thyroid, adrenal cortex, gonad) itself fails

Question 9

What is a secondary disease?

Answer 9

No signals from hypothalamus or anterior pituitary

Question 10

Describe T3 and T4 levels in primary hypothyroidism.

Answer 10

Fall

Question 11

Describe TSH (and TRH) levels in primary hypothyroidism.

Answer 11

Increases

Question 12

What is a cause of primary hypothyroidism?

Answer 12

Autoimmune destruction of thyroid gland

Question 13

What is a cause of secondary hypothyroidism?

Answer 13

Pituitary tumour damaging thyrotrophs

Question 14

Describe T3 and T4 levels in secondary hypothyroidism.

Answer 14

Fall

Question 15

Describe TSH levels in secondary hypothyroidism.

Answer 15

Falls (Can’t make TSH)

Question 16

What is cortisol regulated by?

Answer 16

ACTH

Question 17

What does ACTH regulate?

Answer 17

Cortisol

Question 18

What is aldosterone regulated by?

Answer 18

Renin-angiotensin

Question 19

What does renin-angiotensin regulate?

Answer 19

Aldosterone

Question 20

What is a cause of primary hypoadrenalism?

Answer 20

Destruction of adrenal cortex (e.g. autoimmune)

Question 21

Describe cortisol levels in primary hypoadrenalism.

Answer 21

Falls

Question 22

Describe ACTH (and CRH) levels in primary hypoadrenalism.

Answer 22

Increases

Question 23

What is a cause of secondary hypoadrenalism?

Answer 23

Pituitary tumour damaging corticotrophs

Question 24

Describe cortisol levels in secondary hypoadrenalism.

Answer 24

Falls

Question 25

Describe ACTH levels in secondary hypoadrenalism.

Answer 25

Falls (Can't make ACTH)

Question 26

What is a cause of primary hypogonadism?

Answer 26

Destruction of testes or ovaries

Question 27

What is a common cause of destruction of testes?

Answer 27

Mumps

Question 28

What is a common cause of destruction of ovaries?

Answer 28

Chemotherapy

Question 29

Describe sex steroid levels in primary hypogonadism.

Answer 29

Fall

Question 30

Describe LH and FSH (and GnRH) levels in primary hypogonadism.

Answer 30

Increase

Question 31

What is a cause of secondary hypogonadism?

Answer 31

Pituitary tumour damaging gonadotrophs

Question 32

Describe sex steroid levels in secondary hypogonadism.

Answer 32

Fall

Question 33

Describe LH and FSH levels in secondary hypogonadism.

Answer 33

Fall (as can't make)

Question 34

What can we divide causes into?

Answer 34

Congenital and acquired

Question 35

Which of congenital and acquired causes are more common?

Answer 35

Acquired

Question 36

What examples of acquired causes are there?

Answer 36

1. Tumours eg adenomas, metastases, cysts 2. Radiation (hypothalamic/pituitary damage) 3. Infection eg meningitis 4. Traumatic brain injury 5. Pituitary surgery 6. Inflammatory 7. Pituitary apoplexy - haemorrhage (or less commonly infarction) 8. Peri-partum infarction (Sheehan’s syndrome)

Question 37

What is inflammation of the pituitary gland called?

Answer 37

Hypophysitis

Question 38

What is hypophysitis?

Answer 38

Inflammation of the pituitary gland

Question 39

What is total loss of anterior and posterior pituitary function called?

Answer 39

Panhypopituiarism

Question 40

What is panhypopituitarism?

Answer 40

Total loss of anterior and posterior pituitary function

Question 41

What is the presentation of hypopituitarism regarding FSH/LH?

Answer 41

1. Reduced libido 2. Secondary amenorrhoea 3. Erectile dysfunction 4. Reduced pubic hair

Question 42

What is the presentation of hypopituitarism regarding ACTH?

Answer 42

Fatigue

Question 43

What is the presentation of hypopituitarism regarding TSH?

Answer 43

Fatigue

Question 44

What is the presentation of hypopituitarism regarding growth hormone?

Answer 44

1. Reduced quality of life | 2. Short stature only in children

Question 45

What is the presentation of hypopituitarism regarding prolactin?

Answer 45

Inability to breastfeed

Question 46

Why is hypopituitarism regarding ACTH not a salt losing crisis?

Answer 46

The renin-angiotensin system still creates aldosterone

Question 47

What is Sheehan's Syndrome?

Answer 47

Post-partum hypopituitarism secondary to hypotension (post partum haemorrhage - PPH)

Question 48

What does PPH lead to?

Answer 48

Pituitary infarction

Question 49

Why does the anterior pituitary enlarges in pregnancy?

Answer 49

Lactotroph hyperplasia

Question 50

Which hormone in the treatment of hypopituitarism will not get replaced?

Answer 50

Prolactin

Question 51

How do you measure response to GH treatment?

Answer 51

1. Improvement of QoL | 2. Plasma IGF-1

Question 52

What causes a pituitary apopplexy?

Answer 52

Intra-pituitary haemorrhage or (less commonly) infarction

Question 53

What can a pituitary apoplexy be precipitated by?

Answer 53

Anti-coagulants

Question 54

How would you replace cortisol?

Answer 54

1. Prednisolone | 2. Hydrocortisone

Question 55

What are the congenital causes of hypopiturtarism?

Answer 55

(Rare) Usually due to mutations of transcription factor genes needed for normal anterior pituitary development -eg PROP1 mutation

Question 56

What will someone will congenital hypopituitarism present with?

Answer 56

-Deficient in GH and at least 1 more anterior pituitary hormone - Short stature - Hypoplastic (underdeveloped) anterior pituitary gland on MRI

Question 57

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

Answer 57

- Steroid alert pendant/bracelet - Double steroid dose (glucocorticoid not mineralocorticoid) if fever/intercurrent illness - Unable to take tablets (eg vomiting), inject IM or come straight to A & E

Question 58

What are the features of an adrenal crisis?

Answer 58

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

Question 59

What Addison's patients must be told sick day rules?

Answer 59

Patients who take replacement steroid eg prednisolone, hydrocortisone

Question 60

Who is at risk of an adrenal crisis?

Answer 60

Patients with ACTH deficiency (or Addison’s – primary adrenal failure) are at risk of ‘adrenal crisis’ triggered by intercurrent illness

Question 61

What is the treatment of FSH/LH deficiency in men who do not require fertility?

Answer 61

- Replace testosterone – topical or intramuscular most popular - Measure plasma testosterone - Replacing testosterone does not restore sperm production (this is dependent on FSH)

Question 62

What is the treatment of FSH/LH deficiency in men who do require fertility?

Answer 62

- Induction of spermatogenesis by gonadotropin injections - Best response if secondary hypogonadism has developed after puberty - Measure testosterone and semen analysis - Sperm production may take 6-12 months

Question 63

What is the treatment of FSH/LH deficiency in women who do not require fertility?

Answer 63

-Replace oestrogen -Oral or topical -Will need additional progestogen if intact uterus to prevent endometrial hyperplasia

Question 64

What is the treatment of FSH/LH deficiency in women who do not require fertility?

Answer 64

Can induce ovulation by carefully timed gonadotropin injections (IVF)

Question 65

In FSH/LH deficiency in women not requiring fertility, when and why will additional progestogen be given?

Answer 65

If intact uterus to prevent endometrial hyperplasia