Hypopituitarism

Question 1

Distinguish between primary and secondary disease

Answer 1

Primary is where the gland itself is affected
Secondary is where there is an issue with signalling from the hypothalamus or pituitary gland

Question 2

What is primary hypothyroidism?

Answer 2

Autoimmune destruction of thyroid gland - Hashimoto’s
T4/3 low, TSH high

Question 3

What is secondary hypothyroidism?

Answer 3

Pituitary tumour affecting thyrotrophs so no TSH
TSH, T4/3 all low

Question 4

What is primary hypoadrenalism?

Answer 4

Autoimmune destruction of adrenal glands
Low cortisol, high ACTH

Question 5

What do CRH levels look like in primary hypoadrenalism?

Answer 5

They would be high but it’s difficult to measure

Question 6

What is secondary hypoadrenalism?

Answer 6

Pituitary tumour affecting corticotrophs so low ACTH & cortisol

Question 7

What is primary hyopogonadism?

Answer 7

Destruction of the testes by mumps or ovaries by chemotherapy. Results in low oestrogen/testosterone and high LH/FSH

Question 8

What is secondary hypogonadism?

Answer 8

Pituitary tumour affecting gonadotrophs. Results in low oestrogen, testosterone, LH & FSH

Question 9

Explain the congenital causes of hypopituitarism

Answer 9

It’s rare and caused by a mutation in the TFs that are involved in anterior pituitary development.
Deficiency in growth hormone and one other AP hormone

Question 10

Signs of hypopituitarism

Answer 10

short stature and hypoplastic pituitary gland on MRI (underdeveloped)

Question 11

Causes of acquired hypopituitarism

Answer 11

Tumours
Infection
Surgery
Radiation
Pituitary surgery
Hypophysitis (inflammation)
Pituitary apoplexy - haemorrhage or infraction
Peri-partum infarction (Sheehan’s syndrome)

Question 12

Name of total loss of pituitary function

Answer 12

Panhypopituitarism

Question 13

Presentations of low FSH/LH

Answer 13

Secondary amenorrhoea
Reduced libido
Reduced pubic hair
Erectile dysfunction

Question 14

Presentation of low PRL

Answer 14

Inability to breastfeed

Question 15

Presentation of low ACTH

Answer 15

Fatigue
NOT a salt losing crisis because aldosterone is under control by renin-angiotensin

Question 16

Presentation of low TSH

Answer 16

Fatigue

Question 17

Presentation of low GH

Answer 17

Short stature IN CHILDREN
Reduced QoL

Question 18

What happens to the anterior pituitary during pregancy?

Answer 18

It enlarges aka lactotroph hyperplasia

Question 19

What is Sheehan’s Syndrome?

Answer 19

Post-partum haemorrhage leads to infarction, often secondary to hypotension
Most common in developing countries

Question 20

Signs/Symptoms of Sheehan’s

Answer 20

Inability to resume menses
Lethargy, weight loss, anorexia
Issues with lactation

Question 21

What is pituitary apoplexy?

Answer 21

Haemorrhage or infarction to pituitary gland often inidcates a pituitary adenoma

Question 22

Medical term for double vision

Answer 22

Diplopia

Question 23

What kind of medication precipitates pituitary apoplexy?

Answer 23

Anti-coagulants (blood thinners)

Question 24

Presentation of pit. apoplexy

Answer 24

Severe headache
Bitemoporal hemianopia
Diplopia
Ptosis (drooping of upper eyelid)

Question 25

What is a dynamic pituitary function test?

Answer 25

Where hypoglycaemic stress is induced by administering insulin. GH/ACTH are released in response to stress and are measures TRH and GnRH cause TSH & LH/FSH release respectively

Question 26

Treatment of GH deficiency

Answer 26

Daily injection of GH Measure QoL and see if there is improvement Plasma IGF-1 measured

Question 27

Treatment of TSH deficiency

Answer 27

Replace with levothyroxine in secondary hypothyroidism aim for a T4 above the middle of the reference range

Question 28

Treatment of ACTH deficiency

Answer 28

Replace cortisol rather than ACTH Give synthetic glucocorticoids like hydrocortisone (3x daily) or prednisolone (once daily)

Question 29

Features of adrenal crisis

Answer 29

Vomiting, dizziness, hypotension, may even collapse and die

Question 30

Sick day rules for ACTH deficiency

Answer 30

Wear steroid bracelet Double dose of glucocorticoids Inject intramuscularly (vomiting means they can't take it orally)

Question 31

Treatment of FSH/LH deficiency (men - no fertility)

Answer 31

Topical or intramuscular injections of testosterone Testosterone will not cause spermatogenesis

Question 32

Treatment of FSH/LH deficiency (men - fertility)

Answer 32

Induce spermatogenesis by gonadotropin injections Best response if secondary hypogonadism occurs AFTER puberty

Question 33

Treatment of FSH/LH deficiency (women - no fertility)

Answer 33

Administer oestrogen orally or topically Progesterone also needed

Question 34

Why is progesterone needed alongside oestrogen?

Answer 34

To prevent endometrial hyperplasia if the womb is intact

Question 35

Treatment of FSH/LH deficiency (women - fertility)

Answer 35

Gonadotropin injections needed to induce ovulation - IVF