Hypopituitarism

Question 1

List the anterior pituitary hormones.

Answer 1

growth hormone (somatotrophin)
prolactin
ACTH (corticotrophin)
FSH/LH
TSH (thyrotrophin)

Question 2

How do hypothalamic releasing/inhibitory factors travel to the anterior pituitary?

Answer 2

via portal circulation

Question 3

What is the main difference between primary and secondary hypothyroidism?

Answer 3

primary = failure/loss of function of the thyroid gland 
secondary = failure of hypothalamus/anterior pituitary

Question 4

Name a cause of primary thyroidism.

Answer 4

autoimmunity

Question 5

Name a cause of secondary hypothyroidism.

Answer 5

pituitary tumour damaging thyrotrophs

Question 6

Describe levels of TSH, T3 and T4 in primary hypothyroidism.

Answer 6

TSH high

T3/4 low

Question 7

Describe levels of TSH, T3 and T4 in secondary hypothyroidism.

Answer 7

TSH can’t make it/falls

T3/4 low

Question 8

Describe levels of ACTH and cortisol in primary hypoadrenalism.

Answer 8

ACTH increase

cortisol falls

Question 9

Describe levels of ACTH and cortisol in secondary hypoadrenalism.

Answer 9

ACTH falls

cortisol falls

Question 10

Describe levels of FSH/LH and testosterone/ oestrogen in primary hypogonadism.

Answer 10

FSH/LH high

testosterone/oestrogen low

Question 11

Describe levels of FSH/LH and testosterone/ oestrogen in secondary hypogonadism.

Answer 11

FSH/LH low

testosterone/oestrogen low

Question 12

What are congenital causes of hypopituitarism?

Answer 12

mutations of transcription factor genes needed for normal anterior pituitary development e.g. PROP 1 mutation

Question 13

List acquired causes of hypopituitarism.

Answer 13

Tumours
Radiation
Infection
Traumatic brain injury
Pituitary surgery
Inflammation
Pituitary apoplexy
Peripartum infarction

Question 14

What is the term that describes the total loss of anterior and posterior pituitary function?

Answer 14

Panhypopituitarism

Question 15

What affect does radiotherapy have on the pituitary?

Answer 15

Direct > acromegaly

Indirect > nasopharyngeal carcinoma

Question 16

Which anterior pituitary cells are most sensitive to radiotherapy?

Answer 16

Gonadotrophs

Question 17

List some presentations of hypopituitarism.

Answer 17

Reduced libido, erectile dysfunction, secondary amenorrhea
Fatigue
Reduced quality of life (short stature in children)
Inability to breastfeed

Question 18

Explain the pathophysiology of Sheehan’s syndrome.

Answer 18

Hypotension in pregnancy / post partum haemorrhage > damage to pituitary > deficiency in pituitary hormones

Question 19

Describe presentation of Sheehan’s syndrome.

Answer 19

Lethargy, anorexia, weight loss, failure of lactation, failure to resume menses post delivery

Question 20

What is a pituitary apoplexy?

Answer 20

Intra pituitary haemorrhage or infarction

Question 21

Pituitary apoplexy can be precipitated by?

Answer 21

Anti coagulants

Question 22

Pituitary apoplexy presents as?

Answer 22

Severe sudden onset headache, visual field defect (compressed optic chiasm > bitemporal hemianopia), cavernous sinus involvement may lead to diplopia, ptosis

Question 23

When using biochemical means to diagnose hypopituitarism you should take caution because?

Answer 23

Cortisol - what of time of day?
T4 - circulating time of 1/2 6 days
FSH/LH cyclical in women
GH/ACTH pulsatile

Question 24

What would you see on a MRI of someone with hypopituitarism?

Answer 24

May be haemorrhage, adenoma, empty sella

Question 25

Treatment of GH deficiency?

Answer 25

Daily injection of genotropin | Measure response by: improvement in QoL, plasma IGF-1

Question 26

Treatment of TSH deficiency?

Answer 26

Replace with levythyroxine, (aim for a fT4 above the middle of the reference range)

Question 27

Treatment of ACTH deficiency?

Answer 27

Replace cortisol | Synthetic glucocorticoids to mimic diurnal variation: prednisolone once daily AM, hydrocortisone 3x daily

Question 28

Patients with ACTH deficiency are at risk of ‘.........’ triggered by intercurrent illness.

Answer 28

Adrenal crisis

Question 29

Features of adrenal crisis?

Answer 29

``` Dizziness Hypotension Vomiting Weakness Can result in collapse and death ```

Question 30

What are sick day rules for those that take replacement steroid e.g. prednisolone, hydrocortisone?

Answer 30

Steroid alert pendant/bracelet Double steroid dose if fever/intercurrent illness Unable to take tablets, inject IM or come straight to A&E

Question 31

Describe the treatment of FSH/LH deficiency in men (no fertility required).

Answer 31

Replace testosterone Measure plasma testosterone (This doesn’t restore sperm production)

Question 32

Describe the treatment of FSH/LH deficiency in men (fertility required).

Answer 32

Induction of spermatogenesis by gonadotrophin injections (best response if develops after puberty) Measure testosterone/semen analysis Sperm production may take 6-12 months

Question 33

Describe the treatment of FSH/LH deficiency in women (no fertility required).

Answer 33

Replace oestrogen | Additional progestogen if intact uterus to prevent endometrial hyperplasia

Question 34

Describe the treatment of FSH/LH deficiency in women (fertility required).

Answer 34

Can induce ovulation by carefully timed gonadotrophin injections (IVF)