Pituitary Disorders

Question 1

What is a Pituitary Incidentaloma?

Answer 1

an asymptomatic pituitary tumor

Question 2

What determines management for a Pituitary Incidentaloma?

Answer 2

size

Question 3

How do you manage an Pituitary Incidentaloma <1cm in size?

Answer 3

Prolactin level and yearly MRI

Question 4

How do you manage a pituitary incidentaloma >1cm in size?

Answer 4

Prolactin and year MRI along with TSH, T4, LH, FSH, IGF, 24 hour cortisol and visual field test for optic chiasm compression

Question 5

What is Empty Sella Syndrome?

Answer 5

Pituitary is undersized, flattened and not visible on MRI

Question 6

What is Empty Sella Syndrome often associated with?

Answer 6

Surgery, Obesity and radiation therapy

Question 7

How do you manage asymptomatic Empty Sella Syndrome?

Answer 7

Check thyroid and adrenal function

Question 8

What causes Panhypopituitarism?

Answer 8

Anything that compresses or damages the pituitary gland
-Tumor
-Trauma and radiation
-Hemochromatosis, Sarcoidosis, Histiocytosis X
-Infection: Fungi, TB, parasites
-autoimmune lymphocytic infiltration

Question 9

How does Prolactin deficiency present?

Answer 9

No symptoms in men

Women cannot lactate properly

Question 10

How does Growth Hormone (GH) deficiency present?

Answer 10

Children: short stature and dwarfism

Adults: central obesity, elevated LDL/Chol, Reduced lean muscle

Question 11

How does LH and FSH deficiency present?

Answer 11

Men: cannot make testosterone or sperm: ED and Decreased muscle

Women: failure to ovulate/menstruate: amenorrhea

Both: decreased libido, axillary, pubic, and body hair

Question 12

What Causes Kallman Syndrome?

Answer 12

KAL-1 mutation

Question 13

What hormones are affected in Kallman syndrome?

Answer 13

Decreased GnRH causes decreased FSH and LH

Question 14

What are the typical characteristics of Kallman Syndrome?

Answer 14

Anosmia and renal agenesis

Question 15

How do you treat Kallman Syndrome?

Answer 15

Replace testosterone

Question 16

What causes Klinefelter Syndrome?

Answer 16

47 XXY Karyotype

Question 17

What are the hormonal effects of Klinefelter Syndrome?

Answer 17

Androgen deficiency results from insensitivity to LH/FSH: however FSH and LH levels are high

Question 18

What are typical characteristics of Klinefelter syndrome?

Answer 18

Tall

Question 19

How do you treat Klinefelter syndrome?

Answer 19

Replace testosterone

Question 20

What electrolyte abnormality is common secondary to Hypothyroidism?

Answer 20

Hyponatremia

Question 21

What are the initial tests for suspected Panhypopituitarism?

Answer 21

TSH, T4, IGF, Estrogen, Testosterone, LH, FSH, Prolactin

Question 22

What is the best initial stimulatory test for suspected GH deficiency?

Answer 22

Inject GHRH: the normal response is a rise in GH level

Question 23

How do you confirm Low TSH and T4 levels?

Answer 23

Decreased TSH response to Thyrotropin-releasing hormone (TRH)

Question 24

How do you confirm decreased ACTH and Cortisol Levels?

Answer 24

Normal response to cosyntropin: rise in cortisol: no rise in disease

No rise in ACTH with Corticotropin-releasing hormone (CRH) in disease

Question 25

How do you treat hormone deficiencies?

Answer 25

Replace deficient hormones -Cortisone -Thyroxine: only after cortisone has been replaced -Testosterone -Estrogen -Recombinant HGH

Question 26

What are the 2 products of the Posterior Pituitary?

Answer 26

ADH and Oxytocin

Question 27

What is ADH deficiency known as?

Answer 27

Central Diabetes Insipidus

Question 28

What is Acromegaly?

Answer 28

Overproduction of Growth Hormone (GH) leading to overgrowth of soft tissue throughout the body

Question 29

What are common causes of Acromegaly?

Answer 29

Pituitary Adenoma Men Syndrome: With parathyroid/pancreatic disorder Ectopic production: lymphoma or bronchial carcinoid

Question 30

What are common symptoms of Acromegaly?

Answer 30

Increased hat, ring, shoe size Carpal tunnel, obstructive sleep apnea Body odor from sweat gland hypertrophy Hypertension Colonic polyps, Skin tags and colon cancer Cardiomegaly and CHF ED: increased prolactin cosecreted with pituitary adenoma Hyperglycemia

Question 31

What is the best initial test for Acromegaly?

Answer 31

IGF-1 level

Question 32

What is the most accurate test for Acromegaly?

Answer 32

Glucose Suppression test: glucose should normally suppress GH

Question 33

How do you treat Acromegaly?

Answer 33

Transphenoidal Resection Cabergoline Octreotide or Lanreotide Pegvisomant Radiation: only if no response to drugs or surgery

Question 34

What is the mechanism of Cabergoline in Acromegaly treatment?

Answer 34

Dopamine agonist which inhibits GH release

Question 35

What is the mechanism of Octerotide and Lanreotide in Acromegaly treatment?

Answer 35

Somatostatin analogues: inhibits GH release

Question 36

What is the mechanism of Pegvisomant in Acromegaly treatment?

Answer 36

GH receptor Antagonist which inhibits IGF release from the liver

Question 37

What are common causes of Hyperprolactinemia?

Answer 37

Physiologic Hypothyroidism Acromegaly Cutting the pituitary stalk Certain drugs

Question 38

What are physiologic causes of Hyperprolactinemia?

Answer 38

Pregnancy intense exercise renal insufficiency Increased Chest Wall Stimulation

Question 39

How does hypothyroidism cause Hyperprolactinemia?

Answer 39

Extremely high TRH stimulates Prolactin secretion

Question 40

How does cutting the pituitary stalk cause Hyperprolactinemia?

Answer 40

Eliminates dopamine delivery to the anterior pituitary which would normally inhibit prolactin release

Question 41

What are common drugs that cause Hyperprolactinemia?

Answer 41

Antipsychotics Methyldopa Metoclopramide Opioids TCA Verapamil

Question 42

What are common symptoms of Hyperprolactinemia in Women?

Answer 42

Galactorrhea, Amenorrhea and infertility

Question 43

What are common symptoms of Hyperprolactinemia in Men?

Answer 43

Erectile Dysfunction and Decreased Libido, possible Gynocomastia

Question 44

After prolactin is confirmed to be elevated, what diagnostic tests are used?

Answer 44

Thyroid function tests Pregnancy test BUN/Cr: kidney disease elevates prolactin LFT: Cirrhosis elevates prolactin

Question 45

What should you always rule out first with high prolactin level?

Answer 45

Pregnancy

Question 46

When is an MRI indicated for Hyperprolactinemia?

Answer 46

After Confirmation of elevated Prolactin, 2nd causes are ruled out and the patient is confirmed to not be pregnant

Question 47

How do you treat Hyperprolactinemia?

Answer 47

Dopamine agonists Transphenoidal surgery if no response to medication Radiation

Question 48

How do you treat asymptomatic Hyperprolactinemia?

Answer 48

No treatment needed

Question 49

What Dopamine agonist is commonly used to treat hyperprolactinemia?

Answer 49

Cabergoline: better tolerated than Bromocriptine

Question 50

What are common side effects of Bromocriptine?

Answer 50

Orthostasis, Lightheadedness and Nausea/vomiting

Question 51

What is Gynocomastia?

Answer 51

Increased breast size commonly resulting from -Klinefelter syndrome -Hyperprolactinemia -Drugs -Liver and renal failure: elevates prolactin -Testicular lesions

Question 52

What drugs are commonly associated with Gynocomastia?

Answer 52

Spironolactone Opiates PO ketoconazole Estrogen

Question 53

What type of testicular cells produce estrogen leading to Gynocomastia?

Answer 53

Sertoli Cells

Question 54

What testing is done for Gynocomastia?

Answer 54

R/o common causes and Mammography to rule out cance r

Question 55

What is the treatment for Gynocomastia?

Answer 55

Tamoxifen Replace testosterone if deficient surgery if refractory and idiopathic