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ENDOCRINOLOGY phase 1b > 1b Hypopituitarism > Flashcards

1b Hypopituitarism Flashcards

1
Q

What are the five anterior pituitary hormones?

A

growth hormones, prolactin, thyroid stimulating hormone (TSH), luteinising hormone, follicle stimulating hormones (FSH), ACTH

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2
Q

What is the purpose of hypothalamic releasing factors?

A

travel in the portal circulation to the anterior pituitary to regulate anterior pituitary hormone production

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3
Q

What is primary disease in relation to the pituitary?

A

When the gland itself fails

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4
Q

What is secondary disease in relation to pituitary function?

A

when no signal are received from the hypothalamus or anterior pituitary

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5
Q

What happens to TSH and T3 and T4 when a patient has primary hypothyroidism? Why?

A

T3 and T4 fall and TSH increases - Primary = problem with the gland itself therefore thyroxine levels are lowered, and due to the negative feedback of TSH, this causes the levels to rise

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6
Q

What happens to T3 and T4 and TSH levels when a patient has secondary hypothyroidism?

A

TSH Falls as the patient cant make it from the pituitary, and because of this T3 and T4 also lower

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7
Q

Why is only cortisol impacted with disorders of the adrenal gland?

A

Cortisol is regulated by ACTH, aldosterone is through the renin-angiotensin system

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8
Q

What happens to cortisol and ACTH levels during primary hypoadrenalism?

A

Cortisol falls, ACTH Increases - this is due to destruction of the adrenal cortex

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9
Q

What happens to cortisol and ACTH levels during secondary hypoadrenalism?

A

pituitary tumour damaging corticotrophs
Can’t make ACTH
ACTH falls, cortisol falls

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10
Q

What happens to TESTOSTERONE/OESTROGEN and FSH/LH levels during secondary hypogonadism?

A

Can’t make LH/FSH
LH/FSH fall, and therefore Testosterone/oestrogen fall

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11
Q

What happens to Testosterone/Oestrogen and LH and FSH levels during primary hypogonadism?

A

Testosterone (men) or oestrogen (women) fall, LH
& FSH increase

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12
Q

Causes and features of congenital hypopituitarism?

A

Usually due to mutations of
transcription factor genes needed for normal anterior pituitary development

Deficient in GH and at least 1
more anterior pituitary hormone

Short stature

Hypoplastic (underdeveloped)
anterior pituitary gland on MRI

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13
Q

What are some acquired causes of hypopituitarism?

A

Tumour
Radiation
Infection eg meningitis
Traumatic Brain Injury
Pituitary surgery
Inflammatory (hypophysitis)
Pituitary apoplexy - haemorrhage
Peri-partum infarction (Sheehan’s syndrome)

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14
Q

What is hypophysitis?

A

Inflammation of the pituitary

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15
Q

What is panhypopituitarism?

A

Total loss of anterior and posterior pituitary function

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16
Q

Describe the relationship between the dosage of radiotherapy and the risk of HPA Axis damage?

A

higher total dose = higher risk

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17
Q

Which hormones are most sensitive to Radiotherapy?

A

GH and gonadotrophins

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18
Q

Which endocrine organs are highly sensitive to radiation?

A

Pituitary and hypothalamus

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19
Q

Why is continual assessment required for patients with radiotherapy induced hypopituitarism?

A

Risk persists up to 10y after
radiotherapy, so annual assessment

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20
Q

What are the presentations of hypopituitarism (FSH/LH)?

A

Reduced libido
Secondary amenorrhoea
Erectile dysfunction
Reduced pubic hair

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21
Q

What are the presentations of hypopituitarism (ACTH)?

A

Fatigue

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22
Q

What are the presentations of hypopituitarism (TSH)?

A

Fatigue

23
Q

What are the presentations of hypopituitarism (GH)?

A

Lower QoL
short stature in children

24
Q

What are the presentations of hypopituitarism (PRL)?

A

no breastfeeding

25
Q

What is Sheehan’s syndrome?

A

Post partum hypopituitarism secondary to hypotension (PPH - Post Partum Haemorrhage)

26
Q

What happens to the anterior pituitary in pregnancy?

A

Enlarges - lactotroph hyperplasia

27
Q

How does a post partum haemorrhage lead to a pituitary infarction?

A

Haemorrhage = blood pressure drops, as not enough blood to the enlarged pituitary = infarction as the pituitary is deprived

28
Q

Why does the anterior pituitary enlarge in pregnancy?

A

enlarge as they prepare to lactate

29
Q

Four key symptoms of sheehans?

A

Lethargy, anorexia, weight loss –
TSH/ACTH/(GH) deficiency

Failure of lactation – PRL deficiency

Failure to resume menses post-delivery

Posterior pituitary usually NOT affected

30
Q

Why is the posterior pituitary usually not affected by Sheehan’s syndrome?

A

posterior pituitary is a downward extension from the hypothalamus and therefore is neuronal tissue

31
Q

What is a pituitary apoplexy?

A

Bleeding (Haemorrhage) into the pituitary

32
Q

What might be the first presentation of a pituitary adenoma?

A

Pituitary apoplexy

33
Q

hat can help precipitate a pituitary apoplexy?

A

Anti-coagulants

34
Q

What are the key symptoms of a pituitary apoplexy?

A

Severe sudden onset headache

Visual field defect – compressed optic chiasm,
bitemporal hemianopia

Cavernous sinus involvement may lead to diplopia (IV, VI), ptosis (III)

35
Q

Why must you exercise caution when interpreting basal plasma hormone concentrations?

A

Cortisol – what time of day?
* T4 – circulating t1/2 6 days
* FSH/LH – cyclical in women
* GH/ACTH - pulsatile

36
Q

How is the “stressed” state enduced when performing a dynamic pituitary function test?

A

Giving the patient insulin in order to replicate the hypoglycaemic state

37
Q

What are the two “stress” hormones?

A

GH and ACTH Release

38
Q

What does the insulin-induced hypoglycaemia stimulate?

A

GH release and ACTH Release

39
Q

Why are MRI’s used to diagnose hypopituitarism?

A

Highest resolution - CT not good

40
Q

What radiological landmark is looked for on an MRI of the pituitary?

A

Posterior pituitary bright spot

Empty sella- thin rim of pituitary tisssue

41
Q

What is the treatment for GH deficiency?

A
  • confirm GH deficiency on dynamic function test and assess QoL
  • give daily injection
42
Q

How is the effect of GH treatment measured?

A

Improvement in QoL and plasma IGF-1

43
Q

What is the treatment for TSH deficiency?

A

Levothyroxine

44
Q

What must you aim for when treating a TSH deficiency and why?

A

Aim for fT4 above the middle of the reference range - the TSH will be low therefore you cannot use this to adjust the dose

45
Q

What challenge is faced hen treating ACTH deficiency?

A

Difficult to mimic diurnal variation of
cortisol

46
Q

What are the two main treatment options for ACTH deficiency?

A

Prednisolone once daily AM and hydrocortisone three times a day

47
Q

What is an adrenal crisis?

A

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

48
Q

What is important to mention to patients who are on steroid replacement?

A

Sick Day Rules

49
Q

What are sick day rules?

A

Steroid alert pendant/bracelet

Double steroid dose (glucocorticoid not mineralcorticoid) if fever/intercurrent illness

Unable to take tablem to inject IM or straight to A&E

50
Q

What is the treatment for FSH/LH deficiency in men if fertility is and isnt required?

A

NO FERTILITY REQUIRED
replace testosterone (topical or intramuscular)
measure plasma testosterone
replacing testosterone does not restore sperm production

FERTILITY REQUIRED
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

51
Q

What is the treatment for FSH/LH deficiency in women if fertility is and isnt required?

A

No fertility = replace oestrogen (oral/topical)
will need progesterone if intact uterus to prevent endometrial hyperplasia

Fertility = induce ovulation. by carefully timed gonadotropin injections

52
Q

Which hormone increases its levels after radiotherapy?

A

Prolactin

53
Q

Sudden onset headache and bitemporal hemaniopia…what is the diagnosis?

A

Pituitary apoplexy

54
Q

Which patients should be told sick day rules?

A

Patients who take replacement steroids like prednisolone, hydrocortisone

ENDOCRINOLOGY phase 1b (12 decks)

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