Adrenocortical, Aldosterone, Pituitary

Question 1

How do you distinguish primary hypogonadism from secondary hypogonadism?

Answer 1

History
Exam
Check LH/FSH
- If elevated: primary gonadal failure
- If low: secondary gonadal failure

Question 2

Clinical presentation includes anorexia, nausea/vomiting, weight loss, weakness/fatigue, abdominal pain, lightheadedness

Answer 2

Adrenal Insufficiency

Question 3

Cushing’s disease is a condition of

Answer 3

Excess cortisol

Question 4

Frequent cause of hyperaldosteronism

Answer 4

bilateral adrenal hyperplasia

may also be caused by a single adrenal adenoma

Question 5

Caused by destruction of both adrenal cortices

Answer 5

Primary adrenal insufficiency

Low cortisol, low aldosterone, high ACTH

Question 6

In primary adrenal insufficiency, there is ___________ hyperkalemia

Answer 6

Pronounced hyperkalemia (++)

Question 7

______ is produced by the adrenal cortex after ______ stimulation via the hormone ________

Answer 7

CORTISOL is produced by the adrenal cortex after PITUITARY stimulation via the hormone ACTH

Question 8

What is the most common pituitary adenoma?

Answer 8

Prolactinoma

Question 9

Due to hypothalamic or pituitary disease that decreases secretion of CRH/ACTH

Answer 9

Secondary adrenal insufficiency
Low cortisol, normal aldosterone, low ACTH

–> associated with other pituitary hormone deficiencies, rarely isolated

Question 10

Secondary gonadal failure or pituitary disease causes hypogonadism via

Answer 10

decreased GnRH, LH, FSH –> impaired gonadal function

Question 11

Clinical presentation includes central weight gain, round facies, striations, thin skin/bruising, mood disturbance, insomnia, HTN, diabetes, sexual dysfunction, bone loss

Answer 11

Cushing’s disease

Question 12

How are pituitary tumors treated?

Answer 12

ALL - except prolactinoma - are treated surgically

Can give radiation after surgery

Medical:

• Acromegaly: octreotide, pegvisomant
• Cushing’s: metyrapone, ketoconazole, mifepristone

Replace missing hormones

Question 13

What accounts for most of the differences in symptoms between primary and secondary adrenal insufficiency?

Answer 13

Aldosterone secretion (or lack of)

Question 14

Nuances of ectopic Cushing’s

Answer 14

• May not present with weight gain (underlying malignancy)
• More severe HTN/hyperglycemia
• Low potassium due to very high cortisol levels

Question 15

How do you treat hypogonadism?

Answer 15

Estrogen +/- progesterone if premenopausal woman

Testosterone if man (SE: polycythemia, oily skin/acne, prostate enlargement, progression of prostate cancer)

Question 16

In secondary adrenal insufficiency, there is ______ hyperkalemia

Answer 16

NO hyperkalemia (-)

Question 17

How do you diagnose Cushing’s disease?

Answer 17

1) Establish high cortisol (urinary, midnight control, suppression test)

2) Establish if ACTH dependent or not
- dependent = pituitary tumor, ectopic
- independent = adrenal tumor

3) If dependent, establish if pituitary or ectopic with suppression test
4) Localize tumor (CT, MRI)

Question 18

Treatment for secondary adrenal insufficiency includes

Answer 18

ONLY glucocorticoids

Question 19

Consequences of high aldosterone

Answer 19

• -> sodium retention + water retention
• -> potassium wasting
• -> feedback suppression of renin

Question 20

How do you evaluate a pituitary adenoma?

Answer 20

1) Tumor function (prolactin, ACTH, GH, TSH, none)
2) Surrounding tissue (compression, hormonal impairment)
3) Surrounding structures (optic chiasm, CN, temporal lobe)

Question 21

What is the best treatment for Cushing’s disease?

Answer 21

Remove the cause (tumor/cancer)

Then:

• enzyme inhibitors (metyrapone, ketoconazole)
• cortisol receptor blocker (mifepristone)

Question 22

Presents with hypogonadism and galactorrhea (W)

Answer 22

Prolactinoma (pituitary adenoma)

–> diagnose with elevated prolactin level

Question 23

High aldosterone + high aldosterone/renin ratio

Answer 23

Hyperaldosteronism (diagnostic)

–> follow with adrenal CT

Question 24

Hypotension may indicate _________ Adrenal Insufficiency.

Answer 24

Primary - yes

Secondary - yes or no

Question 25

Hyperaldosteronism patients tend to have

Answer 25

• HTN at a young age
• Resistant hypertension
• Spontaneous hyperkalemia

Question 26

Hyperpigmentation is characteristic of ________ Adrenal Insufficiency

Answer 26

Primary (elevated ACTH)

Question 27

How do you treat hyperaldosteronism?

Answer 27

• After diagnosis (high aldosterone + high aldosterone/renin ratio) perform adrenal CT to find tumor
• Adrenal venous sampling to see if bilateral
• Excise tumor if unilateral
• Aldosterone receptor blocker if bilateral (spironolactone or eplerenone)

Question 28

Tissue swelling and enlargement is characteristic of

Answer 28

Acromegaly

–> diagnose with elevated IGF-1 level

Question 29

Treatment for primary adrenal insufficiency includes

Answer 29

glucocorticoids and mineralocorticoids

Question 30

How do you diagnose Acromegaly?

Answer 30

Elevated IGF-1, failure to suppress GH with glucose load

Question 31

How do you treat prolactinomas?

Answer 31

With dopamine agonists cabergoline or bromocriptine
–> lower prolactin, shink tumor

With BCP if patient premenopausal (testosterone in men)

Observe if postmenopausal/older male

Question 32

How do you treat acromegaly?

Answer 32

surgical + ocreotide (somatostatin analog to decrease GH secretion) or pegcisomant (GH receptor blocker, inhibits production of IGF-1)

Question 33

What are the possible causes of increased prolactin?

Answer 33

If high HCG --> pregnancy
If high TSH --> hypothyroidism
If high Creatinine --> renal failure 
Medications
Pituitary prolactinoma