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Endo > Anterior pituitary > Flashcards

Anterior pituitary Flashcards

1
Q

How do you diagnosis hyperprolactinemia?

A

A single measurement of increased serum prolactin

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2
Q

What are some differentials if the serum prolactin is >250 ng/ml?

A
  1. Prolactinoma - prolactin secreting pituitary tumor
  2. Some drugs - metoclopramide and risperidone (dopamine antagonists), may increase prolactin > 200 ng/ml
  3. Microprolactinomas can also have prolactin levels in the 100-250 ng/ml range
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3
Q

What can cause mild to moderate hyperprolactinemia (25-100 ng/ml)??

A

Infundibular stalk compression - a larger pituitary mass

Non-prolactin secreting tumor with infundibular stalk compression and inhibition of dopamine transport to the lactotroph

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4
Q

Physiological causes of hyperprolactinemia

A 
Pregnancy
Lactation
Exercise
Sleep
Stress
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5
Q

What are some medications that may cause hyperprolactinemia?

A

Antihypertensives (methyldopa)
Estrogens
D2 dopamine receptor antagonists (metoclopromide, domperidone)
Neuroleptics/antipsychotics (phenothiazines, butyrophenones, risperidone - block dopamine receptors)

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6
Q

Pathological causes of hyperprolactinemia

A

Hypothalamic-pituitary stalk damage – infiltrative disorders (Sarcoidosis), irradiation to the brain, trauma, tumors

Pituitary-prolactinomas, macroadenoma (with compression of infundibular stalk), lymphocytic hypophysitis (autoimmune)

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7
Q

How does hyperprolactinemia present in young women?

A

Menstrual irregularities, galactorrhea (50-80%) and infertility

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8
Q

How does hyperprolactinemia present in men?

A

Decrease in libido and erectile dysfunction as a result of hypogonadism, galactorrhea is less common (20-30%)

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9
Q

How do patients with hyperprolactinemia get hypogonadism?

A

Hyperprolactinemia inhibits the pituitary gonadotropins, FSH and LH

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10
Q

How might macroprolactinomas present?

A

Headaches
Neurologic deficits d/t cavernous sinus involvement and vision changes d/t optic chiasm compression and cavernous sinus involvement

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11
Q

Treatment for hyperprolactinemia

A

Dopamine agonists
Cabergoline
Bromocriptine

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12
Q

How do domaine agonists treat hyperprolactinemia?

A

Suppress prolactin production via activation of D2 receptors

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13
Q

How does cabergoline treat hyperprolactinemia?

A

Dopamine agonist

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14
Q

SE of Cavergoline

A 
Nausea
Vomiting
Orthostatic lightheadedness
Dizziness
Nasal congestion
Cardiac valvulopathy in Parkinson's patients
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15
Q

When is bromocriptine used to treat hyperprolactinemia?

A

When patients are undergoing fertility induction that also have hyperprolactinemia
It’s also the initial treatment for macroprolactinomas that have caused compromise of vision, neurologic deficits and pituitary function

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16
Q

What are some clinical features of acromegaly?

A 
Headache 
Enlargement of lips, nose and tongue
Cardiomyopathy
Hypertension
Enlargement of liver
Enlargement of hands
Arthropathy
Carpal tunnel syndrome
Skull growth 
Prognathism
Increased sweating
Thickened skin
17
Q

How is acromegaly diagnosed?

A

Measurement of serum IGF-1

Oral glucose test

18
Q

How does the oral glucose test diagnose Acromegaly?

A

Give 100 gram glucose load
Normally glucose suppresses GH level to less than 1 ng/ml by 2 hours
GH levels may paradoxically increase, remain unchanged or decrease but not <1 ng/ml

19
Q

Treatment for acromegaly

A 
Transsphenoidal surgery 
Radiation therapy 
Drug therapy -- 
somatostatin receptor ligands (SRLs) = octreotide and lanreotide 
Cabergoline = dopamine agonist
Pegvisomant = GH receptor antagonist
20
Q

What are some causes of panhypopituitarism/hypopituitarism??

A

Mass lesions
Treatment of sellar, parasellar and hypothalamic disease
Infiltrative disease - autoimmune, sarcoidosis
Traumatic
Vascular - Sheehan’s syndrome, pituitary tumor apoplexy
Medications - opiates, pharmacologic glucocorticoid therapy
Infectious
Genetic
Developmental

21
Q

Clinical findings of panhypopituitarism

A

ACTH deficiency or secondary adrenal insufficiency
TSH deficiency or secondary hypothyroidism
GH deficiency in adult
Prolactin deficiency
Gonadotropin deficiency or hypogonadotropic hypogonadism

22
Q

What are some diagnostic test findings in panhypopituitarism?

A

Low free T4 with low or inappropriately normal TSH
ACTH – Cortisol fasting, ACTH stimulation test, Insulin tolerance test
Males: insufficiency if testosterone is below reference range with low or inappropriately not increased LH and FSH
Females: insufficiency if estradiol is low with low or inappropriately not increased FSH and LH
GH – Basal IGF1, insulin tolerance test, GHRH arginine stimulation test, glucagon stimulation test

23
Q

What hormone replacements are given for panhypopituitarism?

A

Thyroid: levothyroxine (T4), adjust dose according to free T4 and not TSH
Adrenal: hydrocortisone or prednisone (no mineralcorticoid needed)
Gonadoropins: Female = replaced with estrogen and progesterone, OCP, patch; fertility requires gonadotropins for ovulation
Male = replaced with testosterone, injections, gel, patch; fertility requires HCG injections 3x perk
GH: given as daily subcutaneous injections

24
Q

What are some clinical signs of GH deficiency?

A 
Neonate = jaundice, hypoglycemia, microphallus, traumatic deliver
Child = propensity for hypoglycemia, increased fat, high pitched voice, microphallus, absent or delayed pubery, weight less affected than height, occasionally present physical defects of skull, midline craniofacial abnormalities
25
Q

What are GH deficiencies noticed on the growth chart?

A

Usually after the first two years of life when GH is more important in growth
Weight is less affected than height

26
Q

What are some diagnostic techniques for diagnosing GH deficiency in children?

A 
Stimulus
Exercise
Levodopa
Clonidine
Arginine HCl
Insulin
Glucagon
GHRH
27
Q

What therapy is used for GH deficiency in children?

A

Recombinant human growth hormone (rGH) - subcut injection

  • Given each evening to mimic the normal diurnal pattern of growth hormone release
  • Dosing based on mg/kg/week and the etiology
28
Q

How does dosing of rGH differ for a child with GH deficiency and a child with ISS (idiopatic short stature)??

A

True growth hormone deficiency need much smaller doses of GH than a child with idiopathic short stature – they are much more sensitive to it

Endo (11 decks)

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