Endocrine

Question 1

Symptoms of adrenal insufficiency

Answer 1

• weakness, fatigue (100%)
• anorexia (100%)
• gastrointestinal (86%)
  nausea, vomitting, abdo pain
• salt craving (16%)
• postural dizziness (12%)
• muscle/joint pains (10%)

Question 2

Signs of adrenal insufficiency

Answer 2

Primary and secondary:

• weight loss (100%)
• Hypotension (90%)
• Hyponatremia (88%)
• Uremia (55%)
• Anemia (40%)
• Hypercalcemia (6%)
• Hypoglycemia (5%)

Primary only:

• Hyperpigmentation (94%)
• Vitiligo (15%)
• Hyperkalemia (64%)

Question 3

Causes of adrenal insufficiency

Answer 3

Primary adrenal disorder: -Addisons disease
- autoimmune adrenalitis (most common)
- tuberculosis
- other infections (eg HIV)
- haemorrhage
- adrenoleukodystrophy
- congenital adrenal hypoplasia 
Secondary to loss of ACTH secretion:
hypopituitarism

Question 4

Diagnosing adrenal insufficiency

Answer 4

hyponatremia and hyperkalaemia
Low plasma cortisol that fails to respond to synthetic ACTH (short synacthen test)

In primary only:
High ACTH
High plasma renin activity

Question 5

Features of primary aldosteronism

Answer 5

hypertension
hypokalaemia (50% of cases)

Symptoms of hypokalaemia:

• weakness
• cramps
• parasethesia
• polyuria and polydipsia

Question 6

Screening test for suspected primary aldosteronism

Answer 6

plasma aldosterone to renin ratio
- High aldosterone, low renin

Electrolytes
- high Na, low K

Question 7

Causes of aldosteronism

Answer 7

Aldosterone secreting adenoma (Conn’s syndrome)

Bilateral adrenal hyperplasia

Question 8

Management of aldosteronism

Answer 8

Surgical for Conn’s syndrome (adrenal adenoma)

Medical for others - spironolactone

Question 9

Clinical symptoms/signs of Cushing syndrome

Answer 9

proximal muscle wasting and weakness
central obesity
Cushing facies: plethora, moon face, acne
hirsutism
abdominal striae
thin skin, easy bruising
hyperglycaemia 
hypertension
menstrual changes 
osteoporosis
depression
back ache

Question 10

Screening tests for Cushing syndrome

Answer 10

24 hour urinary free cortisol
Dexamethasone suppression test
late night salivary cortisol

Question 11

Causes of Cushing syndrome

Answer 11

Iatrogenic - chronic steroid administration
Pituitary ACTH excess (Cushing disease)
Bilateral adrenal hyperplasia
Adrenal tumour (adenoma or adenocarcinoma)
Ectopic ACTH (or rarely CRH) from non-endocrine tumours

Question 12

Diagnostic test in Cushing syndrome

Answer 12

Serum ACTH
- Distinguishes between adrenal and other

Imaging: MRI for ACTH producing pit. tumours
CT for adrenal tumours

Inferior petrosal sinus sampling - confirms presence of pituitary micro adenoma

Question 13

Investigations of amenorrhoea

Answer 13

HCG, FSH, LH, oestradiol, TSH, prolactin

Pelvic ultrasound

Question 14

Causes of primary amenorrhoea

(absence of menarche by 13 in female with breast development, 15 without breasts or 5 years since breast development before age 10)

Answer 14

Hypogondadotrophic

• constitutional delay (30%)
• hypothalamic
• pituitary (hypopit. prolactinoma)

Hypergonadotrophic

• ovarian dysgenesis
• prom. ovarian insufficiency

Anatomical

• mullerian agenesis
• imperforate hymen

Less common :

• PCOS
• nonclassical congenital adrenal hyperplasia

Question 15

Causes of secondary amenorrhoea

Answer 15

Pregnancy
Perimenopause (>45yo)
PCOS

Hypogonadotrophic

• hypothalamic (functional most common)
• pituitary tumours (causing prolactin elevation)
• Hypopituitarism (eg. tumours, iron overload)

Hypergonadotrophic

• early menopause
• premature ovarian insufficiency

Medications (antipsychotic, steroids, COCP, depot medroxyprogesterone, goserelin)

Other endocrine disorders

• hypo/hyperthyroid
• CAH

Question 16

Causes of primary male androgen deficiency

Answer 16

Kleinfelter syndrome 
cryptorchidism 
Bilateral orchidectomy 
Orchitis
trauma or torsion
Cytotoxic or radiation damage to testes
Systemic disease (haemochromatosis)

Question 17

Causes of secondary male androgen deficiency

Answer 17

pituitary macroadenoma
prolactinoma
infiltrative disorders