Endocrine Flashcards
How is cushings distinguished from the simple obesity of metabolic syndrome?
You check the anabolic changes (found in cushings)
S/s that point away from metabolic syndrome and to cushings?
Osteopenia
Thin skin
3+ ecchymoses >1cm
With these 3 findings probability is 90%
S/s of cushings?
- obesity
- HTN
- DM2
- hirsutism
- thin skin
- osteopenia
- ecchymoses
- elevated urinary free cortisol (24 hr urine)
Pt with cushings symptoms but urinary cortisol is low or zero?
Look for exogenous glucocorticoids
- plasma corticotropin levels are suppressed
Pseudo cushings?
Alcohol induced pseudo cushings
Common cause of cushing syndrome?
Adrenal tumor
- surgery
What common cushing test is actually not good at detecting?
Dexmethasone suppression test
What biochemical tests are needed for cushings?
- urinary free cortisol
- plasma corticotropin
- plasma cortisol
MC type of secretory pituitary tumor?
Prolactinomas
Male Pt presentation for prolactinoma?
Middle aged Decreased libido ED Headaches Testicular size decrease Sellar mass on optic chiasm Prolactin levels = high
No
- wt change
- gynecomastia
- fatigue
Prolactinoma prognosis?
Typically benign
- though can be part of multiple endocrine neoplasm type 1 syndrome
Female presentation for prolactinoma?
Oligoamenorrhea
Infertility
Galactorrhea
Low bone density (2/2 estrogen deficiency)
Causes of hyperprolactinemia?
Post partum - Nursing 6 wks - non nursing 2-3 wks Renal failure - clearance issue Hepatic failure - clearance issue HYPOthyroid - neurogenic stimulation Chest wall injury Nipple stimulation Pituitary tumors Prolactinomas Meds
Meds that cause hyperprolactinemia?
Antidepressants Antipsychotics - risperidone Dopaminergic blockers - metoclopramid Antihypertensive agents Opiats H2-receptor blockers
Indications for therapy if pt has prolactinoma?
Microadenoma Enlarging microadenoma Infertility Bothersume galactorrhea Gynecomastia Testosterone deficiency Oligomenorrhea/amenorrhea Acne and hirsutism
Macroadenomas almost always require therapy, microadenomas dont always require therapy
What is the primary therapy for micro and macro adenomas?
Dopamine agonists
MOA of dopamine agonists in prolactanomas?
Normalize prolactin levels
Restore reproductive function
Reverse galactorrhea
Decrease tumor size
Dopamine agonist?
Bromocriptine
Cabergoline
Cabergoline has fewer side effects and is more effective
Main goals of therapy for prolactanoma?
Normalizing hormones
Preventing mass effect
Fix visual field compromise
There is no evidence that continued elevation of prolactin is harmful if these are avoided
Therapy for prolactonoma if meds fail?
Neuro surgery (transsphenoidal) or radiation therapy
Microadenoams 80-90% effective
Macroadenomas 50% effective
Pregnancy and prolactonomas?
Increased estrogen increases prolactin levels -> lactotroph hyperplasia
It poses a risk
What meds are pregnancy safe for prolactonomas?
Bromocriptine is not associated w birth defects
Indications for neurosurgery in patients with prolactinomas?
- Increasing tumor size (w med therapy)
- pituitary apoplexy
- inability to tolerate dopamine agonist therapy
- Dopamine agonist resistant macroadenoma
- Dopamine agonist resistant microadenoma (if pregnancy desired)
- persistent chiasmal compression despite optimal med therapy
- medically unresponsive cystic prolactinoma
- CSF leakage w dopamine agonist
- macroadenoma in pt w psych (cant take dopamine)
Thyroid nodules in children?
Less common than adults but the malignancy rate is much higher
FNA is unreliable in kids so surgery is prob best option
Prevalence of thyroid nodules?
Palpable 4-7% in adults
Incidentallomas - found in 40% of pax w thyroid US
Found on 36-50% of pax on autopsy
How common is thyroid cancer?
1% of all malagnancies
1.5% -17% in nodules found
However: rate of malignancy for palpable nodule w hx of radiation - 20-50%
Thyroid nodule presentation?
Palpated on exam Protrusion of neck Compression sx - difficulty swallowing - choking sensation
Primary goal in evaluating a thyroid nodule?
Determine malignancy
Hot nodules?
Produce thyroid hormone
- unlikely to be malignant
You have a thyroid nodule, what do you need to do in a workup?
Check TSH
Perform US
Radionuclide scintigraphy (tech 99)
- hot vs cold nodule
Overactive thyroid gland causes?
Toxic multinodular goiter
Cold nodule?
14-22% chance of malignancy
What nodules need to be biopsied?
Those > 1cm get a FNA
If they have a lot then you can sample 3 or so
Any size if encapsular invasion by the lesion
- shows lymphadenopathy
Hx of head and neck irration
Hx of thyroid cancer
Hx of MEN 2
Nodules you dont need to biopsy?
Hyperfunctioning nodules
Tx for thyroid nodules?
1st line
- Radioactive idione 131 ablation
If path report looks like cancer
- surgery
If path report looks benign
- Repeat US 18 months later
- if they grow repeat at 3-5 yrs
Who is at an increased risk for developing thyroid nodules?
Pregnant women
- though cancer risk is no higher
