HYPOPITUITARISM

Question 1

Name all anterior pituitary hormones and their respective effects

Answer 1

prolactin - milk production
growth hormone - growth in tissues and IGF-1/2 in liver
TSH - production of T3/4 in thyroid
ACTH - cortisol production in zona fasciculata
LH/FSH - production of testosterone/oestrogen/progesterone by gonads

Question 2

What is the difference between primary and secondary disease

Answer 2

primary - problem with the gland itself

secondary - problem with hypothalamus or pituitary

Question 3

Describe primary hypothyroidism vs secondary hypothyroidism and examples

Answer 3

primary - autoimmune destruction against thyroid gland. T3/4 decrease, TSH increase

secondary - pituitary tumour damaging thyrotrophs. Low TSH, low T3/4

Question 4

Describe primary hypoadrenalism vs secondary hypoadrenalism and examples

Answer 4

primary - autoimmune destruction of adrenal cortex (addison’s). Cortisol decrease, ACTH increase

secondary - pituitary tumour damaging adrenotrophs. Cortisol decrease, ACTH decrease

Question 5

Describe primary hypogonadism vs secondary hypogonadism and examples

Answer 5

primary - destruction of testes (mumps) or ovaries (chemotherapy). Testosterone/oestrogen decrease, LH/FSH increase

secondary - pituitary tumour damaging gonadotrophs. Testosterone/oestrogen decrease, LH/FSH decrease

Question 6

What usually causes congenital hypopituitarism

Answer 6

Mutations of transcription factor genes e.g. (PROP1)

Question 7

Outline features of congenital hypopituitarism

Answer 7

Low GH and at least 1 more anterior pituitary hormone
Short stature (low GH)
Hypoplastic anterior pituitary on MRI

Question 8

List causes of acquired hypopituitarism

Answer 8

tumours e.g. adenomas, radiation, infection, traumatic brain injury, inflammation, pituitary apoplexy (haemorrhage or infarction), Sheehan’s syndrome, pituitary surgery

Question 9

What is total loss of anterior and posterior pituitary function called?

Answer 9

Panhypopituitarism

Question 10

Example of direct and indirect radiotherapy to pituitary

Answer 10

acromegaly (direct), nasopharyngeal carcinoma (indirect)

Question 11

What does radiotherapy of pituitary especially effect?

Answer 11

GH and gonadotrophins most sensitive

Prolactin can increase after radiotherapy because of loss of hypothalamic dopamine

Question 12

How long does the risk of radiotherapy persist up to?

Answer 12

10 years so need to do annual checkups

Question 13

What is Sheehan’s syndrome?

Answer 13

After giving birth, postpartum haemorrhage may occur causing hypotension/hypovolemia in mother. This causes ischaemic necrosis of pituitary and hypopituitarism of mother

Question 14

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

Answer 14

Posterior pituitary is neural and doesn’t depend on blood supply

Question 15

List symptoms of Sheehan’s syndrome

Answer 15

Lethargy, anorexia, weight loss
Failure of lactation
Failure to resume menses (periods) post-delivery

Question 16

What is pituitary apoplexy?

Answer 16

Intra-pituitary haemorrhage or infarction often with dramatic presentations in a patient who has an adenoma. Could be first sign of adenoma. Can be caused by anti-coagulants.

Question 17

What are some symptoms of pituitary apoplexy?

Answer 17

Severe sudden onset of headache
Defect in visual field (compressed optic chiasm)
if cavernous sinus involved - can cause diplopia (CN IV, VI) and ptosis (CN III)

The blood can cause compression of the surroubnding structures

Question 18

What should you be aware of when measuring cortisol, T4, LH/FSH and GH/ACTH

Answer 18

Cortisol is diurnal so measure in morning
T4 has a half time of 6 days
LH/FSH is cyclical in women and depends on when in the menstrual cycle it is measured
GH/ACTH are pulsatile

Question 19

What is the method of measuring ACTH and GH?

Answer 19

Insulin-induced hypoglycaemia in patient stimulates GH and ACTH release since they are stress hormones. Cortisol is measured instead of ACTH.

Question 20

What is the method of measuring TSH and FSH/LH?

Answer 20

Inject TRH or GnRH to stimulate release and measure

Question 21

What is the best way if radiologically diagnosing hypopituitarism?

Answer 21

MRI

Question 22

What is it called when no/little pituitary tissue is seen in an MRI?

Answer 22

Empty sella

Question 23

Which anterior pituitary hormone deficiency cannot ben treated?

Answer 23

Prolactin

Question 24

What is the treatment of GH deficiency in adults?

Answer 24

Assess quality of life in patients using questionnaire.

If low QoL give daily injections of GH and measure the progress by improvement in QoL and plasma IGF-1

Question 25

What is the treatment of TSH deficiency?

Answer 25

One daily tablet of levothyroxine and aim for a free T4 above the middle of the reference range

Question 26

What is the treatment of ACTH deficiency?

Answer 26

Replace cortisol rather than ACTH.
Give patient synthetic glucocorticoids:
- Prednisolone once daily AM or
- Hydrocortisone 3 times per day

This mimics the diurnal variation of cortisol

Question 27

What are patient’s with ACTH deficiency/Addison’s primary adrenal failure at risk of?

Answer 27

Adrenal crisis which can be triggered by an intercurrent illness e.g. UTI

Question 28

What are the sick day rules and who are they told to?

Answer 28

patients who take replacement steroids
steroid alert pendant/bracelet
double glucocorticoid does if fever /intercurrent illness
if unable to take tablets e.g. vomiting come to A&E or inject IM

Question 29

What is the treatment of FSH/LH deficiency in men where fertility is not required?

Answer 29

Replace testosterone with topical gel or intramuscularly. Measure plasma testosterone

(testosterone does not restore sperm production)

Question 30

What is the treatment of FSH/LH deficiency in men where fertility is required?

Answer 30

Inject gonadotrophin to induce spermatogenesis. Best response if the secondary hypogonadism has developed after puberty.
Measure testosterone and semen analysis.

Question 31

How long does sperm production take after treatment of FSH/LH in men?

Answer 31

6-12 months

Question 32

What is the treatment of FSH/LH deficiency in women where fertility is not required?

Answer 32

Replace oestrogen with oral or topical method\

If uterus intact administer additional progestogen to prevent endometrial hyperplasia

Question 33

What is the treatment of FSH/LH deficiency in women where fertility is required?

Answer 33

Induce ovulation by carefully timed gonadotrophin injections (IVF)