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Endocrinology > Hypopituitarism > Flashcards

Hypopituitarism Flashcards

1
Q

What are the 5 main hormones of the anterior pituitary?

A

-GH
-Prolactin
-TSH
-LH/FSH
-ACTH

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2
Q

What is anterior pituitary failure?

A

Under functioning of the anterior pituitary gland

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3
Q

What are the 2 types of anterior pituitary failure?

A
  1. PRIMARY hypothyroidism (all fail-gland itself fails)
  2. SECONDARY hypothyroidism (no signal from hypothalamus or anterior pituitary)
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4
Q

Explain the congenital cause of hypopituitarism?

A

-Rare
-Mutations of transcirption factor genes needed for normal anterior pituitary development
-Results in hypoplastic (underdeveloped) anterior pituitary gland on MRI
-Deficient in GH and at least 1 more anterior pituitary hormone
-Results in short stature

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5
Q

List the acquired causes of hypopituitarism

A

*MORE COMMON
Tumours eg adenomas, metastases, cysts
* Radiation (hypothalamic/pituitary damage)
* Infection eg meningitis
* Traumatic brain injury
* Pituitary surgery
* Inflammatory (hypophysitis)
* Pituitary apoplexy - haemorrhage (or less
commonly infarction)
* Peri-partum infarction (Sheehan’s syndrome)

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6
Q

What is panhypopituitarism?

A

-total loss of anterior AND posterior pituitary
-Usually due to inflammation or surgery of the anterior pituitary causing damage to the posterior pituitary

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7
Q

Why are annual assessments required following radiotherapy to/around the pituitary?

A
  • Higher total radiotherpy dose=higher risk of HPA axis damage
  • GH and gonadotrophins most sensitive
  • Hormones can deplete slowly
  • Risk persists up to 10y after radiotherapy
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8
Q

What are the presentations of hypogonadism?

A

FSH/LH:
Reduced libido
Secondary amenorrhoea
Erectile dysfunction
Reduced pubic hair

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9
Q

What are the presentations of hypocorticolism?

A

ACTH:
Fatigue
NB Not a salt losing crisis (still has aldosterone due to reninangiotensin system)

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10
Q

What are the presentations of hypothyroidism?

A

Fatigue

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11
Q

What are the presentations of growth hormone deficiency

A

Reduced quality of life
NB short stature only in children

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12
Q

What are the presentations of hypoprolactinaemia?

A

Inability to breastfeed

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13
Q

Explain the pathophysiology of Sheehan’s syndrome

A

Caused by post partum haemorrhage
As you continue along the pregnancy:
-Lactotrophs get larger preparing for lactation after birth (lactotroph hyperplasia)
-Pituitary increases in size
-HAEMORRHAGE
-b.p. decreases
-blood does not fulfill the increased demand to pituitary (now that it’s larger)
-Pituitary infarction= decreases function

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14
Q

What are some symptoms of Sheehan’s syndrome?

A
  • Lethargy (tired), anorexia, weight loss –
    TSH/ACTH/(GH) deficiency (low cortisol)
  • Failure of lactation – PRL deficiency
  • Failure to resume menses post-delivery (no period)-loss of FSH/LH
  • Posterior pituitary usually NOT affected (anterior pituitary is made of glandular tissue and posterior is neuronal tissue- therefore unaffected by the haemorrhage
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15
Q

What scan would you do to monitor pituitary function?

A
  • MRI
  • Pituitary is v. small- found at the base of the skull
  • Other scans do not have enough resolution
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16
Q

What is pituitary apoplexy?

A

Swelling due to filling of blood OR infarction
There are 2 types:
1. Bleeding (haemorrhage) into the pituitary
2. Loss of blood flow (infarction) to the pituitary

17
Q

What are some symptoms of pituitary apoplexy?

A
  • Severe sudden onset headache
  • Visual field defect – compressed optic chiasm,
    bitemporal hemianopia
  • Cavernous sinus involvement may lead to
    diplopia (IV, VI), ptosis (III)
18
Q

What are some cautions that need to be taken when diagnosing hypopituitarism?

A
  • Cortisol – what time of day?
  • T4 – circulating t1/2 (takes the T4 6 days to reduce to it’s half life)
  • FSH/LH – cyclical in women
  • GH/ACTH - pulsatile
19
Q

What is a dynamic pituitary function test?

A

“Used to monitor pituitary function”

*to measure ACTH/GH- induce stress
-give patient insulin
-hypoglycemic (<2.2mM)
-adrenaline/ NA increases to restore blood glucose
-ACTH/ GH increases (ACTH difficult to measure- measure cortisol)

*to measure TSH- inject TRH
*to measure FSH & LH- inject GnRH

20
Q

What is the treatment for GH deificiency?

A
  • NICE guidance
  • Confirm GH deficiency on dynamic
    pituitary function test
  • Assess Quality of Life (QoL) using
    specific questionnaire
  • Daily injection
    Measure response by
  • improvement in QoL
  • plasma IGF-1
21
Q

What is the treatment for TSH deficiency?

A
  • Straightforward
  • Replace with once daily
    levothyroxine
  • Don’t forget, TSH will be low, so you
    can’t use this to adjust dose as you
    do in primary hypothyroidism
  • Aim for a fT4 above the middle of
    the reference range
22
Q

What is the treatment for ACTH deficiency?

A
  • Replace cortisol rather than ACTH
  • Difficult to mimic diurnal variation of cortisol
  • Two main options in the UK using synthetic glucocorticoids
  • Prednisolone once daily AM eg 3mg
  • Hydrocortisone three times per day eg 10mg/5mg/5mg
23
Q

What is “adrenal crisis”?

A
  • Patients with primary adrenal failure (Addison’s) or secondary adrenal failure (ACTH deficiency) at risk of ‘adrenal crisis’ triggered by intercurrent illness
    (cortisol usually increases to help fight illness)
  • Adrenal crisis features – dizziness, hypotension, vomiting, weakness, can result in collapse and death
24
Q

What precautions must be taken for patients taking replacement steroids for ACTH deficiency?

A
  • Patients who take replacement steroid eg prednisolone,
    hydrocortisone must be told sick day rules
  • Steroid alert pendant/bracelet
  • Double steroid dose (glucocorticoid not mineralocorticoid)
    if fever/intercurrent illness
  • Unable to take tablets (eg vomiting), inject IM or come straight to A & E
25
Q

How do you treat FSH/LH deficiency in men?

A

If no fertility required:
* Replace testosterone – topical or
intramuscular most popular
* Measure plasma testosterone
* Replacing testosterone does not restore
sperm production (this is dependent on FSH)

if fertility required:
* Induction of spermatogenesis by gonadotropin injections
* Best response if secondary hypogonadism has developed after puberty
* Measure testosterone and semen analysis
* Sperm production may take 6-12 months

26
Q

How do you treat FSH/LH deficiency in women?

A

If no fertility required:
* Replace oestrogen
* Oral or topical
* Will need additional progestogen if intact uterus to prevent endometrial hyperplasia
Fertility required
* Can induce ovulation by carefully timed gonadotropin injections (IVF)

27
Q

How do you treat FSH/LH deficiency in women?

A

If no fertility required:
* Replace oestrogen
* Oral or topical
* Will need additional progestogen if intact
uterus to prevent endometrial
hyperplasia
Fertility required
* Can induce ovulation by carefully timed
gonadotropin injections (IVF)

Endocrinology (14 decks)

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