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Year 2 Endo > Hypopituitarism > Flashcards

Hypopituitarism Flashcards

1
Q

What does hypo mean?

A

Under active

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2
Q

What are the anterior pituitary hormones?

A 
GH
Prolactin
TSH
LH/FSH
ACTH
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3
Q

Summarise the hypothalmo-pituiraty portal system

A

Hypothalamic released or inhibitory factors travel in the portal circulation the anterior pituitary to regulate anterior pituitary hormone productions

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4
Q

What is primary failure of a gland?

A

When the gland itself is not working

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5
Q

What is secondary failure of a gland?

A

When there is no signal to the gland and it cannot be told what to do

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6
Q

What is primary hypothyroidism?

A

e.g. Autoimmune destruction of thyroid gland
T3 and T4 fall
TSH increases
TRH would also be high

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7
Q

What is secondary hypothyroidism?

A

E.g. pituitary tumour damagingly thyrotrophs

Can’t make TSH
TSH falls
T3 and T4 fall as no TSH

The signal is the problem

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8
Q

What is cortisol regulated by?

A

ACTH

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9
Q

What is aldosterone regulated by?

A

Renin-angiotensin

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10
Q

What is primary hypoadrenalism?

A

e.g. Destruction of adrenal cortex

Cortisol falls
ACTH increases

Addison’s

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11
Q

What is secondary hypoadrenalism?

A

e.g. Pituitary tumour damaging corticotrophs

Cannot make ACTh
ACTH falls, cortisol falls

No hyperpigmentation like in additions because low ACTH

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12
Q

What is primary hypogonadism?

A

E.g. destruction of testes (mumps) or ovaries (chemo)

Testosterone or Oestrogen falls
LH and FSH increase
GnRH would also be high (don’t measure)

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13
Q

What is secondary hypogonadism?

A

E.g. pituitary tumour damaging gonadotrophs

Can’t make LH/FSH
LH/FSH fall
Testosterone and oestrogen fall

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14
Q

Why might the anterior pituitary not be working?

A

Congenital

Acquired

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15
Q

What are the congenital causes of hypopituitarism?.

A

Rare
Usually due to mutations of transcription factor genes needed for normal anterior pituitary development

e.g. PROP1 mutation

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16
Q

What are the acquired causes of hypopituitarism?

A 
Tumours
Radiation
Infection e.g. meningitis 
Traumatic brain injury
Pituitary surgrey
Inflammatory (hypophysitis)

Pituitary apoplexy - haemorrhage (less commonly infarction)

Peri-partum infarction (Sheehan’s syndrom)

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17
Q

Which axis’ would hypopituitarism affect?

A

Can use one, several or all axis

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18
Q

What processes also damage the posterior pituitary?

A

Inflammation

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19
Q

What is pan-hypopituitarism?

A

When it affects the anterior and posterior pituitary

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20
Q

How can radiotherapy damage the pituitary?

A

Direct e.g acromegaly

Indirect e.g. nasopharyngeal carcinoma

21
Q

What is most sensitive to radiation damage?

A

GH and Gonadotrophin

22
Q

What can increase after radiotherapy?

A

Prolactin

23
Q

Are the affects of radiant seen in the long-term?

A

Yes, up to 10 years after treatment

24
Q

What is an example of primary ovarian failure?

A

The Menopause
Ovaries stop working
Oestrogen falls
FSH/LH goes up

25
Q

How would low FSH/LH present?

A

Reduced libido
Secondary amenorrhoea
Erectile dysfunction
Reduced pubic hair

26
Q

How would low ACTH present?

A

Fatigue
Weight loss

(No salt loosing crisis like Addisons)

27
Q

How would low TSH present?

A

Fatigue

28
Q

How would low GH present?

A

Reduced quality of life

Short stature only in children

29
Q

How would low prolactin present?

A

Inability to breastfeed

30
Q

What is Sheehan’s syndrome?

A

Post-partum hypipituitarism secondary to hypotension (post partum haemorrhage)

More common in developing countries

Anterior pituitary enlarges in pregnancy (lactotroph hyperplasia)

PPH leads to pituitary infarction due to lack of blood supply

Pituitary cells no longer produce hormones

31
Q

What are the symptoms of Sheehan’s syndrome?

A 
Lethargy
Anorexia
Weight Loss
TSH/ACTH/GH deficiency
Failure of lactation (PRL deficiency)
Failure to resume messes post-delivery 
Posterior pituitary usually not affected
32
Q

What is the best way to visualise the pituitary?

A

MRI

33
Q

What is pituitary apoplexy?

A

Intra-pituitary haemorrhage (less commonly infarction)

Often dramatic presentation in patients with pre-existing pituitary adenomas

May be first presentation of a pituitary adenoma

Can be precipitated by anti-coagulants

34
Q

What are the symptoms of pituitary apoplexy?

A

Severe sudden onset headaches

Visual field defect- compressed optic chiasm (bitemporal hemianopia)

Cavernous sinus involvement may lead to diplopia - double vision (IV, VI), ptosis - droopy eyelid (III)

Compromising cranial nerves that run through the cavernous sinus

35
Q

Why is hypopituitarism diagnosis difficult?

A

Cortisol - differs during the day

T4 - circulating half life of 6 days

FSH/LH - cyclical in women

GH/ACTH - pulsatile

36
Q

How is hypopituitarism diagnosed?

A

Dynamic pituitary function

Stress the body with hypoglycaemia by giving insulin

ACTH and GH are ‘stress hormones’ and are released

We can give TRH which stimulates TSH release

We can give them GnRH which stimulates FSH and LH release

Then do many blood tests and plot them (every few mins for an hour)

37
Q

How can we diagnose hypopituitarism with imaging?

A

Pituitary MRI

May revela specfic pituitary pathology e.g. haemorrhage, adenoma

Empty sella - thin rim of pituitary tissue

38
Q

How do we treat hypopituitarism?

A

Replacement apart from prolactin

39
Q

How do we treat GH deficiency?

A

NICE guidance
Assess QoL using specific questionnaire repeatedly

Daily injection

Measure response by

  • improvement in QoL
  • IGF 1
40
Q

How do you treat TSH deficiency?

A

Replace with once daily levothyroxine

TSH will be low you cannot use this to adjust dose as you do in primary hypothyroidism

Aim for fT4 to be within reference range

41
Q

How do you treat ACTH deficiency?

A

Replace cortisol rather than ACTH
Difficult to mimic diurnal variation

Two option in UK using synthetic glucocorticoids

  • Prednisolone once daily AM
  • Hydrocortisone
42
Q

Why are there rules for patients for ACTH deficiency?

A

They are at risk of adrenal crisis which is triggered bu intercurrent illness

They MUST take tablets every day

43
Q

What are the features of adrenal crises?

A 
Dizziness
Hypotensions (less common)
Vomiting
Weakness
Collapse and death
44
Q

What are the ‘sick day’ rules?

A

Steroid alert pendant/bracelet
Double steroid dose if fever/intercurrent illness
Unable to take tablets (e.g. vomiting) inject IM or come straight to A&E

45
Q

How do you treat FSH/LH deficiency for men?

A

If they don’t need fertility

  • replace testosterone (topical or IM)
  • measure plasma testosterone
  • does not restore spermatozoon production
46
Q

How do you treat FSH/LH for men with fertility?

A

Induction of spermatogenesis by gonadotrophin injections
best response if secondary hypogonadism has developed after puberty
measure testosterone and semen analysis
sperm production may take 6-12 months

47
Q

How do we treat FSH/LH deficiency for women?

A

No fertility

  • replace oestrogen
    oral or topical
  • will need additional progestagen if intact uterus to prevent endometrial hyperplasia
  • mimics normal menstrual cycle
48
Q

How do we treat FSH/LH deficiency for women with fertility?

A

Can induce ovulation via IVF

Year 2 Endo (15 decks)

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