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Z YEAR 2 BRS ENDO > Hypopituitarism > Flashcards

Hypopituitarism Flashcards

1
Q

What are the anterior pituitary hormones?

A
  1. Growth Hormone (somatotrophin)
  2. Prolactin
  3. TSH (thyrotrophin)
  4. LH + FSH
  5. ACTH (corticotrophin)
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2
Q

How do the hypothalamic releasing or inhibitory factors travel and to where?

A
  • portal circulation to anterior pituitary

- Travel via blood supply from hypothalamic neurones down capillary plexus + pituitary stalk to anterior piuitary

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3
Q

What is GH responsible for?

A

Growth (children height and adults like lean muscle strength)

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4
Q

What prolactin responsible for?

A

Milk production

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5
Q

What is FSH responsible for?

A
  • Oestrogen
  • Progesterone
  • Testosterone
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6
Q

What is LH responsible for?

A
  • Oestrogen
  • Progesterone
  • Testosterone
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7
Q

What can fail in primary disease?

A
  1. Thyroid
  2. Adrenal cortex (cortisol)
    3 Gonads
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8
Q

What is an example of primary hypothyroidism?

A

autoimmune destruction of thyroid gland (common)

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9
Q

What happens to levels in primary hypothyroidism?

A
  1. T3 + T4 fall

2 . TSH increases (we don’t measure TRH but that would also be high)

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10
Q

What is an example of secondary hypothyroidism?

A

pituitary tumour damaging thyrotrophs

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11
Q

What happens to levels in secondary hypothyroidism?

A
  1. Can’t make TSH
  2. TSH falls
  3. T3 + T4 fall (as no TSH)
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12
Q

How is cortisol regulated?

A

by ACTH - aldosterone is NOT (renin-angiotensin)

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13
Q

What is an example of primary hypoadrenalism?

A

destruction of adrenal cortex (eg autoimmune)

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14
Q

What happens to levels in primary hypoadrenalism?

A
  1. Cortisol falls

2. ACTH increases (we don’t measure CRH but that would also be high)

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15
Q

What is an example of secondary hypoadrenalism?

A

pituitary tumour damaging corticotrophs

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16
Q

What happens to levels in secondary hypoadrenalism?

A
  1. Can’t make ACTH
  2. ACTH falls
  3. cortisol falls
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17
Q

What is an example of primary hypogonadism?

A

destruction of testes (eg mumps) or ovaries (eg chemotherapy)

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18
Q

What happens to levels in primary hypogonadism?

A
  1. Testosterone (men) or oestrogen (women) fall

2. LH + FSH increase (we don’t measure GnRH but that would also be high)

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19
Q

What is an example of secondary hypogonadism?

A

pituitary tumour damaging gonadotrophs

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20
Q

What happens to levels in secondary hypogonadism?

A
  1. Can’t make LH/FSH
  2. LH/FSH fall
  3. Testosterone/oestrogen fall
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21
Q

What are some congenital causes of hypopitutarism?

A
  1. mutations of transcription factor genes needed for normal anterior pituitary development
    - eg PROP1 mutation
    - Rare
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22
Q

How would you be able to tell if someone had congential hypopituitarism?

A
  • Deficient in GH and at least 1 more anterior pituitary hormone
  • Short stature
  • Hypoplastic (underdeveloped) anterior pituitary gland on MRI
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23
Q

What are some acquired reasons for hypopituitarism?

A
  1. Tumours eg adenomas, metastases, cysts
  2. Radiation (hypothalamic/pituitary damage)
  3. Infection eg meningitis
  4. Traumatic brain injury
  5. Pituitary surgery
  6. Inflammatory (hypophysitis)
  7. Pituitary apoplexy - haemorrhage (or less commonly infarction)
  8. Peri-partum infarction (Sheehan’s syndrome
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24
Q

What axis is affected in hypopituitarism?

A

one axis, several or all

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25
Q

Is hypopituaitrism exclusively for anterior pituitary?

A
  • Often just anterior

- BUT certain process (inflammation (hypophysitis) or surgery) may cause posterior dysfunction too

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26
Q

What is panhypopituitarism?

A

Total loss of anterior + posterior pituitary function

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27
Q

Is the pituitary and hypothalamus sensitive to radiation?

A

yes

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28
Q

When might there be radiotherapy be given to pituitary?

A
  1. direct to pituitary eg. to treat acromegaly

2. indirect eg nasopharyngeal carcinoma

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29
Q

What does the extent of radiotherapy induced hypopituaitarism depend on? Which areas are most senstivie?

A
  • depends on total dose of radiotherapy delivered to the hypothalamo-pituitary axis (Gy)
  • GH and gonadotrophins most sensitive
30
Q

What can increase after radiotherapy? Why?

A

PRL can increase after radiotherapy (loss of hypothalamic dopamine)

31
Q

What is the presentation if FSH/LH is affected in hypopituitarism?

A
  1. Reduced libido
  2. Secondary amenorrhoea
  3. Erectile dysfunction
  4. Reduced pubic hair
32
Q

What is the presentation if ACTH is affected in hypopituitarism?

A
  1. Fatigue (no cortisol)

2. NB Not a salt losing crisis as Addisons as still have aldosterone (renin-angiotensin)

33
Q

What is the presentation if TSH is affected in hypopituitarism?

A

Fatigue

34
Q

What is the presentation if GH is affected in hypopituitarism?

A
  1. Reduced quality of life

2. NB short stature only in children

35
Q

What is the presentation if PRL is affected in hypopituitarism?

A

Inability to breastfeed

36
Q

What is Sheehan’s syndrome?

A
  1. Post-partum hypopituitarism secondary to hypotension (post partum haemorrhage - PPH)
  2. Posterior pituitary usually not affected
37
Q

Where is Sheehan’s syndrome more common?

A

Developing countries (as related to how much blood a woman looses in pregnancy)

38
Q

What happens to the anterior pituitary in pregnancy?

A

enlarges in pregnancy (lactotroph hyperplasia) very normal

39
Q

What can Post party haemorrhage lead to?

A

pituitary infarction, so bigger than normal anterior pituitary needs more blood as bigger then doesn’t receive enough

40
Q

What happens in Sheehan’s syndrome?

A
  1. Lethargy, anorexia, weight loss – TSH/ACTH/(GH) deficiency
  2. Failure of lactation – PRL deficiency
  3. Failure to resume menses post-delivery
41
Q

What is pituitary apoplexy?

A

Intra-pituitary haemorrhage or (less commonly) infarction

42
Q

What is the presentation of pituitary apoplexy?

A

dramatic presentation in patients with pre-existing pituitary tumours (adenomas)

43
Q

What can pituitary apoplexy be the first presentation of?

A

Pituitary adenoma

44
Q

How can a pituitary apoplexy be precipitated?

A

Anti-coagulants (blood thinner)

45
Q

What are happens in pituitary apolexy?

A
  1. Severe sudden onset headache
  2. Visual field defect – compressed optic chiasm, bitemporal hemianopia
  3. Cavernous sinus involvement may lead to diplopia (IV, VI), ptosis (III)
46
Q

What do you need to be aware of in a biochemical diagnosis of hypopituitarism?

A

What time of day / when to take it

47
Q

What is the pattern of the hormones cortisol, T4, FSH/LH and GH/ACTH?

A
  • Cortisol – what time of day?
  • T4 – circulating t1/2 6 days, T4 may be fine several days after complain of headache when worried about apoplexy
  • FSH/LH – cyclical in women
  • GH/ACTH - pulsatile
48
Q

How would you measure ACTH/GH for the diagnosis of hypopituitarism?

A

Dynamic test: ACTH/GH are stress hormones
1. Insulin-induced (give insulin injection to stress body) which makes blood glucose very low
•Hypoglycaemia (<2.2mM) = ‘stress’
2. hypoglycaemia stimulates
-GH release
-ACTH release (cortisol measured)

49
Q

How would you measure TSH for the diagnosis of hypopituitarism?

A

Give TRH to stimulate TSH release (dynamic test)

50
Q

How would you measure FSH/LH for the diagnosis of hypopituitarism ?

A

Give GnRH stimulates FSH+LH release (dynamic test)

51
Q

How would you conduct a radiological diagnosis of hypopituitarism?

A

Pituitary MRI (CT not so good at delineating pituitary gland)

52
Q

What can a pituitary MRI reveal?

A
  1. May reveal specific pituitary pathology
    eg haemorrhage (apoplexy), adenoma
  2. Empty sella – thin rim of pituitary tissue
53
Q

How do you treat GH deficiency?

A
  1. Confirm GH deficiency on dynamic pituitary function test
  2. Assess Quality of Life (QoL) using specific questionnaire
  3. Daily injection
54
Q

How do you measure the response of GH deficiency treatment?

A
  • improvement in QoL (questionnaire)

* plasma IGF-1

55
Q

How do you treat TSH deficiency?

A
  1. Replace with once daily levothyroxine
  2. Don’t forget, TSH will be low, so you can’t use this to adjust dose as you do in primary hypothyroidism
  3. Aim for a fT4 above the middle of the reference range (in secondary)
56
Q

What do you replace in ACTH deficiency?

A
  • cortisol rather than ACTH

- Difficult to mimic diurnal variation or cortisol

57
Q

What are the two synthetic glucocorticoids used to treat ACTH deficiency?

A
  • Prednisolone once daily AM eg 3mg

* Hydrocortisone three times per day eg 10mg/5mg/5mg

58
Q

Who is at risk of adrenal crisis?

A

Patients with ACTH deficiency (or Addison’s – primary adrenal failure)

59
Q

What are the features of an adrenal crisis?

A
  1. dizziness
  2. hypotension
  3. vomiting
    4 weakness
  4. can result in collapse and death
60
Q

What is a sick day rule and who has them?

A
  • Patients who take replacement steroid eg prednisolone, hydrocortisone must be told sick day rules
  • Steroid alert pendant/bracelet
  • Double steroid dose if fever/intercurrent illness
  • Unable to take tablets (eg vomiting), inject IM or come straight to A + E
61
Q

How do you treat FSH/LH deficiency in men when no fertility is required? What do you measure?

A
  1. Replace testosterone – topical or intramuscular most popular
  2. Measure plasma testosterone
  3. Replacing testosterone does not restore sperm production (this is dependent on FSH)
62
Q

How do you treat FSH/LH deficiency in men when fertility is required? What do you measure?

A
  1. Induction of spermatogenesis by gonadotropin injections
  2. Best response if secondary hypogonadism has developed after puberty
  3. Measure testosterone and semen analysis
  4. Sperm production may take 6-12 months
63
Q

How do you treat FSH/LH deficiency in women when no fertility is required?

A
  1. Replace oestrogen
  2. Oral or topical
  3. Will need additional progestogen if intact uterus to prevent endometrial hyperplasia
64
Q

How do you treat FSH/LH deficiency in women when fertility is required?

A

Can induce ovulation by carefully timedgonadotropin injections (IVF)

65
Q

What is ACTH responsible for?

A

Tells adrenal cortex to make cortisol (aldosterone from adrenal cortex is not under control of ACTH)

66
Q

What is primary failure?

A

Gland itself fails

67
Q

What is secondary failure?

A

No signal from hypothalamus or anterior pituitary

68
Q

Are the effects of radiation on the pituitary immediate?

A

Risk persists up to 10y after radiotherapy, so annual assessment

69
Q

What is the best radiological way to visual the pituitary gland?

A
  • MRI

- CT good macroscopic view and not great as small pituitary

70
Q

Can you replace prolactin?

A

No

71
Q

What is adrenal crisis triggered by?

A

Intercurrent illness

Z YEAR 2 BRS ENDO (13 decks)

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