Pituitary Disease (clinical)

Question 1

What symptoms would make you think a patient had Acromegaly?

Answer 1

Increased shoe size in an adult
Enlargement of soft tissues
"Swollen" hands (rings can't fit on)
Change in bite, jaw growth
Sweating
Nodular goiter
Bowel polyps

Question 2

Which investigations would you carry out for a patient with suspected acromegaly?

Answer 2

Oral glucose tolerance test (see if GH NOT suppressed)
IGF1 (progression of disease)
MRI pituitary
Screen other pituitary hormones (TSH, T4, T3, synacthen test (synthetic ACTH), prolactin, LH, FSH)

Question 3

In post-menopausal women, how should the LH and FSH levels be?

Answer 3

HIGH

if low or normal, something wrong

Question 4

Name 4 causes of galactorrhoea:

Answer 4

Pregnancy/breastfeeding (physiological cause)

Prolactinoma (tumour)

Dopamine antagonist drugs (e.g. anti-psychotics) (dopamine inhibits prolactin)

Compression of pituitary stalk

Question 5

Which symptoms would make you suspect Cushing’s syndrome?

Answer 5

Hypertension
Weight gain
Alopecia
Thin skin
Chemosis (red conjuncta)
Back pain (due to osteoporosis and wedge fractures)

Question 6

What is Cushing’s?

Raised….

Answer 6

Raised Cortisol

Question 7

What causes Cushing’s DISEASE?

Answer 7

A pituitary tumour

Question 8

Name 2 causes of Cushing’s SYNDROME?

Answer 8

Iatrogenic - High dose steroids (e.g. asthmatic)

Excessive ACTH production - from peripheral source driving cortisol

Question 9

Which is caused by high dose steroids, Cushing’s DISEASE or Cushing’s SYNDROME?

Answer 9

Cushing’s SYNDROME

Question 10

Which is caused by a pituitary tumour, Cushing’s DISEASE or Cushing’s SYNDROME?

Answer 10

Cushing’s DISEASE

Question 11

How do we test for HIGH cortisol?

Answer 11

Overnight Dexomethasone suppression test

Give Dexomethasome at night and test cortisol levels in morning

(In person without high cortisol –> low cortisol in morning, switched off production)
(In person with high cortisol (e.g. Cushing’s) –> cortisol NOT low, production has NOT been switched off)

(also do 24 hour urine cortisol)
(also check ACTH levels) –> HIGH –> PITUITARY cause
LOW –> ADRENAL cause

Question 12

If a patient has high cortisol and high ACTH, is the high cortisol due to pituitary or adrenal gland?

Answer 12

PITUITARY CAUSE
(e.g. Cushing’s DISEASE)

HIGH –> PITUITARY cause
LOW –> ADRENAL cause

Question 13

If a patient has high cortisol and low ACTH, is the high cortisol due to pituitary or adrenal gland?

Answer 13

ADRENAL CAUSE

Question 14

Which disease is associated with pigmentation of palmer creases and buccal mucosa?

Answer 14

Addison’s disease

Question 15

Which test would you do to test for Addison’s disease?

Answer 15

Synacthen test

(Cortisol won’t rise)

(In person without Addison’s, cortisol rises to about 550)

Question 16

Name 6 causes of cortisol deficiency:

Answer 16

TB
On steroids long term then suddenly stop
Hypothalmic/pituitary tumours
Haemorrhage/infarction (bilaterally)
HIV
Metastases from tumour elsewhere (bilateral metastases)

Question 17

Name 5 causes of HYPOPITUITARISM:

Answer 17

Tumour 
Trauma (head injury)
Meningitis (or syphilis)
Infarction (vascular)
Radiotherapy or chemotherapy

Question 18

What tests would you do if you suspected hypopituitarism?

Answer 18

Test all pituitary hormones (TSH, T4, T3, GH, LH, FSH, Prolactin, etc)

Pituitary scan (MRI)

Question 19

What does PCOS stand for?

Answer 19

Polycystic Ovarian Syndrome

Question 20

Symptoms of PCOS include:

3

Answer 20

Cystic ovaries
Amenorrhoea
Hirsutism

(associated with insulin resistance often)

Question 21

Treatment options for PCOS:

Answer 21

Metformin
Oral contraceptive
Weight loss (may help with insulin resistance)

Question 22

What does MEN stand for?

Answer 22

Multiple endocrine neoplasm

Question 23

What are the “3 Ps” of MEN1?

Answer 23

Pancreatic tumour (e.g Gastinoma)
Parathyroid adenoma
Pituitary adenoma

Question 24

What occurs in MEN2b?

Answer 24

Also get neurofibromatous features