The Nuts and Bolts of the Endocrine System: Anatomy and Histology Roadshow Flashcards
1
Q
What is the composition of the endocrine system?
A
hormone-secreting glands
2
Q
Hormones are … molecules
A
mediator
3
Q
The endocrine system is essential for
A
normal growth and development adaptation to internal and external environment contribute to the process of sexual reproduction
4
Q
The nervous system and the endocrine system interact at what?
A
the hypothalamus (major controlling centre of the ANS)
5
Q
What does the hypothalamus control? (3 things)
A
temperature circadian rhythms hunger
6
Q
Each hormone elicits a response from any cell carrying a …
A
receptor sentitive for that hormone
7
Q
Endocrine glands - do they have ducts?
vascularised?
A
ductless - hormone released to interstitial space - blood stream or lymphatic system
highly vascularised
8
Q
Hormones affect other cells metabolism according to:
A
number of molecules available
number of receptors available
affinity hormone-receptor
9
Q
Chemical classification of hormones: (3 main categories) + examples?
A
amine (adrenaline, noradrenalin, dopamine)
steroid (oestradiol, testosterone)
protein/peptide (ADH, oxytocin, insulin)
10
Q
Nitric oxide is both … and …
A
neurotransmitter and hormone
11
Q
What is this image showing?
A
Germ layers of developing embryo
12
Q
Source of Steroid hormone
What is it derived from?
A
ovaries, testis, adrenal cortex
embryonic mesodermal tissue
13
Q
Source of Protein/Peptide hormone
cells of what origin?
A
Adenohypophysis (pituitary) - ectodermal tissue of the oral cavity
Thyroid, Paraythyroids, Pancreas - cells of endodermal origin of GI tract
Scattered endocrine cells in epithelium of GI tract and lungs
14
Q
Source of Amine hormone
cells of what origin?
A
Thyroid, adrenal medulla
cells of ectodermal origin
15
Q
Where are discrete glands found? (4)
A
Hypophysis, thryoid, parathyroid, adrenal
16
Q
Where are large glands found? (3)
they have both … and… function
A
kidneys, ovaries/testis, placenta
endocrine and exocrine
17
Q
Diffuse endocrine system is composed of
A
scattered nerve cells with endocrine function
18
Q
List the endocrine glands in the body? (10)
A
Pineal gland
Parathyroid gland
Hypothalamus
Thyroid gland
Pituitary gland
Adrenal gland
Thymus
Testis
Ovary
Pancreas
19
Q
Other glands include:
A
ovaries/testes
pancreas/kidney/liver/thymus
skin, pineal gland, placenta etc
20
Q
What is this image showing?
A
The hypophysis (pituitary gland)
21
Q
What kind of gland is the hypophysis?
What is is suspended from?
A
compound gland - two main components
suspended from the hypothalamus by stalk or infundibulum
22
Q
Where is the hypophysis located?
A
Sella turcica, a depression in the superior surface of the sphenoid bone
23
Q
What is the function of the hypophysis?
What is it known as?
A
produces several hormones that influence activity of other endocrine glands (E.g. liver)
‘master’ endocrine gland
24
Q
A
25
What is the sella turcica?
A depression in the superior surface of the sphenoid bone
26
Hypophysis gross anatomy
what are the two lobes?
two lobes
adenohypophysis - anterior lobe
neurohypophysis - posterior lobe
27
Hypophysis gross anatomy - it is no larger in size than that of what?
a pea
28
Adenohypophysis is the ... part of the hypophysis
glandular
29
Neurohypophysis is the ... part of the hypophysis
neural
30
The adenohypophysis is an outpouch of what?
what is the outpouch called?
ectoderm of oral cavity
Rathke's pouch
31
The neurohypophysis is a downgrowth from
the diencephalon of the brain
32
What hormones does the neurohypophysis produce?
Oxytocin, ADH
33
What hormones does the adenohypophysis produce?
FSH, LH, TSH, etc
34
What is this image showing?
blood circulation of the hypophysis
35
Blood supply to the hypophysis - supplied by which 2 blood vessels? (branches of internal carotid)
Superior hypophyseal
Inferior hypophyseal
36
The superior hypophyseal supplies
median eminence
upper part of stalk
37
The inferior hypophyseal supplies
neurohypophysis
lower part of stalk
38
arteries supplying median eminence and stalk end as ... ...
capillary plexuses
39
Hypophysis - veins
capillary plexuses in median eminence and stalk ending are drained by ...
These veins pass to what?
veins then form a ... ... plexus
portal veins (shown in image)
anterior lobe of pituitary
secondary capillary
40
Hypophysis - veins
Veins forming a secondary capillary plexus - setup provides a route for ... substances released from the ... to also reach the ... lobe
neurosecretory
hypothalamus
anterior lobe
41
Hypophysis - control (Activity)
signals from the ... are responsible for hormone release from both ... and ...
hypothalamus
adenohypophysis
neurohypophysis
42
What is this image showing?
Thyroid cartilage
Isthmus
43
The thyroid gland is a ... gland in the neck
how much does it weigh?
whats its measurement?
bilobed
30g
4 x 2cm in size
44
The thyroid gland has ... lateral lobes connected by an ... that courses anterior to the ...
2
isthmus
trachea
45
The thyroid gland lies just below the ... ... of thyroid cartilage to .../6 tracheal ring, immediately ... to the trachea
olbique
5/6
anterior
46
The thyroid gland is derived from what?
It develops as a growth from the floor or ...
endoderm
floor of pharynx, near base of tongue
47
The thyroid gland is under control from the ... and ...
hypothalamus (thyrotropin-releasing hormone)
Hypophysis (thyroid stimulating hormone)
48
The thyroid gland has an essential role in regulating what things?
tissue metabolism
growth and development
(T3, T4)
49
What is this image showing?
blood course of the thyroid gland
50
Thyroid - blood supply (arteries)
... thyroid from what?
... thyroid from what?
superior thyroid (from external carotid)
inferior thyroid (from subclavian)
51
Thyroid gland - blood drainage (veins) from an extensive plexus into the
... ... vein
... vein
internal jugular vein
brachiocephalic vein
52
Thyroid gland - care in surgery - why? (2 things)
blood loss
recurrent nerve (from vagus) damage
53
What are the arrows pointing to (6)?
External carotid (Top arrow right)
Vagus nerve (Second arrow right)
Common carotid (third arrow right)
Recurrent nerve (fourth arrow right)
Superior parathyroids (top left)
Inferior parathyroids (bottom left)
54
'Para' = to the ... of the thyroid gland
side - although some variation can occur
55
There are ... parathyroid glands: ... superior and ... inferior; embedded in ... of thyroid (posterior aspect)
what size are they?
4
2 superior, 2 inferior
capsule of thryoid - posterior aspect
grain of rice - very small - 40mg
56
The parathryoid glands develop mostly from cells originating from ...rd/...th ... pouches; migrate caudally with the ...
3rd/4th pharyngeal pouches
thymus
57
Role of parathyroid glands - secrete ... hormone which regulates ... and ... levels within homeostasis
parathryoid
calcium and phosphate levels
58
Inferior parathyroids travel ... to lie ... compared to superior parathyroids
further to lie lower
59
Parathyroid glands -
artery:
vein:
nerve:
artery - primarily inferior thyroid (also superior)
vein: superior, middle + inferior thyroid
nerve: from middle and inferior cervical ganglions
60
The parathyroid glands must be preserved during ...
if removed what happens?
thyroidectomy; if removed blood calcium levels fall = muscles, including respiratory and laryngeal, go into tetanic contraction - death
61
What is this arrow pointing to?
adrenal glands
62
Adrenal glands, also known as ... glands
where are they located?
hormone released in response to ...
are they retroperitoneal?
suprarenal
stress
superior pole of kidneys (T12); yes, retroperitoneal
63
What is this image showing?
Coronal cut of adrenal glands
outer capsule, cortex and medulla
64
Adrenal glands - shape
right side is
left side is
what is the size and weight?
pyramidal - right
semilunar - left
2-3 x 1cm, 3.5-5 grams
65
The cortex of the adrenal glands are derived from ... whereas the medulla is derived from ... ... cells
mesoderm
neural crest cells
66
_Adrenal glands - cortex_
The adrenal cortex secretes ...
* cells subjacent to capsule secrete ... e.g. aldosterone
* deeper part of cortex - cells secrete ... e.g. hydrocortisone
The cortex also produces ... ... e.g. testosterone
adrenal cortex secretes - corticosteroids
cells subjacent to capsule - secrete mineralocorticoids - function to maintain electrolyte balance
deeper part of cortex - cells secrete glucocorticoids - affect metabolism and electrolyte balance
adrenal androgens
67
_Adrenal glands - medulla_
* What are the secretory cells of the medulla?
* What do they develop from?
Chromaffin cells
develop from the same embryonic tissue as sympathetic ganglia
68
The medulla of the adrenal gland is regarded as a
modified sympathetic ganglion
69
Medulla cells of the adrenal gland secrete ... and smaller amounts of ... i.e. ...
adrenaline
noradrenaline
i.e. catecholamines
70
The medulla of the adrenal glands
... secreted are responsible for the ... response
this response affects what?
catecholamines
fight or flight response
affects heart rate, blood pressure and smooth muscle of viscera
71
What are Catecholamines ?
Catecholamines are hormones made by your adrenal glands, which are located on top of your kidneys
72
Blood Supply of the adrenal glands:
... (from inferior phrenic)
... (From aorta)
... ... arteries (from renal)
Supplied by:
superior (from inferior phrenic)
middle (From aorta)
inferior suprarenal arteries (from renal)
73
Arteries going into the adrenal glands branch before entering what?
the rami supply the ... and ... of gland
capsule
cortex
medulla
74
Adrenal glands:
cortical arteries give rise to ... ... and in turn to cortical ... that distrubutes blood to cortical cells
subcapsular plexus
cortical sinusoids
75
... arteries pass through cortex to supply the ... - it receives blood from how many sources?
Thus, hormones produced by cortical cells influence ... of cells in the ...
medullary - to the medulla
2 sources
cortical cells influence activity of cells in the medulla e.g. cortisol mediates NA convertion to adrenaline
76
Venous drainage of the adrenal glands:
The ... adrenal vein drains into the ..., whereas the ... adrenal vein drains into the left ...
right adrenal vein drain into IVC
left adrenal vein drain into renal vein
77
Adrenal glands - activity is under control of:
hypothalamus, e.g. ACTH release from hypophysis
Symp division of ANS: coeliac plexus; splanchnic nerve
78
ACTH stands for what?
What does it stimulate?
adrenocorticotrophic hormone
stimulates secretion/release of corticosteroids
79
The medulla of the adrenal glands is under direct control from the ... meaning the response is ...
ANS (sympathetic)
fast
80
The cells of the medulla are innervated by ... ... fibres that end in the ... cells of the medulla
these cells then release ... into adjacent circulation
**preganglionic** **sympathetic** fibres that end in the **chromaffin** cells of the medulla
chromaffin cells then release **catecholamines**
81
Which glands have a duct system, endocrine or exocrine glands?
exocrine glands
82
Hormones are ... chemicals released at specific times in ... amounts into the tissue fluids or blood vessels
organic
small
83
The pancreas is both ... and ... gland
exocrine and endocrine
84
Define endocrine (action of hormones)
action of the hormone on a target organ away from the secreting cell
85
Define autocrine (action of hormones)
action of the hormone on the secreting cell
86
Define paracrine (action of hormones)
action of the hormone on the adjacent cell
87
Define neuroendocrine (action of hormones)
neural stimulation of endocrine cells to secrete hormones e.g. the medulla of adrenal gland (nerve fibres stimulate endocrine cells to produce adrenaline/noradrenaline)
88
_Overall Structure of Endocrine Glands_
* Functional unit consist of ... ... cells with a ... at the centre
* ... cells supported by ... cells
* not all endocrine functional units have ... e.g. pituitary and parathyroid gland cells have no ...
cuboidal secretory cells with a lumen at the centre
secretory cells supported by myoepithelial cells
lumen - they have no lumina - just secrete directly into blood vessels
89
What are the clinical manifestations of endocrine diseases? (3)
1. Hormone overproduction
2. Hormone underproduction
3. Tumour/Mass lesion which can be:
* non-functional -\> pressure effect
* associated over production of hormones
90
The pituitary gland (hypophysis) is divided into:
adenohypophysis (anterior lobe)
neurohypophysis (posterior lobe)
91
What hormones are secreted in the posterior lobe? (pituitary gland)
ADH and oxytocin
92
Histological features of cells of the anterior pituitary gland:
Acidophils -
Basophils -
Chromophobe -
the staining pattern is not related to specific hormone secretion e.g. .... is secreted by both chromophobes and basophils
To identify which hormone is secreted by specific cells we use ...
Acidophils take up the acidic dyes
Basophils take up the acidic dyes
Chromophobe have no specific staining features
ACTH is secreted by both
Immunocytochemistry
93
Antibody staining against specific hormone termed ... assists in identifying specific cells of the pituitary gland
immunocytochemistry
e.g. antibodies to growth hormone will identify cells which secrete GH if there is tumour secreting this hormone
94
What is this image showing?
histology of anterior pituitary
95
_Hormones from Anterior Pituitary Gland:_
* Cell - Hormone - Target Organ*
* Somatotroph - what hormone? what target organ?
Growth hormone, Bones
96
_Hormones from Anterior Pituitary Gland:_
*Cell - Hormone - Target Organ*
Lactotroph - what hormone? what target organ?
Prolactin, Breasts
97
_Hormones from Anterior Pituitary Gland:_
*Cell - Hormone - Target Organ*
Corticotroph - what hormone? what target organ?
Adrenocorticotrophic hormone (ACTH), adrenal glands
98
_Hormones from Anterior Pituitary Gland:_
*Cell - Hormone - Target Organ*
Gonadotroph - what hormone? what target organ?
Follicle stimulating hormone (FSH) & Luteinising hormone (LH), Ovary & Testis
99
_Hormones from Anterior Pituitary Gland:_
*Cell - Hormone - Target Organ*
Thydrotroph - what hormone? what target organ?
Thyroid stimulating hormone (TSH), thyroid gland
100
The pituitary hormones are under the influence of the ... releasing or inhibitory hormones
hypothalamic
101
Hormones from Posterior pituitary gland: ADH & Oxytocin
ADH facilitates the ...
what has the opposite effect?
Oxytocin promotes ...
absorption of water in kidneys which concentrates the urine (alcohol has the opposite effect)
contractions of the smooth muscle in the uterus during childbirth and myoepithelial cells in the breast during breastfeeding
102
Pathology of the Pituitary Gland: Pituitary .... (benign tumours)
* where do they arise from?
* functional or non-functional?
* constitute ...% of intra-cranial neoplasms
* ... adenomas cause hyperpituitarism
* ... effect causing ...
adenomas
arise from anterior lobe
can be functional or non-functional
10%
productive adenomas cause hyperpituitarism
pressure effect causing hypopituitarism (too large)
103
productive adenomas can cause ... whereas ... effect can cause ...
hyperpituitarism
pressure effect - hypopituitarism
104
space occupying effect of functional or non-functional adenomas - what do patients present with clinically?
headaches, vomiting, nausea, diplopia (double vision), impaired vision
105
What is shown in this image (histology - pituitary)
post mortem pituitary adenoma
106
What has been removed in this image?
what is it illustrating?
what would the patient have presented with?
(histology - pituitary)
adenoma removed
illustrate optic chiasma - compressed previously by tumour
bitemporal hemianopsia
107
Bitemporal hemianopsia, is the medical description of a type of partial ....
blindness where vision is missing in the outer half of both the right and left visual field.
108
The thyroid gland synthesises two hormones, what are they? what do they do?
Synthesis of these hormones requires what?
Thryoxine - T4
Triiodothyronine - T3
stimulate metabolic rate
iodine required
109
What is rich in iodine?
what does lack of iodine lead to? (medical term)
why does this happen?
sea salt
an enlarged thyroid gland termed - goitre
gland enlarges to absorb the maxmium concentration of iodine
110
'Normal' thyroid gland - weight?
how many lobes?
what joins them?
what is the tissue composed of?
what are these containing?
35-45 grams
2 lobes
joined by isthmus
composed of follicles with variable-sized lumina
follicles contain colloid with eosinophilic or pink appearcnce
111
What is this image showing? (histology - endocine system)
Normal thyroid gland - follices are lined by cuboidal cells
112
Other features of the thyroid gland:
very ...
endothelial cells lining the capillaries are ... this is a common feature in endocrine glands
... allows passage of hormones into the ...
vascular
fenestrated (i.e. have gaps between them) - common feature in endocrine glands
fenestration allows passage of hormones into the circulation
113
What is this image showing? (thyroid gland - histology)
increased vascularity in a thyroid gland
114
Pathology of the thyroid gland
can present with... (5 things)
is it euthyroid, hyperthyroid or hypothyroid? for each
goitre - euthyroid
grave's disease - hyperthyroid
hashimoto's disease - hypothyroid
adenoma - euthyroid
cancer - euthyroid
115
Mulit-nodular Goitre
what do they lack?
the gland ... to maximise the amount of ... absorbed
... in size overcomes the hormone ... and the patients are therefore ...
Iodine - leading to an enlarged thyroid gland termed goitre due to hyperplasia and hypertrophy of the thyroid cells
enlarges to maximise amount of iodine absorbed
increase in size overcomes the hormone deficiency and the patients are therefore euthyroid
116
What is this image showing? (clinical)
multi-nodular Goitre
117
This surgical procedure is for what condition?
Multi-nodular goitre
118
pathology of what is shown in this image?
multi-nodular goitre
119
What is in this image?
what is it compressing?
whats important to assess before surgery? why?
what happens to what it is compressing?
multi-nodular goitre
compressing the trachea
important to assess the radiology before surgery as the patient may arrest after successful thyroidectomy due to tracheomalacia
softening of the trachea which collapses and obstructs the airways
120
What is tracheomalacia?
Tracheomalacia is a condition or incident where the cartilage that keeps the airway (trachea) open is soft such that the trachea partly collapses especially during increased airflow.
121
A retrosternal goitre caused what?
post-op respiratory distress necessitating ICU admission due to tracheomalacia
122
What is Grave's Disease?
Auto-antibodies stimulate what receptors?
what happens to the thyroid gland?
What can the patient present with? (2 things)
Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism)
TSH receptors
Diffuse enlargement of the thyroid gland goitre due to hyperplasia of thyroid cells
Infiltrative opthalmopathy / Infiltrative dermopathy
123
What is Infiltrative opthalmopathy?
what disease is it apparent in?
accumulation of soft tissue and inflammatory cells behind the eye leading to proptosis
Grave's disease
124
What is Infiltrative dermopathy?
What disease is it apparent in?
Thickening and induration of the skin on the anterior shin -\> pre-tibial myxoedema (low TSH, high T3 and T4)
Grave's disease
125
What disease is present?
Grave's disease (thyroidectomy)
note the vascular surface
126
Pathology of what disease is shown?
the colloid has a ... apperance due to ...
Grave's disease
Colloid has a soap bubble appearance due to hyperactivity
127
_Hasimoto's Thryoiditis_
It is the most common cause of ... in areas where ... is readily available
it is an ... disease
progressive ... of thyroid cells by ... and replaced by ...
high levels of ..., low levels of ...
most common cause of **hypothyroidism** where **iodine** is readily available
an **autoimmune** disease - immune system destroys it's own thyroid tissue
progressive **depletion** of thyroid cells by **inflammation** and replaced by **fibrosis**
high **TSH**, low **T3/T4**
128
What disease is shown?
the gland is ... with what surface?
on histology - there is a prominent ... infiltrate
Hashimoto Thyroiditis
gland is irregular with a solid cut surface
prominent lymphocytic infiltrate
129
What is shown in this image? (histology of thyroid gland)
Hashimoto thyroiditis with prominent lymphocyte infiltrate/inflammation
130
Thyroid Tumours:
* Follicular ...
* Four main types of ...
adenoma - benign tumour of the thyroid follicular cells
four main types of carcinoma
131
Thyroid tumour - what are the 4 main types of carcinoma? constitutes what % of thyroid cancers? what happens in each?
Papillary (75-85%) - increased risk of lymph node metastasis
Follicular (10-20%) - increased mets to bone, lung and liver
Medullary (5%) - arises from C cells; 20% associated with MEN 2 syndrome (multiple endocrine neoplasm)
Anaplastic (\>5%) - older patients, poor prognosis
132
What is shown in the image? (thyroid gland pathology)
Benign adenoma vs Cancer
133
Para-follicular Cells (also known as c-cells) secrete ... which promotes reduction of ... concentration in the blood
these cells or clear cells are found between the ...
... cells are the origin of medullary ... of the thyroid
calcitonin - reduction of calcium conc
found between follicles
c cells - origin of medullary carcinoma of the thyroid
134
The parathyroid gland secretes ... hormone (PTH)
it controls the level of ... in the blood
decrease in levels of this stimulates ... secretion
what cells?
Parathyroid
calcium levels
decrease in blood calcium stimulates PTH production
chief cells with no lumen - prominent vascularity
135
Pathology of Parathyroid glands
main two abnormalities are ?
how many glands are involved?
both cause...
adenoma - involves one gland
hyperplasia - involves all 4 glands
both cause hypercalcaemia
136
What is shown in the images? (parathyroid gland)
mm? grams?
left - normal parathyroid gland, 6mm - 2g
right - parathyroid gland adenoma, 19mm - 9g
137
The adrenal glands are ... glands in the ... ... of the ...
they consist of ... ... and ... ... which are embryonically, morphologically and functionally distinct
what is derived from mesoderm?
what is derived from neural crest?
paired glands
upper pole of the kidneys
adrenal cortex and adrenal medulla
cortex - mesoderm, medulla - neural crest
138
What is shown in the image?
Why is it yellow/orange?
normal adrenal gland
cells rich in lipids
139
Adrenal cortex has 3 distinct zones, these are...
The cells appear ... on histology because the ... are cleared by chemicals during processing
Zona glomerulosa
Zona fasciculata
Zona reticularis
The cells appear pale because the lipids are cleared by chemicals during processing
140
What is shown in image? (histological slide of)
adrenal gland
illustrates the zones of the cortex and medulla
141
Functional zonation of the adrenal cortex: salt, sugar and sex
Zona glomerulosa produces a ... called ..., for absorption of
Zona fasciculata produces ... such as ... and ... and some ... hormones
Zona reticularis produces 17 ..., and ... hormones
Zona glomerulosa: mineralcorticoid aldosterone , for absorption of salts
Zona fasciculata: glucocorticoids. cortisol and corticosterone and sex hormones
Zona reticularis: 17 ketosteroids and sex hormones
142
What is shown in the image? (histology of adrenal cortex)
Zona glomerulosa - closely packed round cells
Zona fasciculata - clear cells arranged in cords
Zona reticularis - smaller darker staining cells
143
Pathology of the adrenal glands:
2 manifestations in addition to adenomas are adrenocortical ... or adrenocortical ...
what can they be due to ?
what syndromes/ disease do they result in?
adrenocortical hyperactivity - due to hyperplasia, adenoma or cancer (Rare)
lead to cushings syndrome (excess cortisol), conn's syndrome (Excess aldosterone), adrenogenital syndrome (Excess androgens)
adrenocortical insufficency (addison's disease)
144
Adrenal cortex adenoma
is it functional?
what can a functional one cause?
non-functional cortical adenoma
incidental finding
functional can cause cushing's syndrome or conn's syndrome
145
Adrenal medulla has ... cells which secrete ... and ... in response to intense emotional reactions
... or .... hormones
secretion results in ....
increased ... and ...
compact cells - secrete adrenaline and noradrenaline
fight or flight hormones
secretion results in vasoconstriction
increased HR and increased blood sugar levels
146
Histology of the adrenal medulla - cells are... meaning they have ... staining than adrenal cortex cells
adrenal medulla cells are neuroendocrine - darker staining than the adrenal cortex cells
147
Pathology of adrenal medulla - ... tumour
constitues 0.1-0.3% cause of treatable ...
why 10% tumour?
pheochromocytoma tumour
treatable hypertension
10% tumour because 10% are familial as part of the MEN2, 10% are extra-adrenal, 10% bilateral, 10% malignant, 10% arise in childhood
148
What is this image showing?
Due to high levels of ...
what does the patient present with?
complications of increase BP?
Pheochromocytoma
catecholamines
precipitous increase BP + tachycardia, palipitations, headache, sweating, tremor and sense of apprehension
Congestive Cardiac Failure, Ischaemic Heart Disease, cardiac arrhythmias, Cerebrovascular accident / stroke
149
Take home message of histology:
endocrine diseases are due to hormone ... or ...
tumour/ mass lesion which can be ... = ... effect, associated with ... of hormones or ... of hormones
overproduction or underproduction
tumour/ mass lesion can be non-functional - pressure effect or associated with overproduction of hormone or underproduction of hormone
150
151
152
