The Pituitary Gland Clinical Case & Discussion

Question 1

what are some pituitary diseases?

Answer 1

hypersecretion
hyposecretion
space occupation

Question 2

what are the diseases within hyper secretion?

Answer 2

GH acromegaly (gigantism)
ACTH Cushing’s disease
Prolactin hyperprolactinaemia

Question 3

what are the diseases within hypo secretion?

Answer 3

Anterior (FSH/LH, GH, ACTH, TSH)

Posterior (vasopressin)

Question 4

what is the disease within space occupation?

Answer 4

optic chiasmal compression

Question 5

what are clinical features of acromegaly?

Answer 5

Soft tissue overgrowth
‘spade like’ hands (rings)
wide feet (shoes)
coarse facial features
thick lips & tongue
carpal tunnel syndrome
sweating

Question 6

what are complications of acromegaly?

Answer 6

headache
chiasmal compression
diabetes mellitus
hypertension
cardiomyopathy
sleep apnoea
accelerated OA
colonic polyps & CA

Question 7

what is cushings syndrome?

Answer 7

excess corticosteroids

Question 8

what causes cushings syndrome?

Answer 8

Cortisol is a catabolic hormone:
Tissue breakdown
causes weakness of skin, muscle & bone
Sodium retention
may cause hypertension & heart failure
Insulin antagonism
may cause diabetes mellitus

Question 9

what are symptoms and signs of cushings syndrome?

Answer 9

skin atrophy
spontaneous purpura
proximal myopathy
osteoporosis
growth arrest in children
pink striae
facial mooning & hirsutism
oedema

Question 10

what are the causes of hyperprolactinaemia?

Answer 10

Physiological
- Pregnancy, lactation, stress
Pharmacological 
- DA depleting and DA antagonist drugs
Pathological
- Primary hypothyroidism
- Pituitary lesions (prolactinoma or pituitary stalk pressure)

Question 11

what are the drugs that may cause hyperlactinaemia?

Answer 11

Dopamine antagonists
 neuroleptics (eg chlorpromazine)
 anti-emetics (eg metoclopramide)
DA-depleting agents
Oestrogens (not in OCP dosage)
Some antidepressants

• Don’t forget to ask about homeopathic or herbal remedies!

Question 12

what are the clinical features of hypopituitarism

Answer 12

adults-
Tiredness, weight gain, depression, reduced libido, impotence, menstrual problems
Skin pallor
Reduced body hair

children-
reduced linear growth
delayed puberty

Question 13

what are differential diagnosis of cranial diabetes insipidus

Answer 13

Idiopathic (autoimmune hypophysitis?)
Post-trauma (including pituitary surgery)
Metastatic carcinoma
Craniopharyngioma
Other brain tumours: eg. germinoma
Rare causes: eg. sarcoidosis

Question 14

what is the management of hyper secretion?

Answer 14

dopamine agonists (prolactinoma)
somatostatin analogues (acromegaly)
GH receptor antagonist (acromegaly)

Question 15

what is the management of hypo secretion?

Answer 15

cortisol, T4, sex steroids, GH

desmopressin

Question 16

what is the management of tumour?

Answer 16

surgery (mostly transsphenoidal)

radiotherapy

Question 17

what are beneficial effects of somatostatin analogues in acromegaly?

Answer 17

Improve soft tissue overgrowth, sweating, headache, sleep apnoea in most patients
Normalise GH and IGF-1 levels in over 50% patients
Induce tumour shrinkage in the majority
Reduce morbidity & mortality from acromegaly

Question 18

what are adverse effects of somatostatin analogues?

Answer 18

Nausea, cramps, diarrhoea, flatulence (often transient)
Cholesterol gallstones occur in 20-30% (mostly asymptomatic)
Slow-release preparations require monthly IM/SC injections
High cost (£6-12,000 annually)

Question 19

whose likely to get microprolactinoma?

Answer 19

Usually women with galactorrhoea, amenorrhoea, infertility & serum PRL <5000 mU/l (N<500)

Question 20

what are the typical responses to a dopamine agonist?

Answer 20

Rapid fall in serum PRL (hours)
Tumour shrinkage (days/weeks)
Visual improvement (often within days)
Often recovery of pituitary function