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GH, ACTH, TSH, FSH/LH, Prolactin
Name the hormones that the anterior pituitary gland releases
ADH, Oxytocin
Name the hormones that the posterior pituitary gland releases
tumor, hyperplasia, infarction, genetic disorders, trauma
Major causes of pituitary gland disorders
gigantism, acromegaly
Increased levels of GH leads to
lactrotroph (prolactin)
What is the most common pituitary adenoma?
Pituitary Adenoma
A benign tumor that is usually slow growing and arise from any type of cell of the anterior pituitary
increased secretion of hormones, could be silent, decrease secretion of hormone due to compression
What are some things that can occur with pituitary adenomas
Head MRI, serum prolactin, GH, IGF-1, 24 hr urine free cortisol, ACTH, LH, FSH, T4, TSH
Patient presents to the clinic for amenorrhea which she states has been going on for about a year. She also reports that recently she has loss her peripheral vision in the last couple weeks as well as frequent headaches. What do you want to order?
endoscopic transphenoidal hypophysectomy, serial hormonal testing
Treatment plan for large, active pituitary adenomas
dopamine agonist (cabergoline), bromocriptine (not as good)
Phase 1 treatment plan for lactotroph
observation (mass, vision, hormone levels)
Game plan for <20 mm incidentalomas
Serial Serum prolactin, No further testing (2-4 mm), annual MRI (5-9 mm)
Game plan for <10 mm incidentalomas if asymptomatic
Empty sella syndrome
Enlarged sella turcica that is not entirely filled with pituitary tissue because it is flattened or shrunken and patient tends to be asymptomatic
Acromegaly
An excessive secretion of growth hormone (usually due to a pituitary somatotroph) AFTER epiphyseal closure that has an insidious onset with slow progression
Serum IGF-1
A 39 y/o male presents to the clinic for repeated HA and visual changes. Patient reports a PMHx of HTN, OSA, type 2 DM, and back pain. On physical exam you note an enlarged jaw, swollen hands and feet, coarse/acral facial features and a very deep voice. What lab do you want initally?
Oral glucose tolerance test with GH
A 39 y/o male presents to the clinic for repeated HA and visual changes. Patient reports a PMHx of HTN, OSA, type 2 DM, and back pain. On physical exam you note an enlarged jaw, swollen hands and feet, coarse/acral facial features and a very deep voice. IGF-1 came back iffy, what should you order next?
pituitary MRI
A 39 y/o male presents to the clinic for repeated HA and visual changes. Patient reports a PMHx of HTN, OSA, type 2 DM, and back pain. On physical exam you note an enlarged jaw, swollen hands and feet, coarse/acral facial features and a very deep voice. IGF-1 came back iffy, OGTT with GH levels showed inadequate suppression. What is your next step?
Look for ectopic source of GH
A 39 y/o male presents to the clinic for repeated HA and visual changes. Patient reports a PMHx of HTN, OSA, type 2 DM, and back painOn physical exam you note an enlarged jaw, swollen hands and feet, coarse/acral facial features and a very deep voice. IGF-1 came back iffy, OGTT with GH levels should inadequate suppression. Pituitary MRI is normal. Next step?
endoscopic transphenoidal surgery, Somatostatin analog, Cabergoline, competitive GH receptor agonist, radiation therapy
A 39 y/o male presents to the clinic for repeated HA and visual changes. Patient reports a PMHx of HTN, OSA, type 2 DM, and back painOn physical exam you note an enlarged jaw, swollen hands and feet, coarse/acral facial features and a very deep voice. IGF-1 came back iffy, OGTT with GH levels should inadequate suppression. Pituitary MRI is shows a mass. What is your treatment plan?
get the IGF-1 and GH concentrations to normal ranges, control adenoma size
Treatment goals for acromegaly
Gigantism
An excessive secretion of growth hormone that occurs BEFORE the fusion of the epiphyseal growth plates in a child/adolescent and results in a height 3 or 4+ SD
IGF-1, OGTT with GH, pituitary MRI
15 y/o girl presents to the clinic for a regular check up. On a physical exam you large hands and feet, coarse facial features, excessive sweating, an enlarged head. Mother notes that the child has yet to start her periods. Which labs/imaging do you want?
endoscopic tranphenoidal surgery, Bromocriptine (dopamine analong), octreotide (somatostatin analog), pegvisomant (competitive GH receptor antiagonist), radiation therapy (last resort)
Treatment plan for gigantism
Dwarfism
A growth hormone deficiency results in
xrays for bone age, Serum IGF-1, growth hormone provocation
Diagnostics for dwarfism
Recombinant GH (as young as possible), therapeutic monitoring every 4-6 months (height velocity, IGF-1, bone age)
Treatment plan for dwarfism
