clinical 1/2- hypothalamus + pituitary

Hypopituitarism

diminished or absent secretion of one or more pituitary hormones

hypopituitarism results from

pituitary, hypothalamic, or parasellar diseases

acquired loss in hypopituitarism follows what pattern

1. GH

2. LH/FSH

3. TSH

4. ACTH

5. PRL

9 I's of hypopituitarism

invasive, infarction, infiltrative, injury, immunologic, iatrogenic, infectious, idiopathic, isolated

invasive causes of hypopituitarism

adenoma

craniopharyngioma

CNS tumors

metastatic lesions

causes of infarction leading to hypopituitarism

Sheehan's syndrome

pituitary apoplexy

Sheehan syndrome

ischemic infarct pituitary follow post partum hemorrhage

Sheehan syndrome presents with

failure to lactate

amenorrhea

cold intolerance

Pituitary apoplexy

sudden hemorrhage of pituitary gland

often in presence of existing pituitary adenoma

s/s of pituitary apoplexy

sudden onset severe headache

visual impairment

features of hypopituitarism

infiltrative causes of hypopituitarism

sarcoidosis

hemochromatosis

langerhan's histiocytosis

immunologic causes of hypopituitarism

lymphocytic hypophysitis

iatrogenic causes of hypopituitarism

surgery and radiation

infectious causes of hypopituitarism

TB

syphilis

mycotic infections

effect of opiates on pituitary function

suppress GnRH

can cause ACTH deficiency

inc prolactin

checkpoint inhibitor immunotherapy can lead to

hypophysitis

Empty sella syndrome

subarachnoid space extends into the sella turcica

empty sella syndrome is associated with

benign intracranial HTN

what percent of the pituitary tissue has to be compressed/atrophied in empty sella syndrome for pituitary failure

> 90%

pts with sellar mass may also have what s/s

headache

visual loss

diplopia

due to mass effect

Hypogonadotropic hypogonadism

low FSH/LH

ovarian hypofunction is dec

estradiol

s/s of ovarian hypo function in premenopausal women

amenorrhea/irregular menses

infertility

vaginal atrophy

hot flashes

late manifestations of ovarian hypofunction

dec breast tissue

dec bone mineral density

s/s of testicular hypofunction

infertility

dec libido

erectile dysfunction

hot flashes

late manifestations of testicular hypofunction

dec muscle mass

dec bone density

prolactin def s/s

failure of postpartum lactation

TSH def s/s

hypothyroidism- cold intolerance, dry skin

ACTH def (secondary adrenal insufficiency) s/s

weakness

N/V

anorexia

fever

weight loss

hypotension

RAAs intact

how is primary adrenal insufficiency different from secondary

salt wasting

volume contraction

hyperkalemia

skin hyperpigmentation (inc ACTH)

dec aldosterone

treatment of hypopituitarism

hormone replacement therapy

medical alert bracelets

causes of sellar masses

pituitary adenomas

pituitary hyperplasia

craniopharyngioma

meningiomas

pituicytomas

malignant tumors

most common cause of sellar masses

pituitary adenoma

vision changes from pituitary tumors

compress optic chiasm --> bitemporal hemianopsia

if the pituitary adenoma extends laterally what CN can be affected

CN III, IV, VI

Microadenoma

< 1cm

Macroadenoma

> 1cm

top 3 MCC of secreting pituitary adenomas

1. prolactinoma

2. GH secreting

3. ACTH secreting

imaging of choice for pituitary

MRI w/ contrast

pituitary incidentaloma

unsuspected pituitary lesion discovered in imaging

when should a pt with a pituitary adenoma be referred for formal visual field testing

if > 1cm

do we expect FSH to be high or low in postmenopausal women

high

physiological factors that cause inc prolactin

pregnancy

nursing

nipple stimulation

pharmacological factors that cause inc prolactin

TRH

estrogen

VIP

opioids

prolactin levels for prolactinoma

> 200-300

most common pituitary adenoma

Prolactinoma

s/s of prolactinoma in women

amenorrhea

galactorrhea

s/s of prolactinoma in men

dec libido

erectile dysfunction

in what pts should you order a prolactin level

galactorrhea

enlarged tella turcica

hypogonadotropic hypogonadism

treatment for prolactinoma

meds FIRST

surgery 2nd option

radiotherapy 3rd option

meds for prolactinoma

cabergoline (preferred)

bromocriptine

(dopamine agonists)

first thing done if a pt presents with amenorrhea

pregnancy test

second most common pituitary tumor

GH secreting pituitary tumor

GH secreting pituitary tumor causes clinical syndromes of

acromegaly

gigantism

GH secreting pituitary tumor is associated with increased

mortality rate

best test to screen/diagnose acromegaly

IGF-1 level (elevated)

confirmatory testing for acromegaly

oral glucose tolerance test

oral glucose tolerance test for acromegaly

no suppression of GH w/ glucose admin

what is seen in skull radiograph for acromegaly

thickening of calvarium

what is seen in plain hand films for acromegaly

distal phalangeal hypertrophied with spade appearance

what is seen in foot plain films for acromegaly

inc heel pad thickness

treatment for acromegaly

1. transsphenoidal surgical resection (treatment of choice)

2. meds

3. radiation

medical therapy for acromegaly if the pt cant have surgery

octreotide

cabergoline

pegvisomant

what should also be screened for in pts diagnosed with acromegaly

colonoscopy (associated with colon polyps)

causes of Cushing syndrome

glucocorticoid use

ACTH secreting pituitary adenoma (Cushing disease)

MCC of Cushing syndrome

exogenous steroids

Pituitary Cushing's

ACTH secreting pituitary tumor

cushing syndrome

too much glucocorticoids

Cushing disease

ACTH-secreting pituitary adenoma

classification fo Cushing syndrome

ACTH dependent

ACTH independent

causes of ACTH dependent Cushing's syndrome

pituitary adenoma (Cushing disease)

non pituitary neoplasm (ectopic ACTH production)

causes of ACTH independent Cushing's syndrome

iatrogenic (exogenous steroids)

adrenal tumor

nodular adrenal hyperplasia

s/s of cushing syndrome

central obesity w/ thin extremities

buffalo hump, moon facies

purple abdominal striae

3 steps to diagnosing cushing syndrome

first must exclude exogenous glucocorticoids

demonstrate inappropriate cortisol secretion

localize cause

what tests can we use to establish endogenous increased production of cortisol

24 hour free cortisol

1 mg dexamethasone suppression test

midnight salivary cortisol test

most widely used screening test for cushings

24 hour urinary free cortisol

what is diagnostic for cushings from the 24 hour urinary free cortisol

3-4x above upper limit of normal

what physiological test would cause the 24 hour urinary cortisol test to be abnormal

1mg dexamethasone suppression test

1mg dexamethasone by mouth at 11pm

measure cortisol at 8am the following morning

what is normal for the 1mg dexamethasone suppression test

cortisol < 1.8 ug/dL

considerations for late night salivary cortisol

must have normal sleeping pattern

once endogenous hypercortisolism is confirmed, what is done next

measure plasma ACTH determine if ACTH dependent or independent

ACTH suppressed --> ACTH independent

ACTH > 20 --> ACTH dependent

if the pt has a high cortisol and ACTH, how do we differentiate btw pituitary and ectopic causes

high dose dexamethasone suppression

will suppress pituitary cause

will not suppress ectopic causes

treatment for cushing disease

transphenoidal resection of pituitary adenoma

once a biochemical diagnosis of cushing disease is made, what is done next

MRI w/ contrast (attention to pituitary)