Hypopituitarism (Anterior Pituitary) Testing Algorithm

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Hypopituitarism (Anterior Pituitary) Testing Algorithm

Hypopituitarism (Anterior Pituitary) Testing Click here for topics associated with this algorithm INDICATIONS FOR TESTING Suspected hypopituitarism (anterior pituitary) Symptoms: fatigue, depression, and other endocrine dysfunction Baseline morning levels based on clinical presentation ORDER ORDER ORDER ORDER ORDER Prolactin Luteinizing Hormone (LH) and Growth Hormone (GH) Adrenocorticotropic Thyroid Stimulating AND/OR Hormone (ACTH) Hormone (TSH) Follicle Stimulating Hormone (FSH) AND Insulin-Like Growth AND with Reflex to Free Factor 1 (IGF-1) with Cortisol, Serum Thyroxine (free T4) Testosterone, Free and Total High Low (Includes Sex Hormone Binding calculated Z-Score Globulin), Adult Male AND/OR OR IGF Binding Protein-3 Prolactin- Estrogens, Fractionated by FSH Low or normal TSH Tandem Mass Spectrometry induced Normal cortisol Low cortisol High TSH deficiency and high suspicion hypogonadism Normal ACTH Low or normal and high ACTH suspicion Repeat Suggests primary testing Normal LH/FSH Low LH/FSH hypothyroidism High LH/FSH Normal and Normal Low testosterone Low Repeat (See Thyroid Low testosterone high suspicion testing Disorders Testing testosterone or or estrogen and PERFORM or estrogen algorithm) estrogen high suspicion Metyrapone testing or insulin- Repeat Normal testing Low induced Gonadotropin Primary cortisol cortisol hypoglycemia deficiency hypogonadism and Low or with repeat ACTH ACTH normal and 11- Normal TSH High TSH Normal or low TSH GH ACTH Deoxycortisol Normal free T4 Low free T4 Low free T4 Normal Low stimulation Quantitative by testing No adrenal HPLC-MS/MS, axis Serum or Plasma No thyroid No GH Primary TSH insufficiency component to component to hypothyroidism deficiency GH <4 ng/mL insufficiency Repeat insufficiency testing (adults), <5 ng/ mL (children) Low 11- Low 11- deoxycortisol deoxycortisol Normal Low LH/FSH Low ACTH High ACTH Low testosterone or estrogen GH deficiency No Pituitary ACTH Adrenal Gonadotropin gonadotropin deficiency etiology deficiency deficiency © 2006 ARUP Laboratories. All Rights Reserved. www.arupconsult.com Content Reviewed: August 2017 Last Update: March 2020.

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HYPOPITUITARISM YOUR QUESTIONS ANSWERED Contents
PATIENT INFORMATION HYPOPITUITARISM YOUR QUESTIONS ANSWERED Contents What is hypopituitarism? What is hypopituitarism? 1 What causes hypopituitarism? 2 The pituitary gland is a small gland attached to the base of the brain. Hypopituitarism refers to loss of pituitary gland hormone production. The What are the symptoms and signs of hypopituitarism? 4 pituitary gland produces a variety of different hormones: 1. Adrenocorticotropic hormone (ACTH): controls production of How is hypopituitarism diagnosed? 6 the adrenal gland hormones cortisol and dehydroepiandrosterone (DHEA). What tests are necessary? 8 2. Thyroid-stimulating hormone (TSH): controls thyroid hormone production from the thyroid gland. How is hypopituitarism treated? 9 3. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH): LH and FSH together control fertility in both sexes and What are the benefits of hormone treatment(s)? 12 the secretion of sex hormones (estrogen and progesterone from the ovaries in women and testosterone from the testes in men). What are the risks of hormone treatment(s)? 13 4. Growth hormone (GH): required for growth in childhood and has effects on the entire body throughout life. Is life-long treatment necessary and what precautions are necessary? 13 5. Prolactin (PRL): required for breast feeding. How is treatment followed? 14 6. Oxytocin: required during labor and delivery and for lactation and breast feeding. Is fertility possible if I have hypopituitarism? 15 7. Antidiuretic hormone (also known as vasopressin): helps maintain normal water Summary 15 balance. What do I need to do if I have a pituitary hormone deficiency? 16 Glossary inside back cover “Hypo” is Greek for “below normal” or “deficient” Hypopituitarism may involve the loss of one, several or all of the pituitary hormones.
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From Isolated GH Deficiency to Multiple Pituitary Hormone
European Journal of Endocrinology (2009) 161 S75–S83 ISSN 0804-4643 From isolated GH deficiency to multiple pituitary hormone deficiency: an evolving continuum – a KIMS analysis M Klose, B Jonsson1, R Abs2, V Popovic3, M Koltowska-Ha¨ggstro¨m4, B Saller5, U Feldt-Rasmussen and I Kourides6 Department of Medical Endocrinology, Copenhagen University Hospital, PE2131, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark, 1Department of Women’s and Children’s Health, Uppsala University, SE-75185 Uppsala, Sweden, 2Department of Endocrinology, University of Antwerp, Antwerp, Belgium, 3Neuroendocrine Unit, Institute of Endocrinology, University Clinical Center Belgrade, Belgrade, Serbia, 4KIMS Medical Outcomes, Pfizer Endocrine Care, Sollentuna, Sweden, 5Pfizer Endocrine Care Europe, Tadworth, UK and 6Global Endocrine Care, Pfizer Inc., New York, New York 10017, USA (Correspondence should be addressed to M Klose; Email: [email protected]) Abstract Objective: To describe baseline clinical presentation, treatment effects and evolution of isolated GH deficiency (IGHD) to multiple pituitary hormone deficiency (MPHD) in adult-onset (AO) GHD. Design: Observational prospective study. Methods: Baseline characteristics were recorded in 4110 patients with organic AO-GHD, who were GH naı¨ve prior to entry into the Pfizer International Metabolic Database (KIMS; 283 (7%) IGHD, 3827 MPHD). The effect of GH replacement after 2 years was assessed in those with available follow-up data (133 IGHD, 2207 MPHD), and development of new deficiencies in those with available data on concomitant medication (165 IGHD, 3006 MPHD). Results: IGHD and MPHD patients had similar baseline clinical presentation, and both groups responded similarly to 2 years of GH therapy, with favourable changes in lipid profile and improved quality of life.
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Delayed Diagnosis of Pituitary Stalk Interruption Syndrome with Severe Recurrent Hyponatremia Caused by Adrenal Insufficiency
Case report https://doi.org/10.6065/apem.2017.22.3.208 Ann Pediatr Endocrinol Metab 2017;22:208-212 Delayed diagnosis of pituitary stalk interruption syndrome with severe recurrent hyponatremia caused by adrenal insufficiency Kyung Mi Jang, MD1, Pituitary stalk interruption syndrome (PSIS) involves the occurrence of a thin Cheol Woo Ko, MD, PhD2 or absent pituitary stalk, hypoplasia of the adenohypophysis, and ectopic neurohypophysis. Diagnosis is confirmed using magnetic resonance imaging. 1Department of Pediatrics, Yeungnam Patients with PSIS have a variable degree of pituitary hormone deficiency and a University College of Medicine, 2 wide spectrum of clinical manifestations. The clinical course of the disease in our Daegu, Department of Pediatric patient is similar to that of a syndrome of inappropriate antidiuretic hormone Endocrinology, Kyungpook National University Children’s Hospital, Daegu, secretion. This is thought to be caused by failure in the suppression of vasopressin Korea secretion due to hypocortisolism. To the best of our knowledge, there is no case report of a patient with PSIS presenting with hyponatremia as the first symptom in Korean children. Herein, we report a patient with PSIS presenting severe recurrent hyponatremia as the first symptom, during adolescence and explain the pathophysiology of hyponatremia with secondary adrenal insufficiency. Keywords: Pituitary stalk interruption syndrome, Hyponatremia, Hypopituitarism, Inappropriate ADH syndrome, Adrenal insufficiency Introduction Pituitary stalk interruption syndrome (PSIS) involves the occurrence of a thin or absent pituitary stalk, hypoplasia of the adenohypophysis, and ectopic neurohypophysis1). Diagnosis of this disease is confirmed using magnetic resonance imaging (MRI). PSIS was first reported in 1987, based on MRI results1).
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Hypopituitarism
Revista de Endocrinología y Nutrición Volumen Suplemento Julio-Septiembre Volume 13 Supplement 1 July-September 2005 Artículo: Hypopituitarism Derechos reservados, Copyright © 2005: Sociedad Mexicana de Nutrición y Endocrinología, AC Otras secciones de Others sections in este sitio: this web site: ☞ Índice de este número ☞ Contents of this number ☞ Más revistas ☞ More journals ☞ Búsqueda ☞ Search edigraphic.com Revista de Endocrinología y Nutrición Vol. 13, No. 3. Supl.1 Julio-Septiembre 2005 pp S47-S51 Hipófisis Hypopituitarism Mark E. Molitch* * Division of Endocrinology, Metabolism and Molecular Medicine. Northwestern University Feinberg School of Medicine. Hypopituitarism indicates the diminished production of one Gene mutations have been found at several steps lead- or more anterior pituitary hormones. Although the recog- ing to pituitary hormone secretion, including those for the nition of complete or panhypopituitarism is usually straight- hypophysiotropic releasing factor receptors for GnRH, GHRH, forward, the detection of partial or selective hormone and TRH; those for the pituitary hormone structures for GH, deficiencies is more challenging. Pituitary hormone defi- ACTH, and the a subunits of FSH, TSH, and LH; and those for ciencies can be caused by loss of hypothalamic stimula- the target organ receptors for GH, ACTH, TSH, and LH. Best tion (tertiary hormone deficiency) or by direct loss of pi- studied are mutations of the GH gene, which include large tuitary function (secondary hormone deficiency). The deletions and point mutations; some of these can be inher- distinction between hypothalamic and pituitary causes of ited in an autosomal dominant manner, apparently because hypopituitarism is important for establishing the correct the mutant hormone impairs GH biosynthesis and normal diagnosis and but less so when applying and interpret- function of the somatotroph cell.
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Distinguishing Constitutional Delay of Growth and Puberty from Isolated Hypogonadotropic Hypogonadism: Critical Appraisal of Available Diagnostic Tests
SPECIAL FEATURE Clinical Review Distinguishing Constitutional Delay of Growth and Puberty from Isolated Hypogonadotropic Hypogonadism: Critical Appraisal of Available Diagnostic Tests Jennifer Harrington and Mark R. Palmert Division of Endocrinology, The Hospital for Sick Children and Department of Pediatrics, The University of Toronto, Toronto, Canada M5G1X8 Context: Determining the etiology of delayed puberty during initial evaluation can be challenging. Specifically, clinicians often cannot distinguish constitutional delay of growth and puberty (CDGP) from isolated hypogonadotropic hypogonadism (IHH), with definitive diagnosis of IHH awaiting lack of spontaneous puberty by age 18 yr. However, the ability to make a timely, correct diagnosis has important clinical implications. Objective: The aim was to describe and evaluate the literature regarding the ability of diagnostic tests to distinguish CDGP from IHH. Evidence Acquisition: A PubMed search was performed using key words “puberty, delayed” and “hypogonadotropic hypogonadism,” and citations within retrieved articles were reviewed to identify studies that assessed the utility of basal and stimulation tests in the diagnosis of delayed puberty. Emphasis was given to a test’s ability to distinguish prepubertal adolescents with CDGP from those with IHH. Evidence Synthesis: Basal gonadotropin and GnRH stimulation tests have limited diagnostic spec- ificity, with overlap in gonadotropin levels between adolescents with CDGP and IHH. Stimulation tests using more potent GnRH agonists and/or human chorionic gonadotropin may have better discriminatory value, but small study size, lack of replication of diagnostic thresholds, and pro- longed protocols limit clinical application. A single inhibin B level in two recent studies demon- strated good differentiation between groups. Conclusion: Distinguishing IHH from CDGP is an important clinical issue.
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Sheehan's Syndrome and Lymphocytic Hypophysitis Fact Sheet for Patients
1 Sheehan’s Syndrome and Lymphocytic Hypophysitis Fact sheet for patients Sheehan’s Syndrome and Lymphocytic Hypophysitis (LH) can present after childbirth, in similar ways. However, in Sheehan’s there is a history of profound blood loss and imaging of the pituitary will not show a mass lesion. In Lymphocytic Hypophysitis, there is normal delivery and post-partum, and it can be a month or more after delivery that symptoms start. An MRI in this instance may show a pituitary mass and thickened stalk. Management of Sheehan’s is appropriate replacement of hormones, in LH - replacement hormones and in some circumstances, steroids and surgical biopsy. The key of course is being seen by an endocrinologist with expertise in pituitary and not accepting the overwhelming features of hypopituitarism as just ‘normal’. If features of Diabetes Insipidus are present the diagnosis is usually easier, as severe thirst and passing copious amounts of urine will be present. Sheehan’s syndrome Sheehan’s syndrome is a rare condition in which severe bleeding during childbirth causes damage to the pituitary gland. The damage to pituitary tissue may result in pituitary hormone deficiencies (hypopituitarism), which can mean lifelong hormone replacement. What causes Sheehan’s syndrome? During pregnancy, an increased amount of the hormone oestrogen in the body causes an increase in the size of the pituitary gland and the volume of blood flowing through it. This makes the pituitary gland more vulnerable to damage from loss of blood. If heavy bleeding occurs during or immediately after childbirth, there will be a sudden decrease in the blood supply to the already vulnerable pituitary gland.
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Acromegaly Your Questions Answered Patient Information • Acromegaly
PATIENT INFORMATION ACROMEGALY YOUR QUESTIONS ANSWERED PATIENT INFORMATION • ACROMEGALY Contents What is acromegaly? 1 What does growth hormone do? 1 What causes acromegaly? 2 What is acromegaly? Acromegaly is a rare disease characterized by What are the signs and symptoms of acromegaly? 2 excessive secretion of growth hormone (GH) by a pituitary tumor into the bloodstream. How is acromegaly diagnosed? 5 What does growth hormone do? What are the treatment options for acromegaly? 6 Growth hormone (GH) is responsible for growth and development of the human body especially during childhood and adolescence. In addition, Will I need treatment with any other hormones? 9 GH has important functions during later life. It influences fat and glucose (sugar) metabolism, and muscle and bone strength. Growth hormone is How can I expect to feel after treatment? 9 produced in the pituitary gland which is a small bean-sized organ located just underneath the brain (Figure 1). The pituitary gland also secretes How should patients with acromegaly be followed after initial treatment? 9 other hormones into the bloodstream to regulate important functions including reproduction, energy, breast lactation, water balance control, and metabolism. What do I need to do if I have acromegaly? 10 Acromegaly Frequently Asked Questions (FAQs) 10 Glossary inside back cover Pituitary gland Funding was provided by Ipsen Group, Novo Nordisk, Inc. and Pfizer, Inc. through Figure 1. Location of the pituitary gland. unrestricted educational grants. This is the fourth of the series of informational pamphlets provided by The Pituitary Society. Supported by an unrestricted educational grant from Eli Lilly and Company.
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Pituitary Adenomas: from Diagnosis to Therapeutics
biomedicines Review Pituitary Adenomas: From Diagnosis to Therapeutics Samridhi Banskota 1 and David C. Adamson 1,2,3,* 1 School of Medicine, Emory University, Atlanta, GA 30322, USA; [email protected] 2 Department of Neurosurgery, Emory University, Atlanta, GA 30322, USA 3 Neurosurgery, Atlanta VA Healthcare System, Decatur, GA 30322, USA * Correspondence: [email protected] Abstract: Pituitary adenomas are tumors that arise in the anterior pituitary gland. They are the third most common cause of central nervous system (CNS) tumors among adults. Most adenomas are benign and exert their effect via excess hormone secretion or mass effect. Clinical presentation of pituitary adenoma varies based on their size and hormone secreted. Here, we review some of the most common types of pituitary adenomas, their clinical presentation, and current diagnostic and therapeutic strategies. Keywords: pituitary adenoma; prolactinoma; acromegaly; Cushing’s; transsphenoidal; CNS tumor 1. Introduction The pituitary gland is located at the base of the brain, coming off the inferior hy- pothalamus, and weighs no more than half a gram. The pituitary gland is often referred to as the “master gland” and is the most important endocrine gland in the body because it regulates vital hormone secretion [1]. These hormones are responsible for vital bodily Citation: Banskota, S.; Adamson, functions, such as growth, blood pressure, reproduction, and metabolism [2]. Anatomically, D.C. Pituitary Adenomas: From the pituitary gland is divided into three lobes: anterior, intermediate, and posterior. The Diagnosis to Therapeutics. anterior lobe is composed of several endocrine cells, such as lactotropes, somatotropes, and Biomedicines 2021, 9, 494. https: corticotropes, which synthesize and secrete speciﬁc hormones.
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About Insulin Sensitivity, CRP Levels, and Metabolic Syndrome
Endocrine Care Castillo AlejandroRosell et al. Panhypopituitarism Without GH Replacement:. Horm Metab Res 2018; 00: 00–00 Panhypopituitarism Without GH Replacement: About Insulin Sensitivity, CRP Levels, and Metabolic Syndrome Authors Alejandro Rosell Castillo1, Denise Engelbrecht Zantut-Wittmann1, Arnaldo Moura Neto1, Rodrigo Menezes Jales2, Heraldo Mendes Garmes1 Affiliations ABSTracT 1 Endocrinology Division, Department of Clinical Medicine, A complete deficiency of anterior pituitary hormones from University of Campinas, Campinas, São Paulo, Brazil several etiologies characterizes Panhypopituitarism (PH). De- 2 Imaging Division, Department of Obstetrics and spite advances in treatment, patients with PH maintain high Gynecology, University of Campinas, Campinas, rates of morbidity and mortality, a reason to investigate some São Paulo, Brazil insulin sensitivity, metabolic and inflammatory parameters that could be related to the increase of these indicators. This Key words was a cross-sectional study comprising 41 PH patients under insulin resistance, hypopituitarism, inflammatory activity, hormonal replacement, except for growth hormone, and 37 dyslipidemia individuals in a control group (CG) with similar age, gender and received 22.03.2018 body mass index (BMI). We assessed clinical data as age, sex, accepted 19.06.2018 BMI, waist circumference, waist/hip ratio (WHR), history of hypertension, diabetes mellitus and dyslipidemia as well as Bibliography fasting glycaemia, insulin, HOMA-IR, HbA1c, high-sensitivity DOI https://doi.org/10.1055/a-0649-8010 CRP (hs-CRP), and lipid profile. PH patients presents lower val- Horm Metab Res 2018; 50: 690–695 ues of glycaemia, insulin, HOMA-IR (0.88 vs 2.1) and WHR, but © Georg Thieme Verlag KG Stuttgart · New York higher levels of hs-CRP (0.38 vs 0.16mg/dl) when compared ISSN 0018-5043 with the CG.
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Management of Hypopituitarism
Journal of Clinical Medicine Review Management of Hypopituitarism Krystallenia I. Alexandraki 1 and Ashley B. Grossman 2,3,* 1 Endocrine Unit, 1st Department of Propaedeutic Medicine, School of Medicine, National and Kapodistrian University of Athens, 115 27 Athens, Greece; [email protected] 2 Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford OX3 7LE, UK 3 Centre for Endocrinology, Barts and the London School of Medicine, London EC1M 6BQ, UK * Correspondence: [email protected] Received: 18 November 2019; Accepted: 2 December 2019; Published: 5 December 2019 Abstract: Hypopituitarism includes all clinical conditions that result in partial or complete failure of the anterior and posterior lobe of the pituitary gland’s ability to secrete hormones. The aim of management is usually to replace the target-hormone of hypothalamo-pituitary-endocrine gland axis with the exceptions of secondary hypogonadism when fertility is required, and growth hormone deficiency (GHD), and to safely minimise both symptoms and clinical signs. Adrenocorticotropic hormone deficiency replacement is best performed with the immediate-release oral glucocorticoid hydrocortisone (HC) in 2–3 divided doses. However, novel once-daily modified-release HC targets a more physiological exposure of glucocorticoids. GHD is treated currently with daily subcutaneous GH, but current research is focusing on the development of once-weekly administration of recombinant GH. Hypogonadism is targeted with testosterone replacement in men and on estrogen replacement therapy in women; when fertility is wanted, replacement targets secondary or tertiary levels of hormonal settings. Thyroid-stimulating hormone replacement therapy follows the rules of primary thyroid gland failure with L-thyroxine replacement.
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Hypopituitarism and Pituitary Replacement Hormones
Hypopituitarism and pituitary replacement hormones This leaflet is for patients diagnosed with hypopituitarism who are considering pituitary replacement therapy. What is hypopituitarism? It is when your pituitary gland is not active enough. As a result, the gland does not make enough pituitary hormones. What is the pituitary gland? It is a small pea-sized gland situated in a hollow bony pouch, at the base of the brain, at the back of the bridge of the nose. It is the master gland of the endocrine system and controls the functions of most of the other endocrine glands. What hormones does the pituitary gland produce or release? • Thyroid stimulating hormone (TSH): This hormone circulates to the thyroid gland in the neck, stimulating it to make and release thyroid hormones, Thyroxine and Tri-iodothyronine. • Adrenocorticotrophic hormone (ACTH): This hormone stimulates the adrenal glands (small endocrine glands situated on the top of your kidneys) to produce cortisol. This is a steroid hormone that is essential for everyday activities and health. Lack of cortisol causes severe fatigue and lack of appetite with weight loss. • Growth hormone (GH): This has effects on the various tissue of the body. In children, it is essential to reach normal growth. In adults, it appears to maintain normal energy levels and to keep muscles and bones strong and healthy. • Gonadotrophins - Follicular Stimulating Hormone (FSH) and Luteinising Hormone (LH): These hormones regulate and control the male and female hormones, menstrual cycles, ovulation, sperm production and fertility. • Prolactin (PL): This hormone stimulates the breasts and regulates milk production. It is normally produced in very high levels during pregnancy and breast- feeding.
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7.1.2 Childhood Endocrinology Suspicion Becomes Higher If There Is Evidence for Defi Ciency of Other Pituitary Hormones
OUP UNCORRECTED PROOF ‑- FIRST PROOF, 04/10/2010, GLYPH 1006 PART 7 growth and development during childhood 23. Thodberg HH. An automated method for the determination of bone If a diagnosis of growth hormone defi ciency is considered in a age . J Clin Endocrinol Metab , 2009 ; 94 : 2239 – 44 . newborn, it may be possible to retrieve cord blood (which is stored 24. Bayley N , Pinneau SR. Tables for predicting adult height from skeletal for a few days after birth in many maternity units); if cord blood is age revised for Greulich and Pyle standards . J Pediatr , 1952 ; 40 : 423 – 41 . no longer available, it is preferable to measure growth hormone levels on a ‘critical sample’ (see below) drawn at the time of spon- taneous hypoglycaemia. Because birth size is within normal limits in congenital growth hormone defi ciency, hypoglycaemia may be the only presenting symptom in the neonatal period. The degree of 7.1.2 Childhood endocrinology suspicion becomes higher if there is evidence for defi ciency of other pituitary hormones. These include: ( 1 ) cholestatic jaundice, which G u y V a n V l i e t is very often present in newborns with ACTH defi ciency, because cortisol is necessary for choleresis ( 6 ); ( 2 ) prolonged unconjugated hyperbilirubinaemia, which may be suggestive of hypothyroidism; ( 3 ) in newborn males, micropenis and cryptorchidism, which sug- I n t r o d u c t i o n gest gonadotropin defi ciency (see below). Between embryonic life and the end of growth, the endocrine During later infancy and childhood, the profi le of plasma growth milieu undergoes profound changes that need to be known to hormone concentrations is characterized by low or undetectable understand the common paediatric endocrine disorders, to inter- levels most of the time, with peaks that, until puberty, occur mostly pret results of hormone assays in newborns, infants, children, during the night.
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