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Females: Triggers ovulation, Devt of corpus luteum;
Males: Production of testosterone by Leydig cells
Stimulates Adrenal cortex to release the cortical triad: Aldosterone, Cortisol, Androgens
ADH alternate name and function
Vasopressin; Anti-diuresis [H2O reabsorption] and vascular constriction
Pituitary masses epidemiology
Most are benign, but many secrete 1 or more hormones; 10% of all reported intracranial masses; ≤25% pop
Most common pituitary adenomas; effect and gender distribution. Which MEN do they appear in?
Prolactinomas; hyperprolactinemia; gynecomastia; mostly female. Appear in MEN1 [pituitary, parathyroid, pancreas].
Symptoms of Hyperprolactinemia
Galactorrhea, Breast enlargement & tenderness, Anovulatory amenorrhea, dysmenorrhea, decreased libido, ED
Bromocriptine [Parlodel- a DA agonist] or Cabergoline [Dostinex- an ergot derivative used to Tx Parkinson's, associated with gambling compulsion]
Bromcriptine uses; Mechanism; Contraindications
-Dopamine agonist used in the treatment of pituitary tumors, Parkinson's, Hyperprolactinaemia, Neuroleptic Malignant Syndrome, and DM2.
-For Hyperprolactinemia, given as Parlodel;
-Avoid in Breastfeeding, because decreases Prolactin;
-Triptans [serotonin receptor agonists in migraine treatment],
Cabergoline use; Trade; Mechanism; Contraindications
-Hyperprolactinemia treatment [Dostinex];
-DA agonist @ anterior pituitary,
-Contraindicated in Breastfeeding
Short Stature diagnostic criteria
2 SDs below average for age/gender;
Gold Standard: Insulin tolerance [0.1ug/kg] followed by sampling for GH. If GH <5 [10 in kids] POS for GH deficiency
Short stature treatment. What interactions and side-effects exist?
GH daily injection: Nutropin, Humatrope, Genotropin; Increase [glu], decrease INR in Coumadin pts; Diabetes, HTN, Pancreatitis
Acromegaly diagnosis and treatment. What side effects are there?
GH levels 1 hr after 1 hr-GTT are >1µ/L;
Surgical resection & Octreotide IM (Sandostatin) or Lanreotide IM (Somatuline);
Cardiomegaly/CHF, HTN, Diabetes, RF, HA, visual disturbance from tumor
Thyroxine forms & distribution
T4: 90%, T3: 10% (4X [T4]); 99% is bound to TBG [Thyroid Binding Globulin]. Only free hormone is active.
Thyroxine regulating gland & hormone; regulatory mechanism
TSH [Thyrotropin] made at anterior pituitary in response to T4 levels
Second Thyroid hormone and function
Calcitonin, Ca2+ regulator. Opposes PTH-- decreases serum [Ca2+]
Hashimoto's; Gender distribution; Mechanism
Autoimmune hypothyroidism; 10X more female; Thyroid Peroxidase ABs bind & inhibit T4; Insidious onset w/ hyPER-thyroid 1st; Hi Genetics
Myxedema signs and symptoms
Non-pitting edema with severe hypothyroidism,
Reduced CO, Mental slowing. May result in myxedemic coma precipitated by stroke/MI
Hypothyroidism treatment & allergic issue; alternative
Levothyroxine [Synthroid or Levothroid]; Made with lactose binder OR
Dessicated thyroid (porcine or bovine)
Grave's disease hallmarks
Autoimmune Hyperthyroidism [Agonist effect]; Nervous, Tachy, Weight loss, Exophthalmia, Hyperhidrosis, Tremor, Insomnia
Grave's drugs names, mechanism; side effects
Methimazole and Propylthiouracil; Inhibit addition of iodine to Thyroglobulin to block T4 synthesis; Leukopenia, Agranulocytosis, Aplastic Anemia; Hepatotoxicity (PTU also alters INR in Coumadin Tx
Acute thyroiditis eponym, diagnosis, & treatment
-De Quervain's [also toxic thyroiditis]
-Hyperthyroidism secondary to infection. Differentiate from Grave's by:
1. recent URI or viral infection
2. elevated CRP and ESR
3. radioactive I uptake. [I-131 uptake by Grave's is high, uptake by acute thyroiditis is low;
-Treatment for acute is oral steroids
Thyroid mass epidemiology and evaluation
-Usually benign tumors but may be cysts [rare]; --Ultrasound is Gold Standard, Cysts usually resolve, but may needle aspirate
Thyroid nodule treatment
-Ignore unless >1.5 cm, then do US and/or aspirate
-If unsure, do I-131 uptake. Active uptake ["hot"] is OK. No uptake ["cold"] may be malignant -> biopsy
Four kinds of thyroid tumors
1. Papillary [75%, most female, rarely metastasize, treatment: resection];
2. Follicular [15%, women > 50 yrs, may metastasize to lung/bone, treatment: resection or I-131];
3. Medullary [5%, very aggressive, metastatic to liver, lung, bone; treatment: resection];
4. Anaplastic carcinomas [5%, very aggressive with poor prognosis, treatment: radiation/chemo]
The sequence is:
1. Whole-body I-131 scan to destroy any metastases;
2. High-dose RAI ablation; repeat in 1 year;
3. High-dose Levo-T4 for 5 yrs to ensure TSH is not present, [unidentified metastasis], then normal dose
Thyroid replacement drug that replaces endogenous T3
Liothyronine [Cytomel]; used in conjunction with Levothyroxine for patients with poor T4-> T3 conversion.
When thyroidectomy is done
When there is significant obstructive thyromegaly.
Otherwise, radio-iodine ablation is used.
Distinguishing cancerous thyroid nodules from benign
I-132 uptake scan:
"Hot" [I-131 uptake POS] are usually benign,
"Cold" [I-132 uptake NEG] are likely malignant-- biopsy!!
Adrenal cortex regions and hormones
Go Find Rex, Make Good Sex;
Granulosa [Mineralocorticoid-> aldosterone];
Folliculata [Glucocorticoid-> cortisol];
Reticularis [DHEA-> -> testosterone]
1st line Adrenal Insufficiency treatment and side effects
Adrenal insufficiency-> Addison's-> ADD cortisol!
-Hydrocortisone = Cortef 25-30 qDay, divided BID;
-Side effects: Weight gain, HTN, Immuosuppression, DM
Increase BP, Increase glucose [by gluconeogenesis], inhibit insulin, antidiuretic [water retention]
Adrenal insufficiency name and hallmarks
-Fatigue, dizzy, weakness, weight loss, diarrhea, hypotension, hyperpigmentation
Adrenal Insufficiency Types
-Primary: Adrenal dysfunction;
-Secondary: Ant pituitary fails to make ACTH;
-Tertiary: Hypothalamus fails to make CRH;
-Autoimmune: secondary to DM-1, Grave's, or Hashimoto's
Addisonian Crisis occurence, & signs and symptoms
-In untreated Addison patient or Addison patient with Infection or sepsis [often meningococcal septicemia = Wterhouse Friderichson];
-Fever, hypotension, vomiting, diarrhea, dehydration, weakness, , hypoglycemia,
2nd line adrenal insufficiency treatment
Prednisone or prednisolone. Has less mineralocorticoid activity then hydrocortisone
Ranked causes of Cushing's
1. Iatrogenic (corticosteroids/steroids);
2. Secondary (pituitary mass/tumor);
3. Primary (adrenal adenoma);
4. Ectopic tumor (Small cell lung CA producing ACTH)
Cushing's diagnostic details
Dexamethasone suppression test is NEG:
1. If ACTH: Absent/Low; Cortisol: Not suppressed by high Or low doses; Diagnosis is: Primary
2. If ACTH: Elevated; Cortisol: not suppressed by low, but is suppressed by high; Diagnosis is Secondary
3. If ACTH: Normal to Elevated; Cortiusol: Not suppressed by high OR low doses; Diagnosis: MEN
Cushing's signs and symptoms
Central obesity, Moon face, buffalo hump, hirsutism, amenorrhea, truncal striae, HTN, acne
Iatrogenic: discontinue meds;
Secondary: Resection of pituitary tumor
Primary: Resection of adrenal adenoma
Follow resections by hormone replacement until ACTH rises again
Plasma free metanephrine (Epi metabolite) elevated [Gold standard], 24-hr urine metanephrines/catecholamines; MRI to localize
-May be MEN2A: parathyroid, pharochromocytoma, medullary thyroid tumor
Diabetes Insipidus types & etiology; Tx
1. ADH deficiency from POST pit ; Tx: vasopressin replacement (Desmopressin) given as nasal spray, OR
2. Inability to bind ADH at collecting ducts; Tx: Hydrochlorothiazide
Calcium regulating glands; MOA
Parathyroids; Resorb Ca2+ from bone, Retain Ca2+ at gut (via Vit D) and recover Ca2+ at kidney
Hypocalcemia-> Muscle cramps/tetany, Parasthesia, Dry hair/skin, QT elongation, Brittle nails, Seizure
Ca2+ & Vit D replacement, monitor regularly to avoid arrhythmia (short QT) and Stones, Bones, Moan, Groans
PT tumor resection indications
Under 65, cut it out. Under: monitor
Can't find ectopic tumor but have elevated Ca? Take out largest PT gland.
How are the various types of Adrenal Insufficiency diagnosed?
ACTH Stimulation test: "Cosyntropin" is given, then cortisol levels checked.
If no (or v. slight) cortisol increase: PRIMARY Addison's;
If 2-10X increase: SECONDARY
**For AI Adrenal Insufficiency, 90% in US, measurement of 21-hydroxylase autoantibodies is done
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