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Slide 1-

Pituitary Physiology and Deficiencies Heidi Chamberlain Shea, MD Endocrine Associates of Dallas
Slide 2-

Pituitary Pituitary “Master” gland Most of the pituitary hormones control other endocrine glands
Slide 3-

Goals of Discussion Review pituitary anatomy Understand pituitary physiology Discuss pituitary hormone deficiencies
Slide 4-

Nomenclature Pituitary Greek ptuo (to spit) Latin Pituita (mucus) Mucus was produced by the brain and was excreted through the nose by the pituitary
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Pituitary Development Evagination of the stromodeal ectoderm from buccal cavity Infundibulum, neural stalk and posterior lobe from diencephalon Development 3rd to the 15th week gestation
Slide 6-

Pituitary Anatomy Gross Sits in sella turcica Surrounded by dura Sphenoid Lateral and inferior Lateral Cavernous sinus Internal carotid artery CN III, IV, VI, V1 and V2
Slide 7-

Pituitary Anatomy Gross Symmetrical bean shaped Brownish red 13 mm transverse 9 mm AP 6 mm height Adult 0.4-0.9 grams Larger in women Larger in multiparous women During pregnancy increases to 0.9-1 grams
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Anterior lobe 80% of gland Brown color Posterior lobe Gray/brown color Pituitary Anatomy Microscopic
Slide 9-

Pituitary Anatomy Microscopic Anterior lobe 3 divisions Pars distalis Largest Hormone producing cells Pars intermedia Poorly defined in the human Pars tuberalis Upward extension to the anterior lobe and attached to pituitary stalk Posterior lobe Pars nervosa
Slide 10-

Pituitary Gland Microscopic Pars distalis Pink acidophils Growth hormone Prolactin Dark purple basophils Corticotropin (ACTH) Thyroid stimulating hormone (TSH) Follicle stimulating hormone (FSH) Luteinizing hormone (LH)
Slide 11-

Pituitary Portal System Hypophyseal arteries From carotid Superior 80-90% to adenophysis Inferior Posterior pituitary Posterior lobe Rich nerve supply Unmyelinated nerves
Slide 12-

Goals of Discussion Review pituitary anatomy Understand pituitary physiology Discuss pituitary hormone deficiencies
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Hormones Of The Anterior Pituitary 6 main hormones secreted by the adenohypophysis: Growth hormone Somatotropin Thyroid-stimulating hormone Thyrotropin Adrenocorticotropic hormone Corticotropin Prolactin Follicle-stimulating hormone Luteinizing hormone
Slide 14-

Anterior pituitary Hypothalamic Pituitary Target Hormone product product organ product CRH ACTH Adrenal Cortisol cortex TRH TSH Thyroid T4, T3 GHRH (+) GH Liver; IGF-I (systemic) SRIH (-) Tissues IGF-I (local) PRIH PRL Breast [Lactation] (dopamine) GnRH LH, Gonad Sex hormones (LHRH) FSH
Slide 15-

Hormone Structure Amino acids/Source Polypeptide/proteins ACTH Polypeptide 39 Corticotroph GH Protein 191 Somatotroph PRL Protein 199 Lactotroph Glycoproteins TSH Alpha* / TSH-beta 110 Thyrotroph LH Alpha / LH-beta 115 Gonadotroph FSH Alpha / FSH-beta 115 Gonadotroph [hCG Alpha / beta-hCG] 147 [Placenta] * 92 amino acids
Slide 16-

HYPOTHALAMUS POSTERIOR PITUITARY ANTERIOR PITUITARY GH_AXIS_
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(+) POSTERIOR PITUITARY ANTERIOR PITUITARY (-) CRH HYPOTHALAMUS HYPOTHALAMIC- PITUITARY PORTAL SYSTEM ACTH CORTISOL ADRENAL Fasiculata (-)
Slide 18-

TRH (+) HYPOTHALAMUS ANTERIOR PITUITARY HYPOTHALAMIC- PITUITARY PORTAL SYSTEM T4, T3 (T4 --> T3) THYROID GLAND TSH POSTERIOR PITUITARY (-) (-)
Slide 19-

POSTERIOR PITUITARY PRL BREAST PRIH (-) HYPOTHALAMUS ANTERIOR PITUITARY (DOPAMINE)
Slide 20-

POSTERIOR PITUITARY ANTERIOR PITUITARY LH, FSH SEX HORMONES, INHIBIN GONAD (-) (-) GnRH (+) HYPOTHALAMUS HYPOTHALAMIC- PITUITARY PORTAL SYSTEM (LHRH)
Slide 21-

Posterior pituitary Hypothalamic source (cell body) Target Effect ADH Collecting H2O retention duct Oxytocin Breast Milk let down Uterus Smooth muscle Contraction
Slide 22-

Goals of Discussion Review pituitary anatomy Understand pituitary physiology Discuss pituitary hormone deficiencies
Slide 23-

History 15yr old WF presents with secondary amenorrhea, polydipsia and polyuria Normal growth and development Menarche at 11 years of age Qmonth menses until 12 years of age Withdrawal bleeding only with OCP’s
Slide 24-

History Drinks 32 oz water Q3-4hrs during the day Drinks and urinates Q2-3hrs at night ROS: occasional headaches, fatigue and difficulty losing weight
Slide 25-

Physical Exam Wt 62.9kg (75%) Ht 5ft 3.5in (50%) BMI 24.2 kg/m2 HR 80 B/P 117/86 General: nondysmorphic, well-nourished HEENT: visual fields intact, no thyromegaly Breast: no discharge, Tanner V GU: Tanner V
Slide 26-

Differential Diagnosis Hypopituitarism Isolated hormone deficiencies Acquired or congenital Tumors Pituitary adenomas Pituitary apoplexy Hypothalamic tumors Metastatic carcinoma Inflammatory Granulomatous disease Sarcoidosis, TB and syphilis Eosinophilic granuloma Lymphocytic hypophysitis
Slide 27-

Differential Diagnosis Hypopituitarism Vascular disease Sheehan’s postpartum necrosis Carotid aneurysm Destructive Surgery Radiation Trauma Infiltration Hemochromatosis Amyloidosis
Slide 28-

Hypopituitary Presentation Growth hormone production First hormone to be disrupted Gonadotropin deficiency Easily disrupted Corticotropin Less frequently affected Thyrotropin Rarely affected Anti-diuretic hormone Deficiency usually due to tumor Craniopharyngioma
Slide 29-

Hypopituitary Presentation Growth hormone deficiency Children Short stature Adults Non specific Fine wrinkling around the face Improved insulin sensitivity
Slide 30-

Hypopituitary Presentation Gonadotropin deficiency Women Amenorrhea Primary or secondary Infertility Men Decreased libido Decreased beard and body hair
Slide 31-

Hypopituitary Presentation Corticotropin deficiency Fatigue Decreased appetite Weight loss Decreased pigmentation Abnormal response to stress Hypotension Hyponatremia Fever Primary Adrenal Insufficiency Addison’s disease Fatigue Decreased appetite Weight loss Increased pigmentation Hyperkalemia Abnormal response to stress Hypotension Hyponatremia Fever
Slide 32-

Hypopituitary Presentation Hypothryoidism Fatigue Cold intolerance Puffy skin Absence of goiter Diabetes Insipidus Polyuria Polydipsia
Slide 33-

Evaluation What testing? Polydipsia and polyuria Water deprivation test Secondary amenorrhea Prolactin Gonadotropins Thyroid function
Slide 34-

Laboratory Water deprivation test reveals diabetes insipidus MRI – pituitary seen, no masses, subtle thickening of 3rd ventricle floor and no hyperintense neurohypophysis in sella noted TSH 1.61 ug/dl (0.35-5.54) T4 8.4 uIU/ml (4.0-12.8)
Slide 35-

Laboratory Cortisol 0800 15.5 ug/dl (5-25) ACTH 14 pg/ml BHCG <5 mIU/ml Prolactin 5 ng/ml (3-27) Estradiol 1.3 ng/dl (3.4-17) ESR 101
Slide 36-

Laboratory FSH 6.9 mIU/ml (Tanner V 1.0-9.2) LH 7.1 mIU/ml (Tanner V 0.4-11.7) IGF-1 207 ng/ml (217-589) Skeletal Xray: no lesions and epiphyses closed. Dopamine arginine GH stimulation test <5ng/ml
Slide 37-

Treatment Growth hormone therapy Estrogen and progesterone Birth control pills Testosterone Cypianate or enanthate 200 mg IM Q2 weeks Gels 5-10 gram per day Fertility Refer to Reproductive Endocrinologist Thyroid Levothyroxine (generic) Synthroid Levoxyl Unithroid Dose ranges 75-150 mcg per day
Slide 38-

Treatment Cortisol Hydrocortisone 10mg AM and 5 mg PM 6-8 mg/m2/day Stress dosing Fever, illness, surgery 20 mg/m2/day Double or triple daily dose 100 mg x1 then 25-50 mg Q6-8hrs All hypopituitary patients need a medic alert bracelet
Slide 39-

Treatment Desmopressin (DDAVP) Nasal spray 10 mcg QD-BID Tablets 0.1 to 0.2 mg QD-BID SQ injection 1-2 ug QD-BID
Slide 40-

Treatment DDAVP nasal spray 10mcg QD Ortho-novum 777 Growth hormone therapy
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