Dav

id D

orig

uzzi

, PA

-C

Com

mon

Pitu

itary

Dis

ord

ers

Func

tion

of th

e P

ituita

ry•

Gro

wth

•B

lood

pre

ssur

e

•U

terin

e co

ntra

ctio

ns d

urin

g c

hild

birt

h

•B

reas

t milk

pro

duc

tion

•S

ex o

rgan

func

tions

•Th

yroi

d g

land

func

tion

•W

ater

and

osm

olar

ity re

gul

atio

n in

the

bod

y

•Te

mp

erat

ure

reg

ulat

ion

Func

tion

of th

e P

ituita

ry•

Ant

erio

r P

ituita

ry

•P

rola

ctin

(P

RL)

•Th

yroi

d S

timul

atin

g H

orm

one

(TS

H)

•Fo

llicl

e S

timul

atin

g H

orm

one

(FS

H)

•Le

utin

izin

g H

orm

one

(LH

)

•A

dre

noco

rtic

otro

pic

Hor

mon

e (A

CTH

)

•G

row

th H

orm

one

(GH

)

•E

ndor

phi

ns

Func

tion

of th

e P

ituita

ry•

Ant

erio

r P

ituita

ry

•P

rola

ctin

(P

RL

)

•Th

yroi

d S

timul

atin

g H

orm

one

(TS

H)

•Fo

llicl

e S

timul

atin

g H

orm

one

(FS

H)

•Le

utin

izin

g H

orm

one

(LH

)

•A

dre

noco

rtic

otro

pic

Hor

mon

e (A

CTH

)

•G

row

th H

orm

one

(GH

)

•E

ndor

phi

ns

Func

tion

of th

e P

ituita

ry•

Ant

erio

r P

ituita

ry

•P

rola

ctin

(P

RL)

•T

hyr

oid

Sti

mu

lati

ng

Ho

rmo

ne

(TS

H)

•Fo

llicl

e S

timul

atin

g H

orm

one

(FS

H)

•Le

utin

izin

g H

orm

one

(LH

)

•A

dre

noco

rtic

otro

pic

Hor

mon

e (A

CTH

)

•G

row

th H

orm

one

(GH

)

•E

ndor

phi

ns

Func

tion

of th

e P

ituita

ry•

Ant

erio

r P

ituita

ry

•P

rola

ctin

(P

RL)

•Th

yroi

d S

timul

atin

g H

orm

one

(TS

H)

•F

olli

cle

Sti

mu

lati

ng

Ho

rmo

ne

(FS

H)

•L

euti

niz

ing

Ho

rmo

ne

(LH

)

•A

dre

noco

rtic

otro

pic

Hor

mon

e (A

CTH

)

•G

row

th H

orm

one

(GH

)

•E

ndor

phi

ns

Func

tion

of th

e P

ituita

ry•

Ant

erio

r P

ituita

ry

•P

rola

ctin

(P

RL)

•Th

yroi

d S

timul

atin

g H

orm

one

(TS

H)

•Fo

llicl

e S

timul

atin

g H

orm

one

(FS

H)

•Le

utin

izin

g H

orm

one

(LH

)

•A

dre

no

cort

ico

tro

pic

Ho

rmo

ne

(AC

TH

)

•G

row

th H

orm

one

(GH

)

•E

ndor

phi

ns

Func

tion

of th

e P

ituita

ry•

Ant

erio

r P

ituita

ry

•P

rola

ctin

(P

RL)

•Th

yroi

d S

timul

atin

g H

orm

one

(TS

H)

•Fo

llicl

e S

timul

atin

g H

orm

one

(FS

H)

•Le

utin

izin

g H

orm

one

(LH

)

•A

dre

noco

rtic

otro

pic

Hor

mon

e (A

CTH

)

•G

row

th H

orm

on

e (G

H)

•E

ndor

phi

ns

Func

tion

of th

e P

ituita

ry•

Ant

erio

r P

ituita

ry

•P

rola

ctin

(P

RL)

•Th

yroi

d S

timul

atin

g H

orm

one

(TS

H)

•Fo

llicl

e S

timul

atin

g H

orm

one

(FS

H)

•Le

utin

izin

g H

orm

one

(LH

)

•A

dre

noco

rtic

otro

pic

Hor

mon

e (A

CTH

)

•G

row

th H

orm

one

(GH

)

•E

nd

orp

hin

s

Func

tion

of th

e P

ituita

ry

•P

oste

rior

Pitu

itary

•O

xyto

cin

•A

ntid

iure

tic H

orm

one

(AD

H)

•R

ule

of

"To

o's

"

•To

o m

uch

•To

o lit

tle

•To

o-m

or (

tum

or)

Whe

n Th

ing

s G

o W

rong

Pitu

itary

Mas

s•

Mos

t pitu

itary

mas

ses

are

ben

ign

tum

ors

that

may

or

may

not

sec

rete

exc

essi

ve

amou

nt o

f a p

artic

ular

hor

mon

e

•P

ituita

ry m

asse

s co

mp

rise

10%

of a

ll in

trac

rani

al n

eop

lasm

s (1

)

•U

p to

25%

of t

he g

ener

al p

opul

atio

n ha

ve

a sm

all p

ituita

ry m

ass

•M

ost a

re a

sym

pto

mat

ic

Pitu

itary

Mas

s

•M

ost s

igni

fican

t phy

sica

l co

mpl

icat

ion

is p

ress

ure

on

the

optic

chi

asm

•T

his

resu

lts in

impa

irmen

t of

perip

hera

l vis

ion

Pitu

itary

Mas

s

•M

icro

aden

oma

- <

1 cm

dia

met

er•

Mac

road

enom

a -

> 1

cm

dia

met

er

•Tr

ansp

heno

idal

ssur

gica

l res

ectio

n is

in

dica

ted

if tu

mor

is la

rge

enou

gh to

hav

e ob

stru

ctiv

e ef

fect

s (2

)

Hyp

erp

rola

ctin

emia

•T

he m

ajor

ity o

f clin

ical

ly id

entif

ied

pitu

itary

ade

nom

as

are

prol

actin

omas

. (3)

•T

he m

ost c

omm

on c

ause

of h

yper

prol

actin

emia

is p

resc

riptio

n m

edic

atio

n us

e. (4

)

•D

rug

s w

ith d

opam

ine

anta

gon

istic

act

ion

blo

ck d

opam

ine'

s su

pp

ress

ion

of

pro

lact

in

•R

egla

n, A

nti-p

sych

otic

s, R

ozer

em

•A

lso

can

be tr

igge

red

by C

RF,

Hyp

othy

roid

ism

, Sar

coid

osis

, or

idio

path

ic h

ypot

hala

mic

-pitu

itary

dys

regu

latio

n

Hyp

erp

rola

ctin

emia

•S

ymp

tom

s

•G

alac

torr

hea

•B

reas

t enl

arg

emen

t

•B

reas

t ten

der

ness

•A

novu

lato

ry a

men

orrh

ea

•Ir

reg

ular

per

iod

s

•D

ecre

ased

lib

ido

•In

men

, can

cau

se d

ecre

ased

lib

ido,

ere

ctile

dys

func

tion,

and

infe

rtili

ty

Wor

kup

and

Dia

gno

sis

•B

lood

wor

k sh

ows

elev

ated

pro

lact

in le

vels

•E

stra

dio

l, FS

H, L

H, P

rog

este

rone

, and

Te

stos

tero

ne s

houl

d b

e ch

ecke

d to

rul

e ou

t oth

er h

orm

onal

imb

alan

ce

•K

idne

y an

d li

ver

func

tions

sho

uld

be

chec

ked

to r

ule

out r

enal

and

hep

atic

et

iolo

gie

s

•S

erum

pre

gna

ncy

test

sho

uld

be

per

form

ed

Wor

kup

and

Dia

gno

sis

•P

ituita

ry M

RI c

an id

entif

y a

tum

or a

nd

pro

vid

e a

bas

elin

e m

easu

rem

ent o

f si

ze

•C

T sc

an is

not

the

stud

y of

cho

ice

•Vi

sual

fiel

d te

stin

g s

houl

d b

e p

erfo

rmed

dur

ing

phy

sica

l exa

m

Trea

tmen

t•

Cau

sativ

e m

edic

atio

ns s

houl

d b

e w

ithd

raw

n (if

pos

sib

le)

•D

opam

ine

agon

ists

pro

vid

e sy

mp

tom

atic

relie

f and

can

shr

ink

tum

ors

(5)

•B

rom

ocrip

tine

is d

osed

nig

htly

sta

rtin

g a

t 2.5

mg

QH

S

•C

aber

gol

ine

is d

osed

twic

e w

eekl

y (0

.25

- 0.

5 m

g B

IW)

and

tend

s to

be

mor

e ef

fect

ive

•Fo

llow

up M

RIs

allo

w m

onito

ring

of t

umor

reg

ress

ion

•S

urg

ical

rese

ctio

n m

ay b

e ne

cess

ary

for

mac

road

enom

as w

ith

sig

nific

ant c

omp

ress

ive

sym

pto

ms

Trea

tmen

t•

Ther

apy

shou

ld p

ersi

st fo

r 12

mon

ths

and

then

with

dra

wn

•If

pro

lact

in le

vels

ris

e an

d s

ymp

tom

s re

turn

, the

rap

y is

re

star

ted

•A

fter

24 m

ore

mon

ths,

ther

apy

is w

ithd

raw

n ag

ain

•If

sym

pto

ms

retu

rn, t

hera

py

is c

ontin

ued

for

life

(6)

•D

eXA

sca

n is

war

rant

ed, s

ince

pro

long

ed h

ypog

onad

ism

as

soci

ated

with

hyp

erp

rola

ctin

emia

can

lead

to o

steo

por

osis

.

Gro

wth

Hor

mon

e D

efic

ienc

y•

In c

hild

ren,

gro

wth

hor

mon

e is

res

pons

ible

for

the

man

y pr

oces

ses

in n

orm

al g

row

th in

clud

ing

leng

then

ing

of lo

ng

bone

s

•In

adu

lts, g

row

th h

orm

one

leve

ls n

atur

ally

dec

line

sign

ifica

ntly

, but

is s

till p

rese

nt•

Fun

ctio

ns in

mai

nten

ance

of m

uscl

e m

ass,

reg

ulat

ion

of m

uscl

e m

ass,

and

met

abol

ic r

ates

Gro

wth

Hor

mon

e D

efic

ienc

y•

Def

icie

ncy

of g

row

th h

orm

one

in c

hild

ren

resu

lts in

sh

ort s

tatu

re a

nd r

eten

tion

of c

hild

-like

phy

sica

l fe

atur

es•

“Sho

rt S

tatu

re”

is d

efin

ed a

s he

ight

that

is 2

sta

ndar

d de

viat

ions

be

low

the

aver

age

heig

ht fo

r a

pers

on’s

age

and

gen

der.

(7)

•P

ituita

ry d

war

fism

is n

ot th

e sa

me

as a

chon

drop

lasi

a•

Pitu

itary

dw

arfis

m r

esul

ts in

pro

port

iona

te g

row

th r

etar

datio

n.

Gro

wth

Hor

mon

e D

efic

ienc

yG

row

th H

orm

one

Def

icie

ncy

•G

H D

efic

ienc

y in

adu

lts le

ads

to n

on-s

peci

fic s

ympt

oms:

•Fa

tigue

/dec

reas

ed e

nerg

y

•W

eig

ht g

ain/

diff

icul

ty lo

sing

wei

ght

•D

ecre

ased

stre

ngth

•E

mot

iona

l lab

ility

•D

ecre

ased

lib

ido

•A

sym

pto

mat

ic (8

)

•G

row

th H

orm

one

and

IGF

-1 le

vels

are

low

in c

hild

ren

with

GH

def

icie

ncy.

•A

han

d X

-ray

for

Bon

e A

ge d

eter

min

atio

n he

lps

pred

ict

resp

onsi

vene

ss to

ther

apy.

•In

sulin

tole

ranc

e te

st is

the

stan

dard

test

in a

dults

with

pr

esum

ed G

H d

efic

ienc

y

GG

Gro

wth

Hor

mon

ean

dIG

F-1

leve

lsar

elo

win

child

ren

Wor

kup

and

Dia

gno

sis

Gro

wth

Hor

mon

e D

efic

ienc

y•

Trea

tmen

t is

grow

th h

orm

one

repl

acem

ent

•G

iven

as

a da

ily in

ject

ion

•T

hera

py is

nor

mal

ly in

itiat

ed a

nd m

onito

red

by a

n en

docr

inol

ogis

t

•A

vaila

ble

med

icat

ions

incl

ude

•N

utro

pin

•H

umat

rope

•G

enot

ropi

n•

Nor

ditr

opin

•Te

v-Tr

opin

•S

aize

n

Gro

wth

Hor

mon

e D

efic

ienc

y•

Gro

wth

hor

mon

e an

d IG

F-1

mus

t be

mon

itore

d pe

riodi

cally

th

roug

hout

trea

tmen

t•I

nsuf

ficie

nt le

vels

will

res

ult i

n no

impr

ovem

ent,

exce

ssiv

e le

vels

ca

n in

crea

se th

e po

ssib

ility

of s

ide

effe

cts

incl

udin

g S

lippe

d C

apita

l Fem

oral

Epi

phys

is, P

seud

otum

or C

ereb

ri, a

nd s

ome

canc

ers

•In

chi

ldre

n, tr

eatm

ent c

ontin

ues

until

epi

phys

es c

lose

and

gr

owth

sto

ps.

Acr

omeg

aly

•C

ause

d by

exc

essi

vely

hig

h G

row

th H

orm

one

•U

sual

ly c

ause

d by

a G

H-p

rodu

cing

pitu

itary

ade

nom

a

•P

hysi

cal m

anife

stat

ions

usu

ally

dev

elop

slo

wly

in 3

0s a

nd

40s,

so

the

dise

ase

can

be h

ard

to d

iagn

ose

in it

s ea

rly

stag

es

•C

an c

ause

gig

antis

m, b

ut u

sual

ly c

ause

s ch

arac

teris

tical

ly la

rge

hand

s, b

row

rid

ge, a

nd s

quar

e ja

w

Acr

omeg

aly

Acr

omeg

aly

•D

iagn

osis

is m

ade

by c

heck

ing

GH

leve

ls o

ne h

our

afte

r 1

hour

glu

cose

tole

ranc

e te

st

•G

H le

vels

>1

ug/L

mee

ts d

iagn

ostic

crit

eria

(no

rmal

ly G

H w

ould

be

supp

ress

ed b

elow

1 u

g/L)

•C

ompl

icat

ions

incl

ude

•H

eada

che

•V

isua

l Dis

turb

ance

s fr

om tu

mor

•C

ardi

omeg

aly

& H

eart

Fai

lure

•H

yper

tens

ion

•A

rthr

itis

•D

iabe

tes

•K

idne

y F

ailu

re

Acr

omeg

aly

•Tr

eatm

ent u

sual

ly c

onsi

sts

of s

urgi

cal r

emov

al o

f th

e tu

mor

•M

edic

atio

n is

use

d th

erea

fter

if G

H le

vels

rem

ain

elev

ated

from

res

idua

l tis

sue

•O

ctre

otid

e (S

ando

stat

in)

- in

ject

ed e

very

oth

er w

eek

•La

nreo

tide

(Som

atul

ine)

- in

ject

ed e

very

oth

er w

eek

•D

opam

ine

agon

ists

(B

rom

ocrip

tine

or C

aber

golin

e) (9

)

•R

adia

tion

to th

e pi

tuita

ry c

an b

e us

ed in

pat

ient

s w

ho a

re n

ot c

andi

date

s fo

r su

rger

y

Cus

hing

's D

isea

se•

The

pitu

itary

ove

r-se

cret

es A

CT

H, p

rom

ptin

g th

e ad

rena

ls to

ove

r-se

cret

e co

rtis

ol. (

10)

•M

ost c

omm

only

(80

%)

caus

ed b

y an

ade

nom

a in

the

ante

rior

pitu

itary

.

•C

ause

s cl

assi

c C

ushi

ng S

yndr

ome

sym

ptom

s:

•W

eig

ht g

ain

•M

oon

face

•B

uffa

lo h

ump

•A

bd

omin

al s

tria

e

•H

irsut

ism

•A

men

orrh

ea

•Th

inni

ng s

kin

•H

yper

tens

ion

(11)

Cus

hing

's D

isea

se

Wor

kup

•24

-hou

r ur

ine

cort

isol

leve

l can

be

used

for

dete

rmin

atio

n of

Cus

hing

Syn

drom

e.

•D

exam

etha

sone

Sup

pres

sion

Tes

t ass

ists

in

dete

rmin

atio

n of

the

etio

logy

.

•In

Cus

hing

's D

isea

se, A

CT

H le

vels

rem

ain

elev

ated

eve

n af

ter

expo

sure

to h

igh-

dose

dex

amet

haso

ne. (

12)

•P

ituita

ry M

RI m

ay v

isua

lize

an a

deno

ma.

Cus

hing

's D

isea

se

Trea

tmen

t

•Tr

eatm

ent u

sual

ly in

volv

es tr

ansp

heno

idal

re

sect

ion

of th

e tu

mor

. (13

)

Ref

eren

ces

1.D

aly

AF,

Rix

hon

M, A

dam

C e

t al.

Hig

h pr

eval

ence

of p

ituita

ry a

deno

mas

: a c

ross

-sec

tiona

l stu

dy in

th

e pr

ovin

ce o

f Lie

ge, B

elgi

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