Pituitary gland is master gland of the body and requires ppt to explain in detail.

Great presentation on gland.

1. Pituitary Physiology and Deficiencies
Heidi Chamberlain Shea, MD
Endocrine Associates of Dallas

2. Pituitary
•Pituitary
–“Master” gland
–Most of the pituitary
hormones control
other endocrine glands

3. Goals of Discussion
•Review pituitary
anatomy
•Understand pituitary
physiology
•Discuss pituitary
hormone deficiencies

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

5. Pituitary Development
• Evagination of the stromodeal ectoderm from buccal cavity
• Infundibulum, neural stalk and posterior lobe from diencephalon
• Development 3
rd
to the 15
th
week gestation

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

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

8. •Anterior lobe
–80% of gland
–Brown color
•Posterior lobe
– Gray/brown color
Pituitary Anatomy
Microscopic

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

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)

11. Pituitary
Portal System
•Hypophyseal arteries
–From carotid
–Superior
•80-90% to adenophysis
–Inferior
•Posterior pituitary
•Posterior lobe
–Rich nerve supply
–Unmyelinated nerves

12. Goals of Discussion
•Review pituitary
anatomy
•Understand pituitary
physiology
•Discuss pituitary
hormone deficiencies

13. 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

14. Anterior pituitary
Hypothalamic Pituitary TargetHormone
product product organproduct
CRH ACTH AdrenalCortisol
cortex
TRH TSH ThyroidT4, T3
GHRH (+) GH Liver;IGF-I (systemic)
SRIH (-) TissuesIGF-I (local)
PRIH PRL Breast [Lactation]
(dopamine)
GnRH LH, Gonad Sex hormones
(LHRH) FSH

15. Hormone Structure Amino acids/Source
Polypeptide/proteins
ACTHPolypeptide 39Corticotroph
GH Protein 191Somatotroph
PRLProtein 199Lactotroph
Glycoproteins
TSHAlpha* / TSH-beta110Thyrotroph
LH Alpha / LH-beta115Gonadotroph
FSHAlpha / FSH-beta115Gonadotroph
[hCGAlpha / beta-hCG] 147[Placenta]
* 92 amino acids

16. HYPOTHALAMUS
POSTERIOR
PITUITARY
ANTERIOR
PITUITARY
GHRH
(+)
SRIH
(-)
HYPOTHALAMIC-
PITUITARY
PORTAL SYSTEM
TISSUES
DIRECT
EFFECTS
INCR. [FFA]
INSULIN RESISTANCE
GH
(-)
IGF-I
GROWTH
GH_AXIS_
IGFBP-3

17. (+) POSTERIOR
PITUITARYANTERIOR
PITUITARY
(-)
CRH
HYPOTHALAMUS
HYPOTHALAMIC-
PITUITARY
PORTAL SYSTEM
ACTH
CORTISOL
ADRENAL Fasiculata
(-)

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

19. POSTERIOR
PITUITARY
PRL
BREAST
PRIH
(-)
HYPOTHALAMUS
ANTERIOR
PITUITARY
(DOPAMINE)

20. POSTERIOR
PITUITARYANTERIOR
PITUITARY
LH, FSH
SEX HORMONES, INHIBIN
GONAD
(-)
(-)GnRH
(+)
HYPOTHALAMUS
HYPOTHALAMIC-
PITUITARY
PORTAL SYSTEM
(LHRH)

21. Posterior pituitary
Hypothalamic
source (cell body)Target Effect
ADH Collecting H
2
O retention
duct
Oxytocin Breast Milk let down
Uterus Smooth muscle
Contraction

22. Goals of Discussion
•Review pituitary
anatomy
•Understand pituitary
physiology
•Discuss pituitary
hormone deficiencies

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

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

25. Physical Exam
•Wt 62.9kg (75%)
•Ht 5ft 3.5in (50%)
•BMI 24.2 kg/m
2
•HR 80
•B/P 117/86
•General:
nondysmorphic, well-
nourished
•HEENT: visual fields
intact, no thyromegaly
•Breast: no discharge,
Tanner V
•GU: Tanner V

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

27. Differential Diagnosis
Hypopituitarism
•Vascular disease
–Sheehan’s postpartum
necrosis
–Carotid aneurysm
•Destructive
–Surgery
–Radiation
–Trauma
•Infiltration
–Hemochromatosis
–Amyloidosis

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

29. Hypopituitary
Presentation
•Growth hormone
deficiency
–Children
•Short stature
–Adults
•Non specific
•Fine wrinkling around the
face
•Improved insulin sensitivity

30. Hypopituitary
Presentation
•Gonadotropin deficiency
–Women
•Amenorrhea
–Primary or secondary
•Infertility
–Men
•Decreased libido
•Decreased beard and body
hair

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

32. Hypopituitary
Presentation
•Hypothryoidism
–Fatigue
–Cold intolerance
–Puffy skin
–Absence of goiter
•Diabetes Insipidus
–Polyuria
–Polydipsia

33. Evaluation
•What testing?
–Polydipsia and
polyuria
•Water deprivation test
–Secondary
amenorrhea
•Prolactin
•Gonadotropins
•Thyroid function

34. Laboratory
•Water deprivation test reveals diabetes
insipidus
•MRI – pituitary seen, no masses, subtle
thickening of 3
rd
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)

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

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

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

38. Treatment
•Cortisol
–Hydrocortisone
•10mg AM and 5 mg PM
•6-8 mg/m
2
/day
•Stress dosing
–Fever, illness, surgery
–20 mg/m
2
/day
–Double or triple daily dose
–100 mg x1 then 25-50 mg
Q6-8hrs
•All hypopituitary patients
need a medic alert
bracelet

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

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