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Preface
The human body is primarily governed by two intri- a separate chapter on sellar masses, key elements of
cate communicating networks: the nervous system clinical history, biochemical and radiological assess-
and the endocrine system. The study of the interrela- ment as well as epidemiology of sellar masses are
tionship of these two networks created the discipline discussed. The clinical implications of various phy-
of neuroendocrinology. Recent advances in this field siological principles as well as cases from our clinics
have transformed our view of how human endocrine are included in the text. The text itself is liberally
homeostasis is maintained. For example, the discov- illustrated with full-color, high-resolution images to
ery of the adipokine leptin revolutionized our under- provide concise summaries of information. Extensive
standing of the neural mechanisms by which we lists of references emphasize original papers based
regulate body weight. A further case is the discovery on human data.
of the KISS1 gene, and its encoded neuropeptide kis- We intend the book to be useful at multiple
speptin, now recognized as obligatory for successful levels, though it is especially aimed at those stu-
human reproductive function. dents and clinicians not previously exposed to
Although several texts are currently available that a specific course in neuroendocrinology. For exam-
cover the field of clinical neuroendocrinology, they ple, senior medical students making decisions to
are almost exclusively advanced, multi-author books pursue a specialty will find it helpful, as will those
written by experts and largely aimed at medical spe- residents and clinical fellows who are embarking on
cialists. While these texts provide a comprehensive their chosen fields. In addition, this book should
clinical and basic science review of the subject, there provide a crucial clinical context for biomedical
is a compelling need for an introductory description science graduate students who may already be
of the human neuroendocrine system in health and familiar with basic science research principles.
disease. Our book is therefore designed to emphasize We include an extensive and up-to-date reference
the key physiological principles necessary for an list for each chapter, and additional material is
understanding of various clinical neuroendocrine provided under a further reading list. The latter
disorders. tend to be clinical reviews that may be particularly
Introductory chapters discuss the fundamentals useful to the more advanced reader and will provide
that govern how the hypothalamic–pituitary system a convenient link to the available specialized texts.
interacts with various endocrine target tissues. A selection of review questions is provided at the
Topics include cellular communication, hormone end of each chapter.
receptor systems, hormone assays and a description The field of neuroendocrinology is a rapidly evol-
of the importance of hormonal secretory rhythms. ving area of health sciences. This introduction to
Subsequent chapters outline the essentials of human clinical neuroendocrinology should serve as a guide
female reproduction, the regulation of body weight to medical students, clinicians and biomedical
and metabolism with a focus on obesity, the control science students, as well as their teachers, in nego-
of prolactin secretion and the principles of adrenal, tiating a fascinating and essential clinical field of
thyroid and growth hormone physiology. Finally, in study.
ix
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Chapter
Basic Principles in Clinical
1 Neuroendocrinology I: Receptor
Mechanisms
The homeostatic functions of the body are primarily confronted through addressing the underlying neu-
controlled by neuronal cells communicating through roendocrine principles.
electrical impulses and endocrine cells communicat- For the most part, the brain influences endocrine
ing through chemicals. Neuroendocrinology is the targets in tandem with the pituitary gland; that is,
branch of endocrinology that is concerned with how pituitary hormone secretion is directed by various
the brain regulates the endocrine milieu. stimuli secreted from hypothalamic neurons. Thus,
An essential and critical characteristic of this neural luteinizing hormone (LH) is released from pituitary
control is that endocrine hormones have profound gonadotropes following stimulation by gonadotropin
effects on brain function through homeostatic feed- releasing hormone (GnRH), a neuropeptide produced
back systems. An understanding of the chemical by hypothalamic neurons. Figure 1.1 illustrates the
mechanisms that underpin neuroendocrine regula- hypothalamic releasing hormones that regulate ante-
tion is critical when dealing with clinical disorders rior pituitary hormone secretion. Note that dopa-
of the neuroendocrine system. For example, the mine – a neurotransmitter – controls prolactin
clinical complications of abnormal growth, thyroid (PRL) secretion. In contrast, posterior pituitary hor-
disorders, obesity and Cushing’s syndrome can be mones, such as oxytocin, are not under the influence
HYPOTHALAMUS
Thyrotropin releasing hormone

Growth hormone releasing hormone
Dopamine
Gonadotropin releasing hormone
Somatostatin ANTERIOR
Corticotropin releasing hormone PITUITARY
Growth hormone
Luteinizing hormone
Follicle stimulating hormone
Adrenocorticotropic hormone
Thyroid stimulating hormone
POSTERIOR Prolactin
PITUITARY
Vasopressin
Oxytocin
Figure 1.1 Hypothalamic and pituitary hormones of the neuroendocrine system. Public domain images from Ladyofhats: http://en.wikipedia
.org/wiki/File:Endocrine_central_nervous_en.svg.
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Chapter 1: Basic Principles in Clinical Neuroendocrinology I: Receptor Mechanisms
Regulatory
G protein-coupled receptor (GPCR) superfamily.
neurons
+
Other hormones, such as leptin, bind to so-called
–
– tyrosine kinase-dependent receptors. An additional,
intracellular, superfamily of steroid hormone recep-
tors mediates the feedback effects of steroid hormones
such as estradiol and cortisol at the level of the ante-
rior pituitary and hypothalamus. Thus, an interplay of
± – fluctuating hormonal levels with receptor sensitivity
GnRH
neurons dictates homeostatic neuroendocrine regulation.
The following sections will summarize the receptor-
Infundibular
nucleus signaling systems that: (a) regulate target organ activ-
ity, for example, stimulation of gonadotrophs by
GnRH
Portal GnRH acting through cell surface GPCRs; and (b)
vasculature
control hormonal feedback in the hypothalamus and
± –
pituitary, for example, intracellular estradiol recep-
tors in brain and pituitary.
Anterior
pituitary
LH/FSH
1.1 Cell Membrane Receptors
Peptide hormones, neuropeptides and neurotrans-
Estradiol Testosterone
mitters are generally water soluble and cannot easily
enter their target cells. They regulate cellular activity
Progesterone by binding to specific receptors located in the plasma
Ovary Testis membranes of their target cells. In order to induce
Figure 1.2 Homeostatic control of GnRH secretion and the reproductive biochemical changes within the target cell, they act as
system. Schematic diagram highlighting the role of GnRH neurons in the first messengers to activate an intracellular second
control of human reproduction. Red arrows indicate the positive and messenger, such as cyclic adenosine monophosphate
negative feedback effects of serum estradiol and progesterone exerted
on GnRH secretion. This control is imposed at several levels: directly on (cAMP). The transduction of information from the
GnRH neurons; at the level of gonadotrophs; and on neurons (stimula- first to the second messenger is accomplished through
tory and inhibitory) that regulate GnRH neurons. Blue arrows illustrate the activation of membrane proteins (e.g., G proteins)
the negative feedback effects of testosterone on GnRH release in the
male. Abbreviations: GnRH, gonadotropin releasing hormone; LH, and enzymes, such as adenylate cyclase.
Luteinizing hormone; FSH, Follicle stimulating hormone. This section illustrates the role of membrane recep-
tors for peptide hormone and neurotransmitter action,
of releasing hormones but instead are secreted the mechanisms by which signal transduction across
directly from hypothalamic neuron terminals in the the cell membrane occurs, the role of G proteins and
posterior pituitary. receptor tyrosine kinases in this signal transduction,
A typical neuroendocrine feedback network is and the second messenger systems activated.
exemplified by the reproductive system in which the
target organs (ovary and testis) respond to gonado-
tropin stimulation by releasing sex hormones (estra- 1.2 G Protein-Coupled Receptors
diol, progesterone or testosterone) that, in turn, exert GPCRs are characterized by their seven transmem-
negative feedback on the hypothalamus to influence brane domain structures attached to trimeric
secretion of GnRH and LH/follicle stimulating hor- G proteins (Figure 1.3). They bind multiple neuro-
mone (FSH) (see Figure 1.2 and Chapter 3). Other transmitters, hormones and peptides, and control
examples will be described in subsequent chapters. almost all known physiological processes, including
The target organ sensitivity to stimulation, and the neuroendocrine regulation, cardiovascular function,
neuronal response to hormonal feedback, is depen- behavior and immune function. A variety of
dent upon a variety of receptor mechanisms. For G proteins together with receptors, effectors and var-
example, in Figure 1.2, the response of pituitary gona- ious regulatory intracellular proteins are the compo-
dotrophs to stimulation with the peptide GnRH is nents of a complex and versatile signal transduction
2
governed by specific membrane receptors of the system (for a detailed review see Wettschureck and
GnRH
CRH GHRH
TSH
GPCR
dopamine
Activated G protein
LIN
Extracellular
RE
5 6 7
SO
GH
4
M
Cytoplasm
12 3 +
γ γ
Gα Gα
GDP β
GTP
β +
Gαs Gαq –
Gαs cAMP
AC PLC cAMP/Ca2+ Inhibition of
PLC/IP3/Ca2+ cAMP
Gαq PLC
cAMP
Gαi cAMP
PKA PKC
+ –
GH gene Inhibition
Biological Gene expression
expression; of
response
GH release GH secretion
Nucleus DNA
Figure 1.3 Schematic diagram of GPCR signaling via G proteins

and second messengers. GPCRs, in the inactive state, possess seven GH SECRETION
transmembrane domains coupled to a G protein complex consisting
of α-, β- and γ-subunits, plus a molecule of GDP. Binding of a specific
ligand activates the Gα-subunit by replacing GDP with GTP, followed
by dissociation of the βγ-subunit. This step is reversible following SOMATOTROPH
dissociation or degradation of the receptor stimulus. The Gα-subunit
exists as three forms: (a) a stimulatory Gαs that increases cAMP Figure 1.4 GPCR-dependent mechanisms regulating GH secretion
production and the activation of protein kinase A; (b) a stimulatory from pituitary somatotrophs. Receptors for GHRH and ghrelin are
Gαq that selectively stimulates the PLC pathway to activate PKC; and stimulatory G protein coupled, linked to cAMP/PKA and PLC/PKC
(c) an inhibitory G03B1i pathway that inhibits cAMP production. signals, respectively. GHRH and ghrelin act synergistically to induce
The protein kinases may regulate enzyme activity or gene expression intracellular calcium ion mobilization that, in turn, controls GH
via transcription factors (dotted arrows) that bind to target genes. secretion. These stimuli also induce GH gene expression and GH
Examples of ligands that bind to GPCRs are GnRH, CRH, TSH and synthesis in somatotrophs. In contrast, SOM binds to an inhibitory
dopamine. Image reproduced with permission (Neumann et al., 2014). GPCR that reduces the accumulation of cAMP, decreasing the release
Abbreviations: AC, adenylate cyclase; GDP, guanosine diphosphate; of GH(Ben-Shlomo and Melmed, 2010). Abbreviations: GPCR,
GnRH, gonadotropin releasing hormone; GPCR, G protein-coupled G protein-coupled receptor; IP3, inositol triphosphate; PKA, protein
receptor; GTP, guanosine triphosphate; PIP2, phosphatidylinositol 4,5 kinase A; PKC, protein kinase C; SOM, somatostatin.
bisphosphate; PKC, protein kinase C; PLC, phospholipase C.
Offermanns, 2005). For the purposes of this chapter, (Figure 1.4). This system is covered in more detail in
Figure 1.3 outlines, in general terms, the processes by Chapter 8. A further example is the synergistic stimu-
which extracellular stimuli are rapidly transduced to lation of adrenocorticotropin (ACTH) from pituitary
intracellular signals that ultimately control gene corticotrophs by CRH and vasopressin (see Chapter 5;
expression and biological response. The figure Figure 5.5)
includes typical neuroendocrine stimuli (GnRH, cor-
ticotropin releasing hormone [CRH], thyroid stimu- Clinical Significance of GPCRs
lating hormone [TSH] and dopamine) that act via G protein receptors are firmly implicated in all the
GPCRs. Other examples will be covered in subsequent hormonal systems described in this book. For exam-
chapters. ple, Figure 1.3 illustrates that important neuroendo-
By way of illustration, the pituitary somatotroph is crine molecules such as GnRH (reproductive system),
a cell type that utilizes all three of the GPCRs illu- CRH (regulation of the hypothalamic–pituitary–adre-
strated in Figure 1.3; that is, ghrelin and growth hor- nal system), TRH (hypothalamic–pituitary–thyroid
mone releasing hormone (GHRH) synergize to regulation) and dopamine (PRL secretion) all func-
stimulate growth hormone (GH) secretion, whereas tion through specific GPCRs. Other examples will be
somatostatin serves to inhibit GH secretion covered in later chapters. These receptors represent
3
a superfamily of human membrane proteins. Drugs Desensitization is reversible by replacing continuous

that target them account for approximately 30% of the GnRH treatment with an episodic, pulsatile stimula-
global market share of therapeutic drugs, with esti- tion. This will be described in more detail in
mated sales for 2011–2015 of approximately Chapter 3. A similar phenomenon is reported with
US$890 billion (Hauser et al., 2017). stimulation of LH secretion with the neuropeptide
The responsiveness of GPCRs to stimulation may kisspeptin, which also binds to a GPCR (Jayasena
be compromised in some neuroendocrine disorders. et al., 2009; see Chapter 3).
Receptor function is affected in two principal ways:
(a) when GPCRs are subjected to chronic stimulation Mutations in GPCR Genes
to produce tachyphylaxis, and (b) when mutations The clinical significance of GPCRs in the neuroendo-
occur in the genes for receptor proteins or crine system is reinforced when taking into account
G proteins. endocrine/neuroendocrine disorders that result from
loss-of-function or gain-of-function mutations in the
Chronic Stimulation and GPCR Downregulation genes for receptor proteins or G proteins (Vassart and
For example, continuous stimulation of the human Costagliola, 2011). Table 1.1 lists a group of mutations
female pituitary with the releasing hormone GnRH of GPCRs relevant to endocrine diseases, together
downregulates (desensitizes) the normal response with the appropriate chapter where these receptors
such that LH secretion and ovulation is inhibited are discussed (based on data from Lania et al., 2006;
(Southworth et al., 1991). A major consequence of Vassart and Costagliola, 2011). A detailed discussion
continuous stimulation of gonadotrophs is inhibition of gain-of-function GPCR mutations associated with
of the normal response through the loss of cell surface endocrine disorders is covered elsewhere (Fukami
GnRH receptors (Engel and Schally, 2007). et al., 2018).
Table 1.1 Clinical and biochemical features of endocrine disorders caused by GPCR mutations
Clinical features Biochemical feature GPCR affected (type of

mutation)
Thyroid disorders (Chapter 6)
Isolated central hypothyroidism with normal Normal or low TSH, low fT4 absent TRH receptor (inactivating)
pituitary MRI TSH and prolactin responses to TRH
test
Complete congenital hypothyroidism High TSH, low fT4, no goiter, no TRH receptor (inactivating)
antibodies to thyroglobulin or
thyroperoxidase
Juvenile hyperthyroidism with goiter Low TSH, high fT4, no antibodies to TSH receptor (activating)
thyroglobulin or TSH receptor
Reproductive disorders (Chapter 3)
Delayed puberty Low sex steroids and low–normal Kisspeptin receptor (inactivating)
LH and FSH responsive to GnRH test
Low sex steroids and low–normal GnRH receptor (inactivating)
LH and FSH poorly responsive to
GnRH test
Primary amenorrhea with normal development of High LH, normal or high FSH, and LH receptor (inactivating)
primary and secondary sexual characteristics low estradiol and progesterone
Male precocious puberty with normal pituitary High testosterone and low LH and LH receptor (activating)
MRI FSH with prepubertal response to
GnRH test
Primary or early-onset secondary amenorrhea, High LH, high FSH FSH receptor (inactivating)
variable development of secondary sex
characteristics and premature arrest of follicular
maturation
Ovarian hyperstimulation syndrome during in vitro None FSH receptor (activating)
4 fertilization
Table 1.1 (cont.)
Clinical features Biochemical feature GPCR affected (type of

mutation)
Obesity (Chapter 4)
Early-onset or severe adult obesity, associated with Hyperinsulinemia Melanocortin 4 receptor
hyperphagia (inactivating)
Growth disorders (Chapter 8)
Dwarfism associated with abdominal adiposity Low GH and insulin-like growth GHRH receptor (inactivating)
factor 1, unresponsive to GHRH test
Water balance disorders (Chapter 9)
Nephrogenic diabetes insipidus Hypernatremia, low urine V2R (inactivating)
osmolality, normal or high VP
Nephrogenic syndrome of inappropriate Hyponatremia, low serum V2R (activating)
antidiuresis osmolality, inappropriately high
urine osmolality, undetectable VP
levels
Abbreviations: FSH, follicle stimulating hormone; fT4, free thyroxine; GH, growth hormone; GHRH, growth hormone releasing
hormone; GnRH, gonadotropin releasing hormone; GPCR, G protein-coupled receptor; LH, luteinizing hormone; MRI, magnetic
resonance imaging; TRH, thyrotropin releasing hormone; TSH, thyroid stimulating hormone; VP, vasopressin; V2R, vasopressin
receptor 2.
1.3 Tyrosine Kinase-Dependent LEPTIN

Leptin receptor dimer
Receptors Plasma membrane

Peptide hormones such as leptin, PRL and GH (see
JAK JAK
Chapters 4, 7 and 8, respectively) do not bind to Cytoplasm P P
GPCRs. As shown in Figure 1.5, the receptor struc- P P
tures – in this case the leptin receptor dimer – have P P SOCS3
only two transmembrane domains. Leptin binding to STAT STAT

–
a single transmembrane protein induces receptor

dimerization, which then stimulates a tyrosine kinase
P STAT
pathway rather than the G protein signaling shown in
P
Figure 1.3. For leptin, PRL and GH, this is the second STAT
messenger JAK/STAT pathway (for details of the GH

system see Chapter 8; Figure 8.12). Nucleus
STAT
For example, binding of leptin to its receptor acti- P
Gene
P
vates (phosphorylates) Janus kinase (JAK) proteins STAT expression
that are docked on the intracellular domain.

Activated JAKs then phosphorylate the signal trans-
ducer and activator of transcription (STAT) family of Figure 1.5 Leptin receptor and the JAK/STAT pathway. Binding of
transcription factors. Dimerization of STAT proteins leptin to its receptor dimer activates (phosphorylates; P) JAK
proteins. Activated JAKs then phosphorylate the STAT family of
precedes translocation to the nucleus where binding transcription factors. Dimerization of STAT proteins precedes
to response elements on DNA modulates transcrip- translocation to the nucleus where binding of the transcription
tion of target genes. Unlike the leptin receptor, the factor to response elements on DNA modulates transcription of
target genes. Also included is a negative feedback system where
PRL and GH receptors exist as preformed dimers (see gene expression of SOCS3 modulates leptin stimulation. Image
Figure 8.12 for GH, and Brooks and Waters, 2010) but reproduced with permission (Dodington et al., 2018). Abbreviations:
also employ the JAK/STAT pathway following bind- STAT, signal transducer and activator of transcription; SOCS3,
suppressor of cytokine signaling 3.
ing of the ligand (Bernard et al., 2015).
5
Clinical Significance of Tyrosine insensitivity – mutations in the intracellular STAT5

gene (see Figure 8.12) – is now described; that is, the
Kinase-Dependent Receptors intracellular signaling pathway is defective (Hwa,
The clinical importance of leptin, PRL and GH is 2016). Loss-of-function mutations in the PRL receptor
described in the appropriate chapters. The clinical con- have also been described (Bernard et al., 2015). Such
sequences of abnormal receptor signaling are pro- patients present with hyperprolactinemia, possibly due
found, and defects, either at the receptor or in the to the inability of PRL to exert negative feedback on
intracellular pathway, appear as a hormone deficiency. pituitary lactotrophs.
For example, as described in Chapter 4, obese indivi-
duals are insensitive to their own high levels of leptin. 1.4 Intracellular Receptors for
By analogy with the insulin resistance seen in type 2
diabetes, the common forms of diet-related obesity are Steroid Hormones
thought to be attributable to “leptin resistance,” a state Steroid hormones (e.g., testosterone, estradiol and
in which multiple cellular processes block leptin recep- cortisol; Figure 1.6) and thyroid hormones (see
tor signaling (Myers et al., 2010). Thus, high levels of Figure 6.5) are fat-soluble molecules transported in
endogenous leptin, derived from the increased fat the blood bound to carrier proteins.
mass, fail to reduce food intake or body weight. Also, Steroid hormones readily diffuse through cell
patients with mutations in the leptin receptor are membranes into any cell in the body, but only their
severely obese and effectively leptin-free, even though target cells, in brain and pituitary for example, possess
leptin levels are high (Farooqi et al., 2007). In these specific intracellular receptors. These receptors have
cases, leptin is unable to signal to downstream path- common structural elements and belong to
ways. Due to loss-of-function mutations in the GH a superfamily of receptor proteins (Figure 1.7).
receptor (Rosenfeld et al., 2007; Brooks and Waters, Each receptor protein contains a hormone binding
2010), patients insensitive to GH (Laron syndrome) domain (HBD) that is specific for each hormone.
show severe growth failure and insulin-like growth Thus, for example, the human glucocorticoid receptor
factor 1 (IGF-1) deficiency (see Chapter 8). Over sixty (hGR) binds cortisol in the HBD, whereas the proges-
loss-of-function mutations in the GH receptor have terone receptor (hPR) recognizes only progesterone.
been reported, although a new cause of GH Binding of the hormone to its specific receptor
Figure 1.6 Chemical

structures of the major steroid
hormones. Four principal
families of steroid hormones
are: androgens (e.g.,
testosterone), estrogens (e.g.,
estradiol), glucocorticoids
(e.g., cortisol) and mineralo-
corticoids (e.g., aldosterone).
They are all derived from
cholesterol. An important
family not shown is the
progestogens (e.g.,
progesterone). Note that the
female sex hormone estradiol
is formed by aromatization
from the male hormone
testosterone. Copyright
A. Pincock.
hAR 100
NTD
100
DBD H HORMONE BINDING DOMAIN
100
hERα NTD DBD H HORMONE BINDING DOMAIN

15 51 20
hERβ NTD DBD H HORMONE BINDING DOMAIN

15 56 22
hGR 15
NTD
77
DBD H
50
HORMONE BINDING DOMAIN
hPR 15
NTD
80
DBD H
53
HORMONE BINDING DOMAIN
Figure 1.7 Structures of members of the human steroid receptor superfamily. These intracellular receptors consist of a single polypeptide chain
and all of the family members contain a hormone binding domain that is specific for each hormone. For example, hGR binds cortisol in
this region, whereas the hPR will only recognize progesterone. The DBD enables the hormone-receptor complex to bind to the HRE (see
Figure 1.8) on a target gene. The hinge region (H) is important, along with the DBD, for nuclear localization of the receptor, and the NTD is
crucial for the activation of gene transcription once the hormone-receptor complex reaches the nucleus and binds with the HRE. Numbers
indicate the degree of structural homology in each domain, compared with the hAR (McEwan and Brinkmann, 2016). Abbreviations: DBD, DNA
binding domain; hAR, androgen receptor; hERα, estrogen receptor α; hERβ, estrogen receptor β; hGR, glucocorticoid receptor; hPR,
progesterone receptor; HRE, hormone response element; NTD, amino terminal domain.
enables the DNA binding domain (DBD) to interact Estrogen Receptors

with specific sites on target genes called hormone
It is beyond the scope of this text to provide a description
response elements (HRE; see Figure 1.8). The hinge
of the clinical role of all of the nuclear receptors illu-
region (H) appears to be important, along with the
strated in Figure 1.7, and the estrogen receptor (ER) will
DBD, for nuclear localization of the receptor, and the
be used here as an example. ERs exist in three forms, two
amino terminal domain (NTD) is crucial for the acti-
of which are nuclear (ERα and ERβ, also termed ESR1
vation of gene transcription once the hormone-
and ESR2; Figure 1.7) and the third, located in cell
receptor complex reaches the nucleus and binds with
membranes, is a GPCR. The latter – termed the
the HRE (McEwen and Brinkmann, 2016). Note that
G protein-coupled ER-1 (GPER-1) – is a relative new-
the receptor proteins have no biological activity until
comer to ER physiology, and these receptors permit
they bind to a hormone; that is, the hormone-receptor
rapid, non-genomic (non-nuclear), cellular responses
complex acts as a transcription factor at specific sites
to estrogen treatment. There is evidence of
(HRE) on target genes. Figure 1.8 illustrates the
a physiological role for GPER-1 in the reproductive,
sequence of events that occur when a steroid hormone
nervous, endocrine, immune and cardiovascular sys-
diffuses into target cells, such as pituitary or hypotha-
tems (Prossnitz and Barton, 2011), and GPER-1 appears
lamus. The hormone is released from the binding
to be a promising and novel therapeutic target and
globulin (BG), enters the cell and binds to a specific
prognostic indicator (Barton, 2016). Membrane recep-
receptor (R) in the cell cytosol. The unoccupied R is
tors for androgens, glucocorticoids (GCs), aldosterone
coupled to a so-called molecular chaperone (heat
and thyroid hormone have also been described.
shock protein 90; HSP90) that ensures the receptor
ERα and ERβ, the products of two distinct genes,
is stabilized in the correct shape. Following hormone
are localized in many tissues (Figure 1.9), with ERα
binding to the receptor-HSP90 complex, the HSP90
especially concentrated within the reproductive sys-
dissociates and the remaining hormone-receptor
tem (hypothalamus, pituitary, breast and uterus).
complex dimerizes. The dimer then enters the cell
Details of their functional role in estrogen feedback
nucleus where it attaches to an HRE to modify gene
and the regulation of anterior pituitary secretion of
expression and the export of mRNA into the cell
gonadotropins through the menstrual cycle is out- 7
cytosol where it is translated into protein.
lined in Chapter 3.
Figure 1.8 Schematic view of a steroid

hormone interacting with a target cell.
The hormone is reversibly bound to
a binding globulin (BG) before the free
hormone freely diffuses through the cell
membrane. The unoccupied steroid recep-
tor (R) is coupled to a molecular chaperone
(HSP90) that stabilizes R in the correct
shape. When the hormone binds to the
receptor-HSP complex, the HSP dissociates
and the remaining hormone-receptor
complex dimerizes before it enters the cell
nucleus. The hormone-receptor dimer then
binds to target genes via a specific HRE.
Various factors such as GTFs and RNA POL II
assist in inducing gene transcription and
the export of mRNA into the cell cytosol
where it is translated into protein.
Abbreviations: GTF, general transcription
factor; HSP, heat shock protein; HSP90, heat
shock protein 90; mRNA, messenger RNA;
POL II, polymerase II; RNA, ribonucleic acid.
This figure reveals that ERs are implicated in reg- inflammation and osteoporosis (Paterni et al., 2014;
ulating multiple complex physiological processes in Warner et al., 2017).
humans, and abnormal ER function leads to a variety
of diseases, such as cancer, metabolic and cardiovas- Hormone Resistance
cular disease, neurodegeneration, inflammation and
This section uses the estrogen and GC receptors as
osteoporosis (Jia et al., 2015).
examples of the clinical consequences of hormone
Clinical significance: Using the menopause as
resistance. Other well-described examples include
a specific example, estrogen deprivation has profound
androgen receptor insensitivity (testicular feminiza-
effects particularly in the central nervous system; for
tion syndrome; Hiort, 2013) and thyroid hormone-
example, vasomotor symptoms such as hot flashes
receptor insensitivity (Ortiga-Carvalho et al., 2014;
and night sweats, development of anxiety, depression,
see also Chapter 6).
poor quality of sleep and migraine. Figure 1.10 illus-
trates the widespread influence of estrogen depletion Estrogens
(Monteleone et al., 2018). ER resistance appears to be unknown within the neu-
Estrogen replacement at the menopause inevitably roendocrine system. However, mutations in ERα in
influences many systems, some not without risk, as in metastatic breast cancer are well-described and result
the possibility of breast cancer (Warner et al., 2017). from long-term treatment with antiestrogens, such as
Selective targeting of ERα and ERβ appears to be tamoxifen, and drugs such as fulvestrant that
a promising way to achieve beneficial estrogenic degrades ERα (Huang et al., 2017). Drug-induced
effects while avoiding unwanted side effects. ERβ estrogen resistance could take the form of changes in
selective agonists are now available that have no effect downstream signaling or as intrinsic activation of ERα
in breast tissue but may be therapeutic agents consid- in the absence of estradiol. It is possible that tamox-
ered for prevention and treatment of cancer, meta- ifen or fulvestrant could affect hypothalamic or pitui-
8 bolic and cardiovascular diseases, neurodegeneration, tary ERα receptors.
Figure 1.9 Distribution of hERα and hERβ

throughout the body. Localization of hERα and
hERβ gene expression in normal human pituitary
(Chaidarun et al., 1998) and pituitary adenomas
(Manoranjan et al., 2010) has been added. Not
included in the figure is the localization of both
receptors in the human uterus (Simmen and
Kelley, 2016). Image reproduced with permission
(Warner et al., 2017). Abbreviations: hERα,
estrogen receptor α; hERβ, estrogen receptor β.
Glucocorticoids resistance, increasing patient vulnerability to exagger-

GCs influence multiple physiological processes (see ated inflammatory responses. GC usage is increasing as
Chapter 5), and are routinely used to treat disorders of a result of disease prevalence in an aging population.
inflammation, autoimmune diseases and cancer. For example, GCs are used in the treatment of asthma,
The physiological effects of GCs can, in rare cases, allergic rhinitis, hematologic malignancies, ulcerative
be compromised because of mutations in the GC colitis, rheumatoid arthritis, eczema and psychological
receptor that impair GC action. This reduces tissue disorders. GC resistance can also occur as a result of
sensitivity to GCs, compromises negative feedback chronic stress as well as in major depression
and induces hypersecretion of ACTH, cortisol and (Rodriguez et al., 2016). Efforts to generate new, clini-
androgens (Figure 1.11; Charmandari et al., 2008; cally useful, GC receptor ligands that can overcome GC
Charmandari et al., 2013). resistance are in progress (Vandewalle et al., 2018).
GC receptor sensitivity is also reduced when syn-
thetic GCs are used to suppress allergic, inflammatory 1.5 Chapter Summary
and immune disorders. Patients receiving chronic The neuroendocrine hypothalamus influences endo-
treatment often develop GC insensitivity and
9
crine targets in tandem with the pituitary gland; that
Central nervous system Skin, mucosal and hair changes Figure 1.10 Effects of estrogen depletion in menopause.
• Vasomotor symptoms • Reduced skin thickness Symptoms of menopause include CNS-related disorders,
• Sleep disruption • Reduced elasticity weight gain, bodily alterations related to cardio-
• Depression and anxiety • Reduced hydration metabolic changes, musculoskeletal alterations,
• Cognitive changes • Increased wrinkling
• Migraine • Hair loss urogenital and skin atrophy and sexual dysfunction.
Perimenopause is associated with the worst menopausal
symptom burden, arising from neurochemical changes
within the CNS leading to severe vasomotor symptoms,
sleep disorders and depression, which might affect
cognitive function. Reproduced with permission
(Monteleone et al., 2018). Abbreviation: CNS, central
nervous system.
Weight and metabolic changes
• Weight gain
• Increased visceral adiposity
Sexual function • Increased waist circumference
• Decreased sexual desire
• Dyspareunia
Urogenital system
• Vaginal dryness
• Vulvar itching and burning
• Dysuria
• Urinary frequency
• Urgency
Musculoskeletal system
• Recurrent lower urinary
• Joint pain
tract infections
• Sarcopenia
Figure 1.11 Changes in the HPA axis due to glucocorticoid resistance.

Glucocorticoid negative feedback at the hypothalamic and anterior pituitary
levels is compromised because of glucocorticoid resistance. This results in
increased secretion of CRH and ACTH, followed by adrenal hyperplasia, and
increased secretion of adrenal cortisol and androgens. Abbreviations: HPA,
hypothalamic–pituitary–adrenal. Figure derived from Charmandari et al. (2008).
10
is, pituitary hormone secretion is directed by stimuli and belong to a superfamily of receptor proteins.
secreted from hypothalamic neurons. The target The receptor proteins have no biological activity
organ sensitivity to stimulation, and the neuronal until they bind to a hormone; that is, the hormone-
response to hormonal feedback, is dependent upon receptor complex acts as a transcription factor at
a variety of receptor mechanisms. specific sites (HRE) on target genes. Two ERs (ERα
Peptide hormones (e.g., oxytocin), neuropeptides and ERβ) are encoded by two distinct genes and are
(e.g., thyrotropin releasing hormone) and neurotrans- localized in many tissues, including the hypothala-
mitters (e.g., dopamine) regulate cellular activity by mus and anterior pituitary. These sites are critical for
binding to specific receptors located in target cell regulation of the menstrual cycle. GC receptors are
membranes. Biochemical changes within the target also localized to the hypothalamic–pituitary system
cell are induced via intracellular second messengers, where they control ACTH secretion. The physiolo-
such as cAMP and protein kinase C. The transduction gical effects of GC can be compromised because of
of information from the membrane to the second mutations in the GC receptor that impair GC action.
messenger is accomplished through the activation of This reduces tissue sensitivity to GCs, compromises
membrane proteins (e.g., G proteins) and enzymes, negative feedback and induces hypersecretion of
such as adenylate cyclase. GPCRs are characterized by ACTH, cortisol and androgens. GC resistance can
their seven transmembrane domain structures and are also occur as a result of chronic stress. Other well-
attached to trimeric G proteins. There are stimulatory described examples of hormone resistance include
(Gs) and inhibitory (Gi) proteins. For example, GH androgen-receptor insensitivity (testicular feminiza-
secretion is inhibited by somatostatin (Gi) and stimu- tion syndrome) and thyroid hormone-receptor
lated by GHRH (Gs). The responsiveness of GPCRs is insensitivity.
compromised in some neuroendocrine disorders. For
example: (a) when GPCRs are subjected to chronic
stimulation to produce tachyphylaxis, and (b) when
1.6 Review Questions
mutations occur in the genes for receptor proteins or 1. Cyclic adenosine monophosphate is a well-
G proteins; that is, loss-of-function or gain-of- described second messenger involved in the
function mutations. activation of many cell types. Name two
A second type of membrane stimulation is via other second messenger systems.
tyrosine kinase-dependent receptors. Peptide hor- 2. Neuropeptides and neurotransmitters bind to
mones such as leptin, PRL and GH bind to receptors receptors located in the cell membrane. Based on
having only two transmembrane domains and which structure alone, there are two major membrane
activate tyrosine kinase signaling, employing receptor types. What are they?
the second messenger JAK/STAT pathway. The clin- 3. Name five hormones that act through membrane
ical consequences of abnormal receptor signaling are receptors.
profound. For example, obese individuals are insensi- 4. Which of the following signaling molecules act via
tive to their own leptin (“leptin resistance”) and high a cytosolic receptor, rather than a membrane
levels of endogenous leptin, derived from the protein?
increased fat mass, fail to reduce food intake or body a. Insulin-like growth factor 1
weight. Patients with mutations in the leptin receptor b. Cortisol
are also severely obese. Loss-of-function mutations in c. Growth hormone (GH)
the GH receptor result in severe growth failure and d. Thyroxine (T4)
IGF-1 deficiency. GH insensitivity is also caused by e. Somatostatin
mutations in the intracellular STAT5 gene. Loss-of-
5. The target cells of a hormone such as cortisol
function mutations in the PRL receptor present with
respond to stimulation because:
hyperprolactinemia, possibly due to the inability of
PRL to exert negative feedback on pituitary a. the genome contains hormone response
lactotrophs. elements
In contrast, steroid hormones – such as estradiol b. cortisol receptors are present in the cell
and cortisol – exert their effects via intracellular membrane
receptors that have common structural elements c. only target cells contain cortisol receptors 11
d. cortisol receptor dimers are formed Brooks A J & Waters M J. (2010). The growth hormone
e. cortisol stimulates G protein-coupled receptors receptor: mechanism of activation and clinical implications.
Nat Rev Endocr 6, 515–525.
6. “Intracellular steroid hormone receptors have no
intrinsic biological activity.” Is this statement true Chaidarun S S, Swearingen B & Alexander JM. (1998).
Differential expression of estrogen receptor-β (ERβ) in human
or false? pituitary tumors: functional interactions with ERα and
7. The somatotroph contains three distinct signaling a tumor-specific splice variant. J Clin Endocr Metab 83,
mechanisms that regulate GH secretion; that is, 3308–3315.
GH releasing hormone (GHRH), somatostatin Charmandari E, Kino T, Ichijo T & Chrousos G P. (2008).
and ghrelin combine to control GH release. Which Generalized glucocorticoid resistance: clinical aspects,
G proteins are involved? molecular mechanisms, and implications of a rare genetic
8. Loss-of-function mutations in the genes for disorder. J Clin Endocr Metab 93, 1563–1572.
receptor proteins reveal their importance in Charmandari E, Kino T & Chrousos G P. (2013). Primary
endocrine/neuroendocrine disorders. Which generalized familial and sporadic glucocorticoid resistance
disorders are associated with mutations in the (Chrousos syndrome) and hypersensitivity. Endocr Dev 24,
following receptors? 67–85.
a. Kisspeptin receptor Dodington D W, Desai H R & Woo M. (2018). JAK/STAT –
Emerging players in metabolism. Trends Endocr Metab 29,
b. Thyrotropin releasing hormone receptor
55–65.
c. Melanocortin 4 receptor
d. GHRH receptor Engel J B & Schally A V. (2007). Drug insight: clinical use of
agonists and antagonists of luteinizing-hormone-releasing
e. Vasopressin receptor
hormone. Nat Clin Practice Endocr Metab 3, 157–167.
9. Which of the following hormonal patterns is Farooqi IS, Wangensteen T, Collins S et al. (2007). Clinical
associated with male precocious puberty due to an and molecular genetic spectrum of congenital deficiency of
activating luteinizing hormone (LH) receptor the leptin receptor. New Engl J Med 356, 237–247.
mutation? Fukami M, Suzuki E, Igarashi M, Miyado M & Ogata T.
a. Low testosterone, low LH and follicle (2018). Gain-of-function mutations in G-protein–coupled
stimulating hormone (FSH) receptor genes associated with human endocrine disorders.
b. Normal testosterone, high LH and FSH Clin Endocr 88, 351–359.
c. High testosterone, low LH and FSH Hauser A S, Attwood M M, Rask-Andersen M, Schiöth H B
d. Low testosterone, high LH and FSH & Gloriam D E. (2017). Trends in GPCR drug discovery:
new agents, targets and indications. Nat Revs Drug Discovery
e. Normal testosterone and LH and FSH
16, 829–842.
10. An activating mutation of the thyroid stimulating
Hiort O. (2013). Clinical and molecular aspects of androgen
hormone (TSH) receptor is associated with which insensitivity. Endocr Develop 24, 33–40.
of the following?
Huang D, Yang F, Wang Y & Guan X. (2017). Mechanisms of
a. High TSH resistance to selective estrogen receptor down-regulator in
b. High T4 metastatic breast cancer. Biochim Biophys Acta 1868, 148–156.
c. Goiter Hwa V. (2016). STAT5B deficiency: impacts on human
d. Features of hyperthyroidism growth and immunity. Growth Horm IGF Res 28, 16–20.
e. Congenital hypothyroidism Jayasena C N, Nijher G M K, Chaudhri O B et al. (2009).
Subcutaneous injection of kisspeptin-54 acutely stimulates
gonadotropin secretion in women with hypothalamic
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importance of the G protein-coupled estrogen receptor
GPER. Steroids 111, 37–45. Jia M, Dahlman-Wright K & Gustafsson J A. (2015).
Estrogen receptor alpha and beta in health and disease. Best
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physiology: Receptor and metabolic disorders. In: hormone receptor signaling. Trends Endocr Metab 18,
Endocrinology of Male Reproduction; Simoni M & 134–140.
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Monteleone P, Mascagni G, Giannini A, Genazzani A R & estrogen receptor-beta in endometriosis. J Mol Endocr 57,
Simoncini T. (2018). Symptoms of menopause – global F23–F27.
prevalence, physiology and implications. Nat Rev Endocr 14, Southworth M B, Matsumoto A M, Gross K M, Soules M R
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13
Chapter
Basic Principles in Clinical
2 Neuroendocrinology II:
Assays, Rhythms and Pulses
The clinical investigation of neuroendocrine pro- Figure 2.1. To perform this assay, a specific cortisol
blems is dependent on the quantitative assay of monoclonal antibody (the “capture” antibody) is per-
hormone levels, for example, by immunoassay or manently attached to the bottom of a plastic micro-
mass spectrometry. Blood samples are the primary well plate well (Step A). Cortisol samples are then
source for quantification of hormone concentra- added and allowed to complex with the immobilized
tions, although saliva and hair samples can also antibody (Step B). Unbound products are then
provide valuable information. Automated blood removed with a wash step, leaving cortisol bound to
collection and automated assays permit the deter- the antibodies. A biotin-labeled second antibody, also
mination of circadian and rapid, pulsatile changes specific for cortisol (the “detection” antibody), is then
in, for example, pituitary hormone secretion. This added to the wells, binding to the captured cortisol
chapter will outline the methodology and applica- (Step C). After a further wash step, the biotinylated
tion of these assay techniques. detection antibody is itself now labeled with an
enzyme conjugate capable of generating light or fluor-
escence in response to a particular substrate (Step D).
2.1 Determination of Hormone Levels The quantification step measures the intensity of light
The levels of circulating hormones can be determined produced after the addition of the substrate (Step E).
directly in blood samples or, in the case of steroid Standard curves are generated by adding known
hormones such as cortisol, in the saliva or hair. quantities of cortisol, and these curves then permit
The determination of glucocorticoid (GC) levels in determination of unknowns in the blood samples.
hair, for example, is able to detect prolonged exposure The availability of monoclonal antibodies for
to stress (Wester and van Rossum, 2015). This section many hormones and peptides is a major advantage
will include two routine techniques for the determi- of this method. In general, the samples do not need to
nation of hormone levels: (a) immunoassay and (b) be purified prior to use, and the whole process can be
mass spectrometry. automated to handle large numbers of samples.
Typical uses of this technique are: (a) estimation of
Immunoassays pulsatile secretion of human adrenocorticotropin
Since the 1960s the benchmark in determination of (ACTH) and cortisol (Henley et al., 2009; cf.
hormone levels was the radioimmunoassay. However, Chapter 5, Figure 5.3), and (b) the determination of
this method, employing antibodies specific to each salivary cortisol (Langelaan et al., 2018).
hormone, and radioactively labeled hormones, is A disadvantage of this technique is the inability to
slow, labor intensive and raises safety problems in assay more than one hormone in a single clinical
the use and disposal of radioactive materials. patient sample. Complex pathologies may require
The ready availability of highly specific monoclonal determination of a panel of hormones for diagnosis
antibodies for steroid and peptide hormones aided the or prognosis. Automated multiplex immunoassay
development of rapid and automated chemilumines- technologies are increasingly available, and
cent or immunometric assays that produce data in Figure 2.2 outlines just such a method for the simul-
a matter of hours, rather than days. A widely used taneous assay of insulin, growth hormone (GH), lep-
assay is the ELISA. One form of this technique (there tin, thyroid stimulating hormone (TSH) and
are several variations; Aydin, 2015) for the quantifica- glucagon-like peptide-1 (GLP-1) (Stephen and
14 tion of cortisol levels in blood is illustrated in Guest, 2017).
Chapter 2: Basic Principles in Clinical Neuroendocrinology II: Assays, Rhythms and Pulses
Addition of Addition of
enzyme chemiluminescent substrate
complex
Chemiluminescent
Biotin-labeled substrate
HRP
detection conjugate
antibody
Light
B B B
Cortisol
Cortisol-specific binding
monoclonal
antibody
A B C D E
Figure 2.1 Assay of cortisol using ELISA. Each well of a microwell plate has been pre-coated with a cortisol-specific monoclonal antibody
(capture antibody) (A). Standard amounts of cortisol, or samples, are added to the wells and cortisol binds to the capture antibody (B).
Unbound standard or sample is washed away. A biotin-conjugated, cortisol-specific, detection antibody is then added, which binds to the
captured cortisol (C). Unbound detection antibody is washed away. An avidin–HRP conjugate is then added, which labels the biotin (D).
Unbound avidin–HRP conjugate is washed away. Addition of a chemiluminescent substrate causes the HRP enzyme to induce light emission
(E). The light units of each well are automatically measured. Light units from unknown samples can then be compared with a light unit
standard curve generated using known cortisol concentrations in order to determine serum cortisol concentrations. See www.lsbio.com/pr
oducts/elisakits/clia as a typical example of this technique. Abbreviations: HRP, horseradish peroxidase.
Specific antibodies are covalently attached to dis- may still cross-react with other hormones and this
tinct, dye-coded microspheres and added to the hor- lack of specificity produces misleading results.
mone sample. Each hormone binds to the appropriate In contrast, the mass spectrometer can determine
antibody (simplified here by only showing the absolute values of many substances in blood, with
sequence for GH). As in Figure 2.1, the hormone- high specificity, based on differences in molecular
bound antibody is further decorated with a fluorescent weight. High throughput testing is possible, using
biotin conjugate. The complete mixture – micro- small sample volumes with minimal sample prepara-
spheres, hormones and decorated antibodies – is sepa- tion, and eliminating the requirement for expensive
rated into antibody-specific groups by flow cytometry immunoassay-specific reagents such as antibodies.
and then analyzed by lasers able to quantify each dye- For example, when coupled with liquid chromatogra-
coded microsphere as well as the fluorescence of the phy to separate sample components, mass spectro-
bound hormone. This fully automated technique metry is an efficient and rapid way to assay steroid
enables much information to be derived from a single hormones in a clinical setting (Matysik and Liebisch,
sample, with minimal reagent usage, at lower cost 2017). This technique may also be the only way to
compared with the assay shown in Figure 2.1. determine very low levels of hormones in blood; for
example, estradiol levels in prepubertal children
Mass Spectrometry (Stanczyk and Clarke, 2014) or low levels of cortisol
in saliva (Sturmer et al., 2018).
A second powerful technique to quantify multiple
The collection of biological samples such as saliva,
hormones in single samples of biological fluids is
hair and urine for the analysis of hormone levels is
mass spectrometry. The biggest advantage it possesses
simple, non-invasive and stress-free compared with
over the immunoassays is that it does not require
taking blood samples. Hormone levels can therefore
antibodies to assay the hormones of interest. This is
be determined in newborn children, as well as adults,
not to say that the ELISA is not useful; there are many
outside the laboratory or hospital setting, and mass
hormones for which highly specific antibodies are
spectrometry permits the analysis of multiple hor-
available and therefore can be quantified with 15
mones simultaneously in the same sample. Also,
ELISAs. However, even the most specific antibodies
Figure 2.2 Overview of the multiplex immunoassay protocol. Samples are added to dye-coded microsphere–antibody complexes that capture
specific hormone targets. The capture of GH is shown in this sequence. Following incubation with a fluorescent biotinylated label, the
mixtures are streamed through the detector – via flow cytometry to separate the individual groups of microspheres – which uses lasers for
identification of the antibody–microsphere conjugates and quantitation of the fluorescent bound hormones. The example shows a 5-plex
assay capable of binding the targets GLP-1, GH, insulin, leptin and TSH. This figure is based on the illustration from Stephen et al. (2017).
since cortisol is deposited in the growing hair shaft, an critical systems such as regulation of growth, repro-
estimate of cortisol concentrations in hair serves as duction and stress. Some of these rhythms have per-
a measure of chronic exposure over weeks and months iods longer than 24 hours, typified by the female
(Meyer and Novak, 2012; Wester and van Rossum, menstrual cycle. Circadian or 24-hour rhythms
2015). Nonetheless, it is important to remember that include the sleep–wake cycle and the increase, for
hair, saliva and urine analysis only provides a measure example, in GH secretion seen at night. There are
of the average hormone secretion over a number of also cycles of less than 24 hours – the ultradian
hours or weeks. In the case of cortisol, for example, cycles – such as the pulsatile release of luteinizing
blood samples taken every few minutes is the only way hormone (LH), follicle stimulating hormone (FSH)
to demonstrate pulsatile secretion and its circadian and GH.
variation (see Figure 5.3 showing pulsatile secretion Section 2.1 outlined the analytical approaches
of ACTH and cortisol). Table 2.1 summarizes the used to assess hormone levels in biological fluids.
variations in hair cortisol levels associated with some Since hormone levels often vary dramatically through
clinical situations (Wester and van Rossum, 2015). 24 hours, it is critical to determine hormone secretory
patterns in normal individuals to inform when hor-
2.2 Patterns of Hormone Secretion mone samples should be obtained in clinical practice.
The following sections outline the clinical importance
The neuroendocrine system is defined by rhythms
16 that orchestrate the dialogue between the brain and
of normal hormonal rhythms.
Table 2.1 Clinical and situational factors associated with variations in hair cortisol levels
Increased hair cortisol Decreased hair cortisol

Somatic health factors
Cushing’s syndrome Childhood asthma with inhalation
glucocorticoids
Hydrocortisone use
Obesity
Metabolic syndrome
Diabetes mellitus
Cardiovascular disease
Heart failure severity
Recent myocardial infarction
Chronic and acute stressors
Intensive aerobic exercise Traumatic experience
Trauma
Life events
Unemployment
Shift work
Severe chronic pain
Psychopathology
PTSDa PTSDa
Major depressive disorder Generalized anxiety disorder
Bipolar disorder, late onset Panic disorder
a
Post-traumatic stress disorder (PTSD) has been associated with both increased and decreased hair cortisol concentrations (depending on
the type of traumatic event, characteristics of the patient sample examined, and the timespan between the trauma and assessment)
compared with controls (Wester and van Rossum, 2015).
and peak secretion for these is illustrated in

Daily Rhythms Figure 2.4.
As an example of a well-described daily rhythm, The secretory rhythms of some hormones (e.g.,
Figure 2.3 illustrates that pulsatile cortisol levels in cortisol and TSH) occur independently of sleep-
healthy individuals vary with a 24-hour period, with wake cycles. In a study on healthy young men
blood levels beginning to rise late in the night to peak at the cortisol profile was minimally affected by the
the sleep–wake transition (cf. Chapter 5; Figure 5.3). absence of sleep or when they slept at an abnormal
The figure also reveals that in patients with pituitary- time of day. Over a period of 28 hours of continuous
dependent Cushing’s disease, although the frequency wakefulness, constant light and constant caloric
of cortisol pulses is increased, producing significant intake, the normal wave shape of the rhythm of corti-
cortisol excess, the diurnal pattern of cortisol output sol release was maintained (Oster et al., 2017). This
is absent (van den Berg et al., 1995). These data indicate finding indicates that fluctuations in the levels of some
dysfunction of the hypothalamic–pituitary system in hormones, over the course of the day, are driven, at
Cushing’s disease. These rhythms may also be dis- least in part, by an endogenous circadian mechanism
rupted in other disease states. For example, psychotic (i.e., independent of behavioral rhythms). In contrast,
disorders such as major depression are associated with 24-hour oscillations in the levels of other endocrine
changes in circadian rhythms similar to Cushing’s syn- factors (e.g., GH and prolactin) are dependent on
drome (Keller et al., 2006). sleep–wake cycles. For example, sleep deprivation
Levels of several other circulating endocrine abolishes GH secretion, but daytime sleep, several 17
factors are known to oscillate through 24 hours, hours later, restores the sleep-related surge of GH
Figure 2.3 Diurnal rhythm of human cortisol secretion: control vs.

Cushing’s disease. Circulating cortisol concentrations in a control male
Cushing’s disease (lower profile) and a male patient with Cushing’s disease (upper
1500
profile). Note that both profiles demonstrate the presence of pulsatile
secretion of cortisol, but the 24-hour variation is absent from the
Cushing’s patient. Data obtained from van den Berg et al. (1995).
Cortisol (nmol/L)
1000
800
Lights
600
off
400
200
Control
0
0900 1200 1500 1800 2100 2400 0300 0600 0900
Clock time
Figure 2.4 Peak

variations in circulating
endocrine factors.
The time of day at which
circulating levels of key
endocrine factors peak in
humans. Abbreviations:
FGF 21, fibroblast growth
factor 21; RAAS,
renin–angiotensin–
aldosterone system; T3,
triiodothyronine. Image
reproduced with permis-
sion (Gamble et al., 2014).
(van Cauter et al., 1998; cf. Figure 8.2). Seminal stu- adrenal, liver and adipose tissue – also contain sec-
dies in experimental animals revealed that a specific ondary clock mechanisms that synchronize with the
structure in the hypothalamus – the suprachiasmatic SCN master oscillator (Figure 2.5; reviewed in Oster
nucleus (SCN) – is the site of the clock mechanism et al., 2017).
that governs circadian variations in hormone release, The molecular circuitry that governs the produc-
as well as a variety of physiological functions. Most tion of rhythms, perhaps common to all these oscilla-
18 peripheral tissues, throughout the body – including tors, is represented schematically in Figure 2.6. In its
Pineal gland Figure 2.5 Schematic representation of

synchronization of SCN clock with periph-
eral oscillators. Both neural signals
(transmitted by the autonomic nervous
system; black arrows) and hormonal
signals are involved. The 24-hour rhythms
Plasma melatonin SCN of circulating melatonin (released by the
pineal gland) and cortisol (from the
adrenal cortex) are considered as primarily
controlled by the central SCN clock.
The blue and purple arrows symbolize,
Plasma GCs respectively, the synchronizing effects of
sleep
the GC and melatonin rhythms. Due to the
0 12 24 ubiquity of glucocorticoid receptors in the
Time of day (h) entire organism, the 24-hour rhythm of
circulating GCs plays a major role in
sleep
synchronizing central and peripheral
clocks. Reproduced through open access
0 12 24 (Oster et al., 2017).
Time of day (h)
Adrenal
gland
Figure 2.6 Schematic outline

of how clock gene expression in
BMAL1 RHYTHMIC the SCN regulates circadian
SIGNALS rhythms. Positive and negative
CLOCK gene expression loops
produce output signals
responsible for rhythmic cell
+ function over 24 hours.
The clock genes bmal1 and
clock encode the proteins
bmal1 mRNA BMAL1 and CLOCK that form
clock mRNA a heterodimer transcription
factor that stimulates the per
and cry genes. In turn, their
protein products, CRY and
bmal1
clock per cry PER, reach a critical level

before negatively regulating
the activity of bmal1 and clock,
thereby reducing the amount
NUCLEUS cry mRNA
of CLOCK and BMAL1. Image
per mRNA of DNA structure reproduced
with permission: https://com
mons.wikimedia.org/w/index
.php?title=File:DNA_structur
– e_and_bases_color_FR.svg
CRY &oldid=124826534.
PER
SLEEP,
CIRCADIAN INFORMATION CYTOPLASM
HORMONES,
STRESS, etc.
19
simplest form, neurons in the SCN begin to produce circumference in morbidly obese patients (Gómez-
two proteins at the start of the circadian day. These Abellán et al., 2008), and a clock polymorphism (in
proteins – BMAL1 and CLOCK – form a heterodimer white blood samples) was associated with a 1.8-fold
that acts as a transcription factor able to stimulate risk of obesity (Sookoian et al., 2008).
expression of two further genes – per and cry – that
encode the proteins PER and CRY. The buildup of Neuroendocrine Consequences of Circadian
PER and CRY over the course of the day establishes an
autoregulatory feedback loop that represses the clock Disruption
and bmal1 genes, reducing the levels of CLOCK and Human circadian rhythms are especially sensitive to
BMAL1. This feedback cycle takes approximately 24 multiple adverse influences; for example, shift work,
hours, driving the circadian rhythm. For example, the artificial lighting at night and long-distance flights
circadian signal necessary for the production of night- across time zones (jet lag). The evidence is clear that
time cortisol (Figure 2.3) would be an increase in chronic perturbation of circadian function provokes
corticotropin releasing hormone (CRH) neuron activ- metabolic, reproductive, sleep and mood disorders
ity, increasing CRH secretion into the pituitary portal (Sheikh-Ali and Maharaj, 2014; Bedrosian et al.,
system (see Figure 5.2). 2016; Nicolaides et al., 2017). Some of these issues
Current evidence suggests that the human circa- are summarized in Table 2.2 (Potter et al., 2016).
dian system also uses clock genes. The human SCN The light-dependent rhythm of melatonin secre-
expresses the clock gene (Steeves et al., 1999), and tion from the pineal gland (see Figure 2.5) is
circadian variations in clock mRNA and bmal1 a sensitive indicator of circadian disruption. For
mRNA have been detected in human placenta (Pérez example, low light levels in the early night phase are
et al., 2015). A clock/bmal1 mechanism may therefore sufficient to delay the melatonin rhythm, and the use
be responsible for human circadian rhythms, includ- of a computer or e-book before bed depresses mela-
ing variable adrenal sensitivity to stimulation by tonin secretion and may disrupt sleep (Bedrosian
ACTH (Angelousi et al., 2018). In addition, poly- et al., 2016; Potter et al., 2016). Night-shift workers
morphisms in clock genes are implicated in the sus- are exposed to light levels that far exceed those that
ceptibility to obesity (Gómez-Abellán et al., 2008; affect the circadian system. Several studies of shift
Sookoian et al., 2008). For example, per2 expression workers indicate that exposure to nighttime light
in adipose tissue was negatively correlated with waist leads to metabolic problems. For example, healthcare
Table 2.2 Human circadian rhythm disruption
Source Mechanism
Behavioral Biological
Light Meal/fasting Rest/activity Genetic Physiological
cycle cycle disruption disruption disruption (e.g.,
disruption (e.g., clock retinal dysfunction)
gene
mutations)
Work schedules (e.g., shift work) ✓ ✓ ✓ ✗ ✗
Jet lag ✓ ✓ ✓ ✗ ✗
Unusual photoperiods (e.g., polar ✓ ✗ ✗ ✗ ✗
regions)
Circadian rhythm sleep/wake ✓ ✗ ✗ ✓ ✓
disorders (e.g., non-24-hour
sleep/wake disorder)
Aging ✗ ✗ ✗ ✗ ✓
Disease states (e.g., Alzheimer’s) ✗ ✗ ✗ ✓ ✓
20 Data derived from Potter et al. (2016)
Figure 2.7 Exposure to night-

US light pollution US obesity trends time light parallels incidence of
obesity. The left panel shows
light pollution trends in the
United States from the mid-
1970s through projected levels
in 2025. The right panel shows
obesity trends in the United
States from 1990, 2000 and
2010. Reproduced with per-
mission (Fonken and Nelson,
2014). Abbreviation: BMI, body
mass index.
mid-1970s
1990
1977
2000
2025
<11% above the natural brightness level
11–33% above the natural brightness level
34–99% above the natural brightness level
100% above the natural brightness level 2010
3–9 times the natural brightness level
(the Milky Way is no longer visible) No data Obesity is defined as BMI
<10%
9–27 times the natural brightness level
10–14% ≥30, OR ~30 Ibs
(fewer than 100 stars are visible) overweight for a
15–19%
27–81 times the natural brightness level 20–24% 5′4′′ person
(the North Star is no longer visible) 25–29%
81–243 times the natural brightness level ≥30%
(the Big Dipper is no longer visible)
personnel that work night shifts appear to be at risk of notable in Alzheimer’s disease (Hofman and Swaab,
developing metabolic syndrome; that is, in men and 2006). With respect to hormonal changes, a study on
women, increases in hypertension and cholesterol, obe- age-related changes in sleep and GH secretion in men
sity, and hypertriglyceridemia (Fonken and Nelson, aged 16–83 years showed that the amount of slow
2014; Sheikh-Ali and Maharaj, 2014). This effect wave sleep decreased by 80% between the young
could be due to a combination of exposure to nighttime (16–25 year olds) and middle-aged (36–50 year olds)
light plus the behavioral de-synchrony of working at (Van Cauter et al., 2000). This was associated with
night, although a marked elevation in exposure to light a 75% reduction in spontaneous GH secretion
at night in the US general population has paralleled the (Blackman, 2000). Small increases in early-night cor-
increased incidence of obesity (Figure 2.7). tisol have also been detected in healthy old adults
Aging is also associated with circadian disruption, (Vgontzas et al., 2003). Disruption of the rhythm of
especially in sleep–wakefulness and hormonal circulating GCs impacts multiple functions, including
rhythms. The circadian pacemaker in the human energy metabolism, stress, immune function and cog-
brain becomes progressively disturbed through neu- nition (Oster et al., 2017; cf. Chapter 5). Abnormal
ronal degeneration of the SCN, and this is especially rhythms of cortisol are linked with shift work, 21
Cushing’s syndrome, adrenal insufficiency, anxiety and with GnRH that establishes LH and FSH levels that are
depression, and PTSD. For example, chronic stress consistent with fertility (ovulation). The actual frequency
abolishes the cortisol circadian rhythm and increases of GnRH pulses appears to be important in the normal
appetite, obesity, and metabolic disturbances, such as menstrual cycle. Figure 3.5 (in Chapter 3) reveals that
hyperglycemia, insulin resistance, dyslipidemia, osteo- the frequency of pulses at midcycle is greatly enhanced
penia/osteoporosis and hypertension (Nader et al., to induce a surge in LH, followed by ovulation.
2010). Women in the healthcare and transportation In contrast, continuous stimulation of pituitary GnRH
industries are at a high risk of shift-work-associated receptors induces a state of receptor downregulation,
fertility problems, including abnormal reproductive and loss of LH secretion, which is reversible by applying
cycles, increased latency to pregnancy and miscarriages pulses of GnRH. Figure 2.8 illustrates this principle in
(Sen and Sellix, 2016). In general, the abnormal cortisol a woman suffering from hypothalamic amenorrhea;
rhythm represents an abnormally high level in the that is, there is no endogenous GnRH stimulation of
afternoon and evening. The normalization of the cir- the pituitary, LH levels are low and ovulation does not
cadian rhythm of cortisol should therefore target the occur (Southworth et al., 1991). The figure shows that
evening to re-establish the physiological low point of continuous stimulation with GnRH fails to increase
cortisol secretion. Pharmacological suppression of cor- secretion of LH, FSH and estradiol. In contrast, pulsatile
tisol biosynthesis has been used in healthy human GnRH produces a sustained elevation in LH and FSH
adults to elucidate metabolic implications of cortisol levels, enabling a surge of estradiol secretion and
rhythmicity (Oster et al., 2017). In a multicenter retro- ovulation.
spective study, the synthesis inhibitor metyrapone was The clinical implications arising from these stu-
an effective therapy for short- and long-term control of dies are two-fold: (a) pulsatile stimulation of pituitary
hypercortisolemia (Daniel et al., 2015). secretion of LH and FSH is mandatory for restoration
of gonadotropin secretion, ovarian estradiol produc-
tion and ovulation in the treatment of hypothalamic
Pulsatile Secretion amenorrhea; (b) the ability of continuous stimulation
In subsequent chapters, we will detail the pulsatile with GnRH to suppress LH and estradiol to reduce
pattern of human LH, ACTH, TSH, PRL, GH and fertility. This latter effect is clinically advantageous in
oxytocin secretion within their respective various ways. For example, synthetic, long-acting
hypothalamic–pituitary–target organ systems. It is GnRH agonists induce a castration-like state, and
relevant that the phenomenon of episodic secretion reduce gonadotropin and sex hormone levels in
is not exclusive to pituitary hormones. For example, advanced prostate cancer. They are also able to reduce
insulin secretion from pancreatic islet β-cells is also estradiol levels in the treatment of estrogen-sensitive
pulsatile, with a frequency of approximately 6–10 breast cancer, and are valuable in in vitro fertilization
minutes in healthy adults (Schmitz et al., 2002). protocols (Engel and Schally, 2007).
Pulsatile stimulation of the anterior pituitary with GnRH neurons appear to have an intrinsic ability
releasing hormones to increase secretion of circulat- to secrete GnRH in an episodic manner, although
ing signaling molecules appears to be the optimal additional neural networks – impinging on GnRH
mode of communication. In general, a continuous neurons – can modify pulse frequency and amplitude
stimulation of receptors, rather than a pulsatile sig- (Millar, 2015). In contrast, the pulsatile secretion of
nal, will lead to a decrease in responsiveness of the ACTH may not be the result of oscillation of hypotha-
target cell; that is, via receptor desensitization. Thus, lamic CRH neurons. ACTH pulses are generated
the time between pulses should be sufficient to through a feedforward–feedback interaction between
permit a receptor to re-sensitize. CRH-stimulated pituitary corticotrophs and the cor-
In this section, we will describe two systems to tisol-producing cells of the adrenal cortex (Lightman,
exemplify the importance of pulsatile secretion; that is, 2016; Figure 2.9). This mechanism shows some simi-
gonadotropin releasing hormone (GnRH; reproductive larities to the generation of circadian rhythms illu-
system) and CRH (hypothalamic–pituitary–adrenal sys- strated in Figure 2.6.
tem; HPA). Using the human female reproductive sys- A tight correlation of high frequency ACTH and
tem as an example (described more fully in Chapter 3), cortisol pulses, through 24 hours in a healthy volun-
22 there is an optimal frequency of pituitary stimulation teer is shown in Figure 2.10 (Gibbison et al., 2015).
Figure 2.8 Effects of pulsatile

vs. continuous stimulation with
GnRH. Hormone data
obtained every 1–3 days
throughout the continuous
and pulsatile infusions of
GnRH in a single patient with
hypothalamic amenorrhea.
Arrow indicates ovulation and
menses beginning on day 68
of the pulsatile regimen, but
not during the continuous
regimen. Data obtained from
Southworth et al. (1991).
The slight delay in cortisol pulses, following ACTH especially related to mental and physical fatigue
stimulation, is due to the need for cortisol to be newly (Lightman, 2016). Efforts to establish pulsatile levels
synthesized before release. Each pulse of ACTH is of cortisol with a novel programmable portable pul-
then inhibited by the rapid negative feedback of cor- satile continuous subcutaneous delivery system have
tisol exerted at the pituitary. This constitutes the been successful. Healthy volunteers, whose endogen-
oscillatory rhythm. ous secretion of cortisol was suppressed, responded
This rapid response of the adrenal cortex to sti- with a near-physiological pattern of circadian and
mulation with pulses of ACTH is therefore very dif- ultradian rhythmicity (Russell et al., 2014;
ferent to that of the human ovary responding to LH Figure 2.11).
and FSH pulses. Figure 3.1 (Chapter 3) reveals that the In proof-of-principle studies, this technique was
ovarian response to stimulation with gonadotropins is used to demonstrate that the pattern of GC replace-
not a series of estradiol pulses, but the release ment differentially modulates working memory and
a prolonged surge of estradiol over a 48-hour period. sleep physiology. For example, abolition of physiolo-
There is evidence of abnormal cortisol rhythms in gical cortisol pulsatility correlates with poorer work-
depression, aging, increasing body mass index (BMI), ing memory performance when cognitive demands
PTSD and obstructive sleep apnea (Lightman and are high. In addition, disruption of ultradian rhyth-
Terry, 2014). Equally problematic is the treatment of micity results in a poorer self-perceived quality of
GC deficiency, with GC-replacement regimens that sleep (Kalafatakis et al., 2018). These authors con-
do not recapitulate the physiological pulsatile rhythm cluded that “Future studies in patients with adreno-
of cortisol release. For example, patients undergoing cortical insufficiency are now needed, not only to help
oral, non-pulsatile GC replacement in Addison’s dis- reduce the morbidity of current replacement regi-
ease (see Section 5.5) have double the mortality of age- mens, but also to provide evidence from longer-term
related controls as well as increased morbidity, modification of replacement cortisol rhythmicity for 23
Figure 2.9 Generation of ACTH and cortisol pulses via feedback control.
The hypothalamus responds to circadian signals from the SCN, and
stressors via the central nervous system. Pituitary secretion of ACTH is
controlled by two hypothalamic secretagogues – CRH and VP, which are
secreted into portal blood. Negative feedback from circulating cortisol is
exerted on the paraventricular nucleus and the anterior pituitary.
The cortisol peaks (see Figure 2.10) are slightly delayed from the ACTH
pulses because ACTH is required to induce the synthesis of cortisol before
release from adrenocortical cells. The combination of the positive, delayed,
feedforward connection between ACTH and cortisol and the negative
feedback of cortisol on ACTH release is sufficient to explain the
physiological ultradian activity of the HPA axis. Reproduced with permission
(Lightman and Conway-Campbell, 2010). Abbreviations: CNS, central
nervous system; CRH, corticotropin releasing hormone; PVN, paraventricular
nucleus; SCN, suprachiasmatic nucleus; VP, vasopressin.
60 600
Lights out
50 500
Cortisol
Cortisol (nmol/L)
40 400
ACTH (pg/mL)
30 300
20 200
10 100
ACTH
0 0
1900 2100 2300 0100 0300 0500 0700 0900 1100 1300 1500 1700 1900
Clock time
Figure 2.10 24-hour ACTH and cortisol profile. ACTH and cortisol secretion in a healthy volunteer. Both hormones display a tightly correlated
circadian rhythm (cf. Chapter 5; Figure 5.3). Figure based on data generously provided by Dr. B. Gibbison (Gibbison et al., 2015).
24
600 Figure 2.11 Subcutaneous infusion of

hydrocortisone induces a physiological rhythm
of cortisol. Cortisol (every 10 minute) profile in
a healthy male volunteer following a 5-day
500
endogenous adrenal suppression with
metyrapone, while receiving hydrocortisone
replacement therapy via a subcutaneous
400 portable pulsatile infusion pump (total daily
Cortisol (nmol/L)
dose 19.9 mg). Note that the maximum

(approximately 500 nmol/L) and minimum
300 (approximately 100 nmol/L) values corre-
spond to the normal rhythm (see Figure 2.10).
Figure based on data obtained from Russell
et al. (2014).
200
100
0
1503 1703 1903 2103 2303 0103 0303 0503 0703 0903 1103 1303 1503
Clock time
improved brain function and a more personalized The neuroendocrine system is defined by
approach to glucocorticoid therapeutics.” rhythms that orchestrate the dialogue between the
brain and critical systems such as regulation of
growth, reproduction and stress. Circadian rhythms
2.3 Chapter Summary include the sleep–wake cycle and the increase, for
The investigation of neuroendocrine problems is example, in nighttime GH secretion. There are also
dependent on the assay of hormone levels by immu- cycles of less than 24 hours – ultradian cycles – such
noassay or mass spectrometry. Blood samples are the as the pulsatile release of LH, FSH and GH.
primary source for quantification of hormone concen- The secretory rhythms of some hormones (e.g., cor-
trations, although saliva and hair samples are also used. tisol and TSH) occur independently of sleep–wake
Automated blood collection and automated assays per- cycles, whereas GH and prolactin are sleep-
mit the determination of circadian and rapid, pulsatile dependent. Human circadian rhythms are sensitive
changes in pituitary hormone secretion. to multiple adverse influences; for example, jet lag,
Highly specific monoclonal antibodies are the basis shift work or artificial lighting at night. Chronic
of automated immunoassays that produce data in perturbation of circadian function provokes meta-
a matter of hours. A widely used technique is the bolic, reproductive, sleep and mood disorders.
ELISA, and a typical use is the estimation of pulsatile Pulsatile stimulation of the anterior pituitary with
secretion of human ACTH and cortisol. Automated hypothalamic releasing hormones is the optimal
multiplex immunoassay technologies are also available mode of communication, and the secretion of LH,
for the simultaneous assay of several hormones, such as ACTH, TSH, PRL, GH and oxytocin is pulsatile.
insulin, GH, leptin, TSH and GLP-1, in the same blood As an example, women with hypothalamic amenor-
sample. In contrast, the mass spectrometer does not rhea will respond to pulsatile, but not continuous,
require antibodies and can determine absolute values stimulation with GnRH with restoration of gonado-
of many substances in blood, with high specificity. tropin secretion, ovarian estradiol production, and
When coupled with liquid chromatography to separate ovulation. Thus, under normal conditions, GnRH
sample components, mass spectrometry is an efficient neurons stimulate pulsatile gonadotropin secretion.
and rapid way to assay steroid hormones in a clinical In contrast, the pulsatile secretion of ACTH may not
setting and may also be the only way to determine very be the result of oscillation of CRH neurons.
low levels of hormones in blood. The circadian rhythm of ACTH pulses is generated 25
through a feedforward–feedback interaction between 8. Disruption of circadian rhythms in shift workers

CRH-stimulated pituitary corticotrophs and the is associated with which of the following health
cortisol- producing cells of the adrenal cortex. issues?
Abnormal cortisol rhythms are associated with a. Menstrual irregularities
depression, aging, increasing BMI and PTSD. b. Hypertension
c. Obesity
2.4 Review Questions d. Reduced fertility
e. Increased triglycerides
1. Which of the following are in routine clinical use
in contemporary determination of hormone 9. Long-acting GnRH analogs are used in which of
levels? the following conditions?
a. Radioimmunoassays a. Prostate cancer
b. Monoclonal antibodies b. Breast cancer
c. ELISA c. Treatment of secondary hypogonadism
d. Mass spectrometric assays d. Osteoporosis
e. Polyclonal antibodies e. Delayed puberty
2. Give three examples of physiological hormonal 10. Which of the following statements are true?
rhythms. Illustrate each with a typical hormone a. Hair sampling of hormones is a convenient
(e.g., monthly/estradiol). way to assess the pulsatility of hormonal
3. Several hormones reach peak levels of secretion secretion.
during the night. Give three examples of b. Urine samples collected over several hours
hormones that have nighttime peaks, and one provide a measure of average hormonal
example of a daytime maximum. secretion.
4. Animal experiments indicate that the circadian c. Blood samples drawn at various times during
rhythm of secretion for some hormones is 24 hours can provide information about the
dependent on a clock mechanism that resides in circadian secretory pattern of a hormone.
the suprachiasmatic nucleus (SCN) of the d. Cross reactivity of antibodies used in ELISA
hypothalamus. It is likely that the human clock is may lead to false results.
regulated in a similar manner. In its simplest form, e. Mass spectrometric assays require antibodies
SCN neurons produce two stimulatory proteins at for specificity.
the start of the circadian day. Two proteins that
inhibit formation of the stimulating proteins are
formed during the day, thereby establishing Further Reading
a feedback loop that drives hormonal rhythms. Bedrosian T A, Fonken L K & Nelson R J. (2016). Endocrine
Name the four proteins. effects of circadian disruption. Ann Rev Physiol 78, 109–131.
5. Chronic perturbation of human circadian Budan R M & Georgescu C E. (2016). Multiple pituitary
function provokes metabolic, reproductive and adenomas: A systematic review. Front Endocr 7, 1.
sleep disturbances. Name three causes of such Keenan D M & Veldhuis J D. (2016). Pulsatility of
circadian problems. hypothalamo–pituitary hormones: a challenge in
6. Give four examples of human hormones that quantification. Physiol 31, 34–50.
demonstrate episodic (pulsatile) secretion. Lightman S (2016). Rhythms within rhythms: the
7. The normal secretory pattern of gonadotropins, importance of oscillations for glucocorticoid hormones. In:
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Christen Y, Eds. (New York: Springer), 87–99.
pulsatile release of GnRH from hypothalamic
neurons. What would be the hormonal Oster H, Challet E, Ott V et al. (2017). The functional and
clinical significance of the 24-hour rhythm of circulating
consequences of imposing a continuous –
glucocorticoids. Endocr Rev 38, 3–45.
rather than pulsatile – stimulation of the
Partch C L, Green C B & Takahashi J S. (2014). Molecular
pituitary with GnRH (a) at the level of the
architecture of the mammalian circadian clock. Trends Cell
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26
Prasa M J, Pernicova I, Grant P J & Scott E M. (2011). insufficiency – cost efficient and patient friendly. Endocr
An endocrinologist’s guide to the clock. J Clin Endocr Metab Connect 7, 560–566.
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28
Chapter
Neuroendocrinology of Female
3 Reproduction
This chapter will focus on the neuroendocrine control the substrate necessary for granulosa cells to bio-
of the human female reproductive system, primarily synthesize E2. E2 production is regulated by FSH,
using the menstrual cycle to illustrate the basic prin- acting via FSH receptors on granulosa cell mem-
ciples. Whenever relevant, data from the male will be branes. The rising midcycle levels of E2 beyond
included, but a detailed description of male reproduc- a critical point switches the negative feedback to
tive function may be found elsewhere (de Kretser and a positive stimulus, which in turn induces a surge of
O’Donnell, 2013). LH secretion, and to a lesser extent FSH secretion
(Figure 3.1). Peak LH secretion causes follicle rupture
3.1 The Menstrual Cycle and this precedes release of the ovum from the domi-
nant follicle by 12-36 hrs.
Reproductive function in the human female is pri-
Subsequent to ovulation the now-empty follicle is
marily regulated by neuronal activity in hypothalamic
transformed – luteinized – into a new structure, the
neurons. These neurons secrete pulses of gonadotro-
corpus luteum, whose predominant secretory product
pin releasing hormone (GnRH; see Section 3.3) that
is progesterone, although some E2 is also released
control the release of both gonadotropins, luteinizing
(Figure 3.1). Luteal function is maintained by LH
hormone (LH) and follicle stimulating hormone
stimulation for approximately 14 days. In the absence
(FSH) from the anterior pituitary gland. The ovaries
of fertilization and implantation, the corpus luteum
respond to this GnRH-stimulated pituitary secretion
begins to regress, and progesterone and E2 levels
of LH and FSH by synthesizing and releasing the
decline. This reduction in steroid hormone output
gonadal steroid hormones estradiol (E2) and proges-
relieves the negative feedback on FSH secretion,
terone. These two hormones, in turn, exert negative
allowing follicular stimulation to begin again and to
feedback to restrain GnRH neuronal activity and
initiate the next cycle.
GnRH release. The repetitive nature of the menstrual
The ovary (and testis) produces several non-
cycle, and ovulation, depends upon a transient mid-
steroidal factors, including inhibins and activins.
cycle reversal of this negative feedback, where E2
Although inhibins act as autocrine/paracrine fac-
briefly exerts a positive feedback that leads to an
tors in ovarian function (Knight et al., 2012), they
increased secretion of GnRH into the pituitary portal
also play a role in inhibiting FSH secretion from
circulation, inducing an ovulatory surge of LH.
the anterior pituitary. In the human female, the
A detailed description of ovarian and uterine function
most important of these factors is inhibin B,
is covered elsewhere (Barbieri, 2014; Hall, 2014).
which is secreted from granulosa cells in the grow-
A brief outline will be provided here.
ing dominant follicle (Figure 3.2). Thus, a combi-
Hormonal changes taking place in the menstrual
nation of E2 and inhibin B serves to suppress FSH
cycle are illustrated in Figures 3.1 and 3.2. Following
secretion during the follicular phase (Figure 3.1)
menses, at the onset of the follicular phase, normally
(Robertson et al., 2009; Messinis et al., 2014).
a single dominant follicle responds to stimulation
In contrast, inhibin A is released from the corpus
with LH and FSH by producing steadily increasing
luteum and so levels are highest when progesterone
amounts of E2 (Figure 3.1).
concentrations also reach their peak. It is possible,
The follicular production of E2 is enabled by
although unproven, that inhibin A may be partly
a collaborative two-cell system shown in Figure 3.2.
responsible for inhibiting FSH during the luteal
LH binds to LH receptors, located on thecal cell
phase (Robertson, 2012). 29
membranes, causing the release of androstenedione,
Chapter 3: Neuroendocrinology of Female Reproduction
OVARIAN CYCLE FOLLICULAR PHASE LUTEAL PHASE
EVENTS IN
Dominant follicle Formation of Regression
OVARY
corpus luteum
80 OVULATION
LH
LH PULSATILE
60 SECRETION
LH/FSH (mIU/mI)
Estradiol Progesterone
PROG (pg/ml) (ng/ml)
40 100 10
80 8
E2
E2
60 6
20
40 4
FSH 20 2
0 0 0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 280
DAYS
Figure 3.1 Hormonal changes in the human menstrual cycle. The secretion of LH and FSH from the anterior pituitary gland regulates follicular
maturation, ovulation and the production of the corpus luteum. Estradiol and progesterone are released by the ovary under control of LH
and FSH. The insert illustrates the pulsatile nature of LH secretion. Reproduced with permission (Boron and Boulpaep, 2009). Abbreviations: E2,
estradiol; PROG, progesterone.
3.2 Neural Control of GnRH Secretion 2009). Those situated in the infundibular/median
eminence region of the medial basal hypothalamus,
The previous section outlined the influence of ovarian
plus a smaller population in the preoptic area, are
factors, such as E2, on the temporal progression of
responsible for the secretion of GnRH. Their axon
neuroendocrine events through the menstrual cycle.
terminals secrete GnRH into the capillaries of the
The orchestration of this sequence is ultimately
portal vasculature, allowing transport of the releasing
dependent on multiple stimulatory and inhibitory
hormone to the anterior pituitary (Figure 3.3).
signals that emanate from hypothalamic neurons.
The GnRH neuron is sensitive to diverse neural
Such signals serve to regulate anterior pituitary secre-
inputs, both stimulatory and inhibitory, and these
tion of gonadotropins. It is generally accepted that
influences permit both internal and external stimuli
secretion of both gonadotropins, LH and FSH, is
to modulate the reproductive system, some of which
controlled by a single releasing hormone, GnRH.
are illustrated in Figure 3.3. It is estimated that each
This neuropeptide “represents the final common
GnRH neuron is impacted, directly or indirectly, by at
pathway of a neuronal network that integrates multi-
least 5 million other neurons (Herbison, 2015).
ple external and internal factors to control fertility”
The reader is referred elsewhere for a detailed descrip-
(Dudas and Merchenthaler, 2006). Figure 3.3 is
tion of the many known neurotransmitters and neu-
a schematic representation of this concept. GnRH
ropeptides, and their receptor systems, that can
cell bodies are located in various hypothalamic nuclei
regulate GnRH secretion (Dudas and Merchenthaler,
(Dudas and Merchenthaler, 2006; Skrapits et al.,
2006; Hrabovszky and Liposits, 2013; Herbison,
30 2015), and elsewhere in the brain (Skinner et al.,
2015). In addition, multiple factors, including various
Hypothalamic Neuropeptides
neurons Neurotransmitters
+
–
GnRH secretion
Anterior
pituitary GnRH
+
–
– Inhibin B
Estradiol LH FSH
Theca Granulosa
cell cell
Androstenedione
Estradiol
Ovary
Figure 3.2 Ovarian production of E2 by a collaborative two-cell

system. LH binds to receptors on thecal cell membranes, causing the
release of androstenedione. Granulosa cells utilize this substrate to
biosynthesize E2 via FSH, acting at FSH receptors. The rising levels of
E2 culminate in a brief reversal of E2 negative feedback and the
imposition of a positive feedback stimulus that induces a surge of LH
secretion, and to a lesser extent FSH, at midcycle. Note that
granulosa cells also release inhibin B that selectively reduces FSH
secretion. Reproduced with permission (Wahab et al., 2016) and
redrawn.
Figure 3.3 Control of GnRH secretion. Schematic diagram
highlighting the role of GnRH neurons in the control of human
drugs and medications, are known to modulate neu- reproduction. Red arrows indicate the positive and negative
roendocrine output of the human hypothalamic– feedback effects of serum E2 and progesterone exerted on GnRH
pituitary system (Zatelli et al., 2014). Some of these secretion. This control is imposed at several levels: directly on GnRH
neurons; at the level of gonadotrophs, and on neurons regulating
are shown in Table 3.1. GnRH activity. Blue arrows illustrate the negative feedback effects of
testosterone on GnRH release in the male. Note that GnRH neurons
are subjected to many neurochemical inputs, both stimulatory and
3.3 Pulsatile Secretion of LH inhibitory. They are also sensitive to stress, exercise and changes in
GnRH neurons possess an intrinsic pulsatile mode of body weight. Abbreviations: CRH, corticotropin releasing hormone;
GABA, γ-amino butyric acid; Glu, glutamate; KP, kisspeptin; OP,
secretion that is indispensable for the onset of human opioid peptides.
puberty and for adult fertility. The episodic mode of
GnRH release into the pituitary portal system corre-
lates with the pulsatile secretion of LH/FSH from the
anterior pituitary gland. This important conclusion is is likely that peripheral blood LH levels are an effective
based largely on data from experimental animals surrogate for hypothalamic release of GnRH
(Herbison, 2015), but some evidence for pulsatile (Moenter, 2015). The physiological response of the
secretion of GnRH in human portal blood has been anterior pituitary gland to stimulation with GnRH is
reported (Antunes et al., 1978). Moreover, since pul- dependent on information encoded by the frequency 31
satile LH secretory patterns are induced by GnRH, it
Table 3.1 Examples of drugs and medications that influence pituitary hormone secretion via receptors in the human
hypothalamic–pituitary system
Anterior pituitary Stimulation Inhibition

hormones
LH/FSH • Naloxone blocks endogenous opioid receptors • Opioids; for example, treatment of chronic pain
• GnRH analog; cyclical GnRH therapy is used for • GnRH antagonists such as Degarelix, used for
oocyte retrieval in women undergoing in vitro androgen deprivation therapy of prostate
fertilization cancer
• Kisspeptin • Dopamine
• Cycloserine (glutamate)
• Substance P
Growth hormone • Infusion of L-Arginine leads to robust GH release • Somatostatin; long-acting somatostatin analogs
(GH) by reducing somatostatin secretion. Failure of such as octreotide and lanreotide are used for
peak GH to rise >3 ng/mL indicates GH management of acromegaly
deficiency
• Acute morphine
Prolactin • Drugs that lower dopamine, or dopamine • Dopaminergic agonist drugs such as
antagonists, induce hyperprolactinemia; for bromocriptine and cabergoline are used to
example, opioids, tricyclic anti-depressants, treat elevated prolactin
anti-psychotics and dopamine synthesis
inhibitors like α-methyldopa
• Acute morphine
• Fentanyl anesthesia
Adrenocorticotropin • Corticotropin releasing hormone (CRH; • Dopamine agonists (e.g., cabergoline) or
(ACTH) 1mcg/kg) or arginine vasopressin (VP; ten somatostatin analogs, such as paseriotide, are
units) act as stimulating agents to diagnose used for the management of Cushing’s disease
pituitary ACTH adenoma. A >35% rise in • Acute morphine
ACTH after CRH or VP. is suggestive of an
ACTH-producing pituitary adenoma
(Cushing’s disease)
Thyroid stimulating • Acute morphine • Somatostatin analogs bind to somatostatin
hormone (TSH) receptors in pituitary adenomas; therapy is used
for management of TSH-producing pituitary
adenoma
and magnitude of GnRH pulses, a product of the so- normal range (Figures 3.5A and 3.5B). Consequently,
called neural pulse generator (Krsmanovic et al., serum levels can vary widely during different parts of
2009). As an example, Figure 3.4 illustrates a normal the menstrual cycle.
pattern of episodic LH release in a healthy male, The critical importance of LH pulses for ferti-
compared to the apulsatile pattern seen in a typical lity is illustrated in patients suffering significant
Kallmann syndrome (KS) patient who is infertile, weight loss. For example, when LH pulsatile secre-
lacking GnRH/LH secretion and testosterone (see tion is inhibited by loss of body weight, as in
later). patients with anorexia nervosa or in those engaged
LH is also secreted in a pulsatile fashion through- in strenuous exercise, menstrual cyclicity is
out the normal menstrual cycle (see Figure 3.1). abolished (Figure 3.6). This figure illustrates that
The frequency and magnitude of the pulses varies the process of regaining body weight is sufficient
according to feedback by E2 and progesterone to restore pulsatile secretion of LH and
(Filicori et al., 1986). For example, high frequency, menstruation.
high magnitude pulses drive the ovulatory surge of
LH at midcycle (Figure 3.5A). Contrast this pattern Development of Pulsatile Secretion
with the low-amplitude and lower-frequency pulses GnRH neurons are functional in the human fetus and
seen during menstruation, following the LH surge, in early infancy, producing gonadotropin secretion
32 when the peak values of LH have declined into the that stimulates the ovary and testis to release E2 and
5 Figure 3.4 Pulsatile secretion of LH in a normal male.

* Blood levels of LH (mIU per ml; upper trace) measured
during a 24 hr period in a 36-year-old adult male with
normal levels of testosterone. * Indicates significant
4 *
Blood levels of LH (mIU/ml)
Normal male pulses above the background. Pulses occur

* * approximately every 2–3 hr. The lower trace illustrates the
* attenuated, non-pulsatile, secretion of LH in a KS patient.
3 Reproduced with permission and redrawn (Besser and
* * *
* Thorner, 2002).
2 *
*
1
Kallmann syndrome patient
0
0 6 12 18 24
Hours
* testosterone, respectively (Grumbach, 2002). This

150 A activity is gradually attenuated through childhood
(approx. ages five to eleven years) until it is reinstated
at the time of puberty. The onset of the pubertal
process is signaled by a remarkable increase in sleep-
* **
* * related pulsatile LH release (Figure 3.7). This occurs
100 * in boys and girls (Boyar et al. 1974; Kapen et al., 1974)
* * * * * *
LH (mIU/ml)
with the pulses being correlated with slow wave sleep

** ** * (Shaw et al., 2012). In post-pubertal adults, LH pulses
* occur throughout 24 hrs.
The transition from childhood quiescence to sleep-
50 induced LH secretion at puberty represents
a reactivation of the pulse generator. This probably
occurs as a result of two processes occurring simulta-
neously: (a) the lifting of a hypothalamic neurochem-
ical inhibition and (b) the activation of an excitatory
0 drive to release GnRH (McCarthy, 2013). The latter
1725 2125 0125 0525 0925 1325 1725 may involve kisspeptin (KP) neurons (see Section 3.4).
Clock time
40 B * Why Are Pulses Necessary to Induce Puberty and Sustain
LH (mIU/ml)
*
30
* * * Fertility?
20 * * * * *
An answer to this question became clear from classical
10 experiments in monkeys. Continuous infusion of
0 GnRH was observed to induce a paradoxical suppres-
1725 2125 0125 0525 0925 1325 1725
sion of LH and FSH secretion (Belchetz et al., 1978;
Clock time
Figure 3.8). Restoration of a pulsatile stimulation with
Figure 3.5 Pulsatile secretion of LH in the menstrual cycle. GnRH restored LH and FSH levels.
The frequency and magnitude of LH pulses varies according to These data, and others, suggested that there is an
feedback by E2 and progesterone. In A, high-frequency, high-
magnitude pulses drive the ovulatory surge of LH that induces
optimal frequency of GnRH stimulation that main-
ovulation at midcycle. In B, note the low-amplitude and lower- tains LH and FSH at levels consistent with fertility.
frequency pulses seen during menstruation, following the LH surge, Continuous stimulation of GnRH receptors induces
when the peak values of LH have declined into the normal range. *
Indicate significant pulses of LH above the background. Redrawn
a state of receptor downregulation, reversible by 33
from data in Filicori et al. (1986).
Clinical PREPUBERTAL
6
LH (mIU/ml)
16 remission
4
14
2
LH (mIU/ml)
12 SLEEP
0
10
2200 0200 0600 1000 1400 1800 2200
8 Clock time
6
4
18 EARLY PUBERTAL
0 16
INCREASE IN
BODY WEIGHT 14
LH (mIU/ml)
(+10.5 kg)
Anorexia nervosa 12
6 10
LH (mIU/ml)
4 8
2 6
0 4
2
2200 0200 0600 1000 1400 1800 2200 SLEEP
0
Clock time 2200 0200 0600 1000 1400 1800 2200
Clock time
Figure 3.6 LH pulses in anorexia nervosa and following weight gain.
The lower graph shows a typical non-pulsatile pattern of LH 41 LATE PUBERTAL
secretion over 24 hr in a female patient (22 years) with low body 37
weight due to anorexia nervosa. Such a pattern of LH secretion
causes amenorrhea. The upper graph shows the dramatic effect of
LH (mIU/ml)
restoration of normal body weight. LH pulses are now greatly 29

increased in frequency and magnitude. Treatment with clomiphene
restored menstruation. Graphs based on data from Boyar et al. 21
(1974).
13
applying pulses of GnRH. A similar phenomenon is SLEEP
also observed in humans (Rabin and McNeil, 1980; 5
2200 0200 0600 1000 1400 1800 2200
Southworth et al., 1991). The clinical implications
Clock time
arising from these studies are two-fold: (a) pulsatile
stimulation of pituitary secretion of LH and FSH is Figure 3.7 Appearance of sleep-induced pulsatile secretion of LH at
puberty. The onset of the pubertal process is signaled by
mandatory for restoration of gonadotropin secretion a remarkable increase in sleep-related pulsatile LH release. This
in the treatment of, for example, hypogonadotropic occurs in boys and girls and the pulses are correlated with slow wave
hypogonadism (see in Section 3.3.1, “A Case of sleep. Data from three examples are shown here: a prepubertal girl,
a normal pubertal girl and a girl in late puberty. Note the emergence
Delayed Puberty”); (b) the ability of continuous sti- of sleep-related LH pulses during puberty and the appearance of
mulation with GnRH to suppress fertility is clinically additional LH pulses during the day in late puberty. Graphs are
advantageous in various ways. For example, synthetic, based on data from Boyar et al. (1974).
long-acting GnRH agonists are very effective in redu-
cing gonadotropin and sex hormone levels in Although certain genetic and developmental defects can
advanced prostate cancer, treatment of estrogen- lead to absence of GnRH/LH secretion, there is gener-
sensitive breast cancer, precocious puberty and in ally no obvious neuroanatomic abnormality – other
in vitro fertilization (IVF) protocols (Engel and than atypical GnRH/LH secretion – in most cases of
Schally, 2007). HA. Isolated GnRH deficiency (IGD) typically induces
hypogonadotropic hypogonadism (Stamou et al., 2015),
Absence of Pulsatile LH Secretion: Kallmann Syndrome
which is characterized by low LH and FSH levels leading
Hypothalamic amenorrhea (HA) is characterized by the to low E2 or testosterone production. Consequently,
absence of menstrual cyclicity and the loss of ovarian congenital or very early-onset GnRH deficiency, typi-
function due in large part to the lack of pulsatile GnRH cally leads to incomplete sexual maturation. Similarly,
secretion. Several extraneous factors, such as excessive lack of pulsatile GnRH secretion, which is crucial for the
exercise, loss of body weight and psychological stress, appropriate release of LH and FSH (see e.g., Figure 3.4),
34 contribute to this reversible condition (Liu et al., 2016). impairs gonadal sex steroid synthesis and
Although several mutations have been asso-

25 200
ciated with KS (Balasubramanian et al., 2010;
PULSATILE CONTINUOUS PULSATILE Valdes-Socin et al., 2014), genetic abnormalities in
three genes – KAL1, FGFR1 and PROKR2 – are
GnRH GnRH GnRH
20 150 particularly well described. KAL1 encodes a pro-
LH tein, anosmin 1, which acts as a cell-adhesion mole-
cule essential for migration of GnRH and olfactory
FSH (ng/ml)
15
LH (ng/ml)
neurons. FGFR1 encodes a receptor, FGFR1, which

100 binds a fibroblast growth factor (possibly FGF8)
that is also responsible for neuron migration and
10 development of the olfactory bulb. PROKR2
FSH
encodes a receptor protein that binds prokineti-
50 cin-2, which is involved in the maturation of
5 GnRH precursors and development of the olfactory
system (shown in Figure 3.9A). Mutations in these
genes impair the development and migration of
0 0 GnRH neurons (Figure 3.9B) and loss of olfactory
–15 –10 –5 0 5 10 15 20 25 30 35
neurons, leading to impairment of the sense of
Time (days)
smell. In all, mutations in the three genes men-
Figure 3.8 Non-pulsatile, continuous stimulation with GnRH tioned here account for only approximately 25%
suppresses LH and FSH secretion from the anterior pituitary.
The figure compares the pituitary response to continuous vs.
of KS cases, suggesting the involvement of other
pulsatile stimulation with GnRH. The switch from pulsatile to genes (Bianco and Kaiser, 2009).
continuous infusion of GnRH markedly reduces LH and FSH
secretion. This occurs because the GnRH receptors become over-
stimulated, causing desensitization to further treatment with 3.3.1 A Case of Delayed Puberty
GnRH. However, restoration of a pulsatile pattern gradually, over An 18-year-old Caucasian male was referred to the
several days, restores normal secretion. Reproduced with
permission (Besser and Thorner, 2002). endocrinology clinic for delayed puberty. He was born
through normal vaginal delivery and had been healthy
in the past apart from a knee injury while skating that
required an arthroscopy when he was 15. A lack of
gametogenesis, culminating in delayed puberty and pubertal development was first noticed by the parents
infertility. IGD has an incidence of around 1 in 4,000 when his younger brother (who was 14) began grow-
males, and occurs three to five times more commonly in ing facial hair. On examination, he appeared younger
men than in women (Boehm et al., 2015). KS accounts than his stated age and had a high-pitched voice. He
for approximately 50–60% of all cases and will be used was 174 cm tall (mid-parental height = 176 cm) and
here as an exemplar of IGD (Stamou and Georgopoulos, weighed 59.7 kg. There was no evidence of facial hair
2017). KS patients present with associated anosmia, and he had sparse axillary and pubic hair (Tanner
a partial or total lack of the sense of smell. stage 2). The arm span was 178 cm with an increased
Investigations into the association of anosmia with the limb to trunk span of >2 cm; he had prepubertal male
failure of GnRH neurons to support fertility led to our genitalia with testicular volume of around 3 ml bilat-
current understanding of the embryonic origin of erally and micropenis (penile length of 5 cm). He also
GnRH neurons; that is, GnRH neuronal precursor had anosmia which was confirmed by using serial
cells originate embryonically in the nasal placode and dilutions of multiple odorants.
migrate through the cribriform plate into the brain, and Lab results were:
thence to the hypothalamus, via guidance from olfactory Total Testosterone = 2.7 nM (8.4–28.7 nM)
axons (Figure 3.9A; Stamou et al., 2015). Several genetic Serum LH = 1.1 IU/L (1.5–9.3 IU/L)
mutations result in KS by preventing the migration of Serum FSH = 1.6 IU/L (1.4–18.1 IU/L)
GnRH neurons to the hypothalamus (Figure 3.9B). Based on the clinical and biochemical features,
These mutations may also cause failure of development a diagnosis of KS was made, which was subsequently
of the olfactory bulb, giving rise to anosmia (Bianco and confirmed through a genetic test revealing a mutation
Kaiser, 2009). in the KAL1 gene. 35
Olfactory bulb FGFR1

KP
neurons
GnRH neurons
Median
eminence GnRH
KAL1 Cribriform
plate Pituitary gland
Olfactory axons
PROKR2
LH/FSH
Nasal GnRH neuron

placode precursor cells
Olfactory bulb
X
FGFR1
xons
tory a KP
Olfac
neurons
Median
eminence
X GnRH absent
Cribriform
plate Pituitary gland
X
KAL1
Olfactory axons
X
PROKR2
X
LH/FSH LH/FSH absent
GnRH neuron
precursor cells
Figure 3.9 Neurodevelopmental and neuroendocrine regulation of GnRH neurons. GnRH neuronal precursor cells originate embryonically, in
the first weeks of fetal life, in the nasal placode and migrate through the cribriform plate and across the olfactory bulb (A). They reach the
infundibular nucleus and preoptic area, via guidance from olfactory axons, and synchronize with other neurons, such as KP neurons, to regulate
GnRH secretion (see also Figure 3.3). Mutations in several genes – including KAL1, PROKR2 and FGFR1 – prevent the migration of GnRH neurons
and eliminate LH and FSH secretion (B). These mutations may also cause failure of olfactory bulb development, giving rise to anosmia.
Reproduced and redrawn with the generous permission of Dr. F. Crowley, Jr. (Stamou et al., 2015). Abbreviations: GnRH, gonadotropin releasing
hormone; KP, kisspeptin.
The primary goal of management of KS in male a topical preparation such as Androderm, Androgel
patients is to restore serum testosterone levels into the and Testim. In order to avoid a vigorous rise in tes-
normal range, thereby establishing secondary sexual tosterone level in previously hypogonadal adolescent
characteristics and sexual function. This can be males, it is generally advisable to start testosterone
achieved by initiating testosterone therapy, either as therapy at a low dose and gradually increase to a full
36 long-acting testosterone injection, such as testoster- dose over several months to avoid a too-rapid induc-
one enanthate and testosterone cypionate, or as tion of puberty with concomitant changes in mood
and sleep. However, testosterone therapy alone does Inhibitory Effects of Opioids on the Human
not improve fertility, but rather suppresses LH and Hypothalamic–Pituitary–Gonadal System
FSH through its negative feedback effect on GnRH. Opioid peptides (e.g., β-endorphin) and non-peptides
In order to induce fertility and stimulate spermato- (e.g., morphine) are potent inhibitors of gonadotro-
genesis, patients with KS will typically require either pin secretion, consistent with the presence of opioid
a combination of human chorionic gonadotropin receptors in the human hypothalamus. Opioid recep-
(hCG; which acts like LH to stimulate testosterone tors are G protein-coupled (see Chapter 1) and they
production by Leydig cells) and recombinant FSH exist as three major subtypes: μR, δR and κR. Gene
(such as Gonal F to stimulate spermatogenesis) or expression studies revealed μR messenger ribonucleic
pulsatile GnRH therapy via a subcutaneous pump. acid (mRNA) and κR mRNA, but not δR mRNA,
Female KS patients also lack gonadotropins, and localized to large numbers of human hypothalamic
therefore ovarian function, and require transdermal neurons, indicating that these cells biosynthesize the
treatment with E2 to maximize breast development, μR and κR receptor proteins (Peckys and
and an E2/progestin regimen to induce menstrual Landwehrmeyer, 1999). There is good evidence from
bleeding. Such treatment does not induce ovulation animal studies that injections of morphine can inhibit
and fertility and female patients seeking fertility can GnRH and LH secretion via hypothalamic μ-opiate
be treated with GnRH pump therapy to achieve pul- receptors (Ferin et al., 1982; Williams et al., 1990). It is
satile secretion of LH/FSH and ovulation (Bianco and assumed that drugs such as morphine and β-
Kaiser, 2009). endorphin bind to human hypothalamic μR to inhibit
LH secretion (Reid et al., 1981; Rasmussen et al.,
3.4 Neurochemical Regulation of 1989).
GnRH Secretion The human reproductive system is also regulated
by endogenous opioid peptides (EOPs); that is, pep-
GnRH neurons are sensitive to a variety of exogenous
tides biosynthesized in hypothalamic neurons. One of
and endogenous neurochemical stimuli (see Section 3.2;
these, β-endorphin, has been referred to previously
Table 3.1). Detailed neuroanatomical studies on human
but several families of EOP are known (Table 3.2;
hypothalamic tissue have revealed close apposition of
Wilkinson and Brown, 2015).
various nerve terminals with GnRH neuron axons and
Each precursor peptide (a propeptide) is derived
dendrites, which further implicates endogenous neural
from a different gene; that is, pro-opiomelanocortin is
control of GnRH release. These include investigation of
encoded by the pomc gene, proenkephalins from the
classical neurotransmitters (e.g., norepinephrine; Dudas
enkA gene and prodynorphin is derived from the
and Merchenthaler, 2001), the excitatory neurotrans-
proenkephalin B gene (enkB; Figure 3.10). The large
mitter glutamate and the inhibitory amino acid γ-
precursor peptides are cut into smaller fragments by
amino butyric acid (Hrabovszky et al., 2012). Several
proprotein convertases to produce the final peptide
neuropeptides have also been identified: the opioid pep-
structure, such as β-endorphin. Some of the gene
tides β-endorphin (Dudas and Merchenthaler, 2004)
products have been linked to inhibition of LH secre-
and leu-enkephalin (Dudas and Merchenthaler, 2006);
tion in humans: β-endorphin (Reid et al., 1981);
orexin and melanin-concentrating hormone (Skrapits
et al., 2015); substance P and neurokinin B (NKB;
Borsay et al., 2014); neuropeptideY, galanin and cortico- Table 3.2 Endogenous opioid peptides
tropin releasing hormone (Dudas and Merchenthaler,
Precursor Opioid peptide
2004) and the excitatory neuropeptide KP (Hrabovszky,
2014). Proenkephalin A [Met]enkephalin
The following sections will use two neuropeptides as [Leu]enkephalin
examples of how GnRH secretion can be inhibited or Pro-opiomelanocortin β-endorphin
stimulated. The first will outline the extensive clinical Proenkephalin B Dynorphin A
importance of opioids in inhibiting LH secretion and Prodermorphin Dermorphin
fertility. We will then describe the detailed studies on KP Prodeltorphin Deltorphin
and its ability to stimulate the human reproductive sys- Deltorphin I
tem. KP is the most potent GnRH secretagogue known. 37
Deltorphin II
to widespread opioid prescription abuse. In 2014,

pomc pre-pro-opiomelanocortin
more than 10 million persons were recorded as
using prescription opioid analgesics for nonmedical
purposes in the United States (Compton et al. 2016).
SIGNAL γ–MSH α–MSH β–MSH The full extent of the implications for the reproduc-
PEPTIDE
ACTH β–ENDORPHIN tive system is yet to be explored in detail (see reviews:
Katz and Mazer, 2009; Brennan, 2013), and women
have been found to be at greater risk for opioid abuse
enKA pre-proenkephalin A
in all age groups (Koons et al., 2018).
Opioids have both acute and chronic effects.
In men, gonadotropins and testosterone secretion
SIGNAL met-enk met-enk met-enk met-enk leu-enk met-enk are inhibited within 4 hrs after acute opioid adminis-
PEPTIDE
tration, regardless of whether it is administered by
intravenous, oral, transdermal or intrathecal routes
enKB pre-proenkephalin B
(reviewed in Daniell, 2008). Similarly, long-term
intrathecal morphine or hydromorphone administra-
tion for nonmalignant pain, in women, causes hypo-
SIGNAL
PEPTIDE
leu-enk leu-enk leu-enk gonadotropic hypogonadism (Abs et al., 2000). Of the
DYNORPHIN
21 premenopausal women receiving opioid treatment,
Figure 3.10 Schematic illustration of three opioid pre-propeptides. 14 became amenorrheic and seven developed irregu-
Pro-opiomelanocortin (pomc), enkephalin (enkA) and DYN (enkB) lar cycles, compared with controls who had normal
genes encode large pre-propeptides that are proteolytically
cleaved (scissors) to a series of smaller, biologically active cycles. Serum LH levels were lower in the opioid
neuropeptides (e.g., β-endorphin; metenkephalin), by enzymes group. In the 18 postmenopausal women, serum LH
called proprotein convertases. Abbreviation: MSH, melanocyte- concentrations were significantly lower than those in
stimulating hormone; met-enk, met-enkephalin.
the six postmenopausal control women. Similar find-
ings were obtained in women receiving long-term
(>1 year) oral methadone (Rhodin et al., 2010).
metenkephalin (Giusti et al., 1992) and dermorphin
In summary, there is strong evidence that both acute
(Petraglia et al., 1985). A role for dynorphin (DYN) in
and chronic opioid administration can cause suppres-
LH secretion will be described later in this chapter
sion of sex hormones, leading to sexual dysfunction,
(see Figure 3.13).
infertility, loss of muscle mass and mood disorders.
In summary, opioids, such as morphine, and
Additionally, opioid therapy can also cause loss of
endogenous opioids, such as β-endorphin, bind to
other hypothalamic pituitary hormones, resulting in
hypothalamic opioid receptors to inhibit LH secretion
hypothyroidism, hypocortisolism and growth hor-
in humans. The following sections provide clinical
mone (GH) deficiency (Abs et al., 2000).
examples of these effects, keeping in mind that the
influence of endogenous opioids can best be illustrated
by blocking their action with antagonists such as Inhibitory Effects of Endogenous Opioids on LH
naloxone or naltrexone. Secretion: Stimulatory Effects of Naloxone
As noted, the human hypothalamus expresses several
Inhibitory Effects of Exogenous Opioids on LH Secretion opioid genes encoding peptides such as β-endorphin
The neuroendocrine hypothalamus is highly sensitive and DYN. These endogenous opioids are implicated
to opioids (review: Vuong et al., 2010) and both ther- in the inhibition of LH secretion. A convenient
apeutic and recreational use of opioids can result in experimental route to test whether EOPs regulate
hypogonadism. This is of widespread concern since human LH secretion is to use opioid antagonists
243,000 new heroin abusers were admitted for treat- such as naloxone, naltrexone and nalmefene to
ment in the United States during the year 2000, of reverse the inhibitory effects of the endogenous pep-
which 40% were women (Schmittner et al., 2005). tides (Tenhola et al., 2012). In men, for example,
In addition, the increasing therapeutic use of opioid naloxone infusion or oral nalmefene rapidly and sig-
analgesics for non-cancer pain – such as back injuries, nificantly elevated LH secretion (Graves et al., 1993).
38 sport and automobile injuries and headache – has led Increased LH release was also seen in women given
oral naltrexone (Teoh et al., 1988; Roche and King, resumed normal menstrual cycles and 12 of the 19
2015), with similar responses in the follicular and became pregnant (Roozenburg et al., 1997).
luteal phases of the cycle. In contrast, naloxone- Naltrexone has also been used in women with
induced LH secretion occurred only in the late luteal polycystic ovary syndrome (PCOS). PCOS is the
phase of the cycle (Rossmanith et al., 1989), empha- most common cause of female infertility and affects
sizing that naloxone and naltrexone differ in their over 100 million women worldwide (Azziz et al., 2005;
ability to inhibit endogenous opioids. Nevertheless, Padmanabhan, 2009). It is a heterogeneous disorder
it is clear that EOPs exert inhibitory control of LH characterized by anovulation, hyperandrogenism,
secretion. enlarged polycystic ovaries, insulin resistance and
The literature on the ability of opioid antagonists obesity. Both central and peripheral opioids may
to modify normal hypothalamic–pituitary control of play a role in the pathogenesis of PCOS (Eyvazzadeh
LH secretion is extensive, and in subsequent chapters et al., 2009). One study looked at a group of anovula-
we will see that other pituitary hormones are similarly tory PCOS women treated with either naltrexone or
regulated. However, the clinical utility of opioid naltrexone combined with clomiphene (Ahmed et al.,
antagonists in treating anovulatory conditions by 2008). Results showed that naltrexone not only
increasing blood LH levels remains limited. While restored sensitivity to clomiphene in most of the
initial studies with naltrexone reported significant patients but an improvement in other metabolic para-
increases in LH values, and resumption of menstrual meters – including reduction in body mass index
cycles, in women with ovarian failure (Wildt et al., (BMI) and serum testosterone as well as increased
1993), others were unable to confirm these results insulin sensitivity – was also observed. Another
(e.g., Couzinet et al., 1995). Similarly, naloxone has study showed similar results, with restoration of men-
also been shown to stimulate LH secretion in women strual activity in 80% of women, a reduction in BMI,
with HA (Khoury et al., 1987; Figure 3.11). testosterone and cortisol levels and an improvement
In addition, long-term naltrexone therapy (3–6 in insulin sensitivity (Fruzzetti et al., 2002).
months) in patients with HA due to low body weight In summary, these studies suggest that opioid systems
restored normal menstrual bleeding in 80% of the are abnormal in PCOS, although it is not possible to
patients (Genazzani et al., 1995). In another study of conclude that central opioids are solely responsible.
clomiphene-resistant, normogonadotropic, anovulatory For example, the reduction in BMI could be an indir-
women treated with naltrexone, 19 out of 22 women ect contributor to improved menstrual cyclicity.
Figure 3.11 Naloxone-stimulated LH

release in hypothalamic amenorrhea.
The patient was amenorrheic due to
weight loss (8 years). Despite recovery
to 90% ideal body weight, she
remained amenorrheic. Infusion of
saline did not affect LH or FSH
secretion but treatment with
naloxone (1.0 mg/m2; 4 hrs) markedly
increased LH pulses but not FSH
pulses. Reproduced with permission
(Besser and Thorner, 2002).
39
KP Is a Stimulus for GnRH Secretion (Taziaux et al., 2016). Moreover, tissue from pre- and
KP is a hypothalamic neuropeptide that functions as a post-menopausal women showed that KP neurons
neurotransmitter/neuromodulator to regulate the were co-localized with GnRH neurons in the infundib-
secretion of GnRH (Roa et al., 2008; Skorupskaite et ular nucleus, with a second population in the preoptic
al., 2014; Wilkinson and Brown, 2015). Subcutaneous area (Hrabovsky et al., 2010; Hrabovsky, 2014). KP
infusion of the peptide KP is a powerful stimulator of neuron axons form a dense plexus that makes axo-
LH (and to a lesser extent, FSH) secretion in women, an somatic, axo-dendritic and axo-axonal contacts with
effect comparable with that of GnRH (Skorupskaite GnRH neurons. It seems likely that KP regulates the
et al., 2014; Narayanaswamy et al., 2015). In keeping secretion of GnRH from human GnRH neurons via KP
with many neuropeptides, KP is also expressed in sev- receptors (KISS1 R). However, unlike the situation in
eral other tissues. It was originally isolated as experimental animals (Messager et al., 2005), where
a metastasis-inhibiting peptide (metastin) in several KISS1 R are located on GnRH neurons, the precise
tumors, such as pancreas, ovary, thyroid and breast, location of the receptors in the human hypothalamus
and is also normally expressed in placenta, ovary, pan- is presently unknown.
creatic islets, cardiovascular system, fat tissue and sev- The mechanism by which KP neurons regulate LH
eral brain areas outside of the hypothalamus (Roa et al., secretion, and specifically in generating the preovula-
2008; Brown et al., 2008; Oakley et al., 2009; Cockwell tory surge in LH, was revealed following the discovery
et al., 2013). The human KISS1 gene encodes a pre- that KP is co-localized and co-released with two other
propeptide (pre-prokisspeptin) that contains the neuropeptides: DYN, an endogenous opioid, and
sequence for metastin (KP-54; Figure 3.12; Roa et al., NKB (a tachykinin peptide). These cells have been
2008). The bioactive KP-54 is formed by cleavage, as labeled as KNDy neurons and they play a critical
shown, and three other smaller peptides have been role in controlling reproductive function (Lehman
isolated. However, only KP-10 appears to have signifi- et al., 2010; Pinilla et al., 2012). A possible cellular
cant biological activity in stimulating LH secretion in arrangement is shown in Figure 3.13, where NKB
healthy men (Jayasena et al., 2015). (stimulatory) and DYN (inhibitory) are shown acting
Human brain autopsy samples, from infants and in an autocrine fashion to control KP release.
adults of both sexes, revealed KP-immunoreactive neu- Alternate, reciprocal signaling by NKB and DYN is
rons in the infundibular region of the hypothalamus then a possible locus of pulsatile LH secretion.
Figure 3.12 Structure and cleavage of human pre-prokisspeptin. Pre-prokisspeptin is a 145 amino acid peptide that contains a 54 amino
acid region (KP-54), flanked by two cleavage sites (denoted by scissors). Proteolytic processing of pre-prokisspeptin by the enzyme furin
generates KP-54 (also called metastin) (Harihar et al., 2015). Further cleavage of KP-54 produces KPs of lower molecular weight: KP-14, KP-13 and
40 KP-10. Reproduced with permission (Roa et al., 2008).
Figure 3.13 Tentative model for the role of KNDy

neurons in the control of pulsatile GnRH secretion.
A schematic model shows the putative roles of NKB
(stimulatory) and DYN (inhibitory) as co-transmitters
and putative regulators of the secretory activity of KP
neurons as the major driving signal for GnRH
pulsatile release. In this model, NKB would operate as
a stimulatory autocrine signal for KNDy neurons, and
DYN would inhibit KP secretion. Reciprocal signaling
by NKB and DYN, at G protein-coupled receptors,
could possibly produce pulsatile GnRH secretion.
Abbreviations: KOR, kappa opioid receptor; NK3 R,
NKB receptor. Figure is adapted and redrawn from
Pinilla et al. (2012). The GnRH neuron image is
reproduced with permission (Herbison, 2016).
The neuroanatomical and neurochemical details 2009), suggesting that E2 feedback, both positive and
of such a system were established in experimental negative, may be mediated through steroid-sensitive
animals, including primates, but there is good evi- KP neurons. A speculative arrangement is shown in
dence for colocalization of NKB and KP in human Figure 3.14, where KP neurons mediate the positive
hypothalamic neurons (Hrabovszky et al., 2010; feedback effect of E2 to increase GnRH secretion, and
Hrabovszky, 2014). Supporting evidence exists for KNDy neurons respond to E2 by reducing KISS1 gene
a stimulatory effect of NKB in humans; that is, loss- expression and limiting the release of GnRH
of-function mutations in the NKB gene, or its (Skorupskaite et al., 2014).
receptor gene, produces isolated hypogonadotropic In summary, KP, along with NKB and DYN, is
hypogonadism (Semple and Topaloglu, 2010). a key neuropeptide in the hypothalamic control of the
In addition, treatment of healthy women (regular human reproductive system. Acting as a potent sti-
menses) with an NKB antagonist reduced LH and mulus to LH secretion in healthy men and women it is
E2 secretion (Skorupskaite et al., 2018a), demon- likely that KP could also be clinically invaluable in the
strating the importance of stimulatory NKB signal- treatment of human reproductive disorders
ing in women. In contrast, there is little evidence (Skorupskaite et al., 2014; Prague and Dhillo, 2015).
that places DYN in the same neurons, although NKB antagonism also appears to be a novel treatment
DYN gene expression is present in human hypotha- for menopausal hot flushes (Prague et al., 2017;
lamus (Rometo and Rance, 2008). Further, and as Skorupskaite et al., 2018b).
discussed already, blockade of endogenous opioids
(such as DYN) with naloxone or naltrexone Stimulatory Effects of KP in the Human Reproductive
increases LH secretion. System
An additional key point is that KP neurons possess Exogenous KP potently stimulates the secretion of LH
E2 receptors, strategically located to facilitate hor- and is particularly effective in the early follicular
mone feedback. E2 receptors, NKB and KP are all co- phase of the menstrual cycle (Dhillo et al., 2007;
localized in human hypothalamic neurons (Rance, Skorupskaite et al., 2014). The results from several 41
Figure 3.14 KP neurons mediate hypothalamic E2 feedback. This

schematic representation suggests that E2 exerts hypothalamic
feedback via KP neurons in two anatomical sites. E2 receptors, NKB
and KP are all co-localized in human hypothalamic neurons (Rance,
2009). KP neurons could therefore mediate the positive feedback
effect of E2 to increase GnRH secretion, and KNDy neurons respond
to the negative feedback effects of E2 by reducing KISS1 gene
expression and limiting the release of GnRH.
studies on healthy men and women are summarized continuous stimulation with the secretagogue
in Figure 3.15. GnRH, or its long-acting analogs, that profoundly
For the most part, these data represent the influ- inhibits LH secretion (see Section 3.3 and Figure 3.8;
ence of single injections, illustrated as peak concen- Fraser, 1993). However, note that the effect of KP on
trations or mean LH values. A subcutaneous infusion LH pulsatility in women may be dose- and E2-
of KP over several hours was also highly effective in dependent. For example, chronic subcutaneous injec-
increasing LH secretion in healthy women tions of high-dose KP (6.4 nmol/kg vs. 0.6 nmol/kg in
(Narayanaswamy et al., 2015; Figure 3.16). This result their 2013 study referred to previously) induced
is notable because of the absence of desensitization of tachyphylaxis in the LH response in women
the KP response (tachyphylaxis), suggesting that this (Jayasena et al., 2009).
may constitute a useful therapeutic approach to treat-
ing infertility. Potential Clinical Uses of KP
Of equal significance is the report that a single Adult humans possessing inactivating mutations in
subcutaneous injection of KP (0.6 nmol/kg; see the KISS1 gene or in its receptor gene, KISS1 R, show
Figure 3.15), given to healthy women in the follicular hypogonadotropic hypogonadism characterized by
phase of the menstrual cycle, significantly increased delayed puberty, low gonadotropins and sex steroids
the frequency of LH pulses (Jayasena et al., 2013). (Silveira et al., 2013; Silveira and Latronico, 2013;
These data emphasize that KP stimulation is effective, Prague and Dhillo, 2015). An activating mutation in
not only in elevating LH levels over several hours, but KISS1 R, leading to precocious puberty, has also been
in increasing pulsatile secretion as well. This observa- described (Teles et al., 2008). These seminal studies
42 tion is in marked contrast to the effect on LH of led to the current acceptance of an obligatory role for
LH (IU/L)
Subgroup lsoform Protocol Baseline Stimulated Reference
Healthy Men
KP-54 iv 90 min 4 pmol/kg/min 4.2 10.8 Dhillo 2005
KP-10 iv bolus 0.24 nmol/kg 2.8 7.8 Chan 2011
KP-10 iv bolus 0. 77 nmol/kg 4.1 12.4 George 2011
KP-10 iv bolus 2.3 nmol/kg 4.1 7.0 George 2011
KP-10 iv bolus 10 nmol/kg 2.9 6.5 Jayasena 2011 Men
KP-10 iv 9 h 1.1 nmol/kg/h 5.2 14.1 George 2011
KP-10 iv 22.5 h 3.1 nmol/kg/h 5.4 20.8 George 2011
Healthy Women
Follicular KP-54 sc bolus 0.4 nmol/kg 4.2 4.3 Dhillo 2007
Follicular KP-54 sc bolus 0.6 nmol/kg 3.4 5.7 Jayasena 2013b
Follicular KP-54 sc bolus 6.4 nmol/kg 5.7 14.3 Jayasena 2013a
Follicular KP-54 sc bolus 6.4 nmol/kg BD5d 9.4 17.7 Jaysasena 2013a
Follicular KP-54 sc bolus 6.4 nmol/kg BD8d 6.0 18.7 Jayasena 2013a
Follicular KP-54 iv bolus 1 nmol/kg 3.8 12.1 Jayasena 2011
Follicular KP-10 sc bolus 2–32 nmol/kg 3.8 3.8 Jayasena 2011
Follicular KP-10 iv bolus 0.23 nmol/kg 6.3 9.4 George 2012
Follicular KP-10 iv bolus 0.24 nmol/kg 2.9 3.8 Chan 2012 Women
Follicular KP-10 iv bolus 1–10 nmol/kg 3.8 3.8 Jayasena 2011
Follicular KP-10 iv 90 min 20–720 pmol/kg/min 3.8 3.8 Jayasena 2011
Late follicular KP-54 sc bolus 0.4 nmol/kg 14.5 35.1 Dhillo 2007
Late follicular KP-10 iv bolus 0.24 nmol/kg 34.7 61.3 Chan 2012
Preovulatory KP-10 iv bolus 10 nmol/kg 6.8 26.8 Jayasena 2011
Luteal KP-54 sc bolus 0.4 nmol/kg 3.6 5.8 Dhillo 2007
Luteal KP-10 iv bolus 0.24 nmol/kg 3.4 7.1 Chan 2012
Menopause KP-10 iv bolus 0.23 nmol/kg 35.3 44.7 George 2012
Implanon KP-10 iv bolus 0.23 nmol/kg 4.6 7.5 George 2012
COCP KP-10 iv bolus 0.23 nmol/kg 2.3 3.7 George 2012
0 50 100 150 200 250 350

% Change in LH secretion
Figure 3.15 KP stimulates LH secretion in healthy men and women. KP was administered in different isoforms (KP-54 and KP-10) and by
different protocols (intravenous or subcutaneous, single boluses or continuous infusion). Note that stimulated LH values are either mean LH or
peak LH concentrations depending on how the data were originally presented. Abbreviations: BD5d, twice daily for five days; BD8d, twice daily
for eight days; COCP, combined oral contraceptive pill; Implanon, etonogestrel contraceptive implant; iv, intravenous; sc, subcutaneous.
Reproduced with permission (Skorupskaite et al., 2014).
KP in regulating GnRH/LH release and the neuroen- 2016). In practice, functional HA is the reversible
docrine regulation of human reproduction. absence of menstruation for more than 6 months,
As already described in the previous section, KP is providing there is no indication of anatomical or
a potent stimulus for LH secretion in healthy indivi- organic abnormalities (Meczekalski et al., 2008). It is
duals, and a logical question is whether KP treatment commonly associated, for example, with stress, weight
might be capable of reversing some forms of inferti- loss or intense exercise. HA is observed in many
lity, such as HA. Two examples of KP as a therapeutic female athletes with low body weight and who exer-
intervention will be described. cise excessively, as well as in anorexic women and
Functional HA is a common cause of absent men- girls. Restoration of fertility in HA requires the return
struation. The primary defect appears to be an inabil- of hypothalamic–pituitary function through normal-
ity of the hypothalamus to increase GnRH output in ization of pulsatile LH secretion, a state that is not
response to severe hypoestrogenism. The decrease in provided by supplementation with E2 alone. KP sti-
LH secretion in these women probably reflects an mulation therefore offers a possible route to reverse
impairment of the GnRH pulse generator (Liu et al., HA. In fact, subcutaneous infusion of KP (0.03, 0.10 43
15 30 LH
Mean serum LH (iU/L)

1.0 nmol/kg/hr
Serum LH (iU/L)
10 20
0.3 nmol/kg/hr
1.00 nmol/kg/hr
0.1 nmol/kg/hr
5 10
0.10 nmol/kg/hr
Vehicle
0.03 nmol/kg/hr
Vehicle
0
0
0 120 240 360 480 600
0 60 120 180 240 300 360 420 480
Time (mins)
Time (mins)
Mean serum estradiol (pmol/L)

Figure 3.16 Effectsof KP-54 infusions on serum LH in healthy women 300 Estradiol
during the early follicular phase of the menstrual cycle. Data are
collated from all participants (n=4) in response to 8-hr infusions of
vehicle and KP-54 (subcutaneous; 0.1, 0.3 and 1.0 nmol/kg/h). Mean 200
serum LH results for each time point (from all four participants)
during the 8-hr study are presented as a time profile. The two
highest doses (0.3 and 1.0 nmol/kg/h) significantly increased LH
100
secretion (p<0.001). These two doses of KP-54 also increased FSH
secretion (not shown). Reproduced with permission and redrawn
(Narayanaswamy et al., 2015).
0
0 120 240 360 480 600
Time (mins)
or 1.00 nmol/kg/h; 8hrs) was shown to increase LH
levels and E2 secretion in patients with HA (Jayasena Figure 3.17 Stimulatory effects of KP-54 infusions on serum LH and
E2 in patients with HA. Five women with HA each underwent an
et al., 2014; Figure 3.17). All patients in this study intravenous infusion of saline vehicle or KP-54 (0.03, 0.10 or
demonstrated an increase, albeit variable, in the num- 1.00 nmol/kg/h), between 0 and 480 mins. Graphs based on data
ber of LH pulses at all doses. At this stage, data are from Jayasena et al. (2014).
unavailable as to whether menstrual cyclicity might be
restored by KP infusion. Nonetheless this approach
suggests the obvious potential for use of KP in the as was egg maturation. The two higher doses appeared
treatment of HA. This also seems to be applicable to to improve egg collection. Biochemical pregnancy
hyperprolactinemic amenorrheic patients (Millar occurred in 40% (21/53 patients) and clinical preg-
et al., 2017). nancy was achieved in 23% (12/53 patients treated).
Twelve healthy babies were born. In summary, a single
Use of KP Stimulation for IVF injection of KP is able to induce oocyte maturation in
The data described so far on KP-induced LH surges infertile women undergoing IVF. Moreover, eggs
indicate the possibility that KP could be used to were fertilized, the embryos were transferred and suc-
induce egg maturation in women undergoing IVF cessful pregnancies ensued.
therapy. Patients are normally treated with
a recombinant FSH/GnRH agonist protocol to KP Stimulation in Women at High Risk for Ovarian
achieve superovulation but not premature ovulation. Hyperstimulation Syndrome
The final step, of oocyte maturation, is usually pro- The use of hCG in IVF procedures sometimes induces
voked by treatment with hCG. KP, rather than hCG, excessive ovarian stimulation and ovarian hypersti-
was used to investigate whether the final step, egg mulation syndrome (OHSS), a common, and poten-
maturation, could be achieved (Jayasena et al., tially life-threatening, complication of IVF treatment.
2014a). Four doses of KP were used, with the majority hCG has a prolonged effect, lasting up to a week,
of patients receiving the three highest doses (3.2, 6.4 which can cause excessive ovarian stimulation.
and 12.8 nmol/kg) in an adaptive design for dose OHSS is characterized by ovarian enlargement,
44 escalation. Serum KP and LH levels were increased, ascites, renal failure, acute respiratory distress
Table 3.3 Summary of patient response following KP triggering
KP dose (nmol/kg) 3.2 (n=5) 6.4 (n=20) 9.6 (n=15) 12.8 (n=20) Total=60
Oocytes retrieved 4 20 14 19 57
Number of patients 4 17 13 17 51
with embryo transfer
Clinical pregnancy at 1 10 10 6 27
6 weeks
Miscarriage/stillbirth 0 1 2 1 4
Live births 1 9 8 5 23
syndrome and even death (Delvigne and Rozenberg, ultrasound was conducted that revealed bilateral
2002). A relevant case of infertility is described, fol- ovarian enlargement (right = 11.5 cm and left =
lowed by an argument for replacing hCG with KP in 12.2 cm) and free fluid. Based on these findings, the
an effort to avoid OHSS. patient was diagnosed with moderate OHSS. She was
admitted to hospital for observation and fluid man-
3.4.1 A Case of OHSS and KP agement; she made a full recovery over the next 2
weeks.
A 36-year-old female journalist and her husband pre-
Efforts have been made to overcome the problems
sented to the assisted reproductive technology clinic
with hCG stimulation by using a GnRH agonist
with a history of infertility. She had achieved
(Thomsen and Humaidan, 2015), but Jayasena et al.
menarche at the age of 13 and had regular menstrual
(2014a) suggested that KP stimulation might also
activity until the age of 17. On becoming sexually
safely trigger oocyte maturation in patients at high
active she started oral contraceptive therapy. She
risk for OHSS. In a randomized study of 60 women at
recalled taking a short course of antibiotics for pelvic
high risk of OHSS, KP stimulation was associated
pain and vaginal discharge when she was around 19.
with oocyte maturation in 95% of the women and
She discontinued oral contraceptives when she turned
pregnancy rates of 62–85% were achieved with differ-
31 and since then the couple had been having regular
ent doses of KP. More importantly, no woman devel-
unprotected sexual intercourse without achieving
oped OHSS (Abbara et al., 2015; Table 3.3; see also
conception. She reported regular menstrual activity
Abbara et al., 2017).
(average cycle length = 27 days and duration of flow =
In summary, KP safely stimulates final oocyte
4 days). Further infertility tests confirmed blocked
maturation and high implantation rates in IVF
fallopian ducts on hysterosalpingogram, possibly
patients at high risk of OHSS. The authors conclude
due to pelvic inflammatory disease in the past.
that larger, randomized studies are needed so that KP
The couple was given the options of surgery (salpin-
stimulation can be compared with other triggers (such
gostomy) or IVF, and they opted to undergo IVF.
as hCG) to optimize treatment of patients at high risk
After counseling concerning the risks associated
of developing OHSS during IVF treatment (Abbara
with IVF, including OHSS, multiple pregnancy and
et al., 2018).
the risk of ectopic or heterotopic pregnancy, the IVF
cycle was initiated using the long protocol (GnRH
starting on day 21 of the cycle followed by FSH). 3.5 Chapter Summary
The cycle was carefully monitored and on day 12, 17 This chapter provides a basic introduction to the phy-
follicles (>15 mm) were seen on ultrasound. siology and neuroendocrine control systems of the
Subcutaneous hCG injection (5000 IU) was given to human menstrual cycle. A major focus is on the ability
induce oocyte maturation and 36 hours later 20 of sex hormones, such as E2, to exert feedback on the
oocytes were retrieved without any complication. hypothalamic regulation of GnRH neuron secretion.
However, 4 days after the retrieval she developed GnRH represents the final common pathway of
nausea, vomiting and abdominal tenderness; she had a neuronal network that integrates multiple external
also gained 5 kgs in weight and noticed an increase in and internal factors to control fertility. GnRH neurons
her abdominal circumference. An endovaginal are also the locus of a system that generates pulsatile 45
secretion of LH, a pattern that is crucially important 3.6 Review Questions

for sexual maturation and subsequent fertility. That
human fertility is dependent on GnRH neurons is 1. Which of the following statements regarding
emphasized using a case study of Kallmann syndrome, opioids are correct?
in which GnRH neurons are absent from the a. G protein-coupled opioid receptors are
hypothalamus. expressed in the hypothalamus.
GnRH secretion is regulated through E2 feedback b. Opioid antagonist therapy has been shown to
but also by a variety of neurotransmitters and neuro- improve ovulation in women with polycystic
peptides, and their receptors. Detailed supportive neu- ovary syndrome (PCOS).
roanatomical evidence, obtained from human brain c. Chronic opioid therapy is associated with
tissue, has revealed close apposition of nerve terminals pituitary dysfunction.
containing these factors with GnRH neuron axons and d. Hypothalamic opioid receptors have affinity
dendrites. Two well-described neurochemical systems for endogenous opioids only.
are used as examples to illustrate the extensive clinical e. Opioids lower serum luteinizing hormone
importance of drugs that inhibit LH secretion and those (LH) in premenopausal as well as
that stimulate the reproductive system. Opioids, includ- postmenopausal women.
ing endogenous opioids such as β-endorphin, exert 2. Kallmann’s syndrome is associated with which of
powerful inhibitory effects on LH secretion. KP, on the the following abnormalities?
other hand, is the most potent LH secretagogue known.
Opioid abuse as a result of addiction to drugs, such a. A mutation in the PROKR2 gene
as heroin, results in hypogonadism, one form of which b. Absence of a sense of smell
is the disruption of menstrual function. Chronic opioid c. High serum LH, follicle stimulating hormone
treatment for pain also inhibits the reproductive sys- (FSH) and low testosterone levels
tems of both men and women. Of equal concern, d. An increased arm span-to-trunk ratio
hypogonadism-induced symptoms include hypocorti- e. Small testes
solism, GH deficiency, infertility, osteoporosis, mood 3. A 19-year-old female presented with amenorrhea
disorders, fatigue and hyperalgesia. The inhibitory for 6 months. She was known to have anorexia
influence of hypothalamic EOPs, in men and women, nervosa since she was 12 and had previously
is revealed through the stimulatory influence of responded to counseling. However, after the
antagonists such as naloxone and naltrexone. This separation of her parents, she had a relapse of
effect has been employed in attempts to reverse some symptoms. Her body mass index, which was
aspects of infertility, such as PCOS and functional HA. previously 18.9 kg/m2, had dropped to 15.6 kg/m2
The human hypothalamus contains neurons that and she stopped menstruating. Which of the
express the neuropeptide KP, encoded by the KISS1 following abnormalities would you expect on her
gene. KISS1 R are also localized to this brain region. blood test?
KP is co-localized and co-released with two other a. High serum LH and FSH and low serum
neuropeptides: DYN, an opioid, and NKB. These estradiol (E2)
cells have been labeled as KNDy neurons and they b. High serum LH but low FSH
play a critical role in controlling reproductive func- c. Low serum LH and FSH and low E2
tion. NKB/DYN act in an autocrine fashion to control d. High serum LH and FSH and high E2
KP release. Alternate, reciprocal, signaling by NKB e. Normal LH, FSH and E2 levels
and DYN is a possible locus of pulsatile LH secretion.
4. Regarding opioid therapy for non-cancer pain,
Injection or infusion of KP potently stimulates the
which of the following statements are correct?
pulsatile secretion of LH and is particularly effective
in the early follicular phase of the menstrual cycle. a. Both acute and chronic opioid therapy can
In clinical terms KP has been used in attempts to cause hypogonadism.
reverse the effects of functional amenorrhea by b. Chronic opioid therapy can lead to testicular
increasing pulsatile release of LH. KP also shows pro- atrophy.
mise as a trigger for oocyte maturation in IVF, parti- c. Opioids primarily act on ovaries to reduce E2
46 cularly in women who are at high risk for OHSS. production.
d. Hypogonadism is generally seen with oral e. Unlike GnRH, KP infusion can stimulate LH
opioids whereas injections are safe. release without tachyphylaxis.
e. Naloxone can reverse some of the 8. GnRH is the final common pathway that enables
hypogonadal effects of morphine. the brain to induce puberty and regulate the
5. Regarding infertility management, which of the menstrual cycle. Which of the following
following statements are correct? statements are correct?
a. A midcycle human chorionic gonadotropin a. In patients with delayed puberty, sexual
(hCG) injection as part of an in vitro maturation can be induced with continuous
fertilization protocol can induce oocyte GnRH agonist treatment.
maturation by mimicking the LH surge in b. Precocious puberty may be treated with
women. a GnRH long-acting agonist.
b. hCG injection in men can induce testicular c. KP injections induce pulsatile LH secretion in
growth. women with hypogonadotropic
c. Testosterone treatment alone in men can hypogonadism.
potentially lower LH and FSH and thus cause d. GnRH agonists are used in the treatment of
low sperm count. some breast tumors.
d. The prolonged LH-like effect of hCG can lead e. Kisspeptin acts by increasing the secretion of
to ovarian hyperstimulation syndrome. GnRH.
e. Weight reduction can improve fertility in
obese women suffering from PCOS.
6. A 32-year-old female underwent pituitary tumor
Further Reading
surgery for a non-functioning adenoma. After Besser G M & Thorner M O. (2002). Comprehensive Clinical
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European Consensus Statement on congenital
low E2 levels. Which of the following is an
hypogonadotropic hypogonadism – pathogenesis, diagnosis
appropriate treatment choice for her if she is and treatment. Nat Revs Endocr 11, 547–564.
seeking fertility?
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and Neill’s Physiology of Reproduction, 4th Edition;
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52
Chapter
Neuroendocrine Regulation of Appetite and
4 Body Weight
Anorexia nervosa and obesity constitute two extremes up to 50% of adults deemed overweight, and 29% of
of dysfunctional body weight control. Anorexia ner- obese adults – as determined by BMI – were cardiome-
vosa is characterized by low body weight and global tabolically healthy. For example, heavily muscled indi-
endocrine abnormalities, especially of the viduals with increased body weight will have BMI
hypothalamic–pituitary axis, as well as altered adipo- values that may be interpreted as overweight or obese.
kine function and appetite-regulating hormone levels Conversely, 30% of individuals classified as healthy by
(Schorr and Miller, 2017). These same systems are BMI scores were in fact metabolically unhealthy
implicated in the pathology of obesity. How the (Dhurandhar, 2016; Tomiyama et al., 2016). This mis-
brain regulates appetite and body weight has become classification prompted the suggestion that excess body
a vital public health issue, often described as a global fat – largely deposited in the abdominal region – may
obesity epidemic (Schwartz et al., 2017). Obesity is be a superior indicator of metabolic ill health
strongly associated with a decrease in the quality of (Maffetone et al., 2017).
life and an escalating incidence of cardiovascular dis- A prevailing perspective is that obesity is caused
ease, type 2 diabetes, osteoarthritis, certain cancers, by individual greed and self-indulgence in the face of
hypertension, stroke and Alzheimer’s disease (World an abundance of hyperpalatable, energy-dense and
Obesity Federation, 2017; Goodarzi, 2018). low-cost food, as well as a sedentary lifestyle.
A comprehensive and detailed study, assembling Fundamentally, the pathogenesis of obesity appears
data from 195 countries, examined the prevalence of to be straightforward: calories are consumed in
overweight and obesity among children and youth (<20 amounts that exceed ongoing energy expenditure.
years of age) and adults between 1980 and 2015 Nonetheless, not all people faced with such abun-
(The GBD Obesity Collaborators, 2017; see also NCD dance eat too much or become obese and there are
Risk Factor Collaboration, 2017). Based on body mass now efforts to regard obesity as a disease (Editorial,
index (BMI) measurements (weight in kg/height in m2) 2017; World Obesity Federation, 2017). Considerable
a total of 107.7 million children and 603.7 million progress has been made in our understanding of the
adults were obese (BMI>30) in 2015. High BMI was neuroendocrine pathways that regulate appetite and
responsible for 4.0 million deaths globally. the control of body weight, and it is also clear that
The prevalence of obesity has doubled since 1980 in pronounced genetic components may sometimes
more than 70 countries, and increased in many others. underlie a susceptibility to becoming overweight and
In Canada, for example, recent statistics indicate that obese (Yeo, 2017). For example, studies in twin pairs
6.9 million people (>18 years of age) are obese and and in adopted children revealed that a large percen-
9.4 million are overweight (BMI=25–29) (Stats tage of the risk for obesity is heritable (Stunkard et al.,
Canada, 2017). In the United Kingdom, in 2015, 58% 1990; Schwartz et al., 2017). The search for specific
of women and 68% of men were overweight or obese genes through genome-wide analysis revealed more
(GOV.UK, 2017). The United States has the highest than 100 sites (loci) associated with BMI, as well as
incidence of childhood obesity (12.7%). The World strong support for hypothalamic genes that underlie
Obesity Federation estimates that the global cost of regulation of body mass and the susceptibility to obe-
treating obesity-related illnesses will approach US$1.2 sity (Locke et al., 2015; Pigeyre et al., 2016). More than
trillion per year by 2025. Notwithstanding these alarm- 30 obesity syndromes are known, and gene mutations
ing figures, it is worth noting that the use of BMI as for leptin, leptin receptor, melanocortin-4 receptor
a risk indicator of health may be questionable; that is, (MC4 R) and pro-opiomelanocortin (POMC) induce 53
Chapter 4: Neuroendocrine Regulation of Appetite and Body Weight
Figure 4.1 Obesity and the

incidence of some common
chronic diseases. Adapted and
redrawn from the original
(World Obesity Federation,
2017).
hyperphagia and obesity (Heymsfield and Wadden, humans, weight gain as a result of forced over-
2017). Although rare, these examples will be used in eating inhibits the rewarding aspects of food while
the following sections to provide insights into human enhancing satiety, resulting in reduced food intake,
appetite control (see Section 4.3). increased energy expenditure and a return to nor-
mal body weight (Schwartz et al., 2017).
In contrast, food deprivation induces central adap-
4.1 The Neural Control of Appetite tive responses that amplify the rewarding proper-
The major neural centers for the regulation of ties of food and desensitizes the response to satiety
appetite are located in the hypothalamus and signals. The net result is an increase in food con-
brain stem. Although our present understanding sumption (Morton et al., 2014).
of this system is inevitably based on animal experi- Figure 4.3 illustrates in more detail some of the
ments, these control pathways appear to largely hypothalamic neurochemical pathways known to reg-
conform to the available knowledge from human ulate food intake (Schwartz and Morton, 2002).
data. Figure 4.2 outlines in general terms the The clinical relevance of these systems will be
homeostatic regulation of food intake. The brain, described in the following sections, and a case will
and especially the hypothalamus, integrates signals be described illustrating hypothalamic lesion-induced
(e.g., leptin) from adipose tissue (long-term energy hyperphagia (see Uher and Treasure, 2005).
storage) and short-term meal-related signals An informative online poster (Dietrich and
(nutrients, and gut-derived hormones such as Horvath, 2010) illustrates much of the information to
54 ghrelin) to regulate food intake. In normal-weight follow: http://www.nature.com/nrn/posters/feeding.
Leptin Deficiency
Reward
The crucial importance of leptin in the control of
body weight is revealed in humans carrying mutations
Food intake Satiety
that effectively produce leptin deficiency; that is,
either mutations in the leptin gene – that reduce
biologically active leptin – or in the leptin receptor
gene that abolish the effects of leptin. Mutations in the
Nutrient related Short-term
satiety signals leptin receptor signaling pathway are also known, and
Ghrelin these will be described in Section 4.3.
Adiposity-related
(long term) Blood
glucose GLP-1
Mutations in the leptin gene are rare, but affected
PYY
CCK
3–36
children are severely obese and exhibit intense hyper-
phagia and aggressive behavior when food is denied.
Liver
The earliest patients discovered with leptin gene muta-
Stomach
tions had no circulating leptin and they responded to
Insulin CCK leptin treatment with a remarkable reduction in fat
Leptin GI tract
GLP-1
levels and body weight (in children: Farooqi et al.,
Adipose
tissue PYY3–36
2002; Farooqi and O’Rahilly, 2014; in adults: Licinio
et al., 2004). Rather than mutations in the leptin gene,
Figure 4.2 Hormonal and nutrient regulation of food intake. a complete deletion of the gene has also been reported
The brain, and especially the hypothalamus, integrates signals from
long-term energy stores (e.g., leptin from adipose tissue) and short- (Ozsu et al., 2017). This child was grossly obese by the
term meal-related signals (nutrients, and gut-derived satiety signals age of 6 months and exhibited intense hyperphagia.
such as ghrelin) to regulate food intake. Overfeeding inhibits the The effect of leptin deficiency in children is revealed in
rewarding properties of food while enhancing meal-induced satiety,
thereby reducing food intake. In response to energy deprivation, Figure 4.4.
central adaptive responses are engaged that increase the rewarding Other clinical features include high rates of child-
properties of food and reduce the response to satiety signals,
collectively resulting in increased food consumption until deficient
hood infection, hyperinsulinemia, type 2 diabetes as
fat stores are replenished. Reproduced with permission (Morton adults, hypothyroidism (low thyroxine [T4], high thyr-
et al., 2014). Abbreviations: CCK, cholecystokinin; GI, gastrointestinal; oid stimulating hormone [TSH]), absence of puberty
GLP-1, glucagon-like peptide-1; PYY3-36, peptide YY. and hypogonadotropic hypogonadism. The assay of
serum leptin levels would seem to be an effective test
in patients with severe early-onset obesity; an undetect-
4.2 Leptin: A Fat-Derived Peptide able serum leptin level being suggestive of congenital
Hormone leptin deficiency. However, another form of leptin gene
Adipose tissue is a large endocrine organ that secretes mutation leads to high levels of immunoreactive serum
a new family of hormones called adipokines leptin that has no biological activity; that is, it does not
(Fasshauer and Blüher, 2015). This section will focus bind to leptin receptors (Wabitsch et al., 2015).
on leptin as the prototypical adipokine, although Treatment of these patients with recombinant human
many more adipokines have now been identified leptin normalized weight loss and eating behavior.
(Beall et al., 2017). Since its discovery in 1994, leptin A similar clinical picture is seen in patients with
has generated thousands of publications and is impli- a mutation in the leptin receptor; that is, signaling at
cated in many neural, reproductive, metabolic, the mutant receptor is impaired, so that these patients
immune, endocrine and neuroendocrine systems are effectively leptin free even though leptin levels are
(Farooqi and O’Rahilly, 2014; Friedman, 2016). The high (Farooqi et al., 2007). They are also characterized
generally accepted view of leptin’s mode of action is by severe obesity, hyperphagia, abnormal immune func-
its ability to reduce food intake and to maintain body tion and delayed puberty due to hypogonadotropic
fat levels. It does this by instructing the hypothalamus, hypogonadism. The elevated serum leptin levels are
which contains leptin receptors, to reduce appetite typical of the obese state and reflect the increase in fat
and increase energy expenditure (Figure 4.3). mass.
55
Neuron
NPY
α–MSH Food Energy
intake expenditure
INCREASE AgRP
APPETITE
DECREASE
APPETITE
NPY
NPY/ Arcuate
AgRP nucleus
Third POMC
ventricle
Melanocortin (MC4R)
– receptor for MSH
+
–
+ Ghrelin
GHRELIN
PYY3–36 STOMACH PYY/GLP-1/CCK
GLP-1
INSULIN
CCK AMYLIN NPY
LEPTIN
Insulin or leptin or
amylin
GI TRACT Duodenum
PANCREAS
ADIPOSE
TISSUE
Figure 4.3 Neuroendocrine control of food intake. The figure illustrates the crucial role of the hypothalamic arcuate nucleus in regulating food
intake. Leptin and insulin (co-released with amylin) circulate in the blood at concentrations proportional to body fat mass. They decrease
appetite by inhibiting neurons that produce the molecules NPY and AgRP, at the same time stimulating α-MSH (POMC) neurons in the arcuate
nucleus. NPY and AgRP stimulate eating, and α-MSH inhibits eating, via other neurons (top). Activation of NPY/AgRP-expressing neurons
inhibits POMC neurons, either directly through NPY receptors or by AgRP blocking the effects of α-MSH. The hormone ghrelin stimulates
appetite by activating the NPY/AgRP-expressing neurons. PYY3-36 and GLP-1, released from the small intestine, inhibit these neurons and
thereby decrease appetite. Reproduced with permission (Schwartz and Morton, 2002). Abbreviations: AgRP, agouti-related peptide; CCK,
cholecystokinin; GI, gastrointestinal; GLP-1, glucagon-like peptide-1; MSH, melanocyte-stimulating hormone; NPY, neuropeptide Y; POMC, pro-
opiomelanocortin; PYY, peptide YY.
Leptin and Amenorrhea gonadotropin secretion. This may also be true in

Leptin deficiency – in terms of low serum levels – is leptin-treated adult leptin-deficient males, where tes-
also encountered in certain conditions where the lep- tosterone and free testosterone reached normal adult
tin gene is functional and leptin receptors are normal. values along with the appearance of secondary sexual
For example, anorexia nervosa patients have abnor- characteristics (Paz-Filho et al., 2015). In women with
mally low serum leptin levels, as do some patients an intact leptin gene, and in the absence of organic
with hypothalamic amenorrhea. The critical impor- disease or ovarian failure, hypothalamic amenorrhea is
tance of leptin for normal reproductive function was most commonly associated with stress, weight loss or
clearly demonstrated in those leptin-deficient chil- intense athletic exercise (see Section 3.3). Such condi-
dren described earlier (Figure 4.4). Leptin treatment tions disrupt normal neuroendocrine processes,
resolved the problems of hyperphagia and obesity but, induce premature osteoporosis, decrease fat mass
significantly, allowed these children to enter puberty and reduce serum leptin levels, resulting in anovula-
and to exhibit pulsatile gonadotropin secretion (Chou tion (Chou and Mantzoros, 2014; Paz-Filho et al.,
and Mantzoros, 2014; Farooqi and O’Rahilly, 2014). 2015). In two clinical trials, leptin replacement in
The assumption here is that leptin had a positive effect amenorrheic women reduced body weight and fat
56 mass and significantly elevated luteinizing hormone
on the hypothalamic regulation of pituitary
human leptin increases nocturnal LH secretion in

patients with lipodystrophy, suggesting that leptin has
a direct effect on the hypothalamic–pituitary system
(Abel et al., 2016).
Obesity and Leptin Excess

In contrast to those obese patients with deficient leptin –
that is, because of leptin gene mutations (see earlier in
the chapter) – obesity in the general population is
characterized by increased serum leptin levels due to
the enlarged adipose tissue mass. Figure 4.6A illustrates
that serum leptin concentrations are positively corre-
lated with percent of body fat and are significantly
higher in obese compared with normal-weight indivi-
duals (31.3+/-24.1 vs. 7.5+/-9.3 ng/mL; p<0.001;
Considine et al., 1996; see also Sahin-Efe et al,. 2017).
This figure also includes the different percent body fat
range in males and females (Guerra et al., 2008).
Figure 4.4 Leptin treatment of an obese child. Left panel, a 3-year- Figure 4.6B illustrates that women have significantly
old boy with congenital leptin deficiency (body weight: 42 kg). higher leptin levels than do men (x3.4; p<0.05); in both
On the right, the same boy, after four years of daily subcutaneous
injections of recombinant human leptin. Leptin induced a striking sexes leptin levels are proportional to fat mass and BMI
decrease in body fat (body weight: 32 kg). Reproduced with (p<0.001; Guerra et al., 2008).
permission (Farooqi and O’Rahilly, 2014). The data in Figure 4.6A imply that obese indivi-
duals are insensitive to their own leptin; that is, high
(LH), LH pulse frequency and estradiol concentra- levels of leptin secretion fail to reduce food intake or
tions. The effect of leptin on LH secretion in two body weight. By analogy with the insulin resistance
amenorrheic patients is illustrated in Figure 4.5 seen in type 2 diabetes, the common forms of diet-
(Welt et al., 2004). Evidence of ovulation and related obesity are thought to be attributable to “leptin
increased bone health in some patients confirm the resistance,” a state in which multiple cellular pro-
involvement of the hypothalamus (Chou and cesses block leptin receptor signaling (Myers et al.,
Mantzoros, 2014; Kyriakidis et al., 2016). 2010). The phenomenon of leptin resistance suggests
that leptin treatment of obesity is unlikely to be
Lipodystrophy and Leptin Deficiency a therapeutic option. This proved to be correct.
Lipodystrophy – the complete or partial absence of fat Consistent with an earlier study (Heymsfield et al.,
tissue – is a rare disorder associated with severe insulin 1999), treatment of overweight and obese men and
resistance, diabetes and hyperphagia (Fiorenza et al., women (n=284) for 12 weeks with twice-daily injec-
2011). Most patients with generalized lipodystrophy tions of leptin failed to induce meaningful weight loss
are leptin-deficient and physiological replacement (Zelissen et al., 2005).
doses of leptin induce improvements in insulin sensi- However, one component of leptin resistance is
tivity, glucose tolerance and levels of fasting glucose believed to be leptin’s inability to penetrate the
(Paz-Filho et al., 2015). Lipodystrophic patients also blood–brain barrier to reach hypothalamic leptin
exhibit reproductive dysfunction such as amenorrhea, receptors. This problem may be amenable to clinical
reduced fertility, polycystic ovarian syndrome, hyperan- intervention through development of leptin analogs
drogenism (in adults) and central hypogonadism in that improve access of leptin to the central nervous
children (Brown et al., 2016). Recombinant human system (Yi et al., 2014; Rhea et al., 2017). A further
leptin treatment of adult women with this syndrome promising approach, and one which has shown clin-
decreased free testosterone levels, improved insulin sen- ical utility already (see later in this chapter), is to take
sitivity and induced normal menstruation (Musso et al., advantage of the known anorexigenic properties of
2005). It is possible that leptin replacement acts on the gut peptides such as glucagon-like peptide-1 (GLP-
neuroendocrine hypothalamus; that is, recombinant 1) and amylin (see Figure 4.3). 57
Figure 4.5 Representative patterns of pulsatile LH secretion in two leptin-treated amenorrheic women. Subjects had secondary hypothalamic
amenorrhea for 6 months or more. BMI values were in the normal range (18–24 kg/m2). Leptin treatment (recombinant human leptin) was self-
administered (0.08 mg/kg; daily, subcutaneous). Panel A shows a non-pulsatile pattern (two subjects) at baseline, which improved to
a normal or low-frequency pattern during 2 weeks of leptin treatment. Panel B shows a low-frequency pattern (four subjects) before treatment,
which improved to normal during treatment. Pulses of LH are indicated by asterisks. Data obtained from Welt et al. (2004).
Leptin and Gut Peptides in Control of Appetite and Body subjects, the combination of recombinant human lep-
Weight tin and the amylin analog pramlintide significantly
The ability of amylin – co-released with insulin from induced weight loss compared to leptin or pramlin-
the pancreas (Figure 4.3) – to control appetite and tide alone (Figure 4.7).
body weight in experimental animals is well
described, but this type of peptide may also be clini- 4.3 Other Genetic Forms of Obesity
cally useful (Hay et al., 2015). This topic will be cov- We have seen that mutations in the leptin gene, or
ered in more detail in subsequent sections (see leptin receptor gene, have profound effects on body
Section 4.4), but the successful use of amylin is weight. Other monogenic mutations in the hypotha-
described here. In contrast to the lack of effect of lamic leptin–melanocortin pathway, although rare,
leptin in reducing body weight, the combination of constitute experiments of nature that confirm the
leptin with an amylin agonist induced significant critical importance of this signaling pathway in the
weight loss in obese subjects (Ravussin et al., 2009; control of appetite. For example, since POMC neu-
58 Tam et al., 2011). In a 24-week, randomized, double- rons decrease appetite through the release of α-
blind, proof-of-concept study in obese or overweight melanocyte-stimulating hormone (α-MSH) that
A final example illustrates a contemporary

approach to identifying genes implicated in the induc-
tion of obesity. The sequencing of the human genome
has permitted gene-mapping studies – called genome-
wide association studies – that revealed a new gene
robustly linked to human obesity. This is the fat mass
and obesity related (FTO) gene (Loos and Yeo, 2014).
POMC Deficiency
First reported in 1998, children with mutations of the
POMC gene were deficient in α-MSH and adrenocor-
ticotropin (ACTH) peptides that are normally pro-
duced from cleavage of the POMC propeptide (see
Chapter 5; Figure 5.4) (Krude et al., 1998; Krude and
Grüters, 2000). The absence of ACTH resulted in
adrenal insufficiency, whereas the lack of α-MSH led
to pale skin and red hair, reflecting absent stimulation
of melanocytes in the skin and hair follicles. Life-
threatening adrenal insufficiency was treated with
hydrocortisone. The loss of α-MSH, and the subse-
quent signaling deficit at hypothalamic MC4 R recep-
tors, induced early-onset obesity and hyperphagia.
Subsequent reports have confirmed this early study
(Mendiratta et al., 2011; Çetinkaya et al., 2018).
An important approach in treating this syndrome
was the attempt to use hormone-replacement therapy;
that is, to reverse the α-MSH deficiency by stimulating
hypothalamic MC4 R with a synthetic MC4 R agonist,
setmelanotide (Kühnen et al., 2016; Reitman, 2016),
which is significantly more potent than the endogen-
Figure 4.6 Variation of leptin levels with percentage body fat (A) and
ous neuropeptide α-MSH (Collet et al., 2017). Two
fat mass/sex (B). (A) illustrates the dependence of serum leptin on the patients with POMC deficiency (BMI values: 54.1 and
percentage of body fat in 136 normal-weight and 139 obese 49.8 kg/m2) were markedly hyperphagic and obese
subjects. Plotted with data obtained from Considine et al. (1996). (B)
reveals the positive relationship between serum leptin levels and fat
(Figure 4.8A). Treatment with setmelanotide (subcu-
mass, but also shows that leptin levels are higher in women taneous, daily) over 40 weeks (patient #1) and 12
compared with men (p<0.05; men, n=34; women, n=33). Data weeks (patient #2) induced a large, sustained reduc-
obtained from Guerra et al. (2008).
tion in hunger scores and in body weight (Figure 4.8B
& 4.8C). In addition, a marked darkening of the skin
binds to the MC4 R receptor (Figure 4.3), mutations and hair was observed. Both patients reported
in the POMC gene or in the MC4 R gene are likely to a dramatic improvement in their quality of life after
affect food intake. initiation of treatment. Also shown is the rapid, but
In this section examples of these two mutations will reversible, change in weight gain and hunger during
be described: first, patients with a mutation in the a brief (3 weeks) off-treatment phase in patient #1.
POMC gene have early-onset obesity and severe hyper- Although this proof-of-principle study involved
phagia because of the lack of α-MSH; second, patients only two patients, it confirmed the fundamental
with MC4 R mutations who are insensitive to α-MSH importance of the leptin–melanocortin pathway in
are also obese and hyperphagic. Also included in this regulating human body weight and appetite.
section is an example of a multigenic disorder – A significant clinical question, given the apparent
Prader–Willi syndrome (PWS) – which is the most lack of serious side effects of this drug treatment, is
common cause of syndromic obesity. whether other forms of obesity might also be reversed 59
Figure 4.7 Weight loss with leptin/amylin treatment in obese/

overweight subjects. Absolute change in body weight (kg) from
enrollment (4 weeks) in three groups (BMI values approx.
32 kg/m2): recombinant human leptin, n=19; pramlintide,
n=38; pramlintide/leptin, n=36. Values are means ±SEM. **
p<0.01 for combination treatment vs. leptin or pramlintide
alone. Data obtained from Ravussin et al. (2009).
A. Pre-therapy weight of the two patients B. Patient 1 during treatment

160 0 10
150 Off-treatment
phase 8
Hunger score
140 –20
6
130
120 4
Patient 1 –40
110 2
100
Body Weight (kg)
–60 0
Patient 2 90 0 10 20 30 40 50
80 Week of treatment
97th 70 C. Patient 2 during treatment

0 10
percentile
e 60
–5 8
50th 50
Hunger score
percentile
e
40 –10 6
30
–15 4
20
–20 2
10
0 –25 0
1 2 4 6 8 10 12 14 16 18 0 5 10 25
Age (yr) Week of treatment
Figure 4.8 Obesity in POMC deficiency treated with an MC4 R agonist, setmelanotide. (A) illustrates the body weight changes in two POMC-
deficient girls in the first 18 and 17 years of life, compared with the normal percentiles of girls of the same age. (B) shows the weight change
and hunger scores (on a scale of 0=no hunger, to 10=extreme hunger) in patient #1 during treatment with setmelanotide. After the initial 13
weeks of treatment, this patient entered a 3-week off-treatment phase before treatment was restarted. Note the rapid change in hunger score
60 and a 4.8 kg increase in body weight. These changes were reversed on re-instatement of treatment. (C) shows similar weight change and
hunger scores in patient #2 during 12 weeks of therapy. Data obtained from Kühnen et al. (2016).
by MC4 R agonists (Müller et al., 2016). The following and TSH deficiencies, central adrenal insufficiency
section indicates that setmelanotide does induce (CAI) and hypogonadotropic hypogonadism.
weight loss in obese patients. It remains unknown whether the critical
leptin–melanocortin pathway is in any way responsi-
MC4R Deficiency ble for the obesity in PWS, although several reports
MC4 R deficiency is the most common known cause indicate that leptin levels are elevated, probably
of monogenic obesity. About 150 naturally occurring reflecting leptin resistance in these children. For
MC4 R gene mutations have been identified, and the example, in a large group of PWS patients (ages 7
prevalence of these mutations varies from 0.5 to 5.8% months–5 years) fasting plasma leptin levels were
in obese children and is around 2.3% in obese adults significantly higher compared to controls (Goldstone
(Valette et al., 2013). Some, but not all, of these chil- et al., 2012). The missing chromosome 15q11-q13
dren exhibited mealtime hyperphagia (Valette et al., contains a large number of genes of unknown func-
2014). In addition to severe obesity, patients had tion (Angulo et al., 2015).
increased lean mass, increased linear growth and Clinical implications: Hormonal assessment in
severe hyperinsulinemia (Farooqi et al., 2003). patients with PWS includes testing for GH deficiency,
The incidence of obesity was more severe in patients hypogonadism, adrenal insufficiency, hyperglycemia
with complete loss as opposed to partial loss of func- and osteoporosis. Treatment with human GH has
tion of MC4 R, indicating that control of human body been shown to increase linear height, improve body
weight is sensitive to quantitative variations in the composition by reducing adiposity and improve bone
level of functional MC4 R. quality (Bakker et al., 2017). Hypogonadism is com-
In a 28-day Phase 1b clinical trial, Collet et al. (2017) mon in PWS and may be associated with cryptorchid-
tested the hypothesis that setmelanotide treatment (sti- ism in boys. Treatment with human chorionic
mulation of MC4 R receptors) would induce weight loss gonadotropin has been shown to improve cryptorch-
in MC4 R-deficient patients; that is, by “rescuing” sig- idism (Bakker et al., 2015); additionally, treatment
naling by mutant MC4 R receptors. Their results with sex steroids is given to induce puberty and
showed a significant weight loss in patients with improve bone mass. A high prevalence of CAI in
MC4 R deficiency, and in obese controls. No changes PWS was reported (de Lind van Wijngaarden et al.,
were seen in heart rate or blood pressure, and other 2008), although others have not found a high risk of
adverse events were generally mild and well tolerated. CAI (Farholt et al., 2011). If identified, CAI should be
In a separate short-term study on obese patients, set- treated with glucocorticoid-replacement therapy and
melanotide successfully increased resting energy expen- expert opinion from a pediatric endocrinologist
diture (Chen et al., 2015). Overall, these data suggest should be sought.
that setmelanotide, by targeting the MC4 R receptor, is
a promising drug candidate for the treatment of obesity. The FTO Gene
The initial report on FTO identified a common gene
Prader–Willi Syndrome variant that predisposed patients to type 2 diabetes.
PWS is the most common syndromic obesity disor- It soon became obvious that this was mediated
der, affecting both sexes at similar rates, with esti- entirely through effects on BMI (Frayling et al.,
mates of annual prevalence of 1 in 10,000 to 1 in 2007). This was not detectable at birth, but was evi-
30,000 live births. Infantile hypotonia and failure to dent by the age of 7 years and persisted through
thrive are typical, followed by obesity and hyperpha- adulthood into old age. Several variants are now
gia in childhood (Angulo et al., 2015; Irizarry et al., known and are associated with substantial changes
2016). PWS occurs through a lack of multiple pater- in BMI, hip circumference and body weight (Scuteri
nally inherited genes on chromosome 15q11.2-q13, et al., 2007; Tung et al., 2014). Some reports, although
resulting in features such as short stature, develop- not all, link the FTO gene with increased energy
mental delay, cognitive disability and behavioral pro- intake, elevated intake of dietary fat, increased appe-
blems. Hypothalamic dysfunction is likely responsible tite and impaired satiety (Tung et al., 2014; reviewed
for obesity/hyperphagia, faulty temperature control, in Speakman, 2015).
high pain threshold, hypersomnia and multiple endo- Even though there is compelling genetic evidence
crine abnormalities including growth hormone (GH) that FTO gene variants are associated with increased 61
BMI, the mechanisms by which they lead to increased contraction/relaxation of smooth muscle walls and
eating behavior and obesity remain unknown. sphincters, and secretion of fluids and electrolytes.
However, FTO gene expression is enriched in human Even anticipation of a meal causes secretion of some
brain, especially in hypothalamus and cortex (Frayling hormones, and the mechanical and chemical stimula-
et al., 2007), suggesting that FTO expression is found tion of the stomach and intestine, caused by the pre-
in a brain location appropriate for appetite and body sence of food, induces release of hormones from the
weight control. In this regard, a more specific mechan- GI tract.
istic link has been established between FTO variants Figures 4.2 and 4.3 summarize how some of these
and circulating levels of the gut hormone ghrelin (see peptides target the hypothalamus. Ghrelin (from the
Section 4.4). Ghrelin is known to be orexigenic and stomach) is the only peptide illustrated that is orexi-
appears to be regulated by FTO (Karra et al., 2013). genic, the rest – GLP-1 and peptide YY (PYY; from
In brief, this report suggests that in response to eating, the small intestine), cholecystokinin (CCK; from the
people with an FTO obesity-risk gene variant fail to duodenum) and amylin (from the pancreas) – inhibit
suppress their hunger and circulating ghrelin levels; appetite and are therefore anorexigenic. Note that
that is, food intake suppressed circulating ghrelin these peptides represent variable short-term signals
levels in control subjects, whereas the same caloric triggered by eating patterns. In contrast leptin, for
load failed to suppress ghrelin appropriately in the example, exerts a long-term regulation that reflects
patients carrying the FTO mutation. In a subsequent adipose tissue stores.
study, in much older individuals, an overnight fast The following sections will focus on two clinically-
significantly elevated ghrelin levels in FTO variant relevant peptides that influence food intake in
carriers compared to controls (Benedict et al., 2014). humans: ghrelin (orexigenic) and GLP-1 (anorexi-
In summary, mutations in the FTO gene may genic). GLP-1, together with glucose-dependent insu-
encourage weight gain by affecting hormonal signals, lin releasing polypeptide (GIP), is an incretin
such as ghrelin, that stimulate appetite. However, an hormone released in humans in response to nutrient
influence of FTO on peripheral targets, such as adi- ingestion and serves to potentiate the glucose-induced
pose tissue, cannot be ruled out (Yang et al., 2017). insulin response (Gautier et al., 2008).
A more detailed appreciation of the interaction GIP will not be discussed further other than to
between FTO and its neural/peripheral targets may point out that GIP is implicated in a distinct but rare
offer new therapeutic approaches to reverse the global entity of food-induced hypercortisolism (Cushing’s
obesity epidemic. syndrome; see Chapter 5). In such patients, food
ingestion releases GIP from the small intestine in
4.4 Gastrointestinal Peptides: physiological concentrations. It then binds to aber-
rant adrenal GIP receptors to drive a postprandial
The Gut–Brain Axis increase in plasma cortisol. These patients develop
The neural control systems for energy homeostasis are Cushing’s syndrome due to the exuberant post-meal
dependent on accurate information from nutrient cortisol production, which is independent of ACTH
sensor mechanisms that are distributed through the (Messidoro et al., 2009). The condition is managed by
gastrointestinal (GI) tract. During and after food the removal of the adrenal gland (adrenalectomy).
ingestion, these sensors send signals to central regu- Other gut peptides, not covered here, may be
latory centers, including the hypothalamus. Such clinically useful in controlling energy intake. For
feedback signals are mediated not only by sensory example, a subcutaneous infusion of GLP-1 plus
neurons but by peptide hormones as well. This section PYY significantly reduced food intake by 32% in
will focus on several peptide hormones now known to obese volunteers (Tan et al., 2017). The combination
be important in human appetite control. of leptin and amylin is also effective in reducing body
GI tract tissue represents a large endocrine organ weight (see Figure 4.7; Ravussin et al., 2009).
that expresses at least 30 peptide genes that in turn
produce more than 100 bioactive hormonal peptides Ghrelin
(Rehfeld, 2017). These peptides target the brain to Ghrelin is primarily produced and secreted from the
control both hunger and satiety but also influence stomach. It is the most potent GH secretagogue known.
62 the GI tract directly to influence digestion, Ghrelin infusion, in men and women, synergizes with
Figure 4.9 Meal-related changes in plasma

ghrelin. Plasma levels of (A) ghrelin and (B)
insulin during a 24-hour period in ten healthy
human subjects consuming breakfast, lunch
and dinner at the times indicated (0800, 1200
and 1730, respectively). Note the rapid
increase in ghrelin levels in the preprandial
period, falling back to control values within
1 hour after eating. Insulin surges are exactly
reciprocal. Values are means +/-SEM. Data
obtained from Cummings et al. (2001).
GHRH to stimulate pulsatile release of GH from soma- which is reversed after waking, in anticipation of
totrophs (Chapter 8; see for example Figure 8.9). breakfast (Spiegel et al., 2011).
In this section, we will outline the evidence that The determination of ghrelin levels is complicated
ghrelin is also implicated in the control of energy because the biologically active form of ghrelin is acyl
intake. Studies in experimental animals revealed ghrelin, which constitutes only about 10% of total
that plasma levels of ghrelin are increased by fast- plasma ghrelin. However, using specific immunoas-
ing and that injections of ghrelin potently increased says, a comparison of the secretory profiles of total
food intake (Gardiner et al., 2008). In human stu- ghrelin and acyl ghrelin through 24 hours indicates
dies, under physiological conditions, ghrelin levels that both are affected in the same way (Spiegel et al.,
rise and fall according to meal times, indicating 2011); that is, increases in ghrelin secretion precede
that ghrelin plays a role in the initiation of meals. meals and accompany sleep.
Figure 4.9 shows that ghrelin levels rise before Is there evidence for an effect of exogenous ghrelin
meals, followed by a rapid postprandial decline on human food intake? Infusions of ghrelin to achieve
(Cummings et al., 2001). Figure 4.9 also shows plasma levels in the physiological range in healthy
the reciprocal temporal patterns of insulin and young males failed to increase subjective hunger,
ghrelin peaks. The rise in ghrelin secretion asso- meal timing or meal size (discussed in Lippl et al.,
ciated with sleep reflects what is essentially 2012). This lack of effect is probably due to the short
a prolonged period of fasting followed by half-life of native ghrelin (30 min) and this may
a decline later during the night. This indicates a account for previous contradictory reports of
possible sleep-induced inhibition of ghrelin release, a positive effect of ghrelin on human appetite (see 63
e.g., Druce et al., 2005). In contrast, a synthetic, long- proglucagon polypeptide is cleaved by prohormone
acting, orally active ghrelin mimetic – anamorelin – convertases to glucagon, but in the GI tract it is
significantly increased appetite, food intake and body processed into GLP-1, which is then released from
weight in healthy volunteers (Garcia and Polvino, cells located in both the small and large intestine
2007). Based on this study, anamorelin was tested (see Figure 4.2). Secretion is rapidly stimulated by
for its effects on cancer anorexia-cachexia syndrome food intake, but GLP-1 is quickly degraded in the
(Garcia et al., 2015; Currow et al., 2017). These blood so that only approximately 15% circulates as
patients undergo involuntary weight loss with the biologically active peptide (Steinert et al., 2017).
decreased muscle mass, poor quality of life and Specific immunoassays are available to determine
decreased survival. Results indicated that 12–24 both active and inactive forms (Bak et al., 2014).
weeks of oral anamorelin treatment for patients with “Total” GLP-1 levels (active plus inactive) represent
cancer anorexia-cachexia syndrome produced the amount of GLP-1 secreted from the GI tract,
increases in lean body mass versus placebo, with whereas the “active” amounts represent the biologi-
improvements in muscle strength and quality of life cally active form necessary for the brain to respond.
(Garcia, 2017). In keeping with the studies on anor- Figure 4.10 illustrates that the pattern of meal-
exia-cachexia syndrome, levels of ghrelin are also ele- induced secretion is similar for total and intact GLP-
vated in patients with anorexia nervosa (Colldén et al., 1, although the absolute amounts are not (Carr et al.,
2017). However, as noted earlier, this conclusion is 2010; see also Alsalim et al., 2015).
uncertain because of the different forms of ghrelin These data also show that both forms of GLP-1
assayed. Nonetheless, other reports confirm elevated secretion are significantly reduced in healthy, obese
levels of ghrelin in anorexia nervosa (Hotta et al., young men compared with lean controls. This sug-
2012). Nutritional support of these patients is gests that lower levels of obesity-associated GLP-1 fail
required to improve endocrine problems and quality to reduce appetite and food intake.
of life (Schorr and Miller, 2017), but infusion of ghre- What is the evidence for GLP-1 acting as
lin over 14 days gave inconclusive results. Again, the a satiety factor to inhibit food intake in humans?
short half-life of ghrelin is a shortcoming of this Some, but not all, studies show that intravenous
investigation and the use of anamorelin would be GLP-1 given to healthy subjects significantly
justified in future studies. reduced food intake (Steinert et al., 2017).
Serum levels of ghrelin are also affected by The inconsistent results of GLP-1 treatment prob-
increases in body weight. For example, in obese chil- ably reflect the rapid degradation (elimination half-
dren – either with MC4 R or leptin gene mutations life ~2 min) of injected native GLP-1. Efforts to
(see Section 4.3) – ghrelin levels are significantly make available synthetic, long-acting GLP-1 ago-
reduced (Haqq et al., 2003) and a similar reduction nists to treat obesity have been successful. For
is seen in obese adults (BMI>30 kg/m2; Tschöp et al., example, liraglutide has a half-life of about
2001). These observations seem counterintuitive, in 13 hours and is approved for the indication of
the sense that increases in plasma ghrelin stimulate obesity (Mancini and de Melo, 2017). Figure 4.11
hunger/appetite whereas decreases are coincident illustrates the results of a double-blind, placebo-
with satiety (Figure 4.9). Since obesity is induced by controlled trial that compared the influence of orli-
increases in caloric intake, the reduction in ghrelin stat with daily, subcutaneously injected liraglutide
levels appears to be an unsuccessful attempt to sup- (Astrup et al., 2009; Pi-Sunyer et al., 2015; Halawi
press hunger. It remains possible that a ghrelin et al., 2017). Orlistat is an approved weight-loss
antagonist, by inhibiting the effects of the remaining agent that acts as a GI lipase inhibitor. Liraglutide
circulating ghrelin, could induce weight loss. induced significant weight loss at all doses com-
Research by the pharmaceutical industry is currently pared with placebo.
aimed at developing such antagonists (Davenport and Other GLP-1 agonists – such as exenatide (Byetta),
Wright, 2014). lixisenatide (Lyxumia), dulaglutide (Trulicity) and
albiglutide (Tanzeum) – are already approved in the
Glucagon-Like Peptide-1 United States and Europe for the treatment of type 2
GLP-1 is encoded by the same gene that expresses diabetes (Finan et al., 2015), and newer formulations
64 glucagon in the pancreas; that is, in the pancreas, the of exenatide and others, such as semaglutide, have
Total GLP-1 Intact GLP-1

40 12
35
Intact GLP-1 (pmol/L)

Total GLP-1 (pmol/L)
30 8
25 Lean Lean
4
20
Obese Obese
15
0
10
0 60 120 180 240 300 0 60 120 180 240 300
Time (min) Time (min)
Figure 4.10 Effects of meal ingestion on GLP-1 in obese and lean volunteers. Subjects were given a mixed meal (560 kcals) following an
overnight fast. Plasma samples were obtained at the time intervals shown, over 300 min. Values are +/-SEM; lean volunteers (n=12) and obese
(n=13) had BMI values of 22.3 kg/m2 and 33.8 kg/m2, respectively. Data obtained from Carr et al. (2010).
–1
–2
Mean weight loss (kg)
–3
Randomization
–4 Placebo
Screening
–5
Orlistat
–6
Liraglutide 1.2 mg
–7 Liraglutide 1.8 mg
Liraglutide 2.4 mg
–8
Liraglutide 3.0 mg
–9
–5 –3 0 5 10 15 20
Weeks
Figure 4.11 Liraglutide-induced weight loss in obese individuals. These data were obtained from a double-blind, placebo-controlled trial (564
individuals; BMI=30–40 kg/m2). Four liraglutide doses were used (1.2 mg, 1.8 mg, 2.4 mg or 3.0 mg, n=90–95 per group; or placebo, n=98)
given once a day subcutaneously. Orlistat (120 mg, n=95) was given three times a day orally. The effects of liraglutide vs. placebo at week 20
were significant all doses (p=0.003 to p<0.0001). Liraglutide vs. orlistat was significant at the two highest doses (p=0.003 and p<0.0001).
Reproduced with permission (Astrup et al., 2009).
a longer half-life, making them suitable for once- promising results from early clinical tests (Tschöp
weekly injections. et al., 2016; Kleinert et al., 2017). For example,
The most frequently reported adverse events with Figure 4.12 illustrates the effectiveness of a GLP-1/
GLP-1 treatment were mild or moderate nausea and glucagon poly-agonist. The authors suggest that the
diarrhea. Efforts to circumvent these effects have coordinated action of these two hormones enhanced 65
focused on the use of drug combinations with efficacy and avoided adverse effects.
Target tissues
Pancreas Liver Brain SNS/BAT
Glucose handling Food intake

Insulin sensitivity Energy expenditure
Body weight
Leptin sensitivity
Figure 4.12 Effects of GLP-1/glucagon poly-agonist on obesity and type 2 diabetes. Reproduced with permission (Kleinert et al., 2017).
Abbreviations: BAT, brown adipose tissue; SNS, sympathetic nervous system.
4.4.1 A Case of Hypothalamic Obesity Fasting urine osmolality=80 mmol/kg (50–1400)

A diagnosis of hypopituitarism was made on the
A 20-year-old university student presented to the
basis of low serum cortisol and ACTH (secondary
emergency department with a 3-week history of wor-
hypoadrenalism), low serum T4 and inappropriately
sening headache and deteriorating vision. He also
normal TSH (secondary hypothyroidism), and low tes-
mentioned that during the past 3 months he had
tosterone, LH and FSH (secondary hypogonadism).
been excessively tired and noticed increased thirst
Mildly elevated serum prolactin was likely due to com-
and excessive urination. His parents indicated that
pression of the pituitary stalk (i.e., reduced dopamine
he was rapidly gaining weight (around 15 lbs in less
reaching the pituitary). A high fasting serum osmolality
than 2 months) and was always hungry. The family
with non-concentrated urine (low urine osmolality),
doctor checked his fasting serum glucose, which was
with clinical features of excessive thirst and urination,
normal at 4.8 mmol/L. Imaging studies, including
suggested diabetes insipidus (see Chapter 9). He was
computed tomography and magnetic resonance
initiated on replacement therapy with hydrocortisone,
image of the brain, showed multiple lesions including
levothyroxine, testosterone and desmopressin and was
the suprasellar area (2.1 x 2.0 cm), septum pellucidum
given combined chemotherapy (Carboplatin and
and the posterior fossa (Figure 4.13).
Etoposide) and stereotactic radiation therapy to the
A biopsy of the posterior fossa lesion confirmed
suprasellar lesion. He gained another 25 lbs over the
a germinoma. Due to the sellar involvement, he
next 3 months, at which point his weight stabilized.
underwent pituitary hormonal testing at 0900h,
Follow-up imaging studies showed regression of the
which showed the following:
suprasellar mass and stability of the remaining lesions.
Cortisol < 28 nmol/L (120–550)
He started exercising and had lost 5 lbs at his last visit.
Serum ACTH=1.1 pmol/L (2.3–10.1)
This case describes a typical scenario of hypotha-
LH<0.1 U/L (0.6–12)
lamic obesity (HO; Roth et al., 2015) which generally
FSH<0.1 U/L (1.0–12)
occurs either due to the tumor involving the hypotha-
Testosterone=8.6 nmo/L (9.0–32)
lamus, or as a result of tumor management, such as
Prolactin=42.5 mcg/L (3.5–19.4)
surgery or radiation therapy. Although craniopharyn-
TSH=1.47 mIU/L (0.35–4.3)
giomas account for almost half of these cases, germi-
Free T4=8.3 pmol/L (9.0–19)
nomas are also associated with this syndrome. HO is
GH=0.09 mcg/l (<3.0)
a complex disease caused by dysregulation of energy
Fasting serum osmolality=308 mmol/kg
66 (283–292)
metabolism and characterized by hyperphagia and
Figure 4.13 An MRI image (coronal section) showing the

hypothalamic lesion.
rapid, intractable weight gain. Of note, weight gain in office showed a fasting serum glucose of 6.8 mmol/L
these patients tends to continue despite caloric restric- (normal=3.6–5.7), which when repeated one week
tion (Bray and Gallagher, 1975) with significant reduc- later was 6.6 mmol/L. The referring physician was
tion in energy expenditure (Harz et al., 2003). HO is concerned that the patient had Cushing’s syndrome.
associated with a high risk of type 2 diabetes, cardiovas- The patient denied any clinical features of adrenal
cular disease, sleep apnea and non-alcoholic fatty liver or thyroid dysfunction and her periods were regular.
disease (Deepak et al., 2007). Several treatment options Her blood pressure was 140/92 mm Hg, she had gen-
have been proposed, including: severe caloric restriction, eralized obesity with no other clinical features of
sibutramine (Arango et al., 2002), amphetamines (Ismail excess cortisol (such as skin thinning, bruising, prox-
et al., 2006), metformin (Igaki et al., 2005) and GLP-1 imal muscle weakness and facial plethora) and the
analogs (Thondam et al., 2012). In addition, surgical remaining clinical exam was unremarkable.
options such as bariatric surgery have been reported Preliminary investigations revealed the following:
(Inge et al., 2007; Schultes et al., 2009). Morning serum cortisol=312 nmol/L (120–550)
TSH=2.3 mIU/L (0.35–4.3)
4.4.2 A Case of Drug-Induced Obesity Free T4=12.7 pmol/L (9.0–19)
24-hour urinary free cortisol=118 nmol/total
A 27-year-old legal secretary was referred to endocri-
volume (58–340 nmol/24 hour)
nology for abnormal glucose and weight gain despite
Serum cortisol after 48-hour low-dose dexametha-
watching her diet. Three years earlier (aged 24 years)
sone test≤28 nmol/L; suppression to < 50 is regarded
she had developed features of depression and was
as normal.
diagnosed as having bipolar disorder. Following trials
Based on an unremarkable endocrine work-up,
of several medications, she was eventually given
a preliminary diagnosis of olanzapine-induced weight
a combination of olanzapine and lithium, which sta-
gain was made. The psychiatry team was contacted,
bilized her mood. However, despite this improvement
and aripiprazole was initiated instead of olanzapine.
in mood, she rapidly gained weight and over a course
Over the next 6 months, the patient managed to lose
of 4 months gained 17 lbs and developed features of
12 lbs, her glucose and liver enzymes normalized and
sleep apnea, mild hypertension and abnormal liver
the symptoms of sleep apnea also improved.
enzymes. The latter was thought due to non-
Anti-psychotic drugs are the primary treatment
alcoholic fatty liver disease associated with weight 67
for several mental health disorders. They tend to
gain. Routine tests through her family physician’s
have varied metabolic effects, with certain drugs, such general population is characterized by increased
as olanzapine and quetiapine, causing significant serum leptin from the enlarged fat mass. Obese indi-
increases in caloric intake, weight gain and a trend viduals demonstrate leptin resistance; that is, high
toward increased insulin resistance (Ballon et al., circulating levels of leptin fail to reduce food intake
2018). In contrast, the risk is relatively low with ari- or body weight. Thus, leptin cannot be used to ther-
piprazole. The neural mechanisms underlying human apeutically reduce body weight.
weight gain after anti-psychotic drug treatment are Mutations in the leptin–melanocortin signaling
not fully understood. Several mechanisms have been pathway also induce obesity and hyperphagia.
proposed for the effects of olanzapine, including their Patients with a POMC gene mutation have early-
effect on serotonin, dopamine and histamine recep- onset obesity and severe hyperphagia. They lack α-
tors as well as an effect of these drugs on leptin (Ak MSH that normally stimulates MC4 R receptors.
et al., 2013), adiponectin and ghrelin (Hosojima et al., Patients with this type of mutation respond to
2006; Lu et al., 2015; for review see Henderson et al., MC4 R agonists, such as setmelanotide, with signifi-
2015). Switching therapy to an agent with lower risk cant loss of body weight and reductions in hunger
of weight gain as well as dietary counseling and life- scores.
style changes are generally used as the primary treat- The most common syndromic obesity disorder is
ment for these patients. PWS, although it remains unknown whether the cri-
tical leptin–melanocortin pathway is solely responsi-
4.5 Chapter Summary ble for the obesity. PWS occurs through a lack of
This chapter focuses on how hypothalamic neuroen- multiple paternally inherited genes on chromosome
docrine pathways regulate human appetite and body 15q11.2-q13 and the accompanying hypothalamic
weight, with emphasis on their role in the pathogen- dysfunction results in obesity/hyperphagia, faulty
esis of obesity. Obesity is strongly associated with an temperature control, high pain threshold, hypersom-
escalating incidence of cardiovascular disease, type 2 nia and multiple endocrine abnormalities. A contem-
diabetes, osteoarthritis, certain cancers, hypertension, porary approach to identifying genes implicated in
stroke and Alzheimer’s disease. The major neural the pathogenesis of obesity is possible because of the
centers for the regulation of appetite are located in sequencing of the human genome. A new gene
the hypothalamus, which integrates long-term signals robustly linked to human obesity is the FTO gene.
(e.g., leptin) from adipose tissue, and short-term The GI tract is a large endocrine organ expressing
meal-related signals (e.g., gut-derived hormones many peptide genes. These peptides target the brain to
such as ghrelin) to regulate food intake. This regula- control both hunger and satiety. For example, ghrelin
tory system is called the leptin–melanocortin path- (from the stomach) is orexigenic; GLP-1 and PYY
way, a neuronal complex that includes leptin (from the small intestine), CCK (from the duodenum)
receptors, POMC neurons and receptors for various and amylin (from the pancreas) inhibit appetite and
gut hormones such as ghrelin and GLP-1. are therefore anorexigenic. They represent variable
Adipose tissue is an endocrine organ that secretes short-term signals triggered by eating patterns, in
adipokine hormones, of which leptin is the archetypal contrast to leptin that exerts a long-term regulation
member. The vital importance of leptin is revealed in that reflects adipose tissue stores.
humans carrying leptin gene mutations that reduce Ghrelin levels rise before meals, followed by a rapid
leptin levels. These individuals are severely obese and postprandial decline, suggesting that ghrelin plays
exhibit intense hyperphagia, but respond to recombi- a role in the initiation of meals. However, infusions
nant human leptin with a remarkable reduction in fat of ghrelin in healthy young males failed to increase
levels and body weight. Other forms of leptin defi- hunger or meal size. This lack of effect is probably due
ciency, such as exercise-induced amenorrhea, are also to ghrelin’s short half-life (30 min). In contrast, a long-
treatable with leptin to restore fertility. acting, orally active ghrelin mimetic – anamorelin –
Lipodystrophy – the complete or partial absence of significantly increased appetite, food intake and body
fat tissue – also produces leptin deficiency, severe weight in healthy volunteers. When tested for an effect
insulin resistance and hyperphagia. Replacement in anorexia-cachexia syndrome patients, anamorelin
doses of leptin induce improvements in insulin sensi- increased lean body mass, with improvements in mus-
68 tivity and glucose tolerance. In contrast, obesity in the cle strength and quality of life.
In contrast to ghrelin, GLP-1 secretion is rapidly d. Intravenous GLP-1 infusion readily reduces
stimulated by food intake. That GLP-1 acts as a satiety food intake in humans.
factor to inhibit food intake in humans is demon- e. Liraglutide injection effectively reduces food
strated by the ability of a long-acting agonist – liraglu- intake.
tide – to induce significant weight loss at all doses 6. Which of the following are associated with
compared with placebo. Prader–Willi syndrome?
Two cases of obesity are included.
a. Hypothalamic dysfunction
b. Cryptorchidism
4.6 Review Questions c. Tall stature
1. Which gastrointestinal (GI) tract hormone d. Hyperphagia
stimulates appetite when the stomach is empty? e. Hypogonadism
a. Amylin 7. Which of the following statements are correct with
b. Leptin respect to GLP-1 analogs?
c. Cholecystokinin a. Can cause food-induced Cushing’s syndrome
d. Ghrelin b. Nausea is associated with GLP-1 therapy
e. Glucagon-like peptide-1 (GLP-1) c. Are recommended for management of
2. Which of the following are associated with obesity diabetes
and hyperphagia in children? d. Some patients may experience significant
weight loss with GLP-1 analog therapy
a. Mutations in the leptin receptor
e. Require multiple daily injections due to short
b. Mutations in the melanocortin receptor gene
half-life
c. Absent circulating leptin
d. Elevated biologically inactive leptin 8. Which of the following conditions can lead to
e. All of the above significant weight gain?
3. Exercise-induced amenorrhea (hypothalamic a. Poorly controlled diabetes
amenorrhea) is characterized by which of the b. Hyperthyroidism
following? c. Hypothalamic injury
d. Addison’s disease
a. High, pulsatile secretion of luteinizing
e. Drug-induced hyperprolactinemia
hormone (LH)
b. Low levels of circulating leptin 9. Which of the following statements regarding
c. Low levels of estradiol leptin and type 2 diabetes are correct?
d. Subnormal levels of LH a. Most adult patients with type 2 diabetes are
e. High body mass index leptin deficient.
4. Mutations in the leptin gene cause gross obesity in b. Leptin therapy in obese type 2 diabetes
children and in adults. Leptin treatment induces patients is associated with significant weight
weight loss in such patients. Why is leptin loss.
ineffective in reducing body weight in diet-induced c. Obese type 2 diabetes patients may develop
obesity? Which GI tract peptide has proven useful resistance to endogenous leptin.
in synergizing with leptin to reduce body weight? d. Leptin deficiency in children can lead to type 2
5. GLP-1 is an anorexigenic peptide released from diabetes.
the GI tract after food ingestion. Which of the e. Leptin deficiency in patients with
following statements are correct? lipodystrophy may lead to diabetes.
a. GLP-1 levels are increased in obese individuals 10. Which of the following are correct with regard to
compared to lean subjects. hypothalamic obesity (HO)?
b. GLP-1 levels increase coincident with insulin a. HO is characterized by rapid weight gain.
secretion. b. Weight gain in HO can be effectively treated
c. GLP-1 is rapidly degraded following food with caloric restriction.
ingestion. c. Hyperphagia is a characteristic feature of HO. 69
d. Craniopharyngiomas are the commonest Angulo M A, Butler M G & Cataletto M E. (2015). Prader-
cause of HO. Willi syndrome: a review of clinical, genetic, and endocrine
e. Despite significant weight gain, these patients findings. J Endocr Invest 38, 1249–1263.
do not develop diabetes. Arango C, Rojas M J, Moreno D & Parellada M. (2002).
Sibutramine for compulsive eating in hypothalamic
deficiency. J Am Acad Child Adolesc Psych 41, 1147–1148.
Further Reading Astrup A, Rössner S, Van Gaal L et al., on behalf of the
Albuquerque D, Nóbrega C, Manco L & Padez C. (2017). NN8022-1807 Study Group. (2009). Effects of liraglutide in
The contribution of genetics and environment to obesity. the treatment of obesity: a randomised, double-blind,
Brit Med Bull 123, 159–173. placebo-controlled study. Lancet 374, 1606–1616.
Cataletto M, Angulo M, Hertz G & Whitman B. (2011). Bak M J, Albrechtsen N J W, Pedersen J et al. (2014).
Prader-Willi syndrome: a primer for clinicians. Int J Ped Specificity and sensitivity of commercially available assays
Endocr 2011, 12. for glucagon-like peptide-1 (GLP-1): implications for
Chakradhar S. (2016). All in one: researchers create GLP-1 measurements in clinical studies. Diabetes Obes
combination drugs for diabetes and obesity. Nat Med 22, Metab 16, 1155–1164.
694–696. Bakker N E, Wolffenbuttel K P, Looijenga L H & Hokken-
Flier J S & Maratos-Flier E. (2017). Leptin’s physiologic role: Koelega A C. (2015). Testes in infants with Prader-Willi
does the emperor of energy balance have no clothes? Cell syndrome: human chorionic gonadotropin treatment,
Metab 26, 24–26. surgery and histology. J Urol 193, 291–298.
Friedman J. (2016). The long road to leptin. J Clin Invest Bakker N E, Lindberg A, Heissler J et al. (2017). Growth
126, 4727–4734. hormone treatment in children with Prader-Willi
Heymsfield S B & Wadden T A. (2017). Mechanisms, syndrome: three years of longitudinal data in prepubertal
pathophysiology, and management of obesity. New Eng children and adult height data from the KIGS Database.
J Med 376, 254–266. J Clin Endocr Metab 102, 1702–1711.
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a heritable disorder of the central control of energy balance. 32, 533–540.
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The GBD Obesity Collaborators (2017). Health effects of plasma levels of the hunger hormone ghrelin and lower
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74
Chapter
Hypothalamic–Pituitary–Adrenal Cortex
5 Axis
The adrenal gland secretes several hormones from 5.1 Cortisol Synthesis and
the adrenal cortex: the glucocorticoid (GC) corti-
sol, the mineralocorticoid aldosterone and the sex Assessment of Cortisol Secretion
steroidal androgens. Catecholamines are also Cortisol is produced by the adrenal cortex under the
secreted from the adrenal medulla. Of these, the influence of ACTH. Adrenal steroid hormones are
GCs are responsible for regulating the hypothala- synthesized from cholesterol via three distinct path-
mic–pituitary–adrenal (HPA) axis. The HPA sys- ways, leading to the production of cortisol (zona fas-
tem plays a crucial role in the response to stress, ciculata), aldosterone (zona glomerulosa) and
but GCs, such as cortisol, are implicated in androgens (zona reticularis). Cortisol is rapidly meta-
numerous organ systems in both health and dis- bolized and has a serum half-life of around 40 mins
ease. GC receptors (GRs) are present in almost (Trifonova et al., 2013). Due to this short half-life, and
every tissue of the human body, including nervous, the pulsatile nature of cortisol secretion (see later;
musculoskeletal, cardiovascular, immune, meta- Henley et al., 2009; Lightman and Conway-
bolic, reproductive and respiratory systems Campbell, 2010), analyzing blood cortisol using auto-
(Kadmiel and Cidlowski, 2013). GCs have anti- mated immunoassay analyzers is the preferred
inflammatory, anti-proliferative, pro-apoptotic method of cortisol measurement. Alternatively, deter-
and antiangiogenic properties and so have been mination of cortisol levels in urine, saliva and hair can
beneficial in the treatment of many diseases. also provide an estimation of cortisol production.
However, endogenous GCs are involved in the However, these analyses only provide a measure of
pathogenesis of some neurological diseases such the average hormone secretion over a number of
as multiple sclerosis, stroke, traumatic brain injury hours, or weeks in the case of hair, and would not
(TBI) and Alzheimer’s and Parkinson’s diseases permit the minute-by-minute analysis of cortisol
(Kalafatakis et al., 2016). Figure 5.1 illustrates mul- pulses that can be determined from blood samples.
tiple organ systems that respond to GC, including Nevertheless, circadian rhythms in cortisol secretion
examples of their clinical use. Also highlighted are are detectable in the saliva of preterm infants (Ivars et
some adverse effects of high levels of GC (Kadmiel al., 2017). Also, since cortisol is deposited in the
and Cidlowski, 2013). growing hair shaft, an estimate of cortisol concentra-
In this chapter, we will outline the neuroendocrine tions in hair serves as a measure of chronic exposure
basis of HPA regulatory mechanisms, especially in over weeks or months (Meyer and Novak, 2012;
terms of the neural control of pituitary secretion of Wester and van Rossum, 2015), including in new-
adrenocorticotropin (ACTH) and its effect on the borns (Hollanders et al., 2017).
release of cortisol from the adrenal cortex.
Discussion will also include clinical disorders such 5.2 Regulation of ACTH Secretion:
as GC excess (Cushing’s syndrome), and GC defi-
ciency (hypoadrenalism). Chronic stress is associated Neurotransmitter/Neuropeptide
with depression, anxiety disorders, post-traumatic Control
stress disorder and other stress-related neuropsychia- ACTH is released from human pituitary gland corti-
tric conditions. We will outline the scientific concepts cotrophs, where they constitute 10–20% of the cells of
behind various diagnostic and therapeutic strategies the anterior lobe (Heaney and Melmed, 2004).
for HPA-related disorders. Secretion of ACTH is orchestrated by two major 75
Chapter 5: Hypothalamic–Pituitary–Adrenal Cortex Axis
Nervous system Visual system

Physiological homeostasis Anti-infammatory
Responses to stressors Anti-angiogenesis
Psychiatric disorders Photoreceptor survival
Uveitis, keratitis & glaucoma
Cardiovascular system
Anti-inflammatory Respiratory system
Cardiomyocyte survival Suppression of cytokines,
Homeostasis of blood pressure chemokines & cell adhesion
and vascular tone molecules Fetal lung
Anti-angiogenesis Asthma & COPD development
Cardiovascular disease
Glucose & liver metabolism
Immune system Glucose regulation
Suppression of proinflammatory Lipid homeostasis
cytokines Obesity & hyperglycemia
Regulation of immune
cell maturation, migration &
apoptosis. Reproductive system
Organ transplant Gonadal function in and
Fetal organ development &
Musculoskeletal system maturation
Preterm birth Amenorrhea
Anti-inflammatory Gonadal virilization
Muscle anabolism & catabolism
Insulin resistance Integumentary system
Osteoblast apoptosis Anti-inflammatory
Osteoclastogenesis Delayed wound healing
Rheumatoid arthritis Regulate epithelial integrity
Osteoporosis
Psoriasis & eczema
Figure 5.1 Role of glucocorticoids (GC) in health and disease. This schematic illustrates the physiological roles of GCs in major organ systems of
the human body (black text). Therapeutic roles of GCs are highlighted in green with green text, and adverse outcomes in patients with
elevated GC levels are highlighted in blue with blue text. Reproduced with permission (Kadmiel and Cidlowski, 2013). Abbreviation: COPD,
chronic obstructive pulmonary disease.
control systems: stress and a diurnal (circadian) input, The circadian release of cortisol follows the nor-
both of which are mediated through the release of mal sleep–wake cycle such that cortisol levels peak
hypothalamic corticotropin releasing hormone within 20–30 mins of awakening – a phenomenon
(CRH) and vasopressin (VP). ACTH provides the known as cortisol awakening response. However,
stimulus for the adrenal cortex to secrete cortisol, when the circadian rhythm is disrupted in response
which then exerts a powerful negative feedback to to abnormal sleep patterns, such as in shift workers,
modulate both CRH and ACTH secretion. An over- adverse health consequences may occur, including
view of the orchestration of ACTH release is shown in hyperglycemia, obesity and cardiovascular disease
Figure 5.2. (Scheer et al., 2009; Oster et al., 2017).
Figure 5.3 illustrates the diurnal rhythm in ACTH Clinical implications: A morning basal cortisol
and cortisol, obtained from a group of healthy male measurement (0800–0900 hours) is frequently used
volunteers over 24 hours, using an automated blood for assessment of the HPA axis in clinical practice.
sampling system (Henley et al., 2009; Lightman and However, an awareness of the existing sleep–wake
Conway-Campbell, 2010). Note that each pulse of cor- cycle is crucial in interpreting these levels. For exam-
tisol is preceded by a burst of ACTH secretion. The ple, sleep–wake disruption may occur because of shift
76 rapid decline in ACTH in each pulse represents a half- working, jet lag and aging (Potter et al., 2016; cf.
life of approximately 20 mins (Roelfsema et al., 2016). Chapter 2). The typical serum cortisol peak – within
and β-endorphin. Figure 5.4 illustrates that POMC

is processed into smaller peptides by enzymes called
proprotein convertases (Hook et al., 2008). Thus,
ACTH and β-LPH are cleaved from POMC, and β-
LPH is further converted to β-endorphin and γ-lipo-
tropin (γ-LPH). The anterior pituitary therefore
responds to CRH stimulation by co-releasing
ACTH, β-endorphin and γ-LPH from the same cor-
ticotroph cells (Watson et al., 1987). In terms of
hormone-like effects, β-endorphin and γ-LPH have
no established function when released into the
bloodstream.
Figure 5.2 illustrates the major systems that reg-
ulate ACTH secretion, but especially the significant
synergistic effect of VP on CRH-stimulated human
ACTH secretion (Lamberts et al., 1984; Rittmaster et
al., 1987). Additional evidence indicates that CRH
immunoreactivity and CRH messenger ribonucleic
acid (mRNA) are present in neuron cell bodies pri-
marily located in the paraventricular nucleus (PVN)
of the human hypothalamus. These neurons project
to the infundibulum/median eminence where CRH
is released into the pituitary portal vasculature
(Mihály et al., 2002; Krolewski et al., 2010). The
distribution of VP-positive neurons overlaps with
that for CRH (Bresson et al., 1985; Raadsheer et al.,
1993; cf. Chapter 9; Figure 9.1). VP alone has little
effect on ACTH secretion, but synergizes with the
CRH stimulus. Figure 5.5 outlines the mechanism of
this synergy, with CRH and VP each binding to a
specific GPCR located on corticotroph membranes.
Figure 5.2 Regulation of ACTH and cortisol secretion. Two major These receptors are usually designated CRHR1 and
control systems are stress and a circadian (diurnal) input, each V3, respectively.
mediated by a variety of neurotransmitters and neuropeptides (see Clinical implications: Both CRH and VP are rou-
Figure 5.6). CRH and VP are released from separate neurons in the
paraventricular nucleus of the hypothalamus and reach the anterior tinely used for assessment of Cushing’s syndrome in
pituitary via the pituitary portal system. VP has little effect on ACTH differentiating pituitary versus ectopic sources of
secretion but synergizes with the stimulatory action of CRH (see ACTH (see case later in this chapter). Pituitary
Figure 5.5). The adrenal cortex responds to ACTH stimulation with the
release of cortisol, which then regulates ACTH secretion by a negative ACTH-producing adenomas typically express CRH
feedback influence on CRH/VP as well as the release of ACTH from the and VP receptors and therefore demonstrate a syner-
pituitary. Abbreviations: PVN, paraventricular nucleus; VP, vasopressin. gistic release of ACTH following stimulation with
CRH/VP. In contrast, non-pituitary or ectopic
30 mins of awakening – may not occur in these situa- ACTH-producing tumors lack these receptors and
tions. As a result, a cortisol level drawn at the usual do not respond with release of ACTH.
time of 0800–0900 hours may underestimate the cor- Multiple neurotransmitters and neuropeptides are
tisol by missing the peak response. implicated in the neural control of human CRH neu-
ACTH is encoded by the pro-opiomelanocortin rons, and Figure 5.6 illustrates most of what is cur-
gene (POMC) located on chromosome 2p23. The rently known. Some of the data were obtained from
large pre-propeptide – POMC (Figure 5.4) – con- animal experiments (highlighted in gray), but evi-
tains several smaller peptides within its polypeptide dence from human studies is extensive (Locatelli et
structure, including ACTH, β-lipotropin (β-LPH) al., 2010). 77
Figure 5.3 Diurnal secretion of ACTH and cortisol in humans. The figure illustrates the temporal relationship between ACTH and cortisol pulses.
This 24-hour automated blood sampling profile in humans reveals the positive, delayed relationship between ACTH and cortisol; that is, ACTH
pulses always precede the cortisol pulses. Note that hormone secretion begins to increase in the late stages of sleep. Reproduced with
permission (Lightman and Conway-Campbell, 2010).
ACTH and cortisol in olanzapine-treated schizophre-

nic patients (Cohrs et al., 2006). This inhibitory effect is
thought to be exerted via serotonin 5-HT2 receptors.
Anti-depressants also have complex effects on
ACTH/cortisol secretion (Locatelli et al., 2010).
Ghrelin – either as a bolus or an infusion – signifi-
cantly elevates ACTH and cortisol levels in healthy
subjects (Garin et al., 2013). The cholecystokinin ago-
nist pentagastrin also rapidly increases ACTH and
cortisol in humans (Abelson and Liberzon, 1999), as
does interleukin-2 (Raab et al., 1999). In contrast,
pasireotide – a somatostatin analog, also used to
reduce growth hormone (GH) levels in acromegaly
Figure 5.4 Biosynthesis of ACTH. The POMC gene encodes a large (see Section 8.3) – successfully reduces ACTH and
pre-propeptide (POMC) that is proteolytically cleaved to a series of cortisol levels in Cushing’s patients (Yedinak et al.,
smaller, biologically active neuropeptides. The cleavage sites (red
arrows) are recognized by enzymes called pro-protein convertases 2017). Pasireotide has a high affinity for the SSTR5
that cleave the large POMC molecule to produce smaller peptides, receptor, which is strongly overexpressed in cortico-
including ACTH and α-MSH, as illustrated. Note that β-endorphin troph adenoma cells. Stimulation of this receptor with
and γ-LPH are also formed from POMC and therefore will be secreted
simultaneously with ACTH. Abbreviation: -LPH, gamma lipotropin; α- pasireotide effectively reduces ACTH release and
MSH, alpha melanocyte-stimulating hormone. eventually normalizes free cortisol levels (McKeage,
2013; Cohan, 2014).
Clinical Implications: Some of the neurotransmit-
For example, ACTH and cortisol levels are ters implicated in the regulation of the HPA axis
increased after blockade of endogenous opioid peptides (Figure 5.6) can potentially interfere with the assess-
with naloxone (Jackson et al., 1995). This report also ment of the HPA axis, leading to adverse clinical out-
revealed the involvement of adrenergic receptors; that comes. For example, suppression of the HPA axis
is, α1-agonists and α2-antagonists both stimulate resulting in clinical cortisol deficiency has been
ACTH release. Atypical anti-psychotics such as olan- reported in chronic opioid users (Tennant et al.,
zapine and quetiapine reduce ACTH and cortisol in 1991). Smoked nicotine also stimulates ACTH and
78 healthy humans, a finding consistent with reduced cortisol release (Goletiani et al., 2015).
Figure 5.5 CRH and VP synergize in stimulating the release of ACTH from the anterior pituitary gland. This figure illustrates how two receptors
cooperate to increase ACTH secretion. Corticotrophs express cell surface receptors for CRH, a seven transmembrane domain GPCR. CRH
binding activates a stimulatory Gs and leads to stimulation of adenyl cyclase and generation of cAMP. In turn cAMP activates intracellular PKA.
In contrast, signaling through the VP receptor activates PKC via the Gq subunit. Activation of both pathways induces enhanced secretion of
ACTH, resulting in cortisol production from the adrenal cortex. Cortisol subsequently binds to the GC nuclear receptor in corticotrophs (and
PVN neurons) to exert negative feedback on ACTH secretion. Reproduced with permission (Asa and Ezzat, 2002). Abbreviations: ATP, adenosine
triphosphate; cAMP, cyclic adenosine monophosphate; Gs, stimulatory G protein; PKA, protein kinase A; PKC, protein kinase C.
5.3 Regulation of ACTH Secretion: GC proteins such as the corticosteroid-binding globulin

(CBG). Bound in this form, cortisol is not bioactive.
Negative Feedback Figure 5.7 Illustrates that cortisol is released from the
Cortisol regulates HPA axis activity through a nega- CBG before freely moving through the target cell
tive feedback loop at the level of the PVN and the membrane. Unoccupied GR are present in the cytosol
anterior pituitary gland (Figure 5.2). CRH neurons complexed to molecular chaperones such as HSP90
and pituitary corticotrophs respond to this feedback (heat shock protein 90) that stabilizes GR in the cor-
via two nuclear receptors: GRs and mineralocorticoid rect shape. When cortisol binds to the GR-HSP90
receptors (MRs). complex, the HSP90 dissociates and the remaining
The GR mRNA generates three transcripts in the cortisol–GR complex dimerizes before it enters the
human brain, encoding GRα, GRβ and GR-P receptor cell nucleus. The cortisol–GR dimer complex then
isoforms (Cao-Lei et al., 2013). GRα is the active form binds to target genes via specific GC response ele-
of the receptor that mediates most of the effects of ments (GRE). Various factors, such as general tran-
cortisol. GRα and MR mRNAs are found throughout scription factors (GTFs) and RNA polymerase II
the human brain, including the PVN and hippocam- (POL II), assist in inducing (or repressing) gene tran-
pus (Wang et al., 2008; Cao-Lei et al., 2013), and in the scription and the export of mRNA into the cell cytosol
pituitary gland (López et al., 1992). where it is translated into protein.
GR Mechanism Glucocorticoid Resistance

GR and MR are members of the steroid hormone The biological activity of GCs is dependent not only on
receptor superfamily (see Chapter 1). Cortisol is plasma levels and concentrations attained in tissues,
transported in the circulation bound to carrier but also on the sensitivity of GR. Some patients treated 79
with GCs for inflammatory conditions, such as chronic
Excitatory Inhibitory
α1 adrenergic agonist (methoxamine) GABA
α2 adrenergic antagonist (yohimbine) α2 adrenergic agonist (clonidine)
Norepinephrine reuptake inhibition (atomoxetine) α1 adrenergic antagonist (thymoxamine)
Acetylcholine (phytostigmine; nicotine) Norepinephrine (β-agonist)
Dopamine (L-dopa in children) Acetylcholine (pyridostigmine)
Cocaine Serotonin (sumatriptan; 5-HT1 D receptor)
Serotonin (5-HT1A; 5-HT2 receptors) CRH/VP
Opiates (morphine) and opioid peptides
Histamine (H2 receptor) Endocannabinoids (CB1)
Neuropeptide Y (NPY/CRH colocalization NO
PITUITARY
in human brain) Leptin
Naloxone (opioid antagonist)
Benzodiazepines (alprazolam; GABA
Substance P
receptor?)
Cholecystokinin (pentagastrin; CCK-B agonist)
Atypical antipsychotics (olanzapine)
Endocannabinoids (pituitary CB1 receptors)
Somatostatin (pasireotide)
Angiotensin II
ACTH
Calcitonin
Ghrelin
GLP-1
VIP
Glutamate
IL-1β, IL-2, IL-6, TNF
Prostaglandins (E2)
Figure 5.6 Effect of various neurotransmitters/neuromodulators on human ACTH secretion. The listing consists of examples of a variety of
excitatory and inhibitory stimuli culled from the medical literature. The shaded entries are derived from animal experiments since no evidence
yet exists for a similar effect in humans. Adapted from Locatelli et al. (2010). Abbreviations: CCK, cholecystokinin; GABA, γ aminobutyric acid;
GLP-1, glucagon-like peptide 1; IL, interleukin; NO, nitric oxide; TNF, tumor necrosis factor; VIP, vasoactive intestinal polypeptide.
obstructive pulmonary disease and asthma, demon- loss-of-function mutations result in primary generalized
strate resistance to GC therapy with a poor clinical GC resistance (Nicolaides et al., 2016). In this condition,
response. This is a serious issue in the effective treat- almost all organs of the body have a different degree of
ment of patients with inflammatory diseases. This type insensitivity to GCs, leading to compensatory activation
of GC resistance could be due to a decrease in nuclear of the HPA axis and hypersecretion of ACTH. These
translocation of GRs or, in the case of immune disor- patients are characterized by hypercortisolism without
ders, to pro-inflammatory cytokines interfering with the features of Cushing’s disease (Nicolaides et al., 2014).
GR signaling (Quax et al., 2013). Sex and age also The lack of normal negative feedback produces an
appear to modify negative feedback effects of synthetic increased secretion of ACTH that produces adrenal
GCs such as dexamethasone (DEX). DEX binds with hyperplasia and an increased production of adrenal
high affinity to GR, with low affinity for MR. It is mineralocorticoids and androgens. Treatment is pro-
routinely used in suppression tests to inhibit ACTH vided in the form of a high-dose mineralocorticoid-
and cortisol secretion via negative feedback (Castro et sparing GC, such as DEX, which lowers serum ACTH.
al., 2003; see later in this chapter). In healthy subjects,
cortisol levels vary widely following a DEX suppression Clinical implications
test, indicating that, at least in terms of hypothalamic/ (1) DEX has a powerful ACTH (and cortisol)-
pituitary response, the sensitivity of GR is variable suppressing effect and unlike certain other
(Chriguer et al., 2005; Quax et al., 2013). A typical synthetic GCs, DEX does not cross-react with the
suppression test in healthy males (using an alternative standard cortisol assay. Therefore, DEX is
GC agonist [prednisolone: 10 mg]) shows a rapid inhi- commonly used in diagnostic testing of patients
bition of ACTH and cortisol within 60 mins of intra- with suspected hypercortisolism. A standard dose
venous injection (Figure 5.8; Russell et al., 2010). of DEX (usually 0.5 mg every 6 hours for 48 hours
Genetic factors also affect GC sensitivity. or 1.0 mg at 11.00 PM) is given to the patient and
Polymorphisms in the gene that encodes GR have been serum cortisol is measured at 9.00 AM the
80 identified in healthy subjects and, although rare, some following morning. In normal individuals,
Figure 5.7 Schematic view of cortisol

interacting with a target cell. Cortisol is
transported in the blood bound to
corticosteroid binding globulin (CBG).
Cortisol is released from CBG before moving
freely through the cell membrane. The
unoccupied glucocorticoid receptor (GR) is
located in the target cell cytoplasm coupled
to a molecular chaperone (heat shock
protein; HSP90) that stabilizes GR in the
correct shape. When cortisol binds to the
receptor–HSP complex, the HSP dissociates
and the remaining cortisol–GR complex
dimerizes before it enters the cell nucleus.
The cortisol–GR dimer then binds to target
genes via a specific glucocorticoid response
element (GRE). Various factors such as
general GTFs and RNA POL II assist in
inducing (or repressing) gene transcription
and the export of mRNA into the cell cytosol
where it is translated into protein.
endogenous serum cortisol levels suppress to as stimulatory effect of CAN on ACTH and cortisol
low as <50 nmol/L. A lack of suppression suggests levels during the quiescent phase of HPA activity
hypercortisolemia. indicates that MRs normally restrain HPA output at
(2) The GR antagonist, mifepristone, is used for this time.
management of hypercortisolemia. The drug has a
strong affinity for GR and has been shown to
reduce some of the cortisol-related complications
5.4 Pulsatile Secretion of ACTH and
such as hyperglycemia and hypertension without, Cortisol
however, lowering serum cortisol levels (Fleseriu As is evident from Figure 5.3, ACTH and cortisol are
et al., 2012). secreted in a circadian rhythm, a maximum occurring
in the early morning prior to daily activity. Maximal
MRs and ACTH Secretion secretion is driven by an increase in the amplitude of
MRs are usually associated with renal function – ACTH and cortisol pulses, followed by a gradual
where aldosterone binds to MR to regulate sodium decline extending to approximately midnight. Thus,
ion reabsorption – but brain and pituitary MRs also the pulsatile nature of ACTH secretion is similar to
bind cortisol. MR has a ten-fold higher affinity for that observed for several other anterior pituitary hor-
cortisol than does the GR (de Kloet et al., 2005); that mones (e.g., luteinizing hormone [LH], thyroid sti-
is, low blood levels of cortisol will preferentially acti- mulating hormone [TSH], prolactin [PRL] and
vate MRs, whereas the lower affinity of the GRs for growth hormone [GH]; see Chapters 3, 6, 7 and 8).
cortisol results in its selective activation only when It is assumed that pulsatile release of hypothalamic
cortisol levels increase during circadian and stress- CRH generates bursts of ACTH and cortisol, and
induced production. The involvement of MR in these occur at a frequency approximately 15–20 per
healthy humans is elegantly demonstrated during day (Faghih et al., 2014). Mean and pulsatile ACTH
infusion of an MR antagonist drug, canrenoate are positively correlated with BMI, and ACTH secre-
(CAN; Figure 5.9; Berardelli et al., 2010; 2013). The tion is significantly greater in men than women, even 81
Figure 5.8 Rapid inhibitory effect of the GC

agonist prednisolone on ACTH and cortisol
secretion in healthy males. Six healthy male
subjects were sampled at frequent intervals for
ACTH and cortisol following an intravenous
injection of 10 mg of prednisolone sodium
succinate (blue and gray) or placebo (red) over
5 mins at 6.02 AM. The shaded area represents
the period of lights off. * denotes first significant
difference between the prednisolone and
placebo groups. Figure drawn using data from
Russell et al. (2010).
when normalized to BMI. The sex difference is largely exercise in healthy men induces a rapid response in
due to an elevation in total and pulsatile secretion of ACTH and cortisol secretion (Roelfsema et al., 2017).
ACTH (Veldhuis et al., 2009). The influence of BMI Competitive ballroom dancers exhibit high cortisol
on ACTH/cortisol secretion is covered in Section 5.6. levels, independent of the physical strain of dancing
(Rohleder et al., 2007), and students facing mental chal-
lenges, such as an examination, release high levels of
5.5 Stress and the HPA Axis cortisol (González-Cabrera et al., 2014). Insulin-
Stress – both physical and psychological – is the prin- induced hypoglycemia is also a reproducible stressor
cipal stimulus for activation of the HPA axis and the for ACTH and cortisol secretion (Figure 5.10) and is
HPA system is vital in maintaining the organism’s used to test the integrity of the HPA axis (Insulin
response to stress. In fact, ACTH secretion is typically tolerance test; Sarlos and Inder, 2013; cf. Chapter 8).
preserved until the final stages of pituitary disorders Chronic stress may have many adverse health
and a significant number of patients recover HPA axis effects (Schneiderman et al., 2005). Stimuli include
function even years after the initial pituitary injury critical illness (high cortisol; see Figure 5.12), fever
(Munro et al., 2016). (high cortisol), hypotension (low cortisol), burn
The HPA axis exhibits a biphasic response to stress injury (high cortisol), depression (high cortisol) and
with an initial phase characterized by an increase in both surgery (high cortisol). For example, Figure 5.11 illus-
ACTH and cortisol levels whereas chronic or protracted trates the activation of the HPA axis following cardiac
stress is associated with an elevated cortisol but a surgery, showing ACTH and cortisol reaching supra-
82
decrease in ACTH concentration. Acute moderate normal levels (Gibbison et al., 2015). ACTH levels in
Figure 5.10 Insulin-induced hypoglycemia and ACTH/cortisol

secretion. Effects of hypoglycemia, induced by an intravenous dose
of insulin (0.15 IU/kg), on levels of glucose, ACTH and cortisol. Data
obtained from Besser and Thorner (2002).
increase in adrenal sensitivity to ACTH, although a

reduction in cortisol clearance may also be present.
Critical illness is often accompanied by hypercor-
Figure 5.9 Stimulatory effect of a mineralocorticoid antagonist tisolemia, attributable to stress-induced activation of
(canrenoate; CAN) on ACTH and cortisol secretion in healthy young the HPA axis. An example is illustrated in Figure
women. Experiments were performed at 1400 hours when ACTH and
cortisol levels were at their lowest. Subjects were given an initial 5.12 which shows typical high values of cortisol in a
intravenous bolus of CAN (200 mg) or placebo, followed by an group of patients in the ICU (Boonen et al., 2013).
infusion of CAN (200 mg over 4 h) or placebo. Values are means Note, however, that ACTH values, similar to those in
+/-SEM. (n=8). * p<0.05 versus the placebo values at the same time
point. Figure reproduced with the generous permission of Dr. Figure 5.11, are suppressed. This observation sug-
Emanuela Arvat (Berardelli et al., 2010). gests that cortisol breakdown is reduced, enabling
suppression of ACTH release.
particular are increased approximately 30-fold com- Stress and Reproduction

pared with the normal diurnal variation. However, Elevated levels of GCs, either stress-induced or result-
whereas ACTH declines fairly quickly, elevated corti- ing from exogenous treatment, induce profound
sol levels are sustained and pulsatile over many hours. reproductive dysfunction in animals and humans.
The authors conclude that since the increases in Much of the detailed knowledge on the neuroendo-
ACTH and cortisol occur after, rather than during, crine effects of GCs is the result of animal experi-
surgery the HPA activation may be due to an inflam- ments, but a significant literature on human studies
matory response, rather than surgical stress or also exists (Chrousos et al., 1998; Whirledge and
anesthesia. The elevated levels of cortisol in the face Cidlowski, 2017). Even chronic, low-level stress
of reduced ACTH secretion possibly represents an impairs fertility in women (Berga, 2016). Those with 83
1500 A.Surgical patient 1000 60 B.Healthy volunteer 600

SURGERY
1250 50 500
800
Cortisol (nmol/L)
Cortisol (nmol/L)
Cortisol
ACTH (pg/ml)
ACTH (pg/ml)
1000 Cortisol 40 400
600
750 30 300
400
500 20 200
250 200 10 100

ACTH
ACTH
0 0 0 0
0804 1004 1204 1404 1604 1804 2004 2204 0004 0204 0404 0604 0804 1900 2100 2300 0100 0300 0500 0700 0900 1100 1300 1500 1700 1900
Clock time (hours) Clock time (hours)
Figure 5.11 Changes in cortisol and ACTH levels through a 24-hour perioperative period of cardiac surgery. (A) 24-hour ACTH and cortisol profile
of a patient undergoing coronary artery bypass grafting. The initial large surge of ACTH and cortisol occurred toward the end of the surgical
procedure. Note the different scales of the vertical axes; that is, ACTH secretion increased by approximately 30-fold compared with the healthy
volunteer (B). Post-surgical cortisol levels remained high in the presence of suppressed ACTH. However, both ACTH and cortisol secretion
remained pulsatile. Light gray area: period during which the patient was undergoing surgery (0919–1349 h). (B) 24-hour ACTH and cortisol
profile of a healthy volunteer. ACTH and cortisol both display a tightly correlated ultradian rhythm (see also Figure 5.3). Figure based on data
generously provided by Dr. B. Gibbison (Gibbison et al., 2015).
Figure 5.12 Dissociation between ACTH and cortisol levels among

critically ill patients in the ICU. Shown are mean values for cortisol (A)
and ACTH (B) in 47 patients from day 1 to day 7 in the ICU. Values are
means +/-SEM. The colored areas represent the normal range of
values in 12 healthy controls. The mean values of cortisol, over 7 days,
were significantly elevated over control means p=0.01). The mean
values of ACTH, over 7 days, were significantly reduced compared with
control means (p<0.001). Figure is constructed from data in Boonen et
al. (2013).
functional hypothalamic amenorrhea – that is, with induced inhibition of hypothalamic GnRH release.
anovulation, decreased LH pulses and no identifiable Stress reduction results in restoration of ovulation.
organic cause of amenorrhea – have elevated levels of The high levels of cortisol associated with Cushing’s
cortisol compared with normal cycling women (Berga syndrome (see case later in this chapter) in women are
84 et al., 1997; Prokai and Berga, 2016). This suggests often accompanied by menstrual disturbances. For
that amenorrhea develops in response to stress- example, in a group of female patients with pituitary-
dependent Cushing’s syndrome, 80% showed men- 21-hydroxylase activity. This can lead to cortisol and
strual irregularity accompanied by significantly higher aldosterone deficiency and excessive production of
than normal serum cortisol levels (Lado-Abeal et al., adrenal androgens such as testosterone (Figure 5.13).
1998). These authors also demonstrated that normal- CAH may seriously influence reproductive func-
ization of cortisol levels restored regular menstruation. tion in affected individuals through an array of
Hypogonadotropic hypogonadism has also been effects, including reduced cortisol, elevated andro-
reported in men with Cushing’s disease (Luton et al., gen levels, altered central nervous system develop-
1977). ment and disturbances to functional anatomy
In terms of exogenous GCs, the effects of oral (Reichman et al., 2014). Irregular menstruation and
hydrocortisone treatment on LH and FSH secretion anovulation are common in CAH, affecting 30–75%
have been studied during the normal menstrual cycle. of patients depending on the degree of enzymatic
Hydrocortisone, given in the follicular phase to yield defect (Bachelot et al., 2017). However, pulsatile
supra-physiological GC levels, significantly reduced secretion of LH appears to be normal in most,
the frequency, but not the amplitude, of LH pulses although not all, patients (Bachelot et al., 2012). It
and reduced blood levels of LH and FSH (Saketos et therefore remains unclear whether these patients are
al., 1993). These data suggest that the inhibitory effect infertile because of, for example, abnormal cortisol
is directed at GnRH neurons. In contrast, short-term or androgen levels. Males also present with inferti-
DEX treatment had no effect on LH secretion in lity, probably because of raised androgen levels,
healthy men (Veldhuis et al., 1992). inducing suppression of gonadotropins (Bachelot et
Reduced levels of GCs – adrenal insufficiency – as al., 2017).
in Addison’s disease (Betterlie and Morlin, 2011) may Clinical implications: Depending upon the degree
also impair fertility. This aspect of GC function is and type of enzymatic defects, patients with CAH can
relatively uninvestigated. Kowal et al. (2006) have varying presentations. Those with complete loss
described a single case of male Addison’s disease and of enzymes may be unable to produce cortisol and
infertility. Ross et al. (2014) suggest that male and aldosterone and present during infancy with features
female hypogonadism may be a common complica- of adrenal crisis, whereas those with relatively milder
tion of Addison’s disease. Male patients had signifi- defects may remain undiagnosed or only present later
cantly lower testosterone levels, whereas female on in life with features of androgen excess. Typically,
patients showed premature ovarian failure, very likely reduced production of cortisol leads to excessive
of autoimmune origin. It remains unclear how far the ACTH production (i.e., lack of negative feedback)
hypothalamic–pituitary system is involved, particu- and shunting of the precursor chemicals to andro-
larly since these patients were being treated with gen-producing pathways, producing signs of hyper-
hydrocortisone. androgenism. This can result in an early adrenarche
Much more is known concerning low cortisol in males and signs of virilization in females. These
levels in congenital adrenal hyperplasia (CAH; El- features can be partially reversed by GC and miner-
Maouche et al., 2017), an inherited syndrome caused alocorticoid replacement, which normalizes ACTH
by deficient adrenal cortisol biosynthesis. As men- levels and consequently reduces the production of
tioned earlier, cortisol and other adrenal steroids are androgen.
synthesized from cholesterol via three distinct path-
ways. The outer zone, or zona glomerulosa, synthe- Stress and Psychiatric Disorders
sizes aldosterone; the middle zone, or zona In previous sections emphasis was placed on the para-
fasciculata, produces cortisol, whereas androgens are mount importance of GC feedback in the neuroendo-
synthesized in the innermost zone, or zona reticularis. crine regulation of ACTH and cortisol levels,
Several enzymes are responsible for these pathways primarily exerted through GRα and MR located in
and genetic defects associated with blockade of one the hypothalamus and anterior pituitary gland (see
pathway can lead to shunting of precursor chemical Section 5.3). However, GRα and MR mRNAs are
into the other pathways, thus leading to overproduc- located ubiquitously in the human brain, including
tion of those hormones. One of the commonest enzy- the hippocampus, prefrontal cortex, amygdala, ven-
matic defects is associated with blockade of cortisol tromedial hypothalamus, PVN of the hypothalamus
and aldosterone production because of a deficiency in and pituitary gland (Perlman et al., 2007; Cao-Lei et 85
Figure 5.13 Absence of cortisol biosynthesis in CAH. Simplified schematic view of adrenal cortex biosynthetic pathway illustrating that the
absence of 21-hydroxylase activity blocks the biosynthesis of cortisol and aldosterone from cholesterol. This leads to an overproduction of
testosterone. In the absence of cortisol, and negative feedback, ACTH secretion remains high, further stimulating biosynthesis of testosterone.
al., 2013). It is likely, therefore, that GCs, targeting cortisol. Important mechanistic information has been
these receptor sites, will affect several neural systems derived from experimental animals. At high doses, GCs
in addition to those that control the HPA axis. For decrease branching of dendrites and sprouting of axons
example, the timing of the diurnal rhythm appears to in various brain regions. They also decrease glucose
be disrupted (Miller et al., 2007), which may predis- levels in the hippocampus, decrease neurotrophic fac-
pose some patients to psychiatric problems because of tors such as brain-derived neurotrophic factor in the
the change in circadian control. GCs are implicated in hippocampus and neocortex, and attenuate the synaptic
several neuropsychiatric pathologies (Kalafatakis strengthening essential for memory formation.
et al., 2016). Treatment with GCs improves the sense Similar changes in the living human brain are more
of well-being and causes euphoria during the initial difficult to detect, although magnetic resonance imaging
few days of therapy followed by more depressive (MRI) is providing valuable data (van Honk and
symptoms (Swinburn et al., 1988; Brown and Pruessner, 2010). For example, structural changes have
Chandler, 2001). Similarly, in patients with long- been reported in post-traumatic stress disorder (Bierer
standing Cushing’s disease (hypercortisolemia) there et al., 2015). Cushing’s syndrome also causes irreversible
is a high incidence of depressive symptoms that are changes in the human brain as determined by functional
resolved following surgical removal of the adenoma MRI (Andela et al., 2015), and psychosocial stress in
(Starkman et al., 1986; Rasmussen et al., 2015). otherwise healthy adults disrupts functional connectiv-
The mechanism by which GCs induce neuropsy- ity in the prefrontal cortex (Liston et al., 2009).
chiatric symptoms remains unclear (reviewed in Judd Clinical implications: Short-term GC therapy is used
et al., 2014; Hall et al., 2015). Synthetic GCs, such as to improve the quality of life and sense of well-being in
prednisone and DEX, inhibit ACTH secretion and advanced cancer patients undergoing palliative care
hence suppress the release of cortisol from the adrenal (Bruera et al., 1985; Hardy et al., 2001). This has been
86 cortex, effectively depriving the brain of endogenous shown to reduce fatigue and improve the appetite.
Figure 5.14 CRH stimulation of ACTH and cortisol in obese women. Plasma ACTH (left) and cortisol (right) plotted as percentage increases
after intravenous CRH administration in obese (visceral) women (n=12; BMI: 35.0+/-4.1 kg/m2) and in normal weight healthy controls (n=7; BMI:
22.8+/-1.9 kg/m2). Values are mean +/-SEM; * p<0.05 vs. controls. Data obtained from Pasquali et al. (1993).
5.6 Food Intake and the HPA Axis cortisol deficiency is associated with weight loss
(reviewed in Bose et al., 2009; Berthon et al., 2014;
Circulating cortisol concentrations increase after
Loriaux 2017). Similarly, job stress – through its effect
meals. This well-described effect has been attributed
on the HPA axis – has also been positively correlated
to uptake of protein from the gut (Benedict et al.,
with BMI and obesity (Miranda et al., 2015). Reversal
2005), although other reports indicate that carbohy-
of excess cortisol secretion in Cushing’s patients suc-
drates and fat are also implicated (Stimson et al.,
cessfully reduces the size of visceral fat depots. In a
2014). Efforts to understand the mechanism of post-
detailed review, Rodriguez et al. (2015) concluded
prandial activation of the HPA axis have focused on
that: “there is substantial evidence of differential
the role of gut hormones released following food
HPA axis activity in both generalized and abdominal
intake. For example, glucagon-like peptide-1 (GLP-
obesity.” However, much of the literature is contra-
1; see Chapter 4) is released from the small intestine in
dictory and inconsistent in terms of methodology and
response to food ingestion, and especially by fat and
sample characteristics (Pasquali et al., 2006). We pre-
high protein intake (van der Klaauw et al., 2013).
sent here several examples to illustrate the effects of
Treatment of young, healthy male volunteers (age:
obesity on some aspects of HPA function. Obesity –
34.7+/-2.1 years; BMI: 24.3+/-0.7 kg/m2) with an
especially of the visceral phenotype – is associated
intravenous bolus of GLP-1 induced a prompt
with hyper-responsiveness of the pituitary to stimula-
increase in cortisol secretion (15–90 mins; Gil-
tion with CRH. For instance, in obese, premenopausal
Lozano et al., 2010). It remains unknown whether
women CRH stimulation revealed an increased sensi-
GLP-1 acts on the brain or directly on the pituitary
tivity of the pituitary in terms of ACTH and cortisol
to release ACTH.
secretion (Pasquali et al., 1993; Figure 5.14).
A comparable result is observed when CRH is
5.7 Body Weight and the HPA Axis combined with VP; that is, ACTH and cortisol are
significantly increased in obese men and women,
Obesity
compared with normal weight controls (Pasquali et
There is a significant association between the HPA al., 1996; Pasquali et al., 1999). However, the basal –
axis and body weight. Long-term GC therapy, as well that is, unstimulated – secretion of ACTH is signifi-
as endogenous Cushing’s syndrome, causes excessive cantly reduced in obese, premenopausal women
central fat deposition and weight gain whereas 87
studied in the early morning when ACTH pulses are
normally increased (Pasquali et al., 1998). Basal corti- 5.7.1 A Case of Cushing’s Disease
sol levels were unaffected by visceral or subcutaneous
A 27-year-old female was referred to endocrinology
fat levels, indicating a lack of correlation between
for assessment of rapid weight gain and fatigue. She
ACTH and cortisol release. Interpretation of these
was a member of the military and noticed that she was
data is complicated by other reports that in obese
unable to keep pace with her platoon during the
men there is a marked increase in ACTH secretion
physical training sessions. Over the next few months
in the presence of a reduction in cortisol levels (Jessop
she developed significant proximal muscle weakness,
et al., 2001). The data suggest that the normal negative
requiring assistance to climb the stairs. Her weight
feedback of cortisol is perturbed in the presence of
increased by 60 lbs, with marked central adiposity and
visceral obesity (Rodriguez et al., 2015). These authors
round face, excessive sweating, swelling of the hands
emphasize that BMI is an imprecise criterion of obe-
and bilateral leg edema, as well as bruising of the skin.
sity; that is, an individual with a high BMI but very
She had normal menstruation previously, but with the
low abdominal obesity (e.g., a muscular athlete)
onset of weight gain her cycles initially became irre-
would demonstrate a cortisol profile different from
gular and then completely stopped about 4 months
an individual with high BMI and high abdominal
ago. She was also recently diagnosed with new-onset
adiposity.
depression. On examination, her blood pressure was
To summarize, changes in the HPA axis appear to
140/100 mm Hg, she had several bruises on both
be involved in the etiology of visceral obesity.
arms, a round plethoric face and evidence of supra-
However, it remains uncertain whether obesity initi-
clavicular and dorsal fat deposition. Violaceous striae
ates HPA dysregulation or whether the reverse is true.
were visible on the abdomen, lower back and thighs
and she had marked lower leg edema as well as grade
Anorexia Nervosa 4/5 weakness of the proximal upper and lower limb
Anorexia nervosa is a psychiatric disorder in adoles- muscles. A provisional diagnosis of hypercortisolemia
cent girls and women, characterized by altered body (Cushing’s syndrome) was made.
image, persistent food restriction and low body Preliminary investigations were as follows:
weight. This disorder affects boys and men also, but Morning serum cortisol=818 nmol/L (120–620
is eight times more prevalent in women than in men. nmol/L)
It is associated with profound endocrine dysfunc- ACTH=28.9 pmol/L (2.3–10.1)
tion, especially of the hypothalamic–pituitary axis 24 h urinary free cortisol=1672 nmol/total volume
but also in the regulation of gut hormones and adi- (92–696 nmol/24 h)
pokines (see also Chapter 4). The HPA axis is chroni- Post-48 h low-dose DEX suppression serum
cally activated in at least 30% of anorexic women, cortisol=644 nmol/L (<50 nmol/L)
with some studies reporting that 24-hour mean Post-48 h high dose DEX serum cortisol=72 nmol/
plasma cortisol levels were increased in up to 80% L (>50% suppression)
of patients (Schorr and Miller, 2017). In addition, Serum electrolytes were normal.
patients with anorexia nervosa develop reduced sup- Based on these investigations, a diagnosis of
pressibility of endogenous cortisol in response to ACTH-dependent hypercortisolemia was made and
oral DEX. It remains unknown whether the stress an MRI of the pituitary (Figure 5.15) was requested,
of chronic undernutrition is responsible for the which showed a 6 mm left-sided pituitary adenoma.
hypercortisolemia. To further confirm the pituitary origin of ACTH,
Clinical implications: The biochemical changes in bilateral inferior petrosal sinus sampling was done
anorexia nervosa tend to mimic those of Cushing’s measuring ACTH before and after an injection of
syndrome. These include: elevated serum and 24-hour ovine CRH (Zampetti et al., 2016). The central-to-
urine cortisol levels and non-suppressibility of serum peripheral plasma ACTH gradient pre-CRH was 6
cortisol to exogenous DEX. The exact mechanism and post-CRH was >20 (a pre-CRH gradient of >2.0
causing hypercortisolemia in patients with anorexia and post-CRH of >3.0 indicates pituitary origin of
nervosa remains unclear. However, it is suggested that ACTH). The left-to-right plasma ACTH gradient
the stress of chronic undernutrition may play a role was >4 (a lateral gradient of >1.4 favors localization
via increased hypothalamic CRH secretion (Misra and of the ACTH adenoma toward the higher gradient). A
88 Klibanski, 2014; Schorr and Miller, 2017). left-sided ACTH-producing pituitary adenoma
hypercortisolemia (Lacroix et al., 2015) and have a

higher preponderance in females (Giraldi et al., 2003)
These patients typically present with rapid weight
gain, menstrual irregularities (women), sexual dys-
function, wasting and weakness of the proximal mus-
cles, easy bruisability and central fat deposition. In
addition, a significant proportion of these patients
also have mood disorder at presentation (Starkman,
2013). Removal of the offending ACTH adenoma is
the treatment of choice and provides long-term
remission; however, recurrence rates are high and
these patients require lifelong surveillance. In patients
where surgery is either contraindicated or unsuccess-
ful, treatment options include medical therapy, radia-
tion or bilateral adrenalectomy. Dopamine agonists
such as cabergoline and somatostatin analogs such as
pasireotide have been used to treat ACTH adenomas
(see also Section 5.1). ACTH production is reduced
and may be effective in mild Cushing’s disease. In
addition, adrenal enzyme-inhibitor therapy is used
to block or reduce adrenal cortisol synthesis. These
Figure 5.15 Dynamic MRI (coronal section) showing the adenoma agents include ketoconazole, metyrapone and etomi-
on the left side of the pituitary (arrow).
date and can be used in combination with other
therapies. Newer cortisol synthesis inhibitors like
LCI699 have shown promising results in early clinical
studies; however, long-term data are awaited.
Mifepristone is a GR antagonist that acts by blocking
the GCR and can be used as short-term therapy in
symptomatic patients. Occasionally radiation therapy
to the pituitary is used to treat an unresectable ade-
noma. However, radiation therapy can take several
months to work and patients require medical therapy
in the interim. Bilateral adrenalectomy to remove
both adrenal glands is used as a last resort in patients
who are unable to achieve a remission otherwise.
These patients subsequently require life-long GC
and mineralocorticoid replacement.
Figure 5.16 Post-surgical recovery. (A) shows the patient 3 months
before and (B) 5 years after surgery. 5.7.2 A Case of Cortisol Deficiency
The on-call endocrine team was consulted for assess-
causing Cushing’s disease was diagnosed and the ment of a 32-year-old male with low energy and mild
patient underwent trans-sphenoidal resection of the hyponatremia. He had suffered a severe traumatic brain
adenoma. This led to normalization of muscle injury (TBI) when his all-terrain vehicle rolled over
strength, mood disorder and blood pressure, resolu- during a hunting expedition. After spending several
tion of edema and weight loss. Figures 5.16A and weeks in the acute care facility, he was transferred to
5.16B, respectively, show the patient 3 months before rehab where he initially made good progress but then
and 5 years after surgery. started complaining of poor energy and dizziness. His
This case illustrates a patient with Cushing’s dis- serum sodium was consistently running between 131
ease. ACTH-producing pituitary adenomas account and 133 mmol/L (normal=135–145). He was not taking
for approximately 80% of cases of endogenous any regular medication except occasional paracetamol 89
for headaches. He had a regular sleeping pattern and cortisol deficiency and such patients should be
woke up daily at around 7.00 AM. immediately started on replacement therapy. On
The initial investigations from a blood test drawn the other hand, a morning cortisol of >250 nmol/L
at 0900 hours (around 2 hours after awakening) generally suggests adequate cortisol levels (Yip et al.,
revealed the following: 2013; Munro et al., 2016). In patients with morning
Serum TSH=2.19 mIU/L (0.34–4.5) basal cortisol between these values, or in those with
Serum thyroxine=12.6 pmol/L (11.5 – 19.7) inconsistent sleep-wake cycles, additional dynamic
Serum cortisol=86 nmol/L (normal = 184–512) tests such as the insulin stress test or the ACTH
Serum ACTH=0.03 pmol/L (normal = 2.2–10) stimulation test are required. Typically, serum corti-
Serum prolactin=9.2 mcg/L (2.1–17.7) sol values rise to >500 nmol/L after insulin induced
LH=0.4 IU/L (normal=1.4–18.1 IU/L hypoglycemia or an injection of ACTH. A failure of
FSH=0.9 IU/L (normal=1.5–9.3) serum cortisol to rise above 500 nmol/L suggests
Serum total testosterone=5.5 nmol/L (nor- HPA dysfunction. Measurement of serum ACTH
mal=8.0–32) can reliably differentiate between cortisol deficiency
There was no evidence of a sellar mass in the brain due to adrenal dysfunction (causing high ACTH
imaging. levels due to lack of feedback) and hypothalamic-
Based on the low serum cortisol and low ACTH, as pituitary related cortisol deficiency (low ACTH
well as low serum testosterone and low LH/FSH, a levels).
diagnosis of secondary hypoadrenalism and second-
ary hypogonadism was made. Replacement therapies 5.8 Chapter Summary
in the form of hydrocortisone and testosterone were This chapter outlines the neuroendocrine regulatory
initiated, which led to normalization of serum sodium mechanisms that govern the HPA axis, especially in
and energy levels. terms of the control of pituitary secretion of ACTH
Hypopituitarism is not an uncommon conse- and its effect on the release of cortisol from the adre-
quence of TBI. In fact, almost 50% of patients suffer- nal cortex.
ing a TBI can develop transient cortisol deficiency Glucocorticoid receptors (GR) are present in
(Cohan et al., 2005). Data from long-term follow-up almost every tissue of the human body.
revealed persistent pituitary dysfunction with cortisol ACTH is a product of the POMC gene, which
deficiency in 16% of patients (Agha et al., 2005). encodes the pre-propeptide POMC that is processed
Cortisol deficiency may present either insidiously or into smaller peptides, including ACTH, by enzymes
in rare cases as acute adrenal crisis. Typical features of called proprotein convertases. Thus ACTH, β-endor-
cortisol insufficiency may include fatigue, weight loss, phin and γ-LPH are co-released from the anterior
postural dizziness due to low blood pressure, nausea, pituitary following CRH stimulation.
abdominal pain and muscle pains. Hyponatremia is Secretion of ACTH is orchestrated by two major
seen in up to 80% of patients with cortisol deficiency. control systems: stress and a diurnal (circadian)
If untreated, these patients may present with acute input, both of which are mediated through the
adrenal crisis leading to vomiting, severe hypoten- release of two peptides acting as releasing hormones:
sion, confusion, coma and death. Although the exact hypothalamic CRH and VP. By itself, VP has no
underlying etiology of pituitary dysfunction after TBI significant effect on ACTH secretion but synergizes
is not fully understood, several factors including with CRH to regulate ACTH levels. Following secre-
hypoxia, hypotension leading to pituitary asphyxia tion from the pituitary, ACTH stimulates the adrenal
and direct mechanical injury have been proposed. cortex to secrete cortisol, which exerts a powerful
Autopsy studies have shown evidence of pituitary negative feedback to modulate both CRH and
infarction in patients dying of TBI (Salehi et al., 2007). ACTH secretion. CRH neurons and pituitary corti-
A low morning serum cortisol in patients with a cotrophs respond to cortisol negative feedback via
normal sleep-wake cycle is highly suggestive of cor- the nuclear GR. The GR mRNA encodes several
tisol deficiency. Various cut-off values for morning receptor isoforms, but GRα is the active form that
basal cortisol are reported in the literature. Typically, mediates most of the effects of cortisol. GRα mRNA
a morning basal serum cortisol of <130 nmol/L, in is found throughout the human brain and in the
90 the absence of interfering medication, indicates pituitary gland.
ACTH and cortisol secretion is pulsatile and 5.9 Review Questions

follows a circadian rhythm, with maximum levels
occurring in the early morning prior to daily activ- 1. Name the two primary hypothalamic
ity. Maximal secretion is driven by an increase in neuropeptides that regulate adrenocorticotropin
the amplitude of ACTH and cortisol pulses that (ACTH) secretion from the anterior pituitary
occur at an overall frequency of approximately 15– gland.
20 per day. Mean and pulsatile ACTH are posi- 2. Your patient presents with marked abdominal
tively correlated with BMI, and ACTH secretion is obesity and some muscle wasting in her arms
significantly greater in men than in women, due to and legs. She also complains that she bruises
an elevation in total and pulsatile secretion of easily. Laboratory tests reveal unusually high
ACTH. cortisol and ACTH levels. Further investigation
Stress – both physical and psychological – is the reveals that cortisol secretion fails to undergo
principal stimulus for activation of the HPA axis. For diurnal variation. The cortisol levels are so
example, students facing examinations release high high because:
levels of cortisol, and acute moderate exercise in a. She is receiving anti-inflammatory
healthy men induces a rapid response in ACTH and glucocorticoid treatment.
cortisol secretion. Other stimuli include critical ill- b. She has Addison’s disease.
ness, fever, burn injury, depression, surgery and c. She has an ACTH-secreting pituitary tumor.
hypotension (low cortisol). d. She has type 2 diabetes.
Elevated levels of GCs, either stress-induced or e. She has an adrenal tumor.
resulting from exogenous treatment, induce pro- 3. Addison’s disease is characterized by severe
found reproductive dysfunction in humans. The atrophy of the adrenal cortex, possibly as a result
high levels of cortisol associated with Cushing’s of a destructive autoimmune process. Which of
syndrome is often accompanied by menstrual dis- the following symptoms would you not expect to
turbances in women and hypogonadotropic hypo- encounter?
gonadism in men. Adrenal insufficiency, as in
Addison’s disease, may also impair fertility. CAH, a. Hypertension
characterized by deficient adrenal cortisol bio- b. Weight loss
synthesis and elevated androgen production, c. Muscle weakness
induces irregular menstruation and anovulation d. Fatigue
in 30–68% of women with the salt-wasting form e. Low serum sodium levels
and 30–75% of those with the simple virilizing 4. The plasma levels of ACTH:
form. a. Are elevated at the onset of sleep.
GCs are implicated in several neuropsychiatric b. Undergo marked diurnal changes.
pathologies. For example, in Cushing’s disease there is c. Are elevated during hypoglycemia.
a high incidence of depressive symptoms that are d. Are stimulated by glucocorticoid treatment.
resolved following surgical removal of the adenoma. e. Are reduced by adrenal insufficiency.
Exogenous GC treatment also induces a significant
5. Explain why β-endorphin, γ-lipotropin and
increase in cases of depression, suicide, mania and
ACTH are co-secreted from the same
anxiety.
corticotrophs.
There is an important link between obesity and
6. Which of the following conditions are associated
GCs. Long-term oral GC therapy induces increases in
with elevated cortisol levels?
body fat. Job stress is also correlated with BMI and
obesity. Cushing’s syndrome is accompanied by a a. ACTH-producing pituitary adenoma
high incidence of obesity and reversal of excess corti- b. Anorexia nervosa
sol secretion in Cushing’s patients successfully c. Acute trauma
reduces the size of visceral fat depots. d. Dexamethasone (DEX) therapy
Two clinical cases are included to illustrate: (1) GC e. Congenital adrenal hyperplasia
excess (Cushing’s disease) and (2) cortisol deficiency 7. Features of Cushing’s syndrome typically include
(following TBI). which of the following? 91
a. Amenorrhea Rodriguez A C I, Epel E S, White M L, Standen E C, Seckl J R

b. Postural hypotension & Tomiyama A J. (2015). Hypothalamic-pituitary-adrenal
c. Excessive bruising axis dysregulation and cortisol activity in obesity: a
systematic review. Psychoneuroendocr 62, 301–318.
d. Depressive symptoms
e. Weight loss
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96
Chapter
Hypothalamic Regulation of Thyroid
6 Function
The thyroid, one of the largest endocrine glands, is binding globulin (TBG), pre-albumin, albumin and
comprised of two types of hormone-producing cells – transthyretin. The free hormones, in equilibrium with
the predominant follicular cell, which produces thyr- the bound hormones, constitute about 0.02% of the
oxine (T4; tetraiodothyronine, containing four iodine total T4 and 0.3% of the total T3 pool (Larsen et al.,
atoms) and triiodothyronine (T3; containing three 2008). Only the free hormones enter target cells, via
iodine atoms), and the neuroendocrine parafollicular specific transporters, and about 10% of T4 and 75% of
or C cell, which secretes calcitonin. The secretion of T4 T3 are degraded daily primarily by deiodination (dis-
and T3 is controlled by the hypothalamic–pituitary cussed later in this chapter; see Figure 6.1).
system, whereas calcitonin, primarily involved in Clinical implications: a. Since the developing fetus
calcium regulation, is released in response to derives its THs from the mother during the first tri-
hypercalcemia. This chapter will focus on: mester, the dose requirement for thyroid replacement
hypothalamic–pituitary mechanisms that dictate therapy typically increases by 30–50% in pregnant
thyroid function, and pathophysiological states that hypothyroid women during early pregnancy.
lead to abnormal thyroid activity. b. Several factors can transiently alter the concentra-
The thyroid gland synthesizes both T4 and T3 in tion of TBG and thus interfere with the binding of T4
a relative ratio of approximately 17:1, with a daily and T3 with TBG. These changes can have a profound
production of T4 and T3 being around 100 and 6 effect on assays measuring total TH levels. Therefore,
mcg, respectively. T4 acts as a prohormone that is generally free T4 and T3 (fT4 /fT3) levels are routinely
converted to the biologically active T3 by deiodinase measured in clinical practice, which tend to remain
enzymes in target cells (Figure 6.1). The half-life of T4 relatively stable despite changes in TBG
is approximately 5–7 days and that of T3 is 1 day; concentration.
about 80% of the T3 comes from the extra-thyroid THs exert multiple effects on most cells through-
conversion of T4 to T3. out the body, influencing basal metabolic and respira-
Clinical implications: Due to the long half-life of T4, tion rates, cardiovascular function (Jabbar et al.,
and the fact that most of the daily T3 requirement is 2017), oxygen consumption, carbohydrate and pro-
obtained by peripheral conversion of T4 to T3, replace- tein metabolism, thermogenesis and sodium pump
ment therapy for underactive thyroid (hypothyroid- activity, and provide negative feedback regulation of
ism) is given mainly in the form of T4 alone. thyrotropin releasing hormone (TRH) and thyroid-
The maternal thyroid supplies thyroid hormones stimulating hormone (TSH; also called thyrotropin.)
(THs) to the developing human embryo, but by the secretion (Whitehead and Miell, 2013). THs also reg-
end of the first trimester the fetal thyroid begins to ulate critical aspects of growth and differentiation,
synthesize and secrete THs. The synthesis of T4 and T3 stimulating maturation of the brain, skeleton, heart
is dependent upon the availability of iodine, which is and lungs during prenatal and early postnatal devel-
actively transported into the thyroid follicular cells, opment. For example, bone is a target tissue for THs.
where it is oxidized and attached to the tyrosine mole- Thus, they are essential for normal linear growth and
cule. This process is called organification. Coupling of skeletal maturation (Bassett and Williams, 2016).
two diiodotyrosine residues produces T4, whereas T3 is Animal studies have revealed that THs regulate at
formed by coupling of one dioiodotyrosine and one least 700 genes in the developing brain (Chatonnet
monoiodotyrosine. Most of the circulating T4 and T3 et al., 2015). Consequently, low levels of T3/T4
are bound to various proteins including thyroid- (hypothyroidism) in the fetus or newborn cause 97
Chapter 6: Hypothalamic Regulation of Thyroid Function
Figure 6.1 Hypothalamic–pituitary–thyroid axis. Hypothalamic TRH stimulates TSH release from the anterior pituitary gland. TSH binds to cell
surface receptors in the thyroid gland via membrane TSHR. The thyroid responds by secreting T4 and T3 that are transported in the blood
bound to the TBG, and several other binding proteins such as transthyretin. fT3/fT4, equilibrating with bound T3/T4, enter target cells –
including pituitary and the brain – via specific transporters. T4 is then converted to the bioactive hormone T3 by D2 (see Figure 6.5). T3 and T4
levels are also regulated by D3, which inactivates them by conversion to T2 (diiodothyronine; from T3) and rT3 (from T4). Bioactive T3 binds to
THRs that dimerize with the RXR before binding to target DNA. This final step activates gene transcription (mRNA) and the production of
specific proteins. Note that T3/T4 exert negative feedback on both hypothalamic TRH neurons and pituitary thyrotrophs, decreasing TRH and
TSH release, respectively. Abbreviations: D2, deiodinase 2; D3, deiodinase 3; mRNA, messenger ribonucleic acid; rT3, reverse T3; RXR, retinoid
X receptor; THR, TH receptor; TSH, thyroid-stimulating hormone; TSHR, TSH receptor; T2, diiodothyronine. Image reproduced with permission
(Dayan and Panicker, 2009).
mental retardation, short stature and delay in motor with drugs that reduce the synthesis of T3 and T4 (see
development. Early intervention with T4 treatment, or cases later in the chapter).
treatment of the mother with T4 during pregnancy,
can largely avoid these problems (Grüters and Krude, 6.1 The Hypothalamic–Pituitary–
2012). In adults, hypothyroidism causes weight gain,
lethargy, mental slowness and a decrease in metabolic Thyroid Axis
rate. These symptoms are treatable with The essential components of the hypothalamic–pitui-
thyroid hormone replacement. In contrast, high levels tary–thyroid system are illustrated in Figure 6.1.
of T3/T4 (hyperthyroidism or thyrotoxicosis) induce TRH is a small peptide (three amino acids),
weight loss, tremors, sweating, muscle weakness and whereas TSH is a large heterodimeric polypeptide
increased cardiac output. These patients are treated (210 amino acids) consisting of two subunits (α and
98
Table 6.1 Blood tests to distinguish thyroid disorders
Blood test Thyrotoxicosis due Hypothyroidism Thyrotoxicosis due Hypothyroidism

to primary thyroid due to primary to excessive due to subnormal
disorder thyroid disorder pituitary TSH pituitary TSH
production production
Serum TSH Suppressed Elevated Not suppressed (may be Not elevated (low or
elevated or normal) normal)
Serum fT4 Elevated or high-normal Low Elevated Low
Serum fT3 Elevated or high-normal Low or low-normal Elevated or high-normal Low or low-normal
β). The α-subunit is common to TSH, follicle stimu- (THR) is therefore properly regarded as a T3 receptor,
lating hormone (FSH), luteinizing hormone (LH) and and TH action at target cells occurs via a T3/THR
human chorionic gonadotropin (hCG). The β- hormone/receptor complex that acts as a transcription
subunit is specific to the TSH molecule and becomes factor (see Chapter 1). In contrast to the estradiol/estra-
biologically active when bound to the α-subunit. diol receptor complex, it does not dimerize with itself
Clinical implication: Because of the common α- (forming a homodimer), but forms a heterodimer with
subunit, hCG exerts a TSH-like effect during pregnancy a different molecule, the retinoid X receptor (RXR).
by increasing TH production, associated with This heterodimer, along with co-regulators, binds to
a concomitant compensatory drop in TSH levels. a TH response element to control gene expression
Furthermore, women with very high hCG levels, such (mRNA) and protein synthesis (see Figures 6.1 and 6.2).
as in twin pregnancy or hydatidiform mole, can develop
thyrotoxicosis due to the stimulatory effect of hCG on 6.2 Neural Control of TRH/TSH
the thyroid gland.
In common with other pituitary hormones, TSH Secretion
secretion from the anterior pituitary is regulated by The two primary determinants of TSH secretion are,
a hypothalamic releasing hormone – in this case TSH- first, a stimulatory effect of TRH, released from
releasing hormone, also known as TRH (or thyrotropin hypothalamic neurons and, second, a negative feedback
releasing hormone). T3 and T4, released in response to of circulating T3/T4 exerted at both pituitary and
this hypothalamic stimulus, not only exert profound hypothalamic levels (Figure 6.1). An ultrashort negative
effects in peripheral target tissues but regulate both feedback loop has also been proposed for TSH; that is,
TRH and TSH secreting cells through a negative feed- the localization of TSH receptors (TSHRs) in human
back system, reducing the synthesis and secretion of both anterior pituitary suggests that TSH may regulate its
TRH and TSH. It is important to note that measuring own secretion (Prummel et al., 2004; Hoermann et al.,
TSH alone may lead to an erroneous diagnosis in 2015). Overall, these influences regulate both synthesis
patients with hypothalamic–pituitary dysfunction; that and secretion of TRH and TSH. The precise regulation
is, unlike a normal pituitary, which can respond to the of TSH levels is so delicately preserved that an abnormal
regulatory feedback stimuli, a dysfunctional pituitary is serum TSH is a sensitive indicator of primary thyroid
unable to mount the appropriate response (see clinical dysfunction (Hoermann et al., 2015; Mariotti and Beck-
cases). Peccoz, 2016). Table 6.2 lists many of the known hor-
Clinical implications: Measurement of serum TSH, monal, neurotransmitter and drug effects on human
fT4 and fT3 levels can reliably differentiate between TSH secretion (see also Roelfsema and Veldhuis 2013;
the states of hypothyroidism and thyrotoxicosis. Hoermann et al., 2015).
Table 6.1 illustrates the pattern of these tests in several For example, infusions of dopamine and of soma-
common thyroid disorders. tostatin in healthy volunteers profoundly inhibit the
When T3 and T4 enter the brain, they do so via daily surge in TSH secretion, largely through
specific transporters at the blood–brain barrier (BBB; a reduction in pulse amplitude (Samuels et al.,
see Section 6.3). Note that T4 first enters astrocytes and 1992). Similarly, blockade of endogenous opioids
is converted to T3 by the deiodinase enzyme deiodinase with naloxone also inhibits nocturnal TSH levels
(Samuels et al., 1994). 99
2 (D2; Brent, 2012; see Figure 6.4). The TH receptor
Table 6.2 Drug/hormonal effects on human TSH secretion hypothalamus, suggesting that TRH neurons project to
Stimulatory Inhibitory
the pituitary portal system. That TRH is biosynthesized
in PVN neurons was confirmed by localizing TRH
TRH T3/T4
mRNA using in situ hybridization (Guldenaar et al.,
Opioids Dopamine 1996). In summary, human hypothalamic TRH neu-
Galanin Somatostatin rons and neuronal fibers are ideally situated to regulate
Leptin (obesity) Ghrelin TSH secretion via the pituitary portal system. However,
Estradiol (post-menopausal) Testosterone (males) the presence of TRH mRNA and TRH peptide immu-
Sertraline (serotonin- Glucocorticoids noreactivity in several areas of the brain suggest that
reuptake inhibitor) TRH may regulate other, non-hypophysiotropic,
Amphetamine Cholecystokinin neural systems. For example, TRH has psychotropic
Clonidine Interleukin-6 properties, including anti-depressant and anxiolytic
Reboxetine (norepinephrine effects in some patients with major depressive disorder,
reuptake inhibitor) and in healthy volunteers (Szuba et al., 2005; reviewed
Thymoxamine (α-adrenergic by Khomane et al., 2011).
antagonist)
Vasopressin (blunts TRH
response)
6.3 TH Feedback Regulating TSH
Cholinergic antagonists Secretion
The biological effects of THs on TSH secretion are
primarily dependent on the availability of THRs in
target cells (neurons and thyrotrophs). However, T3
A detailed description of the neurochemical control and T4 do not diffuse passively into the brain or into
of TRH neurons in experimental animals can be found cells, but must be carried there by specific transporters
elsewhere (Lechan and Fekete, 2006), but relatively (Figures 6.1 and 6.4). In addition, T4 acts as a prohor-
little is known about the localization and function of mone, converted to the bioactive hormone T3 by deio-
central neurotransmitter and neuropeptide systems dinases located in T3 receptor-positive cells. Thus, all
that regulate human TRH neurons. Nonetheless, three components – receptors, transporters and deio-
some of the effects listed in Table 6.2 – that is, those dinases – are essential for the biological activity of THs.
mediated by opioids, cholinergic antagonists, amphe- THRs. The negative feedback of THs on TSH
tamine and dopamine – suggest the possible involve- secretion (Figure 6.1) is mediated by THRs located
ment of several neurotransmitter/neuropeptide in the hypothalamus and anterior pituitary. A general
pathways in regulating human TSH secretion. It is model of the action of T3 in the cell nucleus is shown
important to note that some of these effects are tran- in Figure 6.2. In the absence of T3, THRs form hetero-
sient and may not be relevant in day-to-day clinical dimers (with RXR; see Figure 6.1), or homodimers,
practice. that then bind to the TH response element on target
genes. However, gene transcription is actively pre-
Localization of TRH Neurons in the Human Brain
vented by the recruitment of a co-repressor. In the
Early studies in human brain tissue revealed the pre- presence of T3, this repression is destabilized, releas-
sence of TRH in many brain regions. Especially high ing the co-repressor and permitting the binding of
values were observed in the infundibular region of the a co-activator to initiate gene transcription (Ortiga-
basal hypothalamus, a site consistent with TRH acting Carvalho et al., 2014).
as a releasing hormone (Parker and Porter, 1983). Two genes, THRA (chromosome 17) and THRB
Subsequent investigation, with more refined techni- (chromosome 3), encode four receptor isoforms:
ques such as immunohistochemistry and in situ hybri- THRα1, THRα2, THRβ1 and THRβ2. However,
dization, confirmed the presence of TRH in THRα2 does not bind T3 and is therefore unlikely to
hypothalamic neurons. For example, immunoreactive be involved in the feedback effects of T3. The other
TRH was localized to neurons and neuronal fibers in three receptors – THRα1, THRβ1 and THRβ2 – are
the hypothalamic paraventricular nucleus (PVN; Fliers found in many thyroid target tissues, including brain,
et al., 1994). Dense fibers were also present in the basal pituitary, heart, skeletal muscle and retina (Brent,
100
Figure 6.2 Outline of gene regulation by THs. The RXR–THR heterodimer binds to target genes at a TRE located on the DNA. In the absence
of T3, a co-repressor is also bound to the heterodimer and actively represses target gene expression. The presence of T3 releases the
co-repressor, replacing it with a co-activator that permits activation of gene transcription. Image reproduced with permission (Ortiga-Carvalho
et al., 2014). Abbreviations: RXR, retinoid X receptor; THR, thyroid hormone receptor; TRE, thyroid hormone response element.
2012). For example, immunocytochemical analysis of and this is consistent with detailed studies in the fetal
human hypothalamic and pituitary tissue revealed the and postnatal rodent brain, localizing THR through-
presence of all THR isoforms (Alkemade et al., 2005a; out the brain (Puymirat et al., 1991; Bernal, 2015).
2006). Prominent staining was observed in the ante-
rior pituitary and in the PVN and infundibular region TH Transporters
of the hypothalamus. Further, TRH mRNA and THR Figure 6.1 illustrates that fT3 and fT4 are actively trans-
isoforms are strategically located to mediate TH feed- ported from the bloodstream into target cells.
back on TRH secretion (Alkemade et al., 2005b; Fliers Monocarboxylate transporter 8 (MCT8) is the key
et al., 2006). Similarly, in the anterior pituitary, TSH is transporter that accomplishes this uptake (Bernal
co-localized with THR in thyrotrophs (Fliers et al., et al., 2015) and has been localized to human hypotha-
2006). lamus, specifically in the PVN and in the infundibular
It is likely that THR are also located in several region (Alkemade et al., 2005b) and in human pituitary
non-hypothalamic human brain areas. For example, cells (Alkemade et al., 2006). The importance of this
development of the fetal brain is compromised in the transporter is substantiated in patients with X-linked
absence of THs, reflected in impaired psychomotor inactivating mutations in the gene encoding MCT8
and cognitive function and changes in brain mor- (Allan–Herndon–Dudley syndrome; Bernal et al.,
phology (Moog et al., 2017). Many regions of the 2015). In these patients, the brain is deprived of T3.
human fetal brain – including cerebral cortex, cere- More than 100 families are known to be affected world-
bellum, hippocampus and brain stem – contain high wide and such patients have global developmental
concentrations of T3 and D2, necessary for TH acti- delay, lack of speech and severe neuromotor impair-
vation (see later in this chapter), implicating ments, in addition to changes in TH metabolism.
a functional role for THs in many brain regions As shown schematically in Figure 6.4, MCT8 is
(Kester et al., 2004; Bernal, 2015). Adults who also essential for uptake of T3 and T4 into the brain
develop hypothyroidism show symptoms of depres- through the BBB (Visser, 2016; Landers and Richard,
sion, and those with hyperthyroidism exhibit anxi- 2017). An additional transporter, organic ion trans-
ety, mania and emotional lability (Feldman et al., porting polypeptide (OATP1C1), appears to be selec-
2013), implying that THs are associated with psy- tive for T4 and is expressed in astrocytes, where T4 is
chiatric disorders. Powerful imaging techniques converted to T3 (Visser, 2016). A similar situation
have also been used to locate TH-sensitive brain exists in the human anterior pituitary gland where
regions (Bauer et al., 2009; Miao et al., 2011). For folliculostellate (FS) cells process T4 into T3 before
example, some non-hypothalamic brain areas show T3 is transported by MCT8 into thyrotrophs
reduced activity following T4 treatment (Alkemade et al., 2006).
(Figure 6.3A) whereas others, such as the cerebral
cortex, are activated by T4 (Figure 6.3B; Bauer et al., Deiodinases
2005; Brabant et al., 2011). Such studies indicate that Deiodinase enzymes can both activate and deactivate
THR are located in many regions of the human brain THs by a mechanism that selectively catalyzes the 101
Figure 6.3 Regional brain activity affected by thyroid function. (A) T4-induced decreases in brain activity detected by PET and [18 F] FDG. (B)
Increased activity in cerebral cortex of a hypothyroid patient treated with T4. Activity revealed using PET and [18 F] FDG. Abbreviations: [18 F]
FDG, fluorodeoxyglucose; PET, positron emission tomography. (A) reproduced with permission (Bauer et al., 2005). (B) reproduced with
permission (Brabant et al., 2011).
removal of iodine atoms from their structure (Bianco anterior pituitary, where T4 is first taken up by pitui-
and Kim, 2006; Figure 6.5). Extra-thyroid conversion tary FS cells that express D2 activity for conversion of
of T4 to T3 is accomplished through deiodinases. T4 to T3. T3 is then transported into thyrotroph cells
Deiodinase 1 (D1) is the predominant deiodinating where it regulates TSH secretion (Alkemade et al.,
enzyme in the thyroid, kidney and liver, whereas D2 is 2006; Fliers et al., 2006). FS cells are large, star-
the key deiodinating enzyme in brain, placenta, skin, shaped cells that wire together, via paracrine signaling,
muscle and pituitary. D2 removes an iodine moiety the whole anterior pituitary gland. The close associa-
from the prohormone T4 to produce the bioactive tion of FS cells with pituitary endocrine cells, such as
hormone T3 (Gereben et al., 2015). In contrast, deio- thyrotrophs, permits a variety of paracrine regulators
dinase 3 (D3) inactivates T3 by removing a second to influence hormonal secretion. Thus, FS cells are key
iodine atom to form diiodothyronine (T2), and simi- components of the anterior pituitary in the regulation
larly inactivates T4 to produce reverse T3 (rT3). D2 of the endocrine system and may be responsible for
therefore plays a critical role in mediating T3 feedback activating T4 (Fauquier et al., 2002; Fliers et al., 2006).
at the level of the hypothalamus and pituitary.
D2 immunoreactivity in the human brain was
localized to the hypothalamus, but not in hypothala- 6.4 Insensitivity to THs
mic neurons; that is, as shown in Figure 6.4, enzyme Figures 6.1, 6.2, 6.4 and 6.5 reveal the mandatory steps
activity was detectable in glial cells, and in astrocytes in for TH to influence target tissues. For example, TH
particular (Fliers et al., 2006). This emphasizes that T4 must be actively transported through cell membranes,
is converted to T3 in astrocytes before it is transported followed by deiodination to yield the active hormone
102 to TRH neurons. An analogous situation occurs in the T3. A key final step is binding to specific receptors that
Figure 6.4 Model for transport and metabolism of T3 and T4 in

hypothalamus. T3 and T4 are transported from brain capillaries, or
through the BBB, by the MCT8 transporter. T3 is then transported into
target TRH neurons, also by MCT8. In contrast, T4 is first taken up by
astrocytes through the OATP1C1 transporter before being
deiodinated to T3.
Figure 6.5 Structures and deiodinase-dependent interconversion of THs. D2 – the only activating deiodinase in human brain and pituitary –
removes an iodine moiety from the prohormone T4 to produce the bioactive hormone T3. In contrast, D3 inactivates T3 by removing a second
iodine atom to form T2 (diiodothyronine), and similarly inactivates T4 to produce rT3. Not shown in this figure is another important deiodinase
that deiodinates molecules such as T2 in order to recycle the scarce element iodine. Recovery of iodine in this way is necessary to maintain
efficient synthesis of TH. Failure of this enzyme leads to hypothyroidism, goiter and mental retardation.
assemble, along with co-regulators, on TH response very rare X-linked inactivating mutation in the gene
elements (TREs) (Figure 6.2). encoding MCT8 (Allan–Herndon–Dudley syndrome;
As noted in Section 6.3, the importance of the Bernal et al., 2015). In these patients, the brain is
transporter system is confirmed in patients with the deprived of T3, producing severe psychomotor defects 103
Figure 6.6 Clinical consequences of THRB mutations. Patients with mutations in THRB, the gene encoding THRβ, may present with phenotypes
that affect a number of tissues and functions, including increased levels of circulating THs, impaired negative feedback of the HPT axis, goiter,
affected vision and hearing, heart defects and abnormal neuronal development. Abbreviations: HPT, hypothalamic–pituitary–thyroid.
Reproduced with permission (Ortiga-Carvalho et al., 2014).
Figure 6.7 Clinical consequences of THRA mutations. In patients with mutations in THRA, in contrast to those with mutations in THRB, the levels
of circulating THs are only mildly affected. However, these patients have delayed bone development, heart defects, chronic constipation and
impaired neuronal development. Reproduced with permission (Ortiga-Carvalho et al., 2014).
(Dumitrescu and Refetoff, 2015). Genetic abnormal- (THRA and THRB) have been described, the latter
ities in TH deiodinases are also rare, but deserving of (THRβ) constitutes the underlying defect in most
further clinical examination (Gereben et al., 2015; patients with resistance to THs and affects around 1
Taylor et al., 2015). in 40,000 live births. These patients typically present
Mutations in THR genes prevent the binding of with elevated levels of serum fT4 and fT3. TSH levels
TH; that is, they induce resistance to THs (Ortiga- are normal or elevated because the brain and pitui-
Carvalho et al., 2014; Dumitrescu and Refetoff, 2015). tary, lacking functional TH receptors, fail to respond
104 Although mutations in both THRα and THRβ genes to TH negative feedback. The disorder can present
with a varied spectrum, depending upon the extent of relatively unimpaired compared with patients with
the underlying tissue resistance. Most THRβ patients mutations in THRβ (Onigata and Szinnai, 2014;
develop a goiter but are otherwise euthyroid as the Ortiga-Carvalho et al., 2014).
resistance is partially compensated for by high levels
of circulating THs. Other symptoms include sinus 6.5 Rhythmic and Pulsatile Secretion
tachycardia (since the heart predominantly expresses
THRα that remain sensitive to elevated T4 and T3 of TSH
levels) and attention deficit hyperactivity disorder. Daily secretion of TSH in healthy volunteers is stable,
However, some patients have a comparatively more robust and unaffected by sex, BMI and age (Roelfsema
severe defect of the hypothalamic–pituitary axis than et al., 2015). TSH is secreted in a diurnal (nycthem-
other tissues and as a result can present with clinical eral) rhythm (Roelfsema et al., 2009a; Figure 6.8),
features of hyperthyroidism. Figure 6.6 illustrates an comparable with those for prolactin (PRL) and
overview of tissues and functions affected by THRβ growth hormone (GH; see Figures 7.4 and 8.4).
(Ortiga-Carvalho et al., 2014). Valuable mechanistic This rhythm is paralleled by a similar pattern in T3
insights that govern the role of THRβ in various levels (Russell et al., 2008). Superimposed on this
cellular processes, including color vision, develop- secretory rhythm are small pulses, or bursts, of TSH
ment of the cochlea and the cerebellum, and normal (Brabant et al., 1990; Keenan et al., 2003). The number
functioning of the adult liver and heart, were estab- of TSH pulses per day is approximately 18. However,
lished by introducing human THRB mutations into the frequency of TSH pulses, and the mass of TSH per
experimental mice (Ortiga-Carvalho et al., 2014). pulse, is dependent on time of day. Thus, the diurnal
According to Dumitrescu and Refetoff (2015), 13 surge in TSH secretion is characterized by
subjects from nine families have been identified with a significant increase in pulse frequency (2.0-fold)
mutations in the THRA gene. Since the THRα and and mass of TSH per burst (2.1-fold; Keenan et al.,
THRβ proteins are structurally alike, it is noteworthy 2003). Although debated by some, a basic assumption
that patients with mutations in THRA show is that TSH pulses are generated by pulsatile input
a different clinical presentation to that of patients from TRH neurons (Hoermann et al., 2015) and
with mutations in THRB (Figure 6.7). It is likely that a detailed analysis of pulsatile hormone secretion is
the THR isoforms have different physiological roles required for a complete understanding of pituitary
that extend beyond differences in tissue distribution. hormone output in (patho)physiological studies
For example, in patients with mutations in THRA, the (Roelfsema and Veldhuis, 2013). Since the diurnal
hypothalamic–pituitary–thyroid (HPT) axis is rhythm in TSH levels reveals a >2.0-fold difference
Figure 6.8 Diurnal rhythm of human TSH secretion. 24-hour serum

TSH concentrations in 24 healthy men (mean age: 44+/-2.5 years;
BMI: 24.6+/-0.8 kg/m2) and 22 healthy women (mean age: 42+/-3.1
years; BMI: 23.1+/-0.7 kg/m2). Blood sampling started at 0900 h.
Lights were off between 2300 h until 0730 h next morning. Note that
these composite graphs are unable to resolve pulsatile secretion of
TSH (e.g., see Roelfsema and Veldhuis, 2013). Figure is redrawn from
data contained in Roelfsema et al. (2009a).
105
between lowest and highest values, the timing of clin- volunteers. Pulse amplitude is reduced with no change
ical blood sampling, for diagnosis of subclinical in pulse frequency (Roelfsema et al., 2009c). These
hypothyroidism for example, is therefore critical patients were euthyroid with active (untreated) acrome-
(Mirjanic-Azaric et al., 2015). The impact of fasting galy. The authors speculate that somatostatin release, as
was not significant, although long-term fasting (56 a result of adenoma-derived GH feedback (see
hours) induced a 50% inhibition of TSH secretion Figure 8.1), may be responsible for inhibition of TSH
through elimination of the nocturnal surge (Samuels secretion.
and Kramer, 1996). Other adenomas, such as pituitary-dependent
The rising aspect of the daily TSH surge, occurring Cushing’s disease and adrenal adenoma, also inhibit
in the early evening, is not sleep dependent and is the diurnal rhythm of TSH secretion, whereas the
probably regulated by a circadian clock mechanism. rhythm is preserved in patients with prolactinomas
However, with the onset of sleep, maximum TSH (Roelfsema and Veldhuis, 2013). The former effect
secretion declines through the night to reach a nadir appears to be due to a powerful inhibitory effect of
in the middle of the light phase (Figure 6.8). Spectral glucocorticoids on TSH (Samuels and McDaniel, 1997).
analysis of the sleep electroencephalogram revealed
that the decline in TSH is coincident with slow-wave TSH Receptors
sleep (Gronfier et al., 1995). Moreover, an 8 hour TSHRs belong to the G protein-coupled class of cell
delay in sleep onset (i.e., sleep is prevented during membrane receptors, characterized by seven trans-
the night) causes a large increase in nighttime TSH membrane domains (see Chapter 1). TSHRs are
secretion, confirming that sleep is normally inhibitory coupled to two intracellular signaling cascades:
to TSH secretion (Gronfier and Brandenberger, a stimulatory G protein (Gαs) coupled to the adenyl
1998). cyclase–cAMP system, and a Gαq signal mediating
Hypo- and hyper-thyroidism and pulsatile TSH phospholipase C activity. These two pathways are
secretion. Hypothyroidism, usually a consequence of responsible for the biosynthesis and release of T3 and
reduced TH synthesis and release from T4 from the thyroid gland. Loss-of-function muta-
a compromised thyroid gland, has profound effects tions in TSHR cause resistance to TSH stimulation,
on TSH hypersecretion due to decreased negative resulting in thyroid dysfunction that can be overt
feedback (Whitehead and Miell, 2013). Detailed stu- congenital hypothyroidism with thyroid hypoplasia,
dies revealed that the diurnal secretion pattern, and or a compensated state with elevated TSH and normal
TSH pulse frequency, are retained, although pulse TH levels (Persani et al., 2010; Schoenmakers and
amplitude is amplified (Roelfsema et al., 2010). Chatterjee, 2015).
Figure 6.9 illustrates individual cases of mild (subcli- The TSHR response to stimulation is also compro-
nical) and severe hypothyroidism in which TSH secre- mised in autoimmune thyroid disease (Schott et al.,
tion was elevated by ten-fold in subclinical 2005). The large extracellular domain of the TSHR
hypothyroidism and by 200-fold in severe disease. appears to be the principal antigenic region of the
Hyperthyroidism, characterized by increased TH receptor and is targeted by autoantibodies that may
synthesis and secretion (de Leo et al., 2016), may also enhance or diminish receptor function (Morshed et al.,
generate variations in TSH pulses. For example, in 2012). Figure 6.10 illustrates three types of receptor
patients with TSH-secreting pituitary adenomas (see activation/inactivation. Stimulating antibodies are able
Chapter 10) and elevated fT4, TSH secretion is char- to switch on cell signaling pathways, whereas the
acterized by increased pulse frequency, enhanced blocking antibodies prevent TSH from binding to its
TSH release and a delay in the normal diurnal receptor, thereby inhibiting its biological effect.
increase (Roelfsema et al., 2009b). This appears para- Clinical implications: TSHR is a primary antigenic
doxical – a high TSH value in the face of increased target in patients with autoimmune thyroid disease
negative feedback – but the pulses are thought to be such as Graves’ disease (causing thyrotoxicosis;
caused by cellular alterations in the tumor cells, ren- Bartalena, 2013) and Hashimoto’s disease (causing
dering them unresponsive to negative feedback. hypothyroidism). These conditions are characterized
Acromegaly is also associated with low TSH levels, by the presence of antibodies that either activate (in
particularly in terms of a diminished nocturnal surge case of Graves’ disease) or block (in case of
106 when compared with that in matched healthy Hashimoto’s thyroiditis) the TSHR.
Figure 6.9 24-hour serum TSH concentrations in

hypothyroid patients. Graphs show TSH secretion
profiles in one normal subject (fT4: 15.9+/-0.4 pmol/L)
and two representative hypothyroid patients (mild, fT4:
10.9+/-0.6 pmol/L; severe, fT4: 1.5+/-0.6 pmol/L),
revealing the pulsatile and diurnal variations. Note the
ten- and 200-fold increases in TSH secretion in the
hypothyroid patients. Graphs are redrawn from data
provided in Roelfsema et al. (2010).
6.6 TH and Energy Balance patients are known to be hyperphagic, suggesting

a role for THs in the hypothalamic regulation of
The importance of THs in energy metabolism is evi-
food intake (see also Chapter 4). In contrast,
dent in patients with hyper- or hypo-thyroidism.
hypothyroidism decreases metabolic rate, leading to
The former is characterized by high circulating levels
weight gain despite reduced food intake. In healthy
of THs and increased metabolic rate. More than 80%
individuals, an absence of food intake profoundly
of patients with hyperthyroidism lose weight despite
affects TSH secretion (Fliers et al., 2014). For example,
increases in food intake and 85% of hyperthyroid
short-term fasting in healthy men abolishes both the
107
Figure 6.10 Autoimmune antibodies and the TSHR responses. (A) The TSHR is a G protein-coupled receptor, under normal conditions with
a TSH molecule bound to the extracellular domain. Binding of TSH activates the G protein complex (αβγ) via stimulatory G proteins Gαs and
Gαq that in turn induce T3 and T4 synthesis and release from thyroid follicular cells. (B) In the absence of TSH, stimulating antibodies also bind to
the TSHR and induce increased T3/T4 synthesis. (C) In contrast, blocking antibodies prevent TSH binding and reduce T3/T4 synthesis. Adapted
from Balucan et al. (2013).
Figure 6.11 Effect of short-term fasting on TSH levels in healthy men. Twenty-four-hour TSH levels (mIU/L) on the third day of the fed state (red)
and on the third day of fasting (72-hour fast; blue) in healthy men (n=6; age: 23.5+/-1.3 years; BMI: 24.0+/-0.4 kg/m2). Figure is drawn from data
in Chan et al. (2003).
diurnal rhythm and pulsatile secretion of TSH tissue. In addition, a seasonal variability in THs –
(Figure 6.11; Chan et al., 2003). This study also including fT3, total T3 and TSH – has been reported
demonstrated that leptin treatment during fasting and proposed to be related to ambient temperature
could prevent the fasting-induced reduction in TSH and luminosity (Maes et al., 1997; Hassi et al., 2001).
levels, demonstrating that under non-fasting condi- The traditional view of thyroid involvement in
108 tions the hypothalamic regulation of TSH levels is energy balance is that THs act directly on tissues
modulated through leptin feedback from adipose such as skeletal muscle, white adipose tissue, brown
Figure 6.12 The role of THs in energy homeostasis. In response to environmental stimuli (such as food intake or temperature) or to hormonal
stimuli (such as leptin or TH feedback), hypothalamic pathways modulate sympathetic outflow and TH secretion through the HPT axis. TH and
sympathetic output act in concert in multiple organ systems to affect energy metabolism and thus regulate whole-body energy homeostasis.
In particular, TH signaling and SNS stimulation promote adaptive thermogenesis in BAT, regulate cardiovascular functions, including blood
pressure and heart rate, modulate glucose homeostasis through actions in the pancreatic β cell, regulate systemic TH clearance and
endogenous glucose production in the liver, and affect other tissues including WAT and skeletal muscle. Abbreviations: SNS, sympathetic
nervous system; BAT, brown adipose tissue; WAT, white adipose tissue. Reproduced with permission (McAninch and Bianco, 2014).
adipose tissue, liver and heart. However, the neuroen- changes in GH, PRL, LH and TSH levels. These
docrine hypothalamus responds to THs to signifi- changes not only depend on the severity of illness
cantly influence the regulation of metabolism (López but also vary between the acute (hours to days) and
et al., 2013; Martínez-Sánchez et al., 2014). Detailed the chronic (weeks) phases of the illness (Figure 6.13;
evidence for this is inevitably derived from animal Vanhorebeek et al., 2006).
experiments, but Figure 6.12 illustrates the potential In the acute phase T3 levels fall but TSH levels
role of THs in maintaining human energy homeosta- remain in the low-to-normal range, although the diur-
sis via hypothalamic–autonomic nervous system nal rhythm is abolished. Subsequently, during pro-
pathways (McAninch and Bianco, 2014). longed illness, T4 and TSH levels are also severely
reduced, pulsatile secretion is disrupted (Figure 6.14),
6.7 Thyroid Function in Critical Illness and hypothalamic TRH mRNA is depleted (Fliers et al.,
Significant advances in intensive care medicine have 1997).
ensured the survival of patients who would otherwise Clinical implications: Due to the profound effect of
not recover from trauma, complex surgery or severe illness on the HPT axis, it is not advisable to routinely
medical illness. Such critically ill patients are effec- check thyroid function tests in severely ill patients with-
tively subjected to severe stress accompanied by out a strong suspicion of thyroid disease. Furthermore,
derangements in neuroendocrine and metabolic sys- clinical studies have shown no benefit of TH replace-
tems (Boonen and van den Berghe, 2014; Fliers et al., ment in such patients (Kaptein et al., 2010; Fliers et al.,
2015). For example, critical illness causes dramatic 2015).
109
Figure 6.13 Schematic illustration of hormonal changes during the course of critical illness. In the acute phase of illness (hours to a few days
after onset), the secretory activity of the anterior pituitary is essentially maintained (e.g., TSH) or amplified (e.g., GH and PRL), whereas target
organ hormones (e.g., T3 or testosterone) are inactivated. Cortisol levels (and ACTH) are elevated. In the chronic phase of protracted critical
illness (intensive care-dependent for weeks), the secretory activity of the anterior pituitary is uniformly suppressed, as are circulating levels of
target organ hormones. Impaired hormone secretion from the anterior pituitary is reflected in decreases in target organ hormones, with
cortisol being a notable exception. The onset of recovery is characterized by restored sensitivity of the anterior pituitary to reduced feedback
control. Shaded areas represent the range within which the hormonal changes occur. Reproduced with permission (Van Horebeek et al., 2006).
Figure 6.14 Response of the thyroid axis to critical illness. The nocturnal (2100–0600 h) serum concentration profiles of TSH in critical illness are
abnormal and differ markedly between the acute and chronic phase of the disease. The normal diurnal surge of TSH is seen in healthy
individuals (see also Figure 6.8) but is essentially abolished early in the acute phase. The chronic phase is characterized by further reductions in
TSH secretion plus an absence of TSH pulses. Figure prepared from data in Vanhorebeek et al. (2006).
6.8 THs and Fertility induces abnormal sperm motility, whereas hypothyr-
Normal thyroid activity is necessary to maintain nor- oidism causes abnormal sperm morphology.
mal reproductive function. Hyper- and hypo- In women, thyrotoxicosis and hypothyroidism can
thyroidism, in men and women, are associated with cause menstrual disturbances, along with some degree
changes in sex hormone levels (Poppe et al., 2007; of infertility. For example, thyrotoxicosis may shorten
110 Krassas et al., 2010). In men, hyperthyroidism also or lengthen menstrual cycles.
LH and FSH levels are reduced in follicular phase The baseline early morning pituitary testing was as
hypothyroid women (Acharya et al., 2011), and LH is follows:
elevated in hyperthyroid cases (Zähringer et al., 2000). Cortisol=361 nmol/L (184–512)
There are also marked modifications in pituitary TSH=9.1 mIU/L (0.35–5.50)
response to stimulation with gonadotropin releasing fT4=22.1 pmol/L (11.5–22.7)
hormone (GnRH); that is, LH and FSH are increased FT3=8.7 pmol/L (3.5–6.5)
in thyrotoxicosis in men and women, whereas FSH=32 IU/L (23–116.3)
hypothyroidism induces a reduced response to LH=12.68 IU/L (15.9–54)
GnRH (Krassas et al., 2010). In contrast, neither PRL=11.76 (1.39–24.2)
hyper- nor hypo-thyroidism modifies pulsatile secre- Estradiol=92.3 pmol/L (25.7–163.3)
tion of LH and FSH (Samuels et al., 1990; Zähringer GH=0.1 ug/L (<10)
et al., 2000). Since THs have a direct effect on the Insulin-like growth factor 1(IGF-1)=109 ug/L
ovaries and testes (Jannini et al., 2000; Aghajanova (94–252)
et al., 2009), abnormal thyroid function-induced var- A magnetic resonance image (MRI) of the sella
iations in sex hormone production (estradiol and was requested, which showed a pituitary macroade-
testosterone; Krassas et al., 2010), and the consequent noma of 1.2 x 1 cm (Figure 6.15).
alterations in feedback regulation, could account for
the changes in gonadotropin levels and changes in Case Description
fertility. Nevertheless, a direct hypothalamic effect of This case illustrates the importance of recognizing the
THs on central GnRH control cannot be excluded. key physiological principles underlying regulation of
the HPT axis. In patients with a normally functioning
6.8.1 A Case of Hyperthyroidism pituitary, an elevated T4 and/or T3 would suppress
TSH levels. In this case, a failure of TSH to suppress
A 49-year-old post-menopausal female was referred to
despite high TH levels indicates an inappropriate TSH
endocrinology for assessment of hyperthyroidism that
production, as is seen in this rare case of TSH-
was first diagnosed about a year earlier. She had ori-
producing pituitary adenoma.
ginally presented with symptoms of palpitations and
Excessive TSH production from the adenoma led to
anxiety, and a small diffuse goiter. Her serum fT4 on
secondary or central hyperthyroidism. These patients
presentation was 27.2 pmol/L (normal=11.5–22.7), fT3
typically present with features of thyrotoxicosis and
was 11.1 pmol/L (normal=3.5–6.5) and serum TSH was
many develop goiter due to excessive TSH stimulation
5.2 mIU/L (normal=0.35–5.50). Based on elevated T4
of the thyroid. Although these adenomas autono-
and T3 levels, she was initiated on methimazole (to
mously produce TSH, they may remain partially
reduce TH synthesis) by her family physician, which
responsive to TH feedback, which explains a rise in
led to normalization of both fT4 and fT3 to 17.8 pmol/L
serum TSH after normalization T4 and T3 with methi-
and 6.1 pmol/L, respectively; but her TSH went up to
mazole therapy. Methimazole is an anti-thyroid drug
10.45 mIU/L and her symptoms improved. Due to the
that inhibits the production of TH by preventing the
rising TSH level, the physician assumed she was devel-
oxidation of iodide and its incorporation into the
oping hypothyroidism and reduced the dose of methi-
iodotyrosyl residue by blocking the peroxidase enzyme.
mazole. However, a few weeks later her symptoms
The patient underwent trans-sphenoidal tumor
recurred and repeat testing showed a TSH of 6.4
resection and her TSH, T4 and T3 levels normalized.
mIU/L, whereas fT4 had risen to 23.8 pmol/L and T3
Her symptoms of thyrotoxicosis – including tremor,
was 7.9 pmol/L. She had lost 7 lbs during that period
sweating and tachycardia – abated and over the next
and her family physician referred her to endocrinology
24 months the size of the thyroid normalized with
for further opinion.
a complete resolution of the goiter.
On examination, the patient appeared agitated
and had mild tremor of the outstretched hands,
moist skin, tachycardia (heart rate=102/min) and 6.8.2 A Case of Hypothyroidism
a small goiter. Elevated T4 and T3 levels, and a non- A 38-year-old mountain biker presented to his family
suppressed TSH, indicated an inappropriate pituitary physician with fatigue and cold intolerance. He had
TSH secretion, suggesting a TSH-producing pituitary been otherwise healthy apart from being hospitalized
adenoma. about 6 months previously after crashing into a tree 111
Figure 6.15 MRI scan showing a pituitary macroadenoma in the (A) coronal and (B) sagittal planes.
while cycling downhill. Although he was wearing (Tanriverdi et al., 2006). Although GH deficiency is the
a safety helmet, he briefly lost consciousness after commonest pituitary abnormality present after head
the impact and was admitted under neurosurgery. injury, central hypothyroidism due to TSH insuffi-
He made an excellent recovery and was discharged ciency is seen in a considerable proportion of patients.
after 1 week. During the previous 2 months (i.e., 4 Due to an abnormal pituitary, serum TSH levels
months after his accident) he had begun to notice fail to rise significantly above the normal range
excessive fatigue, constipation and felt cold compared despite a marked drop in T4 and T3 concentration.
with the rest of his family. He also noticed that he had These patients develop all the typical features of
gained 5 lbs despite no change in his diet. His pulse hypothyroidism, including weight gain, cold intoler-
rate was 61 per minute and his hands were cold. His ance, bradycardia and constipation. The management
family physician decided to check his thyroid levels. includes replacement with THs (mostly as T4) in order
His TSH was 0.21 mIU/L (normal=0.35–5.50), fT4 to normalize serum T4 levels. It is important to keep in
was 6.6 pmol/L (normal=11.5–22.7) and fT3 pmol/L mind that unlike patients with primary hypothyroid-
was 3.3 (normal=3.5–6.5). An MRI of the sella showed ism, where the dose of T4 is adjusted to normalize
a normal-looking pituitary. serum TSH levels, the aim of T4 therapy in central or
Based on the biochemical profile, unremarkable secondary hypothyroidism is to maintain serum T4 in
MRI and the previous history of head injury, the mid-normal range. Due to the pituitary dysfunc-
a diagnosis of central/secondary hypothyroidism due tion, serum TSH in such patients is not a reliable goal
to traumatic head injury was made and he was initiated of therapy and may remain suppressed, as in this case.
on T4 therapy in order to normalize serum T4 levels. The mechanism by which head trauma modifies
After 3 months on T4 (112 mcg daily), his fT4 and fT3 pituitary function is poorly understood. Several
levels were completely normalized; 14.4 pmol/L and 3.9 pathological mechanisms have been suggested,
pmol/L, respectively, and his symptoms resolved. His including hypothalamic damage, compression of the
TSH remained subnormal at 0.18 mIU/L. pituitary gland or the hypophyseal portal vessels by
edema, direct mechanical trauma to the pituitary
Case Description gland, or any cause of ischemic/hypoxic insult
This case illustrates the typical biochemical abnormal- (Tanriverdi et al., 2015).
ities associated with central or secondary hypothyroid-
ism; that is, inadequate stimulation of the thyroid by 6.9 Chapter Summary
112 TSH, possibly through pituitary disease. Pituitary This chapter stresses the mechanisms by which TSH
insufficiency is frequently associated with head trauma and TH levels are regulated under normal physiological
conditions, and in those states of pathological T3/T4 is characterized by a significant increase in pulse fre-
secretion, such as hyperthyroidism. quency and mass of TSH per burst.
THs influence most cells throughout the body, and THs are important in energy metabolism, evident
provide negative feedback regulation of TSH secre- in patients with hyper- or hypo-thyroidism.
tion. THs also regulate critical aspects of growth and The former is characterized by high circulating levels
differentiation, stimulating the maturation of the of THs and increased metabolic rate. More than 80%
brain, skeleton, heart and lungs during prenatal and of patients with hyperthyroidism lose weight despite
early postnatal development. increases in food intake and many are known to be
TSH secretion from the anterior pituitary is regu- hyperphagic. In contrast, hypothyroidism decreases
lated by a hypothalamic releasing hormone, TRH. T3 metabolic rate, leading to weight gain despite reduced
and T4, released in response to the TSH stimulus, food intake.
exert profound effects in peripheral target tissues, The HPT axis is profoundly affected by critical
and regulate both TRH- and TSH-secreting cells illness. In the acute phase, T3 levels fall but TSH levels
through negative feedback. remain in the low-to-normal range, although the
The biological effects of THs on TSH secretion diurnal rhythm is abolished. Subsequently, during
are primarily dependent on THRs in target cells prolonged illness, T4 and TSH levels are severely
(neurons and thyrotrophs). However, T3 and T4 do reduced and pulsatile secretion is disrupted.
not diffuse passively into the brain or into cells (e.g., Normal thyroid activity is necessary to maintain
thyrotrophs; neurons), but must be carried there by normal reproductive function. Hyper- and hypo-
specific transporters. In addition, T4 acts as thyroidism, in men and women, are associated with
a prohormone, converted to the bioactive hormone changes in sex hormone levels. In men, hyperthyroid-
T3 by deiodinases located in T3 receptor-positive ism induces abnormal sperm motility, whereas
cells. Thus, all three components – receptors, trans- hypothyroidism causes abnormal sperm morphology.
porters and deiodinases – are essential for the biolo- In women, thyrotoxicosis and hypothyroidism can
gical activity of THs. cause menstrual disturbances, along with some degree
The THR is properly regarded as a T3 receptor, of infertility. For example, thyrotoxicosis may shorten
and TH action in target cells occurs via a T3/THR or lengthen menstrual cycles.
hormone/receptor complex. This complex forms
a heterodimer with the RXR and binds to a TRE to
control gene expression and protein synthesis. Two 6.10 Review Questions
genes encode four THR isoforms although only three 1. A young, overweight girl is very concerned about
of them – THRα1, THRβ1 and THRβ2 – bind T3 and her body image and searches the Internet for help.
these are found in many thyroid target tissues, includ- She discovers that a health food supplement is
ing brain, pituitary, heart, skeletal muscle and retina. aggressively advertised as an effective weight-loss
Mutations in THR genes prevent the binding of TH; agent. Unknown to her, it contains high levels of
that is, they induce resistance to THs. Loss-of- thyroxine (T4). After she has taken this
function mutations also occur in the TSHR gene. supplement for several weeks you would predict
In addition, antibodies to TSHR, as in autoimmune all of the following except:
diseases, also modify TSH stimulation.
a. Heat intolerance
Little is known about the neurotransmitter/neu-
b. Tachycardia
ropeptide systems that regulate human TRH neurons,
c. Elevated blood thyroid stimulating hormone
but drugs such as opioids, cholinergic antagonists and
(TSH) levels
dopamine do affect TSH levels, suggesting the possi-
d. Increased appetite
ble involvement of several neurotransmitter/neuro-
e. Weight loss
peptide pathways in regulating human TSH secretion.
Daily secretion of TSH in healthy volunteers is 2. A subnormal level of TSH is seen in which one of
unaffected by sex, BMI and age. TSH is secreted in the following conditions?
a diurnal rhythm comparable to those for PRL and a. In neonates born without a thyroid gland
GH. Superimposed on this secretory rhythm are b. Following thyroidectomy for thyroid cancer
pulses of TSH and the diurnal surge in TSH secretion c. During fasting 113
d. Twin pregnancy b. TSH receptors (TSHRs) are located within the

e. State of nutritional iodine deficiency pituitary itself.
3. Hypothyroidism may cause the following: c. Glucocorticoids can suppress TSH.
d. Amphetamines have a stimulatory effect on
a. A reduction in core body temperature
TSH.
b. Moist hands and feet
e. Lithium can lead to TSH suppression.
c. Infertility
d. Weight gain 8. Insensitivity to THs can be associated with:
e. Weight loss a. Elevated levels of T4, T3 and TSH
4. Which of the following statements about b. A mutation in THRβ genes in most cases
hypothyroidism during pregnancy are c. Thyroid atrophy
correct? d. Classically present with bradycardia in
patients with THRβ defect
a. Uncorrected maternal hypothyroidism is
e. Normal hypothalamic–pituitary response in
associated with neurological defects in the
THRα mutation
fetus.
b. Maternal thyroid hormone (TH) production 9. Concerning the TSHR, which statements are
increases during pregnancy. correct?
c. The dose requirement for TH replacement can a. The TSHR is a steroid nuclear receptor.
increase up to 50% during pregnancy. b. Complete loss-of-function mutation can lead
d. Standard replacement therapy is given in the to thyroid hypoplasia.
form of T3 during pregnancy. c. Patients with Hashimoto’s disease develop
e. Women living in iodine deficiency areas are antibodies against the TSHR.
more likely to develop hypothyroidism during d. The TSHR is a G protein-coupled
pregnancy. transmembrane receptor.
5. A young woman underwent complete thyroid e. Stimulating antibodies against TSHRs can lead
removal for suspected thyroid cancer. Which of to Graves’ disease (thyrotoxicosis).
the following pattern of tests would you expect in 10. With respect to thyroid dysfunction during critical
her case? illness, which statements are correct?
a. Normal TSH, low T4 and low T3 a. Serum TSH is significantly elevated during the
b. Low TSH, low T4 and low T3 acute phase.
c. High TSH, low T4 and low T3 b. Serum T3 drops during acute phase.
d. High TSH, normal T4 and low T3 c. There is a profound drop in TSH and T4
e. Normal TSH, normal T4 and low T3 during prolonged illness.
6. Which of the following statements are correct d. TH replacement is beneficial.
about TH metabolism? e. All critically ill patients should undergo TH
testing within 24 hours of admission.
a. Half-life of T3 is 1 week.
b. Almost 80% of T3 comes from the extra-
thyroid conversion of T4 to T3. Further Reading
c. Extrathyroid conversion of T4 to T3 is Brent G A. (2012). Mechanisms of thyroid hormone action.
accomplished through deiodinases. J Clin Invest 122, 3035–3043.
d. Deiodinase 2 is the key converting enzyme in Chaker L, Bianco A C, Jonklaas J & Peeters R P. (2017).
the pituitary. Hypothyroidism. Lancet 390, 1550–1562.
e. Free T4 constitutes the largest portion of the de Leo S, Lee SY & Braverman L E. (2016).
total TH pool. Hyperthyroidism. Lancet 388, 906–918.
7. With respect to the neurochemical control of TSH Hoermann R, Midgley J E M, Larisch R & Dietrich J W. (2015).
secretion, which of the following statements are Homeostatic control of the thyroid-pituitary axis: perspectives
correct? for diagnosis and treatment. Front Endocr 6, 1–17.
a. Dopamine infusion can lower TSH. Larsen P R, Davies T F, Schlumberger M-J & Hay I D.
114 (2008). Thyroid physiology and diagnostic evaluation of
patients with thyroid disorders. In: Williams Textbook of hormone replacement therapy. J Clin Endocr Metab 94,
Endocrinology, 11th Edition (New York: Saunders Elsevier), 2922–2929.
299–332.
Bernal J. (2015). Thyroid hormones in brain development
Mariotti S & Beck-Peccoz P. (2016). Physiology of the and function. www.thyroidmanager.org.
hypothalamic–pituitary–thyroid axis. www
.thyroidmanager.org Bernal J, Guadaño-Ferraz A & Morte B. (2015). Thyroid
hormone transporters – functions and clinical implications.
Mendoza A & Hollenberg A N. (2017). New insights into Nat Rev Endocr 11, 406–417.
thyroid hormone action. Pharmacol Therap 173, 135–145.
Bianco A C & Kim B W. (2006). Deiodinases: implications
Onigata K & Szinnai G. (2014). Resistance to thyroid
of the local control of thyroid hormone action. J Clin Invest
hormone. Endocr Develop 26, 118–129.
116, 2571–2579.
Ortiga-Carvalho T M, Sidhaye A R & Wondisford F E.
(2014). Thyroid hormone receptors and resistance to Boonen E & van den Berghe G. (2014). Endocrine responses
thyroid hormone disorders. Nat Rev Endocr 10, 582–591. to critical illness: novel insights and therapeutic
implications. J Clin Endocr Metab 99, 1569–1582.
Roelfsema F, Boelen A, Kalsbeek A & Fliers E. (2017).
Regulatory aspects of the human hypothalamus-pituitary- Brabant G, Prank K, Ranft U et al. (1990). Physiological
thyroid axis. Best Prac Res Clin Endocr Metab 31, 487–503. regulation of circadian and pulsatile thyrotropin secretion
in normal man and woman. J Clin Endocr Metab 70,
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117
Chapter
Hypothalamic Regulation of Prolactin
7 Secretion
Prolactin (PRL) plays an essential role in inducing immunoglobulin. Assays using gel filtration chroma-
breast enlargement during pregnancy and in stimu- tography or polyethylene glycol precipitation are used
lating lactation postpartum. PRL is produced and to diagnose macroprolactinemia and as such this con-
secreted from anterior pituitary gland lactotrophs in dition does not require medical treatment.
response to the suckling stimulus. Lactotrophs com-
prise approximately 9% of hormone-secreting ante- 7.1 Regulation of PRL Secretion
rior pituitary cells in males, but this figure may reach The regulation of PRL secretion is singularly different
25% in multiparous women (Heaney and Melmed, from that of other anterior pituitary hormones. First,
2004). This chapter will outline the mechanisms by PRL release does not appear to involve hypothalamic
which PRL levels are regulated under normal physio- releasing hormones; that is, PRL is under tonic inhi-
logical conditions, and in those states of pathological bitory control by the neurotransmitter dopamine,
PRL secretion, such as hyperprolactinemia. released from hypothalamic dopaminergic neurons
Human PRL, a 23 kDa protein, is encoded by a into the hypophyseal portal vessels (see Figure 7.1).
single gene, PRL, located on chromosome 6. However, Second, PRL does not have a target tissue that exerts
several variants of the PRL protein are also identifi- classical hormonal feedback; that is, PRL secretion
able in blood samples. One of these, macroprolactin from the pituitary is thought to be autoregulated by
(macroPRL), is of high molecular mass (>100 kDa) PRL exerting a short-loop feedback to stimulate secre-
and is detectable by PRL radiometric assays. Although tion of hypothalamic dopamine, thereby inhibiting
it has no known biological function, and is therefore further release of PRL (see Section 7.2). The hypotha-
assumed to be clinically irrelevant, its presence in sera lamic–pituitary control system for PRL secretion is
from patients can give misleadingly high values of illustrated in Figure 7.1, and Table 7.1 lists factors
PRL. These may lead to misdiagnosis and misman- known to influence human PRL secretion (Ben-
agement of hyperprolactinemic patients (Fahie- Jonathan and Hnasko, 2001; Melmed and Kleinberg,
Wilson and Smith, 2013; Samson et al., 2015; see 2008). The illustration in Figure 7.1 is unavoidably
Section 7.19). based upon data obtained from experimental animals
PRL is also expressed in a variety of human extra- (Ben-Jonathan et al., 2008). However, the weight of
pituitary tissues such as decidua, ovary, prostate, evidence favors similar regulatory pathways in human
immune system cells and adipose tissue (Marano PRL release, particularly those involving dopamine.
and Ben-Jonathan, 2014; Harvey et al., 2015). PRL is Under some conditions, intravenous thyrotropin
known to exert autocrine effects in human mammary releasing hormone (TRH; see Chapter 6) rapidly
epithelial cells, inducing terminal differentiation dur- increases PRL secretion, suggesting that it may act as
ing late pregnancy, but a physiological role for locally a PRL releasing hormone (PRH; Jacobs et al., 1971).
produced PRL in other tissues is currently unknown Whether TRH is an endogenous PRH remains
(Bernard et al., 2015). unknown and the available data are confusing.
Clinical implications: Presence of high serum PRL Under conditions in which PRL is increased physio-
without the associated clinical symptoms of hyper- logically (e.g., during suckling; Figure 7.5), thyroid
prolactinemia should alert the clinician about the stimulating hormone (TSH) levels are unaffected,
possibility of macroprolactinemia. This condition is suggesting that TRH is not implicated in the suck-
characterized by high levels of biologically inactive ling-induced release of PRL (Gautvik et al., 1974;
118 circulating macroPRL bound with anti-PRL Gehlbach et al., 1989). However, in patients with
Chapter 7: Hypothalamic Regulation of Prolactin Secretion
disease, diabetes and eating disorders (Weikel et al.,

2003; Garin et al., 2013). The physiological relevance
of this phenomenon remains unknown. It is also
unclear whether ghrelin stimulates PRL release from
the pituitary, or if it inhibits dopamine release from
the hypothalamus, or both.
Clinical implications: Before the advent of sensitive
diagnostic imaging techniques and PRL assays, a TRH
stimulation test was used to assess hyperprolactine-
mia (Assies et al., 1980). The test was based on the
assumption that PRL-producing adenoma cells were
less sensitive to the stimulatory effect of TRH than
normal lactotrophs. Therefore, a blunted PRL
response to intravenous TRH suggested an underly-
ing prolactinoma. However, this test is non-specific
and is not routinely used anymore.
7.2 Dopamine and PRL Secretion

Dopaminergic neurons are present in the human
basal hypothalamus, and dopamine D2 receptors are
localized to human lactotrophs (Dudas et al., 2010;
Pivonello et al., 2016). This evidence, coupled with the
known inhibitory effects of dopamine agonists (such
as bromocriptine, cabergoline and quinagolide;
Figure 7.2) on PRL secretion, suggests that human
PRL is regulated essentially as shown in Figure 7.1.
Nevertheless, it remains unknown, in humans,
Figure 7.1 Regulation of PRL secretion. PRL secretion from whether PRL has autocrine effects on its own secre-
lactotrophs in the anterior pituitary is regulated primarily by DA, tion via stimulation of PRL receptors (PRLRs) on
released from hypothalamic dopaminergic neurons into the hypothalamic dopaminergic neurons. An inactivating
hypophyseal portal blood. DA is inhibitory to PRL secretion. The
figure illustrates several of the known influences on PRL release. For mutation of the human PRLR is associated with
example, the suckling stimulus inhibits hypothalamic dopamine hyperprolactinemia, although the interpretation of
release, allowing elevated PRL levels to be achieved. Other stimuli this observation is controversial (Newey et al., 2013;
include sleep, sex hormones and orgasm. Inhibitory factors include
stress and cannabinoids. Further inhibitory control may be exerted Newey et al., 2014; Bernard et al., 2015). Evidence for
via PRL feedback into the hypothalamus, although this is at present a direct effect of PRL on hypothalamic neurons is
unproven in humans. A more detailed list is given in Table 7.1. further substantiated by the known adverse influence
Abbreviations: DA, dopamine.
of hyperprolactinemia on human gonadotropin
releasing hormone (GnRH) neurons; that is, elevated
significant hypothyroidism (high TSH levels), some PRL inhibits GnRH and LH release via inhibitory
patients (36%) had elevated PRL, which was hypothalamic dopamine neurons causing hypogo-
decreased after thyroxine treatment (Hekimsoy et nadism in both men (low libido and erectile dysfunc-
al., 2010). This suggests that TRH, under some cir- tion) and women (anovulation and menstrual
cumstances, may regulate both TSH and PRL irregularities). Pulsatile LH secretion is also inhibited
secretion. by breastfeeding, perhaps due to suckling-induced
Another endogenous factor that regulates PRL PRL release (see Section 7.6).
secretion is ghrelin, a hormone that also stimulates The inhibitory effect of dopamine agonists in
GH release and appetite (Chapters 8 and 4, respec- hyperprolactinemia is well described. For example,
tively). Infusions and bolus injections of ghrelin ele- oral treatment with dopamine D2 agonists such as
vate PRL in healthy adults and across varied patient pergolide, cabergoline, bromocriptine and quinago- 119
populations, including those with obesity, pituitary lide is very effective in normalizing PRL secretion and
Table 7.1 Factors affecting human PRL secretion
Increase Decrease
Physiological
Pregnancy
Nursing
Nipple stimulation
Exercise
Stress
Sleep
Pharmacological/medication
Thyrotropin releasing hormone Dopamine agonists (cabergoline, levodopa, apomorphine,
bromocriptine, pergolide)
Estradiol
Ghrelin
Vasoactive intestinal peptide
Dopamine antagonists (phenothiazines, haloperidol, reserpine,
methyldopa, amoxapine)
Monoamine oxidase inhibitors
Cimetidine (intravenous)
Opioids
Pathologic
Prolactinomas Pseudohypoparathyroidism
Hypothalamic/pituitary stalk lesions Pituitary destruction or removal
Chest wall lesions Lymphocytic hypophysitis
Spinal cord lesions
Hypothyroidism
Chronic renal failure
Severe liver disease
Obesity
inducing tumor shrinkage (Verhelst et al., 1999;

Wong et al., 2015). Figure 7.2 illustrates the inhibitory
effects of the two most commonly used drugs: bromo-
criptine and cabergoline. Note that only two doses per
week of the long-acting cabergoline are required,
whereas bromocriptine requires daily administration.
Cabergoline is generally the first-line therapeutic
choice for PRL-producing adenomas, normalizing
serum PRL levels in 86% and tumor shrinkage in
two thirds of all cases (Verhelst et al., 1999).
In contrast to the inhibitory effect of dopamine
agonists on PRL secretion, anti-psychotics act as
antagonists at dopamine D2 receptors. As a conse-
Figure 7.2 Inhibitory effect of dopamine agonists on
hyperprolactinemia. Women with hyperprolactinemic amenorrhea
quence, the need for long-term therapy in psychotic
were treated with bromocriptine (daily doses: 1.25 mg rising to 2.5 mg disorders, such as schizophrenia, produces unwanted
twice per day; n=236) or cabergoline (0.25 mg twice per week, rising to side effects, including hyperprolactiemia (Haddad
120 0.5 mg twice per week; n=223). Values of PRL are mean+/-SEM. The
and Wieck, 2004; Voicu et al., 2013). This influence
figure is redrawn from the original data (Webster et al., 1994).
function, decreased libido, infertility, mood disorders,

osteoporosis and osteopenia (Brennan, 2013). For
example, long-term oral treatment with methadone
and morphine for chronic pain is associated with
pituitary dysfunction in gonadal, adrenal and PRL
axes, in particular, significantly increased serum PRL
in some patients (Rhodin et al., 2010; Merdin et al.,
2016). There appears to be a sex difference in response
to chronic opioids (Wong et al., 2011) in that male
patients exhibit higher, opioid-dependent PRL levels
than women.
Cannabis and Endocannabinoids

Cannabis use in humans has been known for thousands
of years, especially for its analgesic, euphoric and relax-
Figure 7.3 Changes in PRL secretion following anti-psychotic drug
treatment in healthy men and women. Groups received placebo ant properties. It is also one of the most widely used,
(males, n=7; females, n=11), aripiprazole (males, n=7; females, n=11), and abused, illicit drugs. However, although there is
haloperidol (males, n=10; females, n=8) and reserpine (males, n=10; increasing interest in its medicinal use (Aggarwal
females, n=8). Treatment consisted of gradually increasing doses
over 7 days, and blood was taken on day 8. Each block is framed by et al., 2009; Maule, 2015), there is also evidence that
an upper (75th percentile) and a lower (25th percentile) line, with cannabis may have untoward effects on the neuroendo-
the internal horizontal line representing the median value. P values crine system. The isolation of the active component –
indicate a sex difference in drug response, and * indicates a
significant effect of treatment compared with baseline. The figure Δ9-tetrahydrocannabinol (THC) – led directly to the
illustrates data obtained from Veselinovic et al. (2011). discovery of a brain-derived endocannabinoid system
in which anandamide functions as the endogenous
cannabinoid. Anandamide is found throughout the
is largely restricted to the typical anti-psychotics such human brain, including the arcuate nucleus and pitui-
as phenothiazines and haloperidol, whereas atypical tary (Pagotto et al., 2001; Palkovits et al., 2008; Yasuo
anti-psychotics, such as aripiprazole, olanzapine and et al., 2010). Cannabinoid receptors (CB1Rs) are also
quetiapine, are less likely to induce hyperprolactine- localized in many brain regions, including the hypotha-
mia (Veselinovic et al., 2011; Figure 7.3). lamus and pituitary (Pagotto et al., 2001; Normandin et
Clinical implications: If drug-induced hyperpro- al., 2015). Cannabis and/or endocannabinoids may
lactinemia is suspected, temporary withdrawal of the therefore influence the neuroendocrine system.
suspected drug, if clinically feasible, may be consid- Following the initial study suggesting an association
ered to determine if serum PRL normalizes. between marijuana and gynecomastia (Harmon and
Additionally, dopamine-agonist therapy is known to Aliapoulios,1972), there are conflicting opinions on
induce neuropsychiatric side effects, and patients with whether cannabis has any lasting effect on PRL secre-
pre-existing history of psychosis should be carefully tion. However, recent reviews indicate that frequent
monitored (Athanasoulia-Kaspar et al., 2018). users of cannabis tend to have significantly lower base-
line levels, as well as attenuated PRL responses to THC,
7.3 Drugs and PRL Release compared with healthy controls (reviewed in
Ranganathan et al., 2009; Hillard, 2015). A major lim-
Opioids itation in interpreting the available data is that most
studies have been conducted on relatively small popula-
Opioid analgesics are the most frequently prescribed
tions of patients, using varying dosages of cannabi-
drugs for chronic pain, a practice that has contributed
noids, which may have led to inconsistent results.
to widespread abuse of opioids (Volkow and
McLellan, 2016). Opioid use/abuse has important
clinical implications because of profound effects on 7.4 Sleep and Pulsatile PRL Secretion
the hypothalamic–pituitary system (Vuong et al., PRL secretion, like other pituitary hormones such as
2010). Opioid endocrinopathy causes reduced sexual LH and GH, is pulsatile. The number of pulses in 24 121
Figure 7.4 Serum PRL levels over 24 hours in healthy men and
14
women. Blood samples were obtained every 10 mins from males
(n=33) and women (n=41). The female group consisted of a
12 mixture of women who were pre-menopausal, in the follicular
Prolactin (micrograms/L)
phase, and post-menopausal without estrogen supplementation.

10 The values are means+/-SEM. Note that in this graph it is not
WOMEN possible to discern the pulses of PRL described in Veldhuis et al.
8 (1990). The figure is redrawn from data in Roelfsema et al. (2012).
4 MEN
2
Lights off
0
0900 1200 1500 1800 2100 2400 0300 0600 0900
Clock time (hours)
hours is in the range 12–29, in both men and women. described in the previous section (see Figure 7.1),
However, the amount of PRL per pulse, and the mean which produces surges of PRL, is crucial for continued
value over 24 hours, is significantly higher in women lactation. However, breast examination has no effect
(Veldhuis et al., 1990; Roelfsema et al., 2012; Figure on PRL in pre- or post-menopausal women (Saraç
7.4). The marked stimulatory effect of sleep on PRL et al., 2008). Figure 7.5 illustrates an example of suck-
levels is especially evident during rapid eye movement ling-induced PRL secretion (post-partum, 4 weeks;
(REM) sleep (Latta et al., 2005). Tay et al., 1996). Each breastfeeding is accompanied
by a surge of PRL. Also shown is the dramatic decline
in PRL levels seen in a post-weaning mother, during
7.5 Chest Wall Trauma and PRL the follicular phase of the menstrual cycle. Nipple
Secretion stimulation in men had little to no effect on PRL
An association between chest wall injury and hypersecretion (Noel et al., 1974).
prolactinemia has been known for decades. These Breastfeeding, and the suckling stimulus, induces
include radical mastectomy (Barni et al., 1987) and a period of amenorrhea following parturition. This
burns of the chest area (Goyal et al., 2008), resulting in state of infertility greatly reduces the risk of pregnancy
galactorrhea, which may last for several months. The for up to 6 months post-partum. Nevertheless, it
underlying reason for hyperprolactinemia and galac- remains unresolved whether high, suckling-induced,
torrhea in these instances is thought to be the release PRL secretion is responsible for this (McNeilly, 2001).
of PRL in response to stimulation of the thoracic (T2– Pulsatile secretion of LH is suppressed by the suckling
T6) intercostal nerves (Katsuren et al., 1997, and stimulus and this is assumed to occur via a direct
references therein). This pathway forms the basis of effect of PRL on the hypothalamus, which reduces
the suckling reflex (see Section 7.6), and blockade of the pulsatile release of GnRH. In addition, even the
these nerves reduces serum PRL (Morley et al., 1977). low levels of estradiol in this hypoestrogenic state
exert a powerful negative feedback on LH/FSH
release. Whether or not PRL is involved in suckling-
7.6 Breastfeeding and PRL Secretion induced amenorrhea, there can be no doubt that
During pregnancy, the number of pituitary lacto- chronic high PRL (hyperprolactinemia) can impair
trophs increases and serum PRL levels rise to facilitate fertility in men and women, independently of breast
development of breast alveolar structure. This effect stimulation.
of PRL is estradiol- and progesterone-dependent. PRL Clinical implications: Breastfeeding is possible
is also critical for milk production, but is effective only even without pregnancy and even in post-menopausal
when levels of estradiol and progesterone fall after women. This can be achieved by giving medications
122 parturition. At this point the suckling stimulus, as that increase PRL, such a domperidone. Regular
Figure 7.5 Suckling-induced PRL secretion. (A)

Changes in plasma PRL levels over a 24-hour
period in a woman breastfeeding 4 weeks
post-partum. * indicates periods of suckling. (B)
PRL levels during the post-weaning, follicular
phase of the menstrual cycle. Note the large
difference in PRL levels between A and B. The
figure is redrawn from data in Tay et al. (1996).
manual expression of the breasts or using a breast investigation, with simultaneous assay of sex hor-
pump leads to increased PRL secretion, which also mones, GH and PRL, through the normal menstrual
induces lactation. Additionally, women with galactor- cycle, PRL levels – particularly pulsatile secretion dur-
rhea are advised to avoid the temptation of frequently ing the late afternoon – were elevated during the luteal
checking themselves as repeated self-manipulation of phase (Caufriez et al., 2009). A larger study (>6,000
the breast can worsen galactorrhea. patients) confirmed the luteal phase increase in PRL,
and showed that maximum levels were seen during
the ovulatory phase (Tanner et al., 2011). The study
7.7 Effect of Sex Hormones on PRL also concluded that pre-menopausal women had
Pregnancy is characterized by increasing concentra- significantly higher PRL levels in all phases of the
tions of blood estradiol and progesterone and hyper- menstrual cycle compared to both men and post-
plasia of maternal lactotrophs is evident at 1 month of menopausal women. These variations in PRL are
pregnancy (Karaca et al., 2010; Scheithauer et al., probably due to the influence of estradiol (see Figure
1990). Circulating levels of PRL are increased by 6 3.1). However, efforts to confirm that estradiol stimu-
weeks, progressively reaching a maximum in late lates PRL secretion in women are conflicting. In a
pregnancy in preparing the breasts for lactation. retrospective analysis, high-dose estradiol implants
Fetal PRL increases (20–24 weeks) and attains levels failed to increase PRL in postmenopausal women
equivalent to those in the maternal circulation at (Sathyapalan et al., 2009). In contrast, implants (6
parturition (Ben-Jonathan et al., 2008). Amniotic months) of estradiol, plus a progestagen, significantly
fluid also possesses very high concentrations of PRL, elevated PRL levels in post-menopausal women
likely produced in the decidua rather than the pitui- (Kalleinen et al., 2008; Tikk et al., 2014). Short-term
tary (Ben-Jonathan et al., 2008). Several studies have estradiol exposure (skin patches) also increased PRL
examined PRL secretion through the menstrual cycle, levels in post-menopausal women (Garas et al., 2006).
with inconsistent results (see Caufriez et al., 2009, and The effects of estradiol may therefore be dose depen-
references therein). In a carefully controlled dent, providing a possible explanation for the 123
women. The case emphasizes the need to be aware of

hyperprolactinemia as a complication of testosterone-
replacement therapy.
Clinical implications: Serum PRL levels drop in
post-menopausal women and a significant proportion
of microprolactinomas spontaneously resolve after
menopause – likely due to a fall in estrogen levels.
Therefore, most clinicians would consider withdraw-
ing medical therapy in post-menopausal women with
microprolactinoma.
7.8 PRL Release and Sexual Activity

Sexual intercourse-induced orgasm induces a pro-
nounced increase in plasma PRL levels in healthy
men and women, with PRL secretion remaining sig-
nificantly elevated up to 60 mins post-orgasm (Figure
7.6; Exton et al., 2001). The PRL response is orgasm
dependent and occurs also after masturbation
(Krüger et al., 2005). The biological relevance of this
neuroendocrine response to sexual activity remains
unknown. Since hyperprolactinemia is reported to
induce a reduction in sexual arousal in men and
women (Wierman et al., 2010; Maggi et al., 2013),
one possibility is that the post-orgasm increase in
PRL induces a refractory period (satiation) in sexual
behavior. An alternative is that PRL may be part of a
reproductive reflex that serves to optimize fertility
Figure 7.6 Plasma PRL levels during sexual activity. Blood samples and conception.
were obtained every 10 mins during an emotionally neutral phase,
then through an arousal phase, followed by coitus and orgasm.
Control data were obtained from couples sitting quietly, without 7.9 Stress-Induced PRL Secretion
physical contact, watching a neutral documentary film. Plasma PRL Various stressors are known to affect PRL secretion. A
was increased and remained elevated for at least 60 mins, in both
males and females. * p<0.05; ** p<0.01; *** p<0.001 vs. controls. widely quoted study reported a five-fold increase in
Values are means/-SEM; n= 10 couples. Reproduced with permission PRL during major surgery, with larger changes seen in
(Exton et al., 2001) and redrawn. women compared to men (Noel et al., 1972). Values
returned to pre-surgery levels within 24 hours. It
discordant reports (Ehara et al., 1976). In summary, remains unclear whether surgical stress or general
PRL secretion in women is sensitive to estradiol, and anesthesia was responsible for the increased PRL
possibly progesterone, although the physiological rea- levels. It is likely to be a combination of both, with
son for this – outside of pregnancy – is unknown. different types of stress exerting distinct changes in
There is limited information on the effects of PRL. For example, patients with obstructive sleep
testosterone on PRL secretion in males (reviewed in apnea, treated with continuous positive airway pres-
Sodi et al., 2005). However, individual case reports sure therapy, have significantly lower levels of PRL,
have suggested that testosterone replacement in even in the presence of normal cortisol (Macrea et al.,
patients with secondary hypogonadism may lead to 2010). PRL secretion was also reduced in men follow-
hyperprolactinemia (Nicoletti et al., 1984; Sodi et al., ing 3 weeks of highly stressful military training
2005). This effect is abolished by the estrogen antago- (Gomez-Marino et al., 2005). This differs from the
nist tamoxifen, suggesting that testosterone was effec- situation in acute exercise in trained men, where
tive via aromatization to estradiol. This is in keeping PRL is significantly elevated by treadmill running
124 with the previously discussed effect of estradiol in (Rojas Vega et al., 2011; Hackney et al., 2015) and by
sprint running (Stokes et al., 2013). Psychosocial stress relationship between PRL and body weight is unclear.
also increases PRL secretion. For example, a standard For example, PRL responses to various stimuli, such
stress test (a simulated interview) significantly as TRH or insulin-induced hypoglycemia, may be
increased PRL, ACTH and cortisol in both men and attenuated by obesity (Kopelman, 2000). Although
women, although many other studies indicate highly controversial, PRL-secreting adenomas are associated
inconsistent results (Lennartsson and Jonsdottir, with increases in body weight, and weight loss occurs
2011); that is, examination stress appeared to have after normalization of PRL levels (Greenman et al.,
no effect (Malarkey et al., 1991). In clinical situations 1998; Doknic et al., 2002), although in these cases it is
where stress is thought to play a role in developing a possible that the weight loss could be attributable to
psychotic disorder, patients at high risk have signifi- the bromocriptine used to decrease PRL levels.
cantly elevated levels of PRL compared to healthy However, in a detailed study on obese women, spon-
subjects (Labad et al., 2015). The physiological impor- taneous PRL release assayed every 10 mins over 24
tance of acute, but reversible, stress-induced PRL hours was significantly increased in proportion to
secretion is not known, although PRL is implicated body mass index (BMI) and visceral fat mass, com-
in the immune system, in angiogenesis, and in neuro- pared with women with normal BMI (p<0.001; Kok
plasticity (Freeman et al., 2000; Rojas Vega et al., et al., 2004). Figure 7.7 illustrates that serum levels of
2011). However, those stressors that induce hyperpro- PRL are especially elevated during sleep periods in the
lactinemia are of immediate clinical concern (see obese patients. In a subsequent report this group
Section 7.9). showed that a reduction in BMI and fat mass in
Clinical implications: Measurement of serum PRL obese women significantly reduced, but did not elim-
immediately after a seizure has been used to differ- inate, the enhanced PRL secretion shown in Figure 7.7
entiate epileptic seizures from psychogenic non-epi- (Kok et al., 2006).
leptic seizures (Aydin et al., 2011). A significantly One possible explanation for these observations is
elevated serum PRL would suggest an epileptic as that elevated PRL is a response to high, obesity-
opposed to psychogenic seizure. induced leptin levels (see Chapter 4). Another sugges-
tion is that obesity is a consequence of reduced
7.10 Obesity and PRL Secretion numbers of brain dopamine D2 receptors, which
would, in turn, favor increased secretion of PRL
Animal experiments confirm that PRL stimulates fat
(Kok et al., 2004). This seems unlikely in view of a
deposition in female rats and birds, whereas abdom-
recent report that central D2 receptors are unchanged
inal fat mass is reduced in PRLR-deficient mice
in obese patients (Eisenstein et al., 2013).
(Freemark et al., 2001). In humans, a precise
30 LIGHTS OFF
25 LIGHTS OFF
25
Serum PRL (microgram/L)
Serum PRL (microgram/L)
20
20
OBESE
15 OBESE
LEAN
15
10
10
5
5
LEAN
0 0
1800 2100 2400 0300 0600 0900 1200 1500 1800 1800 2100 2400 0300 0600 0900 1200 1500 1800
Clock time (hour) Clock time (hour)
Figure 7.7 Serum levels of PRL in two obese women. Data are shown for PRL secretion in two pre-menopausal obese and two control (non-obese)
women, studied in the follicular phase of the menstrual cycle. The age of the women in the left panel was 33yr and the BMIs were 20.6 and 31.0.
The age of the women in the right panel was 48yr and the BMIs were 21.5 and 32.3. Basal secretion and total secretion over 24 hours were 125
significantly higher in obese women (p<0.001). Figures were constructed using data generously provided by Dr. H. Pijl (Kok et al., 2004).
Table 7.2 Main causes of hyperprolactinemia. Reproduced with anti-depressants – induce hyperprolactinemia, which
permission (Bernard et al., 2015)
generally returns to normal within 96 hours of dis-
Physiological continuing treatment. Hypothyroidism is also asso-
Pregnancy ciated with hyperprolactinemia, where elevated levels
Lactation of TRH stimulate PRL secretion (Hekimsoy et al.,
Nipple stimulation
2010; see Section 7.1). The clinical consequences of
hyperprolactinemia may include loss of libido, erectile
Analytical
dysfunction in men, infertility/menstrual irregularity
Macroprolactinemia
in women, gynecomastia, galactorrhea, osteoporosis
Pathological and possibly headaches.
Prolactinomas and mixed secreting adenomas
Hypothalamic and pituitary stalk disorders 7.11.1 A Case of Prolactinoma
– Compressive macroadenoma
A 37-year-old car salesman was referred to endocri-
– Hypophysitis nology with a 4-year history of reduced libido, poor
– Granulomatous disease sexual function and painful nipples. Further question-
– Rathke cleft cyst ing revealed that he went through normal puberty and
– Irradiation and/or trauma had normal sexual function until about 4 years ago
– Tumor (craniopharyngioma, germinoma, metastases) when he developed gradual erectile dysfunction and
Medication poor libido. He developed intermittent frontal head-
– Dopamine antagonists (anti-psychotics, anti-emetics,
aches about a year ago and over the last 6 months he
α-methyldopa anti-hypertensive) noticed that whenever he wore a tight shirt, his nip-
– Other (anti-depressants, estrogens, opiates) ples would become sore. Examination revealed nor-
Chronic renal failure
mal genitalia and visual fields; he had bilateral tender
gynecomastia and milky discharge could be expressed
Ectopic PRL secretion
from both nipples.
– Ovarian dermoids
Initial investigations were as follows:
– Hypernephroma PRL=8793 mcg/L (2.1–17.7)
– Bronchogenic carcinoma Cortisol=442 nmol/L (184–512)
Genetic TSH=2.95 mIU/L (0.35–5.4)
– PRLR loss-of-function mutation Free thyroxine=12.4 pmol/L (11–19)
Idiopathic GH=0.2 mcg/L (<3.0)
Unknown IGF-1=206 mcg/L (163–484)
LH=2.3 IU/L (1.4–18.1)
FSH=2.8 IU/L (1.5–9.3)
Total testosterone=6.1 nmol/L (8.0–32)
7.11 Hyperprolactinemia An magnetic resonance imaging (MRI) scan
Table 7.2 lists the main causes of hyperprolactinemia revealed a pituitary adenoma (Figure 7.8). A diagnosis
(Bernard et al., 2015). Prolactinomas are the com- of prolactinoma associated with secondary hypogo-
monest functioning pituitary tumors and around nadism was made on the basis of elevated serum PRL,
40% present as macroadenomas (>1 cm; Al- presence of pituitary adenoma, low serum total tes-
Dahmani et al., 2016). Mildly elevated PRL (<100 tosterone and false-normal serum LH and FSH levels.
mcg/L) is frequently seen in large non-PRL-produ- Typically, in individuals with a normally functioning
cing tumors due to stalk compression. Compression pituitary gland, serum LH and FSH levels would be
of the stalk may interfere with the hypophyseal portal expected to rise to above-normal range. Therefore,
flow of dopamine, which provides the normal tonic “normal” LH and FSH levels in this case despite a
inhibitory control. low serum total testosterone would indicate pituitary
Several drugs (listed in Table 7.1) acting as dopa- dysfunction and are regarded as false-normal.
minergic receptor antagonists can also lead to hyper- Treatment with cabergoline, 1.0 mg twice per
prolactinemia. For example, chronic treatment with week, was initiated and after 3 months serum PRL
126 medications – including anti-psychotics or tricyclic dropped to 108 mcg/L. The patient felt a marked
Figure 7.8 MRI scans of

pituitary
macroprolactinoma. (A)
Coronal and (B) sagittal
MRI sections of the sella
turcica showing the
pituitary macroadenoma
with a necrotic area
(arrows) and upward
tumor projection (small
arrow).
improvement in his sexual function and soreness of sensitive to medical therapy with dopamine agonists.
nipples. There was significant shrinkage of the tumor The two most commonly used agents are bromocrip-
on MRI. However, the patient contacted the clinic 4 tine and cabergoline, which are ergot-derived alka-
months later indicating recurrence of nipple soreness loids (see Section 7.2). Most prolactinomas respond
and a repeat test showed serum PRL had risen to 2468 to medical therapy with normalization of serum PRL
mcg/L. After confirming compliance with medical and shrinkage (or in some cases complete resolution)
therapy, cabergoline was increased to 2.0 mg twice of the tumor. Complete resistance to medical therapy
per week. Eight weeks later, serum PRL had again is relatively rare as almost 90% of patients respond to
risen to 3102 mcg/L and repeat MRI showed tumor medical treatment. In addition to these drugs, a non-
enlargement (Figure 7.9A) and he began experiencing ergot-derived dopamine agonist, quinagolide, is also
nausea, which was thought to be due to the drug. available in certain countries. Side effects include
Options of increasing cabergoline dosage versus nausea, dizziness, nasal stuffiness, risk of depression
surgery were discussed and the patient opted for and psychosis. The tolerability is improved by admin-
trans-sphenoidal pituitary surgery, which led to a istering the tablets at bedtime with a light snack.
reduction of serum PRL to 369 mcg/L 3 months Resistance to dopamine agonists occurs in 10–15%
after the surgical removal of gross disease (Figure of prolactinoma patients. In these cases, treatment
7.9B). Medical therapy was continued with cabergo- options include higher doses of drug therapy (3–
line 2.0 mg twice per week (a brief trial of bromocrip- 6 mg/week of cabergoline), surgery and radiation
tine was given, which the patient was unable to therapy (Olafsdottir and Schlechte, 2006). In addition,
tolerate due to worsening of nausea and dizziness). an alkylating chemotherapy agent, temozolomide, has
Pathology revealed a PRL-producing adenoma with been reported to control tumor growth (Kovacs et al.,
no mitotic activity. 2007). The underlying reasons for DA resistance are
At 9 months post-surgery, serum PRL had again not entirely clear, but a decrease in D2 receptors on
risen to 932 mcgl/L and MRI showed recurrence of lactotroph cell membranes could account for this
tumor. Consequently, the patient underwent fractio- phenomenon (Cuny et al., 2015). Some prolactinomas
nated stereotactic radiation therapy and 2 years later also express somatostatin (SOM) receptors (SOMRs;
his PRL levels normalized and he was subsequently Jaquet et al., 1999; Cuny et al., 2015; SOMR in adeno-
able to discontinue cabergoline therapy. MRI showed mas is discussed in Section 8.3). The SOMR subtype
complete resolution of the tumor (Figure 7.9 C and SSTR5 appears to be enriched in prolactinomas and
7.9 D). combined treatment with cabergoline and the SOM
This case illustrates various treatment strategies agonist octreotide was reported to be effective in nor-
for prolactinoma. Most prolactinomas are highly malizing PRL secretion in a case of dopamine- 127
A B
Enlargement
of the tumor
C D
Figure 7.9 MRI scans confirming recurrence of tumor growth, plus subsequent treatment. (A) Coronal MRI of the sella turcica showing tumor
enlargement despite 8 weeks of dopamine agonist therapy; (B) post-surgical MRI showing removal of the main sellar portion of the tumor and
persistent tumor projection (encircled). Following another period of tumor regrowth, (C) and (D) illustrate coronal and sagittal sections,
respectively, of MRI scans of the sella turcica, showing complete resolution of the tumor following stereotactic radiation therapy and
cabergoline treatment.
resistant macroprolactinoma (Fusco et al., 2011). from other anterior pituitary hormones such as LH,
Pasireotide, a SOM agonist with a higher affinity for PRL has no target tissue that exerts classical hormonal
the SSTR5 subtype, is also effective (personal feedback.
experience). The inhibitory effect of dopamine D2 agonists on
PRL secretion, for example in hyperprolactinemia, is
well described. Oral treatment with cabergoline or
7.12 Chapter Summary bromocriptine is effective in normalizing PRL secre-
This chapter emphasizes the mechanisms by which tion and inducing tumor shrinkage. In contrast, anti-
PRL levels are regulated under normal physiological psychotics such as haloperidol act as antagonists at D2
conditions, and in those states of pathological PRL dopamine receptors, such that long-term therapy in
secretion, such as hyperprolactinemia and obesity. psychotic disorders, such as schizophrenia, produces
Unlike other anterior pituitary hormones, the regula- hyperprolactinemia. PRL secretion is also sensitive to
tion of PRL secretion does not appear to involve other drugs such as opioids. Opioid treatment of
hypothalamic releasing hormones; that is, PRL is chronic pain, especially in men, stimulates high PRL
under tonic inhibitory control by dopamine, released levels. Other stimulatory agents include TRH, ghrelin
from hypothalamic dopaminergic neurons into the and estradiol. In contrast, cannabis is inhibitory.
128 hypophyseal portal vessels. In addition, and distinct CB1 Rs are localized in many brain regions, including
the hypothalamus and pituitary, and frequent use of d. Estradiol

cannabis induces low baseline levels of PRL. e. Pregnancy
PRL release, like LH and GH, is pulsatile. 3. Which of the following pairs of hormones are
Physiological stimulation of PRL is seen in sleep, most intimately associated with the process of
pregnancy, breastfeeding, menstrual cycle and sexual lactation?
activity. The stimulatory effect of sleep on PRL levels
a. Estradiol and PRL
is especially evident during REM sleep, and is much
b. Progesterone and PRL
higher in women compared to men. Obesity is also
c. Oxytocin and PRL
associated with high sleep-related PRL levels. During
d. Estradiol and progesterone
pregnancy, serum PRL levels rise to facilitate devel-
e. Testosterone and PRL
opment of breast alveolar structure. Post-parturi-
tion, breastfeeding episodes are accompanied by 4. Which of the following statements are correct?
surges of PRL. The suckling stimulus is also respon- a. PRL secretion is stimulated by thyrotropin
sible for the continuation of lactation. PRL levels are releasing hormone (TRH).
increased during the menstrual cycle, particularly b. Maternal blood levels of PRL are increased
through the luteal phase, and estradiol increases during pregnancy.
PRL secretion in post-menopausal women. c. PRL is biosynthesized in immune cells.
Testosterone stimulation of PRL levels is clearly d. Unlike luteinizing hormone (LH) and growth
seen in hypogonadal men. Sexual intercourse- hormone (GH) secretion, PRL release is non-
induced orgasm induces a significant increase in pulsatile.
plasma PRL levels in healthy men and women, with e. PRL secretion is elevated following pituitary
PRL remaining significantly elevated up to 60 mins stalk compression.
post-orgasm. PRL release is also modified by obesity 5. Which of the following statements regarding
and by stress. Various stressors are known to differ- management of prolactinomas are correct?
entially affect PRL secretion. For example, PRL levels
were reduced in men following 3 weeks of highly a. Surgical excision of the tumor is the first-line
stressful military training, whereas PRL is signifi- therapy.
cantly elevated by treadmill running. Psychosocial b. Prolactinomas with an abundant expression of
stress also increases PRL secretion. It remains dopamine D2 receptors are more likely to
unknown why PRL secretion is sensitive to various respond to dopamine agonist therapy.
stimuli such as sleep, stress, orgasm and the men- c. Quinagolide is an ergot-derived dopamine
strual cycle. A case of hyperprolactinemia is pre- agonist.
sented in which drug treatment and surgery were d. Bromocriptine is an effective treatment option
required to restore normal PRL levels. for psychosis.
e. Dopamine agonist therapy should be ideally
taken at bedtime to improve tolerability.
6. Neurogenic release of PRL in response to chest
1. Which of the following statements are correct? wall injury is:
a. PRL is responsible for milk ejection. a. Likely caused by hypothalamic response to
b. Suckling is the most important stimulus for injury.
milk ejection. b. Mediated by thoracic intercostal nerves.
c. Lactation can be inhibited by dopamine c. May lead to chronic galactorrhea.
antagonists. d. Associated with pituitary tumors.
d. PRL regulates synthesis of milk proteins. e. Caused by an increase in dopamine release.
e. All are correct.
7. Which of the following are typically associated
2. Which of the following may cause with hyperprolactinemia?
hyperprolactinemia?
a. Secondary hypogonadism
a. Repeated breast manipulation b. Infertility
b. Oral treatment with cabergoline c. Failure to lactate 129
c. Stress d. Enlargement of the tongue
e. Testicular enlargement Ben-Jonathan N, LaPensee C R & LaPensee E W. (2008).

What can we learn from rodents about prolactin in humans?
8. Which of the following statements are correct?
Endocr Revs 29, 1–41.
a. Men are more susceptible to an opioid- Bernard V, Young J, Chanson P & Binart N. (2015). New
induced PRL increase than women. insights in prolactin: pathological implications. Nat Revs
b. Sleep-related pulsatile secretion of PRL is Endocr 11, 265–275.
higher in women than in men. Brennan M J. (2013). The effect of opioid therapy on
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133
Chapter
Regulation of Growth Hormone Secretion
8
Linear growth in humans is dependent on a complex pituitary where they control the secretion of GH.
interplay of various endocrine factors including: Figure 8.1 illustrates the homeostatic feedback path-
growth hormone (GH), insulin-like growth factors ways involving GH, hypothalamic neuropeptides
(e.g., IGF-1), ghrelin, thyroid hormones, glucocorti- (GHRH and SOM), ghrelin and IGF-1 from the
coids (GCs), sex hormones and non-endocrine mod- liver. Ghrelin is the most potent GH secretagogue
ulators such as nutritional status, familial growth known. Ghrelin infusion, in men and women, syner-
pattern, physical and psychosocial health. The pri- gizes with GHRH to stimulate pulsatile release of GH
mary determinants, however, are GH, GH-stimulated from somatotrophs, but likely exerts a positive feed-
IGF-1 production by the liver, plus ghrelin derived back on GHRH neurons as well (Veldhuis et al., 2008).
from the stomach. Ghrelin also plays a major role in In contrast, IGF-1 inhibits GHRH release but stimu-
the control of food intake (see Chapter 4). Its involve- lates SOM release, a combination that attenuates GH
ment in GH secretion is covered in Section 8.1. secretion. Note that GH also controls its own release
This chapter will focus on the regulation of pitui- via autocrine regulation exerted via GH receptors on
tary GH secretion and the pathophysiological impli- somatotrophs (Figure 8.1).
cations of abnormal GH production. GH is secreted
from anterior pituitary somatotrophs, which make up 8.2 Pulsatile Secretion
approximately 50% of the cell population of the gland
Similar to various other pituitary hormones, GH is
(Heaney and Melmed, 2004). At least five different
secreted in an episodic manner. Typical GH secretion
isoforms of GH exist, encoded by homologous genes,
consists of a minimal basal secretory rate where GH
Although only one, GH1, is expressed in somato-
levels drop to <0.04 mcg/L, interspersed by bursts or
trophs (Lim et al., 2014).
pulses. Although the average frequency of GH pulses
in both men and women is similar (approx. 11 over 24
8.1 Regulation of GH Secretion hours), the mean GH concentration is significantly
GH secretion is regulated through both central (GH- elevated in women (Veldhuis et al., 2011; Roelfsema
releasing hormone [GHRH] and somatostatin and Veldhuis, 2016). The pulse frequency is also
[SOM]) and peripheral (ghrelin and IGF-1) factors. higher in prepubertal children and adolescents com-
An overview of the orchestration of GH release is pared to adult levels (Steyn et al., 2016). Evidence
shown in Figure 8.1. The hypothalamic neuropeptide from animal experiments confirm that GHRH and
hormones – GHRH (stimulatory) and SOM (inhibi- SOM are released as pulses from the hypothalamus
tory) – constitute the principal central factors of GH into the hypophyseal blood circulation (Thomas et al.,
regulation. However, the hormone ghrelin – released 1991; Goldenberg and Barkan, 2007) and it is likely,
from the stomach – exerts a powerful stimulatory although unproven, that neuronal secretion of human
effect on GH secretion, whereas IGF-1, secreted GHRH and SOM is also inherently pulsatile.
from the liver, inhibits GH secretion. Cell bodies of However, the overall pituitary output of GH is
the GHRH and SOM neurons are located in close achieved, not by increasing pulse frequency, but by
proximity to each other in the basal infundibulum/ amplifying pulse, or burst, size. Pulse amplitude is
median eminence region of the hypothalamus regulated by a combination of GHRH stimulation,
(Proudan et al., 2015). Both peptides are released inhibition by SOM, plus a synergistic stimulation by
from nerve terminals and are transported through ghrelin. GH pulses are particularly evident at night
134 the hypophyseal portal system to reach the anterior (Figure 8.2; Van Cauter et al., 1998).
Chapter 8: Regulation of Growth Hormone Secretion
Figure 8.1 Regulation of GH secretion. Pituitary secretion of GH is stimulated by pulsatile secretion of hypothalamic GHRH. The amplitude
of the GH pulse is modulated by an inhibitory effect of SOM. GH stimulates synthesis of IGF-1 in the liver; about 85% of circulating IGF-1 is liver-
derived. IGF-1 inhibits GH secretion at both hypothalamic and pituitary levels by reducing GHRH, and by stimulating SOM secretion. GH also
acts as an autocrine factor to control its own secretion from the pituitary. Ghrelin, released from the stomach, potently increases GH release by
boosting hypothalamic GHRH secretion. It also synergizes with GHRH to modulate GH pulse amplitude, but its overall role in physiological GH
regulation remains incompletely defined. Reproduced with permission (Kargi and Merriam, 2013). Abbreviations: GH, growth hormone; GHRH,
GH releasing hormone; IGF-1, insulin-like growth factor 1.
This figure shows that sleep deprivation abolishes the night when meals are not anticipated. It is thought
GH secretion and that daytime sleep, several hours that ghrelin may act as a positive modifier of GH
later, restores the sleep-related surge of GH. pulsatile secretion. In fact, intravenous boluses of
Nevertheless, despite the loss of the normal sleep- ghrelin induced slow-wave sleep (SWS) and a signifi-
induced peak of GH, daytime pulses of GH are cant increase in GH secretion in young men (see also
increased, so that the overall quantity of GH per 24 Section 8.3; Weikel et al., 2003).
hours is not compromised by sleep deprivation Clinical implications: Macimorelin is a ghrelin
(Brandenberger and Weibel, 2004). This is also con- receptor agonist that stimulates the production of
firmed in studies where subjects were deprived of sleep GH. This agent is used for testing of GH deficiency
for 24 hours; that is, the sleep-associated peak of GH (see later in this chapter).
was normal (Schüssler et al. 2006; see also Section 8.3). Clinical relevance: The pulsatile nature of the GH
A clear association of increases in ghrelin secretion secretory pattern has profound diagnostic and therapeu-
and GH surges is revealed when GH and ghrelin are tic implications. Not only does a single random measure-
assayed in plasma from a group of fed young men ment of GH provide limited information on GH levels,
(Figure 8.3; Nass et al., 2011). The meal-associated but targeting medical therapies in GH disorders also
peaks of ghrelin are coincident with those of GH. In cannot be reliably based on GH levels alone
addition, ghrelin and GH peaks are coincident during (Goldenberg and Barkan, 2007). 135
Figure 8.2 Sleep-induced GH secretion and effect of sleep deprivation. Plasma GH in ten normal young men studied during a 52-hour period
including 8 hours of normal, nocturnal sleep, 28 hours of sleep deprivation and 8 hours of daytime sleep. GH secretion is abolished by sleep
deprivation, but is reinstated by a sleep period during the normal daytime. Figure is based on data obtained from Van Cauter et al. (1998).
Lunch
70
100
60
Dinner
; pg/mL)
Bkfst GH (
50 10
; microgm/L)
40
Acyl-Ghrelin (
30 1
20
0.1
10
sleep
0
0800 1000 1200 1400 1600 1800 2000 2200 2400 0200 0400 0600 0800 1000
Clock time (hour)
Figure 8.3 Coincidence of ghrelin and GH secretion in the fed state. The figure illustrates that the meal-associated peaks of ghrelin are
coincident with those of GH. Ghrelin and GH peaks are also coincident during the night, when meals are not anticipated, emphasizing that
ghrelin may act as a modifier of GH secretion. Values are mean+/-SEM plasma acyl-ghrelin (picograms per milliliter) and serum GH levels
(micrograms per liter, shown on log scale); n=8 young men during the fed state. Reproduced with permission (Nass et al., 2011).
8.3 Other Factors Regulating GH whereas others are extrinsic, such as age, gender, sex
hormones, glucose, amino acids, sleep, feeding, exer-
Secretion cise, stress, illness, obesity and medication (Table 8.1;
In addition to GHRH, SOM and ghrelin, GH secre- Fanciulli et al., 2009). The effects of some of these
tion is sensitive to an array of other influences. Some regulatory factors form the underlying basis of clinical
136 of these are best described as neural (see Section 8.4), GH testing.
Table 8.1 Regulators of GH secretion in humans. Reproduced with permission (Fanciulli et al., 2009).
Effector Increases GH Reduces GH Notes

Alpha1-adrenergic receptors ✔
Alpha2-adrenergic receptors ✔
Beta-adrenergic receptors ✔
Amino acids ✔
Anorexia nervosa ✔
Bombesin ✔
Dopamine ✔
Muscarinic receptors ✔
Cortisol ✔ ✔ Dose dependent
Diabetes mellitus ✔
Estrogen ✔ Increases pulse
amplitude
Exercise ✔
Free fatty acids ✔
γ-aminobutyric acid ✔
Galanin ✔
Ghrelin ✔
GHRH ✔
GH-releasing peptide ✔
Glucose ✔
Histamine ✔
Hypoglycemia ✔
Hypothyroidism ✔
IGF-1 ✔
Leptin Inversely correlated with
GH levels
Neuropeptide Y ✔
Obesity ✔
Opiates ✔
Senescence ✔
Serotonin ✔
Starvation ✔
Stress ✔
Testosterone ✔
Thyrotropin ✔ Only in acromegaly
Gender and Sex Hormones In addition, detailed studies by Veldhuis et al

Young women have significantly higher blood levels (2011) revealed that total GH secretion per day, and
of GH throughout the day compared to young men the amount of GH released per pulse, was significantly
(Goldenberg and Barkan, 2007; Figure 8.4). However, higher in healthy adult women compared to men,
this is not the case in older men and post-menopausal whereas the number of pulses per 24 hours was not
women, especially during sleep when secretory epi- different. During the menstrual cycle, when sex hor-
mone levels fluctuate (see Figure 3.1), there is a 137
sodes in women disappear (Latta et al., 2005).
12 Figure 8.4 Women have higher GH levels than men. Sexual

dimorphism of GH secretion illustrated with data from a
young man (top) and a young woman (bottom). The
10 difference in secretory pattern is seen during sleep, but is
sleep also readily apparent in baseline states where larger
amplitude pulses of GH can be observed in the young
Plasma GH (ng/mL)
8 woman. Reproduced with permission (Goldenberg and

Barkan, 2007) and redrawn.
0
0600 noon 1800 2400 0600
14
sleep
12
10
Plasma GH (ng/mL)
0
0600 noon 1800 2400 0600
Clock time (hour)
significant increase in GH secretion during the luteal relationship holds for men, but is unconvincing for
phase, suggesting that progesterone, and possibly women. For example, testosterone supplementation
estradiol, might be a stimulatory factor for GH secre- in healthy men drives secretion of GH and IGF-1
tion in normal cycling women (Caufriez et al., 2009). (Veldhuis et al., 2005), although this action of testos-
GH levels typically fall in post-menopausal women, terone is mediated by its conversion to estradiol (aro-
and secretion can be restored by estrogen treatment matization) in the brain (Weissberger and Ho, 1993;
(Kalleinen et al., 2008). These data indicate a role for Veldhuis et al., 1997). The mechanism by which estra-
sex hormones in regulating GH secretion. This is also diol regulates GH secretion in women is incompletely
evident in children, where there is strong evidence for understood. One possible explanation for estrogen-
sex hormone stimulation of GH in boys and girls induced GH release is that estrogen leads to reduced
during puberty (Meinhardt and Ho, 2006). For exam- hepatic production of IGF-1, which in turn exerts a
ple, GH secretion is restored in hypogonadal boys stimulatory effect on GH release; that is, estradiol
treated with testosterone (Veldhuis et al., 1997; attenuates the IGF-1-mediated negative feedback,
138 Giustina et al., 1997). However, in adults, the thereby increasing GH release. Another possibility is
Figure 8.5 Increases in SWS coincident with GH secretion. (A) Profiles of sleep stages, (B) slow-wave activity (EEG spectral power in the 0.5–4 Hz
frequency range), (C) plasma GH concentrations and (D) GH secretory rates derived from plasma GH levels in a healthy young man. Note the
temporal coincidence between major episodes of slow-wave activity and GH secretory pulses. Reproduced with permission (Van Cauter et al.,
2004) and redrawn.
an enhanced stimulatory effect of ghrelin on GH levels young men, as well as narcolepsy patients, with GHB,
in the presence of estradiol (Norman et al., 2014a) or a significantly increased SWS and GH secretion (Van
synergistic influence of estradiol on GHRH stimula- Cauter et al., 1997; Donjacour et al., 2011). The neural
tion of GH release (Norman et al., 2014b). In sum- control underlying the association of SWS and GH is
mary, although there are pronounced sex differences unknown, although the principal factor driving noc-
in GH secretion, the precise role, and mechanism of turnal GH secretion is GHRH; that is, an overnight
action, of gonadal hormones in men and women infusion of a GHRH antagonist largely eliminated GH
remains unclear. release (Ocampo-Lim et al., 1996). This suggests that
Clinical implications: The IGF-1 lowering effect of GHB increases the release of endogenous GHRH.
estrogen has led to the use of estrogen as an additional
therapeutic option in patients with excessive GH pro- Age
duction (acromegaly). GH is present in human fetal pituitary from 8 weeks of
gestation and is measurable in fetal serum from 12
Sleep weeks (Kaplan et al., 1976). Pulsatile secretion of GH
GH secretion is preferentially increased during is detectable in plasma immediately after birth, but
human sleep (Figures 8.2 and 8.3) and is closely asso- declines thereafter (Miller et al., 1993). GH levels are
ciated with slow wave sleep (SWS) (Figure 8.5; van higher than normal in preterm infants, leading to the
Cauter et al., 2004). suggestion that this might be responsible for neuro-
One of the few drugs known to increase SWS is γ- cognitive deficits seen later in life (Scratch et al.,
hydroxybutyrate (GHB), and treatment of healthy 2015). In normal children, however, GH levels 139
A deficiency of GH, either congenital or acquired, is

associated with distinct clinical outcomes. Childhood
onset GH deficiency (GHD) typically leads to short
stature, growth failure and delayed bone age, whereas
adult GHD is associated with loss of muscle mass,
increased adiposity, poor exercise capacity and dete-
rioration of mental function (Sattler, 2013; Bartke et al.,
2016; Milman et al., 2016). Although data on mortality
associated with GHD in humans are conflicting, mice
with mutational defects in somatotropic (GH/IGF-1)
action – and therefore with compromised growth and
body size – have remarkably extended lifespan, with
retention of physical and cognitive function and a
reduced incidence of age-related disease. Human stu-
dies on this phenomenon are limited (Milman et al.,
2016), although one large-scale investigation into
dwarf patients with mutations in the GHR (GH resis-
tance) revealed a highly significant reduction in the
incidence of cancer and diabetes compared to that in
normal relatives, although there was no observed
change in longevity (Guevara-Aguirre et al., 2011;
Guevara-Aguirre and Rosenbloom, 2015). In sum-
mary, age-related reductions in GH are regarded as
deleterious to human health and GH replacement as
an anti-aging therapy has been proposed (Kargi and
Merriam, 2013; Sattler, 2013). However, other evidence
indicates that GH replacement in adults may induce
unwanted consequences, such as increased insulin
Figure 8.6 Age-dependent decrease in GH secretion during 24 hours.
Mean (+/-SEM) values for GH for each age group plotted as total GH resistance and possibly cancer.
release in 24 hours (top) and as GH during sleep only (bottom). Clinical implications: Smaller doses of GH replace-
Probability levels, by analysis of variance, revealed a significant effect ment are typically required in the elderly based on the
of age in both total secretion (p<0.02) and in sleep-related GH
(p<0.001). Data were grouped by age as follows: 16–25 years (n=42); natural decline of GH with age. Section 8.8 will
26–35 years (n=28); 36–50 years (n=26); 51–60 years (n=23); 61–70 describe an example of clinical GHD.
years (n=18); 71–83 years (n=12). Figure is based on data obtained
from Van Cauter et al. (2000).
Glucose
increase substantially through the process of puberty, Glucose administration has a profound effect on GH
corresponding with the period of maximum height secretion. Typically, glucose administration in normal
velocity. In adolescents, the mass of GH per GH pulse individuals is associated with a biphasic GH response –
increases by up to ten-fold (Christoforidis et al., 2005; an initial SOM-mediated GH suppression is followed,
Veldhuis et al., 2006). These pubertal increases in GH 3–5 hours later, by an increase in GH release. On the
output are driven by aromatization of testosterone to other hand, hypoglycemia leads to release of GH, in
estradiol in boys and by estradiol in girls (Veldhuis tandem with hormones such as cortisol, via a reduction
et al., 1997). After puberty, GH secretion declines in SOM control (Giustina and Veldhuis, 1998). The
steadily to reach very low levels as early as 50–60 sensitivity of GH levels to glucose constitutes the basis
years. The decline is observable as an attenuation of of clinical testing of GH disorders. For instance, failure
pulse amplitude (Blackman, 2000) as well as total of GH to suppress after oral glucose administration is
secretion in 24 hours. This is especially notable during regarded as the gold standard for the diagnosis of acro-
sleep (Figure 8.6; van Cauter et al., 2000; Junnila et al., megaly (excessive GH production), whereas failure of
2013) where the day–night rhythm largely disappears GH to rise after insulin-induced hypoglycemia suggests
140
(Latta et al., 2005; Chertman et al., 2015). GHD.
Clinical implications: Acromegaly is confirmed by patients – the influence of GC on GH secretion is in

measuring GH after administering 75 g oral glucose. fact biphasic; the biological activity of GC is depen-
GH levels suppress to <1 mcg/L (<0.4 mcg/L with sen- dent on dose and time of exposure. For example, in
sitive GH assay) in normal individuals. Failure to sup- hypocortisolemic patients, physiological doses of GC
press GH suggests acromegaly. GHD is confirmed by will restore GH secretion (Barkan et al., 2000). In this
measuring GH after an insulin-induced hypoglycemia study, patients with Addison’s disease were with-
of <2.2 mmol/L. GH levels typically rise to >5.0 mcg/L in drawn (24 hours) from cortisol treatment and then
normal individuals. Failure of GH to rise to >5.0 mcg/L given replacement doses of hydrocortisone to main-
suggests GHD. tain physiological levels of cortisol. Withdrawal of GC
maintenance impaired spontaneous GH secretion
Glucocorticoids (Mazziotti and Giustina, 2013), but GH levels were
As described in Chapter 5, the GC cortisol is a major increased significantly following replacement cortisol
influence on most cells of the body. However, negative infusion due entirely to a doubling of pulse amplitude
effects of GCs are well described and include impaired (Figure 8.7). Patients with idiopathic adrenocortico-
growth in childhood, and altered body composition and tropin (ACTH) deficiency are also deficient in GH,
bone metabolism in adults and children. The common and respond to cortisol with increases in GH levels as
view is that an excess of GCs, either endogenous or described for Addison’s patients (Giustina et al.,
exogenous, suppresses GH secretion. This inhibition 1989). The authors concluded that cortisol stimulates
might be imposed at several sites, including inhibition GH output by reducing the inhibitory influence of
of GH production and secretion, inhibition of GHRH hypothalamic SOM.
and ghrelin action and stimulation of SOM activity (see
Figure 8.1). Inhibitory Effects of GC on GH
Both short term (1 hour) and long term (> 3 months)
Stimulatory Effects of GC on GH treatment with pharmacological doses of GC reduce
Notwithstanding the view that GCs are inhibitory to GH secretion and inhibit the stimulatory effect of
GH secretion – for example, in Cushing’s syndrome GHRH on pituitary GH release (Mazziotti and
Figure 8.7 Cortisol-induced secretion of GH in patients with primary adrenal insufficiency (Addison’s disease). Figure shows data from two
patients (A and B) with long-standing Addison’s disease. Patients had received regular hydrocortisone replacement but were withdrawn from
treatment 24 hours prior to admission. Patients were then infused with either saline or hydrocortisone (19 mg/day) given in a pattern designed
to mimic the normal circadian rhythm in cortisol secretion (i.e., peaks in the early morning). Compared to saline infusions, cortisol induced a 141
significant increase in GH secretion. The graphs are based on data obtained from Barkan et al. (2000).
Figure 8.8 Biphasic effects of GCs on GH secretion. The figure outlines a model of the effect of circulating GCs on human GH secretion. The
ascending part of the curve (light blue) reveals the stimulatory effect of GCs observable in a GC-deficient state. At higher doses, the
well-described inhibition of GH becomes apparent. Data were extrapolated from studies in humans performed separately in patients with
hypoadrenalism and in those exposed to an excess of GCs, either endogenous or exogenous. Reproduced with permission (Mazziotti and
Giustina, 2013).
Giustina, 2013). Such effects are seen in patients with focused on drug-induced changes, implicate several
hypercortisolism (Cushing’s syndrome) and in those receptor types in controlling human GH secretion
undergoing long-term immunosuppressive GC treat- (Table 8.1). For example, clonidine and the anti-
ment, for example, following organ transplants. In depressant reboxetine act as hypothalamic α2-adre-
summary, GCs represent a critical component of the nergic stimuli for GH secretion (Schüle et al., 2004;
normal regulation of GH secretion. GC have both Steyn et al., 2016). Baclofen, a γ-aminobutyric acidB
stimulatory and inhibitory effects on GH secretion, agonist, also stimulates GH secretion in women
dependent on dose and time of exposure (Figure 8.8). (Orio et al., 2001). For serotonin, the evidence is
less convincing. Increased secretion of GH, follow-
ing insulin-induced hypoglycemia, is prevented by
8.4 Neural Control of GH Secretion the serotonin receptor antagonist cyproheptadine
Figure 8.1 illustrates that pituitary GH secretion is (Bivens et al., 1973), but the selective serotonin
primarily controlled by GHRH, SOM and ghrelin. reuptake inhibitor citalopram, a drug designed to
However, there are multiple stimulatory and inhibi- increase synaptic serotonin, significantly increased
tory signals, some described in Section 8.1, and ACTH secretion but had no effect on GH levels
some of them of brain origin, that impose further (Berardelli et al., 2010). On the other hand, acetyl-
levels of regulation (see Table 8.1; Fanciulli et al., choline has a profound stimulatory effect on GH
2009). Animal experiments have provided detailed secretion in normal men and women. Inhibition of
knowledge of the neural control systems (Steyn central acetylcholinesterase, by physostigmine, or by
et al., 2016), but evidence for such involvement in donepezil, markedly increased basal as well as
man is limited (Giustina and Veldhuis,1998; Steyn GHRH-stimulated GH secretion (Fedi et al., 2008;
et al., 2016). Extensive immunohistochemical stu- Obermayr et al., 2005). In addition, arginine- or
dies in human brain tissue revealed evidence for exercise-induced GH secretion was blocked by pre-
possible neurotransmitter/neuropeptide synaptic treatment with the cholinergic antagonist atropine
regulation of GHRH and/or SOM neurons, includ- (Casanueva et al., 1984). Inhibitory dopamine recep-
ing dopamine (inhibitory; Rotoli et al., 2011), neu- tors are thought to underlie the effects of the anti-
ropeptide Y (inhibitory; Deltondo et al., 2008), SOM psychotic olanzapine. In this study, olanzapine
(inhibitory; Proudan et al., 2015), enkephalin (sti- abolished the normal nocturnal secretion of GH in
mulatory; Olsen et al., 2014) and CRH (inhibitory; schizophrenic patients (Mann et al., 2006). Opioid
142 Peroski et al., 2016). Complementary reports, receptors appear to be stimulatory for human GH
secretion (Vuong et al., 2010). For example, a met- 8.5 Receptor Mechanisms that Control
enkephalin analog elevated GH secretion in young
men (Giusti et al., 1992), and morphine stimulated GH Secretion from Somatotrophs
GH release in acromegalic patients (Bhansali et al., As noted in Section 8.1, the principal factors
2005). In contrast, blockade of opioid receptors with that enable secretion of GH from somatotrophs
the antagonist naltrexone prevented GHRH induc- are GHRH, SOM and ghrelin, together with nega-
tion of GH release (Villa et al., 1997). In summary, tive feedback from IGF-1. Somatotrophs possess
the regulation of human GH secretion appears to be specific cell membrane receptors for each factor
under the control of the same neurotransmitters (Figure 8.9).
and neuropeptides already implicated in experimen- Three of them are of the GPCR class (described in
tal animals. It remains to be determined whether Chapter 1). Receptors for GHRH and ghrelin are
these influences are imposed on GHRH or on SOM stimulatory and are linked to cyclic adenosine mono-
neurons (or both). For example, opioids could phosphate (cAMP) and inositol triphosphate (IP3)
directly stimulate GHRH neurons or, alternatively, signals, respectively. GHRH and ghrelin act synergis-
SOM neurons could be inhibited by opioids to allow tically to induce intracellular calcium ion mobiliza-
GHRH secretion to occur. tion that, in turn, regulates GH secretion. In addition,
Figure 8.9 Receptor mechanisms

regulating GH secretion from
somatotrophs. Receptors for GHRH and
ghrelin are stimulatory G protein-
coupled, linked to cAMP and IP3
signals, respectively. GHRH and ghrelin
act synergistically to induce
intracellular calcium ion mobilization
that, in turn, regulates GH secretion.
These stimuli also induce GH gene
expression and GH synthesis in
somatotrophs. SOM binds to an
inhibitory G protein-coupled receptor
that reduces the accumulation of
cAMP, decreasing the release of GH
(Ben-Shlomo and Melmed, 2010).
Receptors for IGF-1 are inhibitory, but
not G protein-coupled, and consist of
four subunits: two alpha-subunits plus
two beta-subunits, held together by
covalent disulfide bonds (see Figure
8.10). Abbreviations: cAMP, cyclic
adenosine monophosphate; IP3,
inositol triphosphate; PLC,
phospholipase C; SOM, somatostatin.
143
These, in turn, activate intracellular signaling proteins

(insulin receptor substrate 1; IRS-1). Phosphorylated
IRS-1 then induces other signaling cascades that ulti-
mately regulate gene transcription. In the case of
somatotrophs this involves inhibition of GH synthesis
and release.
The human SOM receptor exists as five distinct
subtypes: SSTR1–SSTR5. All five subtypes are detect-
able in the human fetal pituitary, but adult pituitary
tissue contains only four of them (SSTR1, SSTR2,
SSTR3 and SSTR5). Of these, SSTR2 and SSTR5 are
most abundant on somatotrophs and are effective in
inhibiting secretion of GH. When activated simulta-
neously they induce a synergistic suppression of GH
release (Ren et al., 2003). Knowledge of these sub-
types has important implications for the therapeutic
use of synthetic SOM analogs, including the treat-
ment of neuroendocrine tumors (Theodoropoulou
and Stalla, 2013). SOM receptors are also found in
several human pituitary tumors; that is, GH-,
ACTH-, PRL- TSH-secreting adenomas and in
non-functioning pituitary tumors, suggesting that
these hormones may also be under inhibitory control
by SOM (Eigler and Ben-Shlomo, 2014). In addition,
SOM receptors are expressed in many peripheral
tissues, and influence secretion from the GI tract
(e.g., gastrin and secretin) and from the pancreas
(e.g., insulin and glucagon).
Figure 8.10 Schematic representation of the IGF-1 signaling system. Clinical relevance: Short- and long-acting SOM
IGF-1 receptors consist of four subunits: two alpha-subunits plus two
beta-subunits, held together by covalent disulfide bond. IGF- analogs such as octreotide, lanreotide and pasireo-
1 receptors possess intrinsic tyrosine kinase activity; that is, following tide are used for suppression of GH and normal-
IGF-1 binding, this kinase is activated, auto-phosphorylating ization of IGF-1 in acromegaly (Melmed, 2016). In
(activating) the beta-subunits. The activated beta-subunits then
phosphorylate intracellular signaling proteins (IRS-1). addition, these agents are also used for treatment of
Phosphorylated IRS-1 then induces other signaling cascades that TSH adenomas (see Chapter 10). Both octreotide
ultimately regulate gene transcription. In the case of somatotrophs and lanreotide have an affinity for SSTR2 and
this involves inhibition of GH synthesis and release.
SSTR5 whereas pasireotide has an affinity for
SSTR1, SSTR2, SSTR3 and SSTR5. Figure 8.11 illus-
these stimuli induce GH gene expression and GH trates the inhibitory effects of pasireotide treatment
synthesis in somatotrophs. SOM also binds to a on GH and IGF-1 levels in acromegalic patients
GPCR, but these receptors are inhibitory and prevent, (Schmid et al., 2016).
or reduce, the accumulation of cAMP, thus reducing
the release of GH (Ben-Shlomo and Melmed, 8.6 Receptor Mechanism for GH
2010; see Figure 8.9). Receptors for IGF-1 are not G Stimulation of IGF-1 Production in
protein-coupled and consist of four subunits: two
alpha-subunits plus two beta-subunits, held together Liver Cells
by covalent disulfide bonds, similar to the insulin Figure 8.1 reveals the liver as a major target for GH. In
receptor (Figure 8.10; Schwartz et al., 2000). IGF-1 contrast to the seven transmembrane domains of the
receptors (IGF-1 Rs) possess intrinsic tyrosine kinase GHRH receptor, the GHR has only a single trans-
activity; that is, following IGF-1 binding, this kinase is membrane domain. Binding of GH to the GHR
144 activated and auto-phosphorylates the beta subunits. induces the formation of a dimer (Figure 8.12).
Figure 8.11 Inhibitory effect of

pasireotide on GH and IGF-1 secretion in
acromegalic patients. Patients were
treated with long-acting release
pasireotide (40 or 60 mg intramuscular,
every 28 days) for a period of 24 weeks.
Values of GH and IGF-1 in blood were
analyzed by immunoassay. Error bars
are presented as geometric means
(68% CI; n= numbers of patients in the
study at 24 weeks). Abbreviation: CON,
control. Data reproduced with the kind
permission of Dr. H. A. Schmid (Schmid
et al., 2016).
This type of receptor does not use cAMP as a in skeletal growth. Acromegaly, on the other hand,
second messenger but possesses docking sites for results from excessive GH production in postpubertal
janus kinases (JAKs), a family of tyrosine kinases individuals who have already achieved fusion of the
(see Chapter 1). Thus, when GH binds to its receptor, epiphyseal plates. These patients typically present
and following dimerization, JAK phosphorylates with growth of bone and soft tissue leading to enlar-
other intracellular chemical signals that act as second gement of hands, feet, skull and jaw; excessive sweat-
messengers. The most important of these is signal ing (due to the effect of GH on sweat glands);
transduction and activator of transcription (STAT). visceromegaly and obstructive sleep apnea due to
Once phosphorylated, STAT dimerizes and travels enlargement of tongue and soft tissue. If left untreated
into the cell nucleus where it modulates gene expres- patients with acromegaly die early of cardiovascular
sion for IGF-1 (Figure 8.12). Secretion of IGF-1 from or respiratory complications and cancer. The com-
the liver stimulates bone and muscle growth (Reiter monest etiology of gigantism and acromegaly is an
and Rosenfeld, 2008; Rozario et al., 2015). underlying GH-producing pituitary adenoma.
Clinical relevance: Acromegaly is characterized by Although mostly sporadic, these benign tumors can
somatotroph adenomas and hypersecretion of GH, also be familial in conditions such as multiple endo-
which leads to elevated IGF-1. Pegvisomant is a crine neoplasia type 1, familial isolated pituitary ade-
GHR antagonist that blocks the effect of GH at the noma, McCune–Albright syndrome and Carney
receptor and consequently reduces the production of complex. Acromegaly is suspected in patients with
IGF-1. Pegvisomant is used for treatment of acrome- typical clinical features and is confirmed by failure
galy (Franck et al., 2016; see Section 8.7). of GH to suppress to <1 mcg/L (or <0.4 mcg/L with
sensitive GH assay) after administration of a 75 g oral
glucose challenge. Serum IGF-1 is elevated in patients
8.7 GH Excess with excessive GH and is used as a marker of excessive
Two distinct clinical syndromes – gigantism and acro- GH activity.
megaly – are associated with excessive GH produc- The primary management of acromegaly is trans-
tion. Gigantism results from excessive prepubertal sphenoidal surgical excision of the tumor. Patients
GH secretion and is characterized by a rapid increase who are either unable to achieve a remission after 145
In uncontrolled female acromegaly patients, estrogen

therapy can also be added to these agents to further
reduce IGF-1 (Shimon and Barkan, 2012).
Occasionally, radiation therapy is also used in patients
with residual tumor that fails to respond to medical
therapy. The aim of therapy is removal/shrinkage of
the tumor and normalization of GH and IGF-1 levels.
Unfortunately, several complications related to acro-
megaly are irreversible despite achieving biochemical
normalization.
8.7.1 A Case of Gigantism

A 15-year-old male was referred to the endocrinol-
ogy clinic for excessive fatigue and sleepiness. His
birth weight was 3.5 kg, and he had normal growth
until age 11, after which he experienced an acceler-
ated increase in his height and weight. About 6
months ago he developed pain in his left hip, tin-
gling in both hands and noticed deteriorating vision
for 2 months prior to presentation. His mother
mentioned that he snored heavily during sleep and
he slept on a semi-reclined couch because he was
unable to lay flat. His paternal aunt had undergone
surgery for a pituitary tumor of unknown etiology
17 years ago. On examination, his height was
198.12 cm (mid-parental height=172.3 cm) and
weight was 126.2 kg (BMI=32.2 kg/m2). His shoe
size was 16EEE (extra-wide). He had evidence of
scoliosis and had bilateral field of vision constriction
on confrontation.
Endocrine investigations were as follows:
Cortisol=298 nmol/L (184–512)
Figure 8.12 GHR signaling in the production of IGF-1 by the liver. TSH=2.37 mIU/L (0.35–5.4)
The GHR, unlike those for GHRH and SOM, has only a single
transmembrane domain. Binding of GH to the GHR induces the Free thyroxine (fT4)=8.8 pmol/L (11–19)
formation of a dimer that possesses docking sites for janus kinases PRL=15.4 mcg/L (2.1–17.7)
(JAKs), a family of tyrosine kinases. Thus, following GH-induced GH=13.4 mcg/L (<3.0)
dimerization, JAK phosphorylates other intracellular chemical
signals that act as second messengers. The most important of IGF-1=1600 mcg/L (232–1077)
these is signal transduction and activator of transcription (STAT). Testosterone=<0.3 nmol/L (8.0–32)
Once phosphorylated, STAT dimerizes and travels into the cell Follicle stimulating hormone (FSH)=0.5 IU/L
nucleus where it modulates gene expression for IGF-1. IGF-1 is
then secreted from the liver, binds to a binding protein (BP) and is (1.5–9.3)
transported to target tissues such as bone and muscle. Luteinizing hormone (LH)=0.4 IU/L (1.4–18.1)
Abbreviations: BP, binding protein; mRNA, messenger ribonucleic Ca=2.31 mmol/L (2.23–2.58)
acid. Reproduced with permission (Junnila et al., 2013).
Nadir GH after an oral glucose tolerance test=7.9
mcg/L
surgery or cannot undergo surgery are treated with Figure 8.13A shows a magnetic resonance image
medical therapy. The currently available pharmacolo- (MRI) confirming the presence of a macroadenoma
gic options include: SOM analogs (octreotide, lanreo- and Figure 8.13B reveals that a Goldmann visual field
tide and pasireotide; see Figure 8.11), dopamine test showed bilateral visual field defects.
agonists (bromocriptine and cabergoline) and the A diagnosis of gigantism or early-onset acromegaly
146 GHR antagonist pegvisomant (Franck et al., 2016). was made on the basis of typical clinical features and
A. MRI reveals a macroadenoma
B. Goldmann visual field test shows bilateral visual field defects
Figure 8.13 (A) MRI scans confirming the presence of a macroadenoma; (B) Goldmann visual field test results showing bilateral visual field defects.
elevated serum IGF-1 and non-suppressibility of GH to 8.8 GH Deficiency

<0.4 mcg/L after oral glucose. Based on the family
GHD can occur as a result of congenital pituitary
history, invasive macroadenoma, male gender and
defects, pituitary tumors and infiltrative disorders,
young age at presentation he was offered genetic test-
pituitary surgery or radiation therapy and head
ing. The test confirmed an aryl-hydrocarbon interact-
trauma. GHD in children typically presents with
ing receptor protein mutation associated with familial
growth failure and short stature, whereas adults
isolated pituitary adenomas (Imran et al., 2018). The
show decreased muscle and bone mass, increased
patient underwent trans-sphenoidal excision of the
cardiovascular risk factors and poor exercise reserve.
pituitary tumor followed by SOM analog therapy to
GHD is confirmed by failure of GH to rise in
achieve biochemical remission. Figure 8.14 shows the
response to provocative stimuli such as insulin-
patient with his mother 3 years following treatment.
induced hypoglycemia, L-Dopa, arginine, glucagon 147
asked his family physician to rule out GH deficiency

(GHD) and was referred to the endocrine clinic.
His past history was unremarkable, apart from a
head injury a year ago when he fell off his mountain
bike and briefly lost consciousness. He was admitted
to a local hospital where he underwent computed
tomography scans and was observed for a few days
and then discharged.
His pituitary investigations were as follows:
Cortisol=311 nmol/L (184–512)
TSH=1.17 mIU/L (0.35–5.4)
fT4=14.3 pmol/L (11–19)
PRL=7.7 mcg/L (2.1–17.7)
GH=1.08 mcg/L (<3.0)
IGF-1=88 mcg/L (175–288)
Testosterone=15.4 nmol/L (8.0–32)
FSH=2.2 IU/L (1.5–9.3)
LH=1.9 IU/L (1.4–18.1)
Peak GH after insulin-induced hypoglycemia=2.3
mcg/L
A diagnosis of GHD was made on the basis of low
IGF-1, and failure of GH to rise >5 mcg/L after insu-
Figure 8.14 Acromegalic patient, with his mother, shown 3 years
lin-induced hypoglycemia. The most likely underly-
following trans-sphenoidal removal of pituitary macroadenoma. ing etiology was GHD due to head injury. GH-
Reproduced with permission. replacement therapy was initiated and serum IGF-1
was normalized after 3 months (212 mcg/L). The
and the ghrelin receptor agonist macimorelin. patient experienced significant improvement in exer-
Different cut-off levels of GH response to these tests cise capacity with complete resolution of the fatigue.
are reported in the literature. Typically, a failure of
GH to rise to >5 mcg/L in normal individuals after 8.9 Chapter Summary
insulin-induced hypoglycemia of <2.2 mmol/L, or This chapter outlines the mechanisms by which GH
>2.8 mcg/L after macimorelin, confirms GHD. secretion is regulated to maintain GH homeostasis and
Management of GHD is in the form of injectable in those states of pathological GH secretion, such as
GH replacement, which has been shown to improve acromegaly. Human GH secretion appears to be under
height in children as well as bone and muscle mass, the control of the same neurotransmitters and neuro-
exercise capacity and quality of life in adults (Ahmid peptides already implicated in experimental animals,
et al., 2016). The aim of therapy is to normalize serum although it remains unknown whether these influences
IGF-1. are imposed on GHRH or SOM neurons (or both). GH
Unfortunately, the abuse of GH is high among secretion from somatotrophs is regulated by opposing
professional athletes and bodybuilding enthusiasts hypothalamic releasing factors: GHRH is stimulatory
(Baumann, 2012). Chronic use of excessive doses of and SOM inhibitory. In addition, GH levels are subject
GH are known to induce some features of acromegaly. to peripheral feedback pathways from IGF-1 (negative)
and ghrelin (positive). Ghrelin is the most potent GH
8.8.1 A Case of growth hormone deficiency secretagogue known, and synergizes with GHRH to
A 34-year-old athletic male presented with increasing stimulate pulsatile release of GH from somatotrophs.
fatigue and inability to keep up with his running Somatotrophs possess specific cell membrane receptors
group for the past 6 months. He was becoming fru- for each factor. Similar to other pituitary hormones,
strated because his routine investigations through his GH is secreted in an episodic (pulsatile) manner, espe-
family physician failed to show any concerning cially during SWS. GH secretion is sensitive to an array
148 abnormality. After searching the subject online, he of other influences such as age, gender, sex hormones,
glucose, amino acids, feeding, exercise, stress, illness, a. Hypoglycemia

obesity and medication. For example, sex hormones b. Pasireotide
stimulate GH secretion in pubertal children, and tes- c. Somatostatin (SOM)
tosterone supplementation in men drives GH and IGF- d. Insulin-like growth factor 1 (IGF-1)
1 release, but the role of estradiol in women is unclear. e. Ghrelin
In normal children, GH levels increase substantially 2. Which of the following statements on GH are
through the process of puberty, corresponding with incorrect?
the period of maximum height velocity. After puberty,
a. Secretion is negatively regulated by a
GH secretion declines steadily to reach very low levels
hypothalamic releasing factor.
as early as 50–60 years, especially notable during sleep.
b. Blood levels are higher in children than in
A deficiency of GH, either congenital or acquired, is
older adults.
associated with distinct clinical outcomes. Childhood-
c. Pulses of GH occur during sleep.
onset GHD leads to short stature and delayed bone age,
d. GH modulates the secretion of IGF-1 from the
whereas adult GHD is associated with loss of muscle
liver.
mass, increased adiposity, poor exercise capacity and
e. SOM stimulates GH secretion.
deterioration of mental function. A case of clinical
GHD is provided. 3. A pituitary adenoma in an adult, secreting high
Glucose administration in normal individuals levels of GH, causes:
induces a biphasic GH response – an initial suppres- a. Gigantism
sion followed, 3–5 hours later, by an increase in GH b. Enlargement of the liver
release. Hypoglycemia leads to release of GH. The c. Elevated blood levels of glucose
sensitivity of GH levels to glucose constitutes the d. Reduced circulating levels of IGF-1
basis of clinical testing of GH disorders: failure of e. Acromegaly
GH to suppress after oral glucose administration is 4. Which of the following statements concerning GH
the gold standard for the diagnosis of acromegaly, are correct? Select all that apply.
whereas failure of GH to rise after insulin-induced
hypoglycemia suggests GHD. a. GH shows increased secretion during SWS
GCs are generally regarded as inhibitory to GH sleep.
secretion, but the GH response to GC is in fact bipha- b. The systemic actions of GH are mediated by
sic. Treatment with pharmacological doses of GC IGF-1.
reduces GH secretion and inhibits the stimulatory c. IGF-1 is synthesized mainly in the anterior
effect of GHRH on pituitary GH release. Such effects pituitary.
are seen in patients with hypercortisolism (Cushing’s d. GH is required for growth in stature from
syndrome) and in those undergoing long-term immu- birth to puberty.
nosuppressive GC treatment. e. An increase in serum SOM will inhibit GH
Two distinct clinical syndromes – gigantism and secretion.
acromegaly – are associated with excessive GH pro- 5. A 12-year-old boy presented with short stature
duction. Gigantism occurs due to excessive prepuber- and reduced height velocity over the past 6
tal GH secretion and is characterized by a rapid months. Which of the following factors suggest a
increase in skeletal growth. Acromegaly results from possibility of GH deficiency (GHD)?
excessive GH production in postpubertal individuals. a. Previous diagnosis of celiac disease
A case of gigantism is presented. GHD can occur as a b. Both parents are short
result of congenital pituitary defects, pituitary tumors c. Subnormal serum IGF-1 level
and infiltrative disorders, pituitary surgery or radia- d. Severe asthma requiring glucocorticoid
tion therapy and head trauma. A case of GHD due to therapy
head trauma is presented. e. Presence of 16 mm pituitary adenoma on a
magnetic resonance image
8.10 Review Questions 6. Which of the following therapeutic options are
1. Which of the following inhibit growth hormone used for management of acromegaly?
149
(GH) secretion from somatotrophs? a. Cabergoline
b. Lanreotide Blum W F, Alherbish A, Alsagheir A et al. (2018). The

c. Pasireotide growth hormone–insulin-like growth factor-1 axis in the
d. Estrogen diagnosis and treatment of growth disorders. Endocr
Connect 7, R212–R222.
e. Pegvisomant
Butler A A & le Roith D. (2001). Control of growth by the
7. Which of the following statements regarding somatropic axis: growth hormone and the insulin-like
GHD are correct? growth factors have related and independent roles. Annu
a. The diagnosis of GHD is based on the failure Rev Physiol 63, 141–164.
of GH to rise after an oral glucose load. Eigler T & Ben-Shlomo A. (2014). Somatostatin system:
b. Patients typically present with short stature molecular mechanisms regulating anterior pituitary
and growth failure as children. hormones. J Mol Endocr 53, R1–R19.
c. Serum IGF-1 levels are typically elevated in Melmed S. (2016). New therapeutic agents for acromegaly.
GHD. Nat Revs Endocr 12, 90–98.
d. GHD is associated with poor exercise tolerance Milman S, Huffman D M & Barzilai N. (2016). The
and muscle loss. somatotropic axis in human aging: framework for the
current state of knowledge and future research. Cell Metab
e. Patients with a history of significant head 23, 980–989.
trauma have a higher risk of developing GHD.
Monson J P, Brooke A M & Akker S. (2015). Adult growth
8. Features of acromegaly include: hormone deficiency. www.ncbi.nlm.nih.gov/books/
a. Rapid height gain in patients with postpubertal NBK278982/
onset of disease Murray P G & Clayton P E. (2016). Disorders of growth
b. Sleep apnea hormone in childhood. www.endotext.org
c. Loss of sweating Murray P G, Higham C E & and Clayton P E. (2015). The
d. Enlargement of the tongue hypothalamo–GH axis: the past 60 years. J Endocr 226,
T123–T140.
e. Failure of GH to rise after 75 g oral glucose
test Ranke M B & Wit J M. (2018). Growth hormone – past,
present and future. Nat Rev Endocr 14, 285–300.
9. Which one of the following predisposes to
Rozario K, Lloyd C & Ryan F J. (2015). GH and IGF-1
acromegaly? physiology in childhood. www.endotext.org
a. Celiac disease Sherlock M, Woods C & Sheppard M C. (2011). Medical
b. Head trauma therapy in acromegaly. Nat Rev Endocr 7, 291–300.
c. Familial isolated pituitary adenoma Steyn FJ, Tolle V, Chen C & Epelbaum J. (2016).
d. Sleep apnea Neuroendocrine regulation of growth hormone secretion.
e. Young age Compr Physiol 6, 687–735.
10. Pasireotide is used in the treatment of acromegaly. van der Lely A J, Tschop M, Heiman M L & Ghigo E.
Which of the following statements accounts for its (2004). Biological, physiological, pathophysiological,
and pharmacological aspects of ghrelin. Endocr Rev 25,
effectiveness? 426–57.
a. Pasireotide inhibits GH secretion through a G Vilar L, Vilar C F, Lyra R, Lyra R & Naves L A. (2017).
protein-coupled receptor. Acromegaly: clinical features at diagnosis. Pituitary 20,
b. Pasireotide inhibits IGF-1 secretion. 22–32.
c. Pasireotide synergizes with ghrelin to induce Walters T D & Griffiths A M. (2009). Mechanisms of growth
GH secretion. impairment in pediatric Crohn’s disease. Nat Rev
d. Pasireotide blocks SOM receptors. Gastroenterol Hepatol 6, 513–523.
e. Pasireotide binds to SOM receptors (SSTR) 1 –This paper contains excellent figures and a description
and 2. of the basic physiology of the GH/IGF-1 system.
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153
Chapter
Posterior Pituitary
9
The posterior pituitary (neurohypophysis) secretes where it synergizes with CRH in the regulation of
two peptide hormones: oxytocin (OXY) and vaso- ACTH secretion (see also Figure 5.2).
pressin (VP; also called arginine vasopressin or Immunohistochemistry of the human brain con-
antidiuretic hormone; ADH). OXY has two prin- firmed the presence of VP and OXY in neurons in
cipal functions: to promote uterine contractions both SON and PVN (Ishunina and Swaab, 1999), and
during parturition, and to stimulate milk letdown these data are consistent with the finding that gene
from the breasts during lactation. VP acts as an expression for VP and OXY is also found in neurons
antidiuretic by controlling renal water excretion, of both nuclei (Sukhov et al., 1993).
and also regulates peripheral vasoconstriction and Clinical implications: The storage of VP in the
blood pressure. posterior pituitary produces a distinct bright appear-
ance of the gland in magnetic resonance images. The
9.1 Neuroanatomy of the absence of VP in the posterior pituitary, either due to
infiltrative disorders or stalk injury, is associated with
Hypothalamic–Posterior Pituitary the loss of posterior pituitary bright spots and these
System patients typically develop diabetes insipidus (Lucas
In contrast to the anterior pituitary, the posterior and Zada, 2012).
pituitary consists principally of neural tissue, con-
taining axons and neuron terminals. The cell VP and OXY Receptors
bodies of these neurons are located in two distinct The possibility that VP and OXY may act as neuro-
hypothalamic nuclei (Figure 9.1): the paraventri- peptides is suggested by the localization of these pep-
cular nuclei (PVN) and the supraoptic nuclei tides in many non-hypothalamic brain regions. For
(SON). These are also known as magnocellular example, VP is detected in neurons of the human
neurons. The axons extend from the hypothalamus suprachiasmatic nucleus, and VP and OXY are
to the posterior pituitary where they release OXY found in SON/PVN projections to several other
and VP from nerve terminals. Note that both SON areas of the nervous system, including amygdala, hip-
and PVN contain both types of neuron; that is, pocampus and spinal cord (Sofroniew et al., 1981).
oxytocinergic neurons coexist with vasopressiner- Since VP and OXY are associated with the etiology of
gic neurons in both SON and PVN. Again, this psychiatric disorders such as autism and depression
arrangement is in marked contrast to anterior (see Section 9.9; Dumais and Veenema, 2016), it
pituitary secretion of, for example, ACTH, which appears likely that VP and OXY receptors (OXYRs)
is regulated by CRH that reaches the anterior lobe are present in extra-hypothalamic brain regions.
– not via axons – but via the pituitary portal These receptors are G protein-coupled and the VP
system (see Chapter 5; Figure 5.2). This is illu- receptor exists as two subtypes, V1R and V2R. V2
strated on the left side of Figure 9.1. receptors are found in the distal tubules and collecting
A third group of VP neurons is shown in Figure ducts of the kidney where they enable water and
9.1(C). This group is a component of the hypothala- sodium ion retention (see Section 9.6). V1Rs are pre-
mic–pituitary–adrenal axis, releasing VP into the por- sent in the brain as two further subtypes, V1aR and
tal system from nerve terminals localized, not in the V1bR. V1aRs are also present in vascular smooth
posterior pituitary, but in the median eminence. VP muscle, regulating vasoconstriction and platelets,
154 enters the portal system to reach the anterior lobe where they facilitate thrombosis. V1bRs mediate the
Chapter 9: Posterior Pituitary
Figure 9.1 VP and OXY secretion from the neurohypophyseal system. OXY and VP are biosynthesized in magnocellular neurons of the
hypothalamic SON and PVN. These neurons project to the posterior pituitary (black axons) and OXY/VP reach the posterior pituitary via axonal
transport. Note that there are specific OXY-producing neurons as well as VP-producing neurons, and each nucleus (PVN (A) and SON (B))
contains both kinds of neurons. A separate parvocellular group of VP neurons (C) sends axons (blue) that terminate in the median eminence
where VP is secreted into the portal system and transported to the anterior pituitary where it synergizes with CRH to regulate secretion of
ACTH. The SON and PVN receive information from the periphery to maintain water balance (VP) and to regulate some aspects of reproduction
(OXY; childbirth; lactation). Image reproduced with permission (Christ-Crain and Fenske, 2016). Abbreviations: ACTH, adrenocorticotropic
hormone; CRH, corticotropin releasing hormone; PVN, paraventricular nucleus; SON, supraoptic nucleus.
effects of VP on anterior pituitary corticotrophs in the although some similarities in the location of OXYR
release of ACTH (Ball, 2017). V2Rs are coupled to the exist between human and animal brains, there are
cAMP system (see Figure 9.7), whereas V1Rs act via important differences (Boccia et al., 2013). This con-
the phosphatidyl–inositol pathway that increases clusion may have an impact on our understanding of
intracellular Ca2+ ion concentration via phospholi- the behavioral effects of VP and OXY in human beings.
pase C. The OXYR is also coupled in this way. Clinical implications: As noted before (cf. Chapter
Although the wide distribution of central VP recep- 5) pituitary corticotrophs express V1Rs, which syner-
tors and OXYRs is well described in animal models, the gize with CRH to regulate ACTH production and
human brain is poorly characterized in terms of these secretion. ACTH-producing pituitary adenomas also
receptors (Boccia et al., 2013; Freeman et al., 2017). express VP receptors such that VP induces an exuber-
However, the limited data available indicates that ant ACTH production in patients with ACTH- 155
producing adenomas (Cushing’s disease). An increase

in serum ACTH by 35% or more after injection of VP
(10 units) or desmopressin (10 mcg) is suggestive of
an ACTH-producing pituitary adenoma.
9.2 Central Regulation of VP and OXY

Secretion
VP and OXY Genes
OXY has a very similar structure to VP and the parent
genes are located end-to-end on human chromosome
20p13 (Ball, 2017). The structures of the pre-propep-
tides are illustrated in Figure 9.2. Each of the pre-
propeptides is enzymatically cleaved to smaller enti-
ties including VP and OXY, neurophysins (NPs) I and
II, and, in the case of VP, an additional peptide called
copeptin.
The pre-propeptides are packaged in secretory
vesicles in the cell bodies of the magnocellular neu-
Figure 9.2 Structure and cleavage of OXY and VP peptide precursors.
rons, and migrate within the axons toward the poster- Each pre-propeptide encoded by a specific gene contains the
ior pituitary. During this transit, they are hormone, plus a carrier protein, neurophysin (NP). The pre-
enzymatically cleaved into the mature hormone and propeptides are proteolyticaly cleaved (red arrows) to remove the
signal peptides and to yield active neuropeptides (OXY plus NP I and
the associated NPs (Figure 9.2) and are stored in VP plus NP II). The NPs are understood to assist in transporting OXY
secretory granules in the axon terminals within the and VP to the posterior pituitary. Pre-provasopressin also produces
posterior pituitary. Action potentials in the OXY and the copeptin peptide.
VP neurons induce secretion of OXY and VP, along
with their respective NPs. NPs have no known func- reproductive function. These include many classical
tion other than as carrier proteins for VP and OXY neurotransmitters (e.g., dopamine, serotonin) as well
during axonal migration. Copeptin and VP are as neuropeptides, such as CRH, somatostatin and
secreted in equimolar quantities. However, VP is rela- opioids (Sladek and Kapoor, 2001; Iovino et al.,
tively unstable in vivo, and in stored plasma, with a 2016). In humans, knowledge of the neurochemical
half-life of 5–20 mins. In contrast, copeptin has a half- pathways is limited and the evidence often contra-
life double that of VP (Fenske et al., 2018a) and is dictory. The human SON and PVN are densely inner-
stable in room temperature serum or plasma, and is vated with catecholamine fibers that impinge on OXY
an easily assayed molecule (Morgenthaler et al., 2008). and VP neurons (Dudás et al., 2006; Semeniken et al.,
For this reason, copeptin levels can be used as a 2009). Nevertheless, treatment of human subjects
surrogate marker of VP secretion (Christ-Crain and with a dopamine agonist (apomorphine) or an α2-
Fenske, 2016; Afsar, 2017; Fenske et al., 2018a). adrenergic agonist (clonidine) had no effect on OXY
or VP secretion (Scantamburlo et al., 2005). In con-
Regulation of Human VP and OXY Secretion trast, the α1 agonist methoxamine decreased VP but
A critical central component regulating VP secretion not OXY secretion (Radant et al., 1992). A role for
are osmoreceptors located close to SON/PVN neu- acetylcholine is implicated through the stimulatory
rons. This topic will be covered in Section 9.6. In effect of nicotine (cigarette smoking) on VP secretion
addition, and based on animal experiments, secretion (Fuxe et al., 1989). The serotonergic drug fenflura-
of VP and OXY is regulated by multiple neurochem- mine stimulates OXY secretion (Lee et al., 2003) and
ical pathways that converge on the VP- and OXY- the mixed serotonin/norepinephrine recreational
containing neurons located in the SON and PVN. drug 3,4-methylenedioxymethamphetamine (ecstasy)
These pathways utilize a broad range of neurotrans- elevates VP and OXY in human subjects (Simmler et
mitters and neuropeptides that transmit information al., 2011; Kirkpatrick et al., 2014). These reports indi-
156 regarding fluid balance, blood pressure and cate that OXY/VP secretion is sensitive to some
Figure 9.3 Pulsatile secretion of OXY. Subjects were healthy men (n=5; BMI: 18.5–24.9) who fasted from 8 pm. Blood samples were obtained
every 5 min from 10 pm until 8 am. Plasma OXY was measured following extraction using an ELISA (see Chapter 2). Figure shows data from two
subjects. Peaks represent secretory bursts of OXY (~22 pulses per 10 hour). Images reproduced with permission (Baskaran et al., 2017).
centrally active drugs, although not to others, such as 2016). Whether these differences translate to varia-
alcohol or methamphetamine (Bershad et al., 2015), tions in VP and OXY release – from the posterior
although alcohol is known to inhibit breast stimula- pituitary or within the brain – remains largely
tion-induced OXY secretion and lactation (Cobo, unknown, although there is some evidence for sex
1973; Coiro et al., 1992). differences in OXY and VP secretion (see later in
Opioid receptors are widely distributed in the this chapter).
human brain and posterior pituitary (Jordan et al., In summary, compared to the well-described
1996). In view of the prevalent use/abuse of opioids, effects of sex hormones, neurotransmitters and neu-
effects on OXY/VP secretion have been studied. In ropeptides on OXY/VP secretion in experimental ani-
male volunteers for example, fentanyl induced a five- mals, only fragmentary details are known for the
fold increase in VP levels (Weiskopf et al., 1987). situation in humans.
Nonetheless, in reviewing the many studies on VP,
Vuong et al. (2010) concluded that, overall, the evi- 9.3 OXY Secretion
dence was inconclusive. For OXY secretion, the evi- The secretion of anterior pituitary hormones such
dence for an effect of opioids is more compelling as LH and GH is pulsatile (see e.g., Figures 3.4 and
(Morris et al., 2010), and particular attention has 8.4). Pulsatile release of OXY from the posterior
focused on the effect of opioid analgesics during preg- pituitary is also evident in men (Baskaran et al.,
nancy and labor. For example, morphine and fentanyl 2017) and in women, particularly from stimuli
significantly reduced OXY levels during labor, and in such as parturition (Chard, 1989; Fuchs et al.,
breastfeeding women (Vuong et al., 2010). The inhi- 1991) or breastfeeding (Ueda et al., 1994; Nissen
bitory effects of opioids on OXY secretion during et al., 1996). Figure 9.3 illustrates the frequency of
labor may have unwanted consequences in terms of OXY pulses in young men, determined overnight
infant suckling (Brimdyr et al., 2015). in the resting phase.
Sex hormones may also regulate the VP and OXY Typical profiles of suckling-induced OXY secre-
systems. Estrogen receptors are present in human tion in nursing mothers are shown in Figure 9.4 (Ueda
OXY and VP neurons (Hrabovszky et al., 2004). VP et al., 1994). Some mothers respond with OXY secre-
neurons, but not OXY neurons, appear to be larger in tion without actual contact with the baby; that is,
men than in women with correspondingly higher when the baby cries, or even becomes agitated, higher
brain levels of detectable VP (Dumais and Veenema, brain centers are recruited to release OXY (McNeilly 157
Figure 9.4 Suckling-induced pulsatile secretion of OXY. Typical profiles of suckling-induced OXY release in two nursing mothers (A and B).
OXY concentrations were determined by radioimmunoassay of blood samples obtained at 2-minute intervals for 30 mins. Pulses were
considered significant (asterisks) when values were greater than 2 SDs above background pre-suckling levels. Data were obtained from Ueda
et al. (1994).
et al., 1983). Note that the pulse amplitude is much There is little evidence for a role of OXY in initi-
higher in women than in men, possibly due to the ating labor (Chard, 1989). Nonetheless, although
lactational state or an influence of the female sex basal OXY levels show minimal change, the frequency
hormone estradiol, which is known to stimulate of OXY pulses changes rapidly as labor advances and
OXY secretion (Baskaran et al., 2017). The pulse fre- the number of contractions increases (Figure 9.5;
quency is also different; in nursing mothers this is Fuchs et al., 1991). A surge of OXY does occur during
approximately 6 per hour compared to about 2 per cervical and vaginal distension at birth (Vasicka et al.,
hour in young men. 1978). As parturition approaches, there is also a large
Reports of sex differences in plasma OXY levels elevation in the responsiveness of the uterus to OXY
are inconsistent. Girls had higher plasma concentra- stimulation, achieved via an increase in uterine
tions than boys but adult men had higher plasma OXYRs (Kim et al., 2017).
OXY compared to adult women, whereas several Clinical implication: An OXY infusion is given to
other studies reported no sex differences in plasma pregnant women to induce labor or when labor is not
OXY (cited in Dumais and Veenema, 2016). progressing. OXY exerts a stimulatory effect on uter-
The function of OXY in women is clear, inducing ine smooth muscle causing rhythmic contractions
milk letdown or parturition. OXY binds to G protein- similar to labor.
coupled receptors in breast myoepithelial cells (to
induce milk letdown) and in uterine smooth muscle Other Stimuli
causing contraction. OXY’s role in men is obscure, Several other stimuli alter OXY secretion in man.
particularly in terms of its pulsatile nature. In women, Plasma OXY levels were increased during sexual
pulsatile OXY secretion probably avoids causing arousal in both men and women (Carmichael et al.,
downregulation (desensitization) of the OXYRs. 1987; de Jong et al., 2015), although others have failed
Such an effect, and the physiological consequences, to replicate this in men (Krüger et al., 2003). Exercise
were described for the gonadotropin releasing hor- (running) and psychosocial stress also induced robust
mone receptor in Chapter 3 (see Section 3.3). OXY secretion, with no effect of gender (de Jong et al.,
Whether downregulation of OXYRs in men is impor- 2015). This study is also of interest because these
158 tant, perhaps in behavioral terms, remains to be increases were detectable in saliva, indicating that
established. for some studies the stress of blood collection can be
al., 2017; Lawson, 2017). For example, OXY levels are

7 low in CSF and in serum in such patients. In contrast,
Pulse
frequency levels are high in those with obesity and are positively
Mean peak associated with BMI and fat mass (Lawson, 2017). In
OXY (microU/ml) and Pulses per 30 mins
6
plasma OXY healthy males, OXY reduces reward-driven food
intake (Ott et al., 2013) and caloric intake (Lawson
5 et al., 2015; Lawson, 2017). OXY given over 8 weeks
significantly reduced body weight and BMI in patients
4 with BMI >28 kg/m2 (Zhang et al., 2013). Infants with
Prader–Willi syndrome display poor feeding, and this
is normalized by OXY (Tauber et al., 2017).
3
In general, these studies employed the intranasal
route for OXY treatment. There are serious doubts in
2 some quarters as to whether intranasal OXY can
penetrate the blood–brain barrier (Leng and Ludwig,
2016). This questions the mechanism by which intra-
1
nasal OXY affects appetite and food intake.
No labor Labor: Labor: 9.5 VP Secretion

first stage second and Plasma VP concentrations were higher in preadoles-
third stage
cent and adolescent males, and also in elderly men
compared to females. A more recent study, however,
Figure 9.5 Changes in pulse frequency and pulse amplitude of OXY
release during labor. Changes determined in three groups: women at found that plasma VP was higher in men compared
term but not in labor (n=11); women in first stage of labor (n=13); to women only at night (cited in Dumais and
and women in combined second and third stages of labor (n=8). Veenema, 2016). In contrast to OXY secretion, pul-
Blood samples were collected at 1-minute intervals over 30 mins.
OXY was quantified by radioimmunoassay. Pulses were designated satile release of VP has not been studied in detail,
when levels were 3 SDs over baseline levels. Values are means although nocturnal pulses have been reported in
+/-SEM. Data were obtained from Fuchs et al. (1991). children (Wood et al., 1994) and in adults under-
going carotid artery stenosis (Hammer and Engell,
1982). Given the rapid clearance of VP from plasma
avoided. It is not known whether these examples of (5–20 mins), and the difficulties associated with VP
OXY release are of physiological importance. assays, it would be premature to dismiss the possibi-
lity that VP, like OXY, is released in pulses. As noted
9.4 Effects of OXY on Eating Behavior in Section 9.2, the assay of copeptin, co-secreted with
VP, serves as a surrogate for estimation of VP levels
Animal experiments reveal that OXYRs are found in
and may be useful in eliminating reported inconsis-
many brain areas (see Section 9.1) and in several
tencies in the determination of VP secretion
peripheral sites, including the gastrointestinal tract
(Lewandowski and Brabant, 2016; Fenske et al.,
and pancreas (cited in Lawson, 2017). These data
2018a). For example, copeptin levels were signifi-
suggest that OXY may have physiological effects in
cantly higher in males than in females (Bhandari et
addition to those involving parturition and lactation.
al., 2009), a difference already present at birth
An influence that could have clinical significance is
(Burckhardt et al., 2014). VP pulses have not yet
the regulation of eating behavior (Olszewski et al.,
been investigated in this way.
2017). For example, chronic treatment of male obese
monkeys with OXY over 4 weeks significantly reduced
food intake, increased energy expenditure and slightly 9.6 VP Secretion and Water
reduced body weight (Blevins et al., 2015). Clinical Homeostasis
studies on OXY’s therapeutic potential to regulate The primary physiological role of VP is to act as a
body weight remain preliminary. Anorexia nervosa water-retention hormone. VP is therefore the prin-
has been linked to abnormal OXY secretion (Giel et cipal endocrine regulator of renal water excretion, 159
kinase A pathway to activate (phosphorylate) the

aquaporin 2 water channel protein (AQP2), which is
then transported to the luminal surface of the collect-
ing duct. The AQP2 channels permit recovery of
water from urine, and additional aquaporins (AQP3
and 4) complete the water reabsorption process
(Babey et al., 2011). Figure 9.7 illustrates the sequence
of events by which VP regulates water recovery (anti-
diuresis) from urine.
9.7 Disorders of VP Secretion

Diabetes Insipidus
The critical role of VP in maintaining fluid balance is
revealed when the production or action of VP is
Figure 9.6 Increases in plasma osmolality and stimulation of VP compromised. For example, an inability to facilitate
release. Slow infusion of hypertonic saline (855 mmol/L) in a group of reabsorption of water has several clinical conse-
healthy adults induces an increase in plasma osmolality and a
corresponding elevation in VP concentrations. The area in blue
quences: dilute urine output is increased (polyuria;
represents the range of values obtained and the yellow line is a >3 L/24 hours), producing hyperosmolar plasma and
representative individual response. Note that the threshold value of intense thirst that stimulates an increase in fluid
osmolality that first provokes secretion of VP into plasma is
approximately 285 mOsm/kg. Data obtained from Ball (2017).
intake (polydipsia). This condition is known as dia-
betes insipidus (DI). Unlike diabetes mellitus, which
is associated with glycosuria, the urine in DI is bland
adjusting physiological responses to maintain or insipid. DI may either be due to a deficient release
plasma osmolality; that is, the sodium concentra- of VP from the posterior pituitary – called hypotha-
tion in plasma is regulated by alterations in water lamic or central DI (HDI; also called neurohypophy-
intake or excretion. Hypernatremia develops if the seal or pituitary DI) – or to a reduced effect of VP on
loss of water exceeds its intake, whereas dilutional the renal VP receptors (nephrogenic DI; NDI). HDI
hyponatremia may develop because of water reten- may be idiopathic, congenital (due to mutations in the
tion due to an inability to excrete it, or excessive VP gene; estimated incidence is 1:25,000; Ball, 2017),
intake. Plasma osmolality, detected by central or due to hypothalamic–pituitary disorders associated
osmoreceptors located close to the third ventricle with sellar masses, head injury or surgery, that may
and the VP neurons, is the critical determining damage VP neurons.
factor for VP secretion from axon terminals in the NDI is due to a renal defect that impairs the ability
posterior pituitary. VP secretion is directly propor- of VP to induce antidiuresis. For example, inactivat-
tional to increases in plasma osmolality. Thus, an ing mutations of V2R cause resistance to the effects of
infusion of hypertonic saline in healthy adults VP, and conditions like hypercalcemia, hypokalemia
increases plasma osmolality and thirst, and induces and drugs such as lithium, demeclocycline and certain
secretion of VP in a linear fashion (Figure 9.6; Ball, anti-HIV agents can also lead to NDI. Multiple muta-
2017). The elevation in VP concentration stimulates tions of the VP receptor are known, affecting various
renal water resorption via the collecting ducts, aspects of signal transduction, such as interference
thereby diluting plasma and reducing osmolality. with VP binding, changes in VP receptor gene expres-
Conversely, an oral water load will reduce plasma sion or abnormal G protein coupling. Some muta-
osmolality and suppress VP secretion. Healthy indi- tions lead to a total loss of function, but others
viduals maintain plasma osmolality within the represent a milder phenotype, such that a positive
range 282–295 mOsmol/kg, a threshold above response is seen to high doses of VP. NDI is also
which VP increases are observed (Figure 9.6). caused by metabolic (e.g., hypokalemia) or drug
The antidiuretic effect of VP in the kidney is effects that influence the AQP2 channels (Figure
mediated by G protein-coupled V2R. Binding of VP 9.7). For example, lithium dysregulates the expression
160 to V2R stimulates the adenyl cyclase/cAMP/protein of AQP2 channels.
Figure 9.7 VP-induced antidiuresis. Schematic sequence of events leading to antidiuresis in response to VP stimulation. 1. AQP2 is stored as
unphosphorylated tetramers. 2. V2R is a G protein-coupled seven-transmembrane receptor. 3. Binding of VP leads to activation of the α-
subunit of the stimulatory G protein (GSα), which in turn activates adenylyl cyclase. Adenylyl cyclase converts ATP to cAMP. 4. The increase in
cAMP activates the PKA pathway, which phosphorylates (activates) AQP2. 5. P-AQP2 is rapidly inserted into the apical membrane facing the
luminal side. 6. Water then enters the principal cell via P-AQP2. 7. At the basolateral membrane, water leaves the cell through additional
aquaporins, AQP3 and AQP4. 8. AQP2 is dephosphorylated and is recycled into cytosolic compartments. Abbreviations: ATP, adenosine
triphosphate; P-AQP2, phosphorylated AQP2. Reproduced with permission (Babey et al., 2011).
These two types of DI can be differentiated by: (a) Treatment of HDI patients with the VP analog
the water deprivation test (see case study later in this desmopressin eliminates polyuria and reverses poly-
chapter) or (b) by assaying plasma VP concentra- dipsia and thirst. However, NDI may be either com-
tions that result from controlled osmotic stress fol- pletely or partially unresponsive to desmopressin. In
lowing infusion of a hypertonic 5% solution of this case, a low-sodium/-protein diet to reduce urin-
sodium chloride. Figure 9.8 illustrates that the low/ ary solute excretion, and thiazide diuretics (which
undetectable levels of VP in HDI are unresponsive to cause hypovolemia-induced proximal tubule sodium
increases in plasma osmolality. In contrast, NDI and water reabsorption) are used as therapy.
patients respond to osmotic stress by secreting Prostaglandin (PG) synthesis inhibitors (nonsteroidal
abnormally high levels of VP, consistent with VP anti-inflammatory agents; NSAIDS) are also effective
resistance (Ball, 2017). (Libber et al., 1986). In this case, the inhibitory effects
As noted earlier, quantification of copeptin, rather of endogenous PGs (leading to increased fluid output)
than VP, is a simpler procedure and represents a are counteracted by NSAIDS, such as indomethacin.
promising tool for the diagnosis of VP-dependent Newer agents, including V2R chaperones, are being
fluid disorders (Christ-Crain and Fenske, 2016; studied and the preliminary data seem promising
Fenske et al., 2018b). (Jean-Alphonse et al (2009).
161
pavement. He did not seek medical attention at that

time. A week later he began to notice excessive thirst
and frequent urination. Soon he was drinking 4–5
liters of fluid every day and urinating frequently. He
also had to wake up four to five times during the night
to pass urine. His family physician did a 24-hour urine
volume collection, which was 5.4 liters.
The baseline fasting investigations showed the
following results:
Serum sodium=145 mmol/L (136–145)
Serum potassium=4.8 mmol/L (3.4–5.0)
Serum calcium=2.45 mmol/L (2.20–2.60)
Serum osmolality=312 mmol/kg (283–292)
Urine osmolality=216 mmol/kg (50–1400)
Based on the history of polyuria and polydipsia,
high–normal serum sodium and potassium, high
serum osmolality (indicating water deficit) and dilute
urine (with severe water deficit, urine should become
maximally concentrated to conserve water and urine
osmolality should rise to well over 600 mmol/kg), a
preliminary diagnosis of DI was made. A water depri-
Figure 9.8 Relationship of plasma VP to plasma osmolality in
patients with HDI and NDI. Measurement of plasma VP during vation test was conducted.
controlled hypertonic stress (3% saline) differentiates between NDI In normal individuals, water deprivation increases
and HDI. Darker shades indicate severe defects whereas lighter VP secretion, leading to a reduction in urine volume
shades indicate partial defects. The horizontal broken line indicates
the limit of detection of the plasma VP assay. Image reproduced and (to conserve body fluids; Besser and Thorner, 2002).
modified, with permission (Babey et al. (2011) and Dr. G. L. This results in a concentrated urine characterized by
Robertson). high urine osmolality.
After an overnight fast, the patient was admitted
to the Endocrine Day Unit. He was carefully weighed,
serial blood and urine samples were collected, and
9.7.1 A Case of DI urine output as well as body weight was monitored.
A 66-year-old man was referred to Endocrinology for Fluids were then restricted for 8 hours. The results of
a 3-month history of polyuria and polydipsia. His the water deprivation test are shown below.
family physician had checked the fasting glucose The water deprivation test confirmed significant
level based on the assumption of diabetes mellitus, water deficit based on high serum osmolality, persis-
but the glucose was normal (5.2 mmol/L). tently dilute urine (typically urine osmolality rises
Upon further questioning, it emerged that the above 600 mmol/kg) and a low serum VP. The patient
patient had slipped on ice while cleaning up his drive- was started on desmopressin (DDAVP melt tablets)
way during a snowstorm. He did not lose conscious- and his urine frequency and concentration
ness but remembered hitting his head hard on the normalized.
Fasting 2 hours 4 hours 6 hours 8 hours

Serum sodium (136–145 mmol/L) 146 146 147 148 148
Serum potassium (3.4–5.0 mmol/L) 4.1 4.1 4.2 4.3 4.2
Serum osmolality (283–292 mmol/kg) 305 305 306 308 309
Urine osmolality (50–1400 mmol/kg) 220 220 232 253 210
Urine volume (mL) 200 300 500 200 200
Serum VP (0.8–3.5 pmol/L) 0.20 0.30
162
Figure 9.9 Relationship of plasma VP and

osmolality in SIADH. Data obtained from
Fenske et al. (2016).
Post-traumatic DI – attributed to direct mechan-

ical damage causing tearing of small vessels and neu-
ronal tissue – is a relatively uncommon consequence
of traumatic brain injury (Capatina et al., 2015). Free
access to water and replacement of VP with DDAVP
(injection, nasal spray or tablets) typically restore
normal fluid balance.
Syndrome of Inappropriate Antidiuresis

This syndrome – often referred to as the syndrome of
inappropriate antidiuretic secretion (SIADH) – is a
common cause of hyponatremia and hypoosmolality,
accompanied by urine osmolality greater than that of
plasma. In the majority of patients with SIADH
(~40%) there is an inappropriate, excessive secretion
of VP (Fenske et al., 2016; Figure 9.9). Even so, the
elevated levels remain within the normal physiologi-
cal range and are abnormal only with respect to Figure 9.10 Schematic summary of three patterns of VP secretion in
plasma osmolality. The high levels of VP exert an SIADH following osmotic challenge. Patients with the clinical features
of SIADH were infused with hypertonic saline to reveal three groups
antidiuretic effect – increasing water retention – proof VP response. The area in blue represents plasma VP levels of
ducing hyponatremia. Nevertheless, patients drink normal healthy subjects over physiological ranges of plasma sodium
normal amounts of water, suggesting a resetting of concentration. Each line represents the VP response to increases in
plasma sodium during infusion of hypertonic saline. The lines A–C
the thirst mechanism. refer to the different types of VP secretion referred to in the text. Data
Although the majority of SIADH patients demon- obtained from Robertson (2006).
strate VP levels as shown in Figure 9.9, there are at
least three different types of inappropriate VP secre-
tion. These are revealed when patients are infused
with hypertonic saline (Robertson, 2006; Figure suggesting an uncoupling of the hypothalamic osmor-
9.10). In type A, the high, erratic secretion of VP eceptor mechanism. In type B, VP levels are also
does not respond (decrease) to elevated hypertonicity higher than normal and do not respond to hyperto-
(i.e., the increase in sodium concentration), nicity until the sodium concentration rises into the 163
normal range; this also suggests a resetting of the Serum sodium=124 mmol/L (136–145)
osmoreceptor pathway. Type C is characterized by Serum potassium=3.7 mmol/L (3.4–5.0)
suppressed VP, as expected, but then VP levels rise Serum osmolality=261 mmol/kg (283–292)
inappropriately in advance of the normal range. In Urine osmolality=628 mmol/kg (50–1400)
this case the osmoreceptor sensitivity is reset at a Urine sodium=34 mmol/L (see later)
lower value. The low serum sodium, with low serum osmolal-
SIADH is commonly associated with increased ity, indicated dilutional hyponatremia due to fluid
morbidity and mortality compared to normonatremic retention, whereas the high urine osmolality (indicat-
patients. Symptoms include headache, nausea, vomiting a concentrated urine despite low serum osmolal-
ing and confusion. The list of the causes of SIADH is ity) associated with high urine sodium (typically urine
exhaustive, including: central nervous system (CNS) sodium is expected to drop to <20 mmol/L with low
injury (trauma, surgery), drugs, cyclophosphamide, serum sodium) indicates SIADH.
certain anti-psychotic and chemotherapy agents, SIADH is frequently seen in patients after CNS
interferon, ciprofloxacin and opiates, lung conditions injury-like trauma, surgery, stroke, pulmonary lesions
(pneumonia, tuberculosis, pulmonary malignancy), and around 20% of patients undergoing trans-sphe-
HIV, hypothyroidism and ectopic production of VP noidal pituitary surgery can develop hyponatremia
from certain tumors such as small-cell carcinoma of (Barber et al., 2014). Hyponatremia in these patients
the lung. is dilutional because excessive VP secretion leads to
water retention. If left untreated, SIADH can lead to
Treatment significant morbidity including headache, lethargy
In several cases SIADH is fortunately transient and and nausea in milder cases to seizures, coma and
will respond to fluid restriction and increased salt death in advanced cases. The key treatment is fluid
intake with loop diuretics to increase free water excre- restriction and treating the primary disorder, which is
tion. Occasionally oral urea is prescribed to increase generally sufficient in mild cases. However, in pro-
urinary solute concentration, which promotes water found or resistant hyponatremia, sodium replacement
excretion. Drugs like demeclocycline and lithium, with hypertonic saline and oral salt may be needed to
which cause NDI, are also used to enhance urinary bring sodium into a safe range. Sodium should be
water excretion. Recently drugs have been developed gradually corrected because an overly rapid correc-
that target the principal mechanism that restricts tion can cause permanent neurological damage. It is
water loss; that is, the action of VP at the V2R. generally recommended to correct sodium at a rate of
Orally active VP antagonists, such as tolvaptan, are around 5–6 mmol/L (no more than 8 mmol/L) over 24
now available that show clinical promise (Rondon- hours. Recently VP antagonists like tolvaptan have
Berrios and Berl, 2016). Clinical trials support their been used. In addition, drugs like lithium and deme-
efficacy, but their widespread use is limited by cost clocycline, which normally cause DI, have been used
and side effects such as overly rapid correction of to promote free water clearance in order to correct
sodium, which can result in neurological abnormal- dilutional hyponatremia. The patient was placed on
ities and liver toxicity (Berl, 2015; Rondon-Berrios fluid restriction (1.5 L per day) and over the next few
and Berl, 2017). days her sodium levels gradually normalized when
fluid restriction was eased off.
9.7.2 A Case of SIADH
A 46-year-old female was admitted to Neurosurgery 9.8 Baroregulation of VP Secretion
for an elective trans-sphenoidal surgery to remove an An acute reduction in blood pressure, or blood
enlarging non-functioning pituitary adenoma. volume, induces secretion of VP. Small fluctuations
Surgery was uneventful and she was discharged in blood pressure are without effect and changes of
home on the fourth day. However, she presented to greater than 5–10% are necessary to significantly
emergency 3 days later because she was feeling unwell modify VP levels. Figure 9.11 illustrates the influence
and felt nauseous. of induced hypotension in healthy adults. Infusion of
Nonetheless she was afebrile and hemodynami- a ganglion-blocking drug for 15–30 mins reduces
cally stable and baseline investigations showed the arterial pressure and exponentially stimulates VP
164 following: secretion (Besser and Thorner, 2002).
aggression, as well as anxiety, fear conditioning and

fear extinction (Meyer-Lindenberg et al., 2011). The
distribution of VP and OXY in many areas of the
human brain suggests that these peptides may also
influence neural systems distinct from those involved
in posterior pituitary function. Most attention has
focused on OXY (see e.g., Miller, 2013; Shen, 2015).
In the context of hormonal changes during parturi-
tion and lactation, OXY is believed to influence both
the maternal and the fetal/newborn brain in the estab-
lishment of mother–child attachment (Olza-
Fernández et al., 2014). For example, these authors
speculate that delivery by cesarian section, eliminat-
ing exposure of the newborn to OXY, could influence
brain development. In other examples of behavioral
effects, when healthy adults were given OXY via intra-
nasal spray, changes in social behavior were noted.
People given OXY before playing an investment game
were more willing to give their money to a stranger
than were controls. OXY also improved the ability to
assess the emotional state of others from subtle
expressions (Shen, 2015). Other studies suggest that
OXY may be effective in the treatment of schizophre-
Figure 9.11 Relationship between mean arterial pressure and VP nia (Shilling and Feifel, 2016). The hypothesis that
secretion. An acute fall in blood pressure, or volume, stimulates OXY may have behavioral effects in the human
release of VP. The figure illustrates the exponential rise in VP as a brain is nowhere more controversial than in efforts
response to progressive hypotension induced in normal subjects by
infusion (15–30 mins) of the ganglion-blocking drug trimetaphan. to reverse the symptoms of autism via intranasal
Blood pressure must decline by approximately 10% before a treatment with OXY (Young and Barrett, 2015).
significant rise in VP output is observed. However, a 40% reduction This approach has received serious attention as a
increases VP release by 100-fold. Data obtained from Besser and
Thorner (2002). treatment for autism spectrum disorders (ASD),
with reported enhancements in social abilities in indi-
viduals with ASD (Parker et al., 2017). However, other
Changes in blood pressure are detected via baror- clinical trials have yielded equivocal and mixed results
eceptors in the aortic arch, carotid sinus, cardiac atrial (reviewed in Kendrick et al., 2017), suggesting that
and great veins. VP, at high concentration, also further clinical studies are required. In addition, there
increases blood pressure via V1Rs located in vascular are serious doubts in some quarters as to whether
smooth muscle cells. Here, VP regulates regional intranasal OXY actually reaches the brain (Leng and
blood flow, inducing vasoconstriction of splanchnic, Ludwig, 2016). The question remains as to whether
hepatic and renal vessels at concentrations close to the OXY and VP are released within the brain; that is,
physiological range (Ball, 2017). when OXY and VP are secreted from the posterior
Clinical implication: VP is used in patients with pituitary it is possible that projections from the SON/
vasodilatory shock where it leads to vasoconstriction PVN release OXY/VP elsewhere in the brain to influ-
and elevation of blood pressure. ence human behavior.
9.9 Behavioral Effects of VP and OXY 9.10 Chapter Summary

in Humans The posterior pituitary secretes two peptide hor-
Extensive studies in animals reveal that OXY and VP mones: OXY and VP. OXY has two principal func-
are evolutionarily highly conserved regulators of com- tions: to induce uterine contractions during
plex social cognition and behavior. These include parturition, and to stimulate milk letdown from the
attachment, social exploration, recognition and breasts during lactation. VP acts as an antidiuretic 165
and also regulates peripheral vasoconstriction and low-sodium diet coupled with a thiazide diuretic
blood pressure. OXY and VP secretion is controlled reduces urine flow and increases osmolality.
by dopamine rather than hypothalamic releasing hor- The converse of DI, SIADH, is characterized by
mones. The posterior pituitary contains the axons and inappropriate, excessive secretion of VP. Simple fluid
neuron terminals of cell bodies located in two distinct restriction or salt tablets to restore plasma osmolality
hypothalamic nuclei: the PVN and the SON. may be sufficient.
Oxytocinergic neurons coexist with vasopressinergic An alternative treatment is to use drugs that target
neurons in both SON and PVN. the action of VP at the V2R. Orally active VP antago-
The VP and OXY genes are located end-to-end on nists, such as tolvaptan, are now available that show
human chromosome 20p13. Their pre-propeptides clinical promise. A case of SIADH is included.
are enzymatically cleaved to smaller entities: VP and An acute reduction in blood pressure, or blood
OXY, NP I and II, and, in the case of VP, an additional volume, induces secretion of VP. Small fluctuations in
peptide called copeptin. NPs have no known function, blood pressure are without effect and changes of
but copeptin is far more stable than VP and its levels greater than 5–10% are necessary to significantly
can be used as a surrogate marker of VP secretion. modify VP secretion.
VP receptors exist as two subtypes, V1R and V2R. VP and OXY are found in many areas of the
V2Rs are located in the kidney where they enable human brain outside of the SON/PVN nuclei, sug-
water retention. V1Rs are present in vascular smooth gesting that these peptides might influence neural
muscle, regulating vasoconstriction. OXYRs are systems distinct from those involved in posterior
found in uterus and breast tissue. pituitary function. Most attention has focused on
OXY secretion is pulsatile, although VP pulses behavioral effects and on OXY specifically. For exam-
have not been described. Suckling induces large pulses ple, OXY is believed to influence both the maternal
of OXY, also seen during parturition with greater and the fetal/newborn brain in the establishment of
frequency as labor progresses. Exercise (running) mother–child attachment. Behavioral effects in
and psychosocial stress also induced robust OXY humans is nowhere more controversial than in efforts
secretion. In addition to its action in uterus and to treat the symptoms of autism via intranasal OXY.
breast, OXY may be useful in the regulation of body
weight. However, these human studies employed the
intranasal route for OXY treatment. Whether intra-
nasal OXY can reach the brain is a controversial issue. 1. Oxytocin (OXY) is a polypeptide hormone present
VP is the principal endocrine regulator of renal in the mother’s blood during childbirth, and also
water excretion, adjusting physiological responses to when babies suckle. It regulates contractions of
maintain plasma osmolality; that is, the sodium con- uterine muscle via G protein-coupled OXY receptors
centration in plasma is regulated by alterations in (OXYRs) located in the uterine muscle membrane.
water intake or excretion. For example, infusion of Which of the following statements is correct?
hypertonic saline in healthy adults increases plasma a. OXY is biosynthesized in, and secreted from,
osmolality and induces secretion of VP in a linear the hypothalamus.
fashion. Conversely, an oral water load reduces b. OXY is biosynthesized in the hypothalamus
osmolality and suppresses VP secretion. When the and secreted from the anterior pituitary.
production or action of VP is compromised, in DI, c. OXY is biosynthesized in the hypothalamus
dilute urine output is increased (polyuria) producing and secreted from the posterior pituitary.
hyperosmolar plasma and intense thirst. This stimu- d. OXY is biosynthesized and secreted from the
lates fluid intake (polydipsia). There are two forms of anterior pituitary.
DI: the first, central DI (HDI), caused by VP defi- e. OXY is biosynthesized in the anterior pituitary
ciency; the second, NDI, occurs as a result of renal and secreted from the posterior pituitary.
VP resistance. Treatment of HDI patients with the VP
analog desmopressin eliminates polyuria and reverses 2. With respect to vasopressin (VP) secretion, which
polydipsia and thirst. A case of HDI is included. of the following statements is correct?
However, the absence of functioning VP receptors in a. VP blood levels increase when blood pressure
166 NDI renders desmopressin ineffective. In this case, a is reduced.
b. VP blood levels increase when blood volume c. Rapid normalization of serum sodium is
decreases. crucial
c. VP blood levels increase when blood d. Lithium
osmolality decreases. e. Tolvaptan
d. VP levels are increased in patients with 7. Which of the following suggest central/
nephrogenic diabetes insipidus (NDI). hypothalamic diabetes insipidus in a patient
e. Increases in VP secretion are coincident with presenting with excessive thirst and urination?
decreases in copeptin.
a. Hypernatremia
3. Which of the following statements concerning VP b. A morning fasting urine osmolality of
are correct? 212 mmol/kg
a. VP and OXY are biosynthesized in the same c. A morning fasting serum osmolality of
neurons in the supraoptic nuclei (SON). 279 mmol/kg
b. VP and OXY are bound to the same d. Lithium therapy
neurophysin when transported down e. An elevated serum VP level
paraventricular nuclei (PVN) neuron axons. 8. Which of the following agents are used for the
c. VP is stored in the posterior pituitary and is management of NDI?
released under the control of a VP releasing
a. Desmopressin
hormone.
b. Thiazide diuretics
d. An oral water load stimulates VP secretion.
c. Demeclocycline
e. The effects of VP in the kidney are mediated
d. Indomethacin
through VP receptor 2 (V2Rs) coupled to
e. Lithium
adenyl cyclase.
9. Clinical indications of VP include which of the
4. Which of the following statements are correct?
following?
a. Mutations in the VP gene are responsible for
a. Induction of labor
increased urine output.
b. Vasodilatory shock
b. VP and OXY secretion from the posterior
c. Assessment of ACTH adenoma
pituitary is regulated by specific releasing
d. DI
hormones.
e. Promote milk production
c. VP has a stimulatory effect on
adrenocorticotropin (ACTH) release from the 10. Which of the following can occur in patients with
anterior pituitary. untreated SIADH?
d. VP-mediated antidiuresis depends on a. Nausea
activating aquaporin channels. b. Headache
e. OXY levels are a critical component for the c. Seizures
initiation of labor. d. Severe dehydration
5. With respect to OXY, which of the following e. Polydipsia
statements are correct?
a. OXY pulses are induced by nipple stimulation. Further Reading
b. OXY is unaffected by exercise.
Ball S G. (2017). The neurohypophysis: Endocrinology of
c. OXY release is stimulated by sexual arousal. vasopressin and oxytocin. www.endotext.org.
d. OXY secretion is increased by social stress.
Ball S G & Iqbal Z. (2016). Diagnosis and treatment of
e. OXYRs are located in the uterus and breast hyponatraemia. Best Prac Res Clin Endocr Metab 30, 161–173.
tissue, but not in the brain.
Christ-Crain M, Morgenthaler N G & Fenske W. (2016).
6. Which of the following management strategies are Copeptin as a biomarker and a diagnostic tool in the
used to correct hyponatremia in syndrome of evaluation of patients with polyuria-polydipsia and
inappropriate antidiuretic secretion (SIADH)? hyponatremia. Best Prac Res Clin Endocr Metab 30, 235–247.
a. Fluid restriction Leng G & Sabatier N. (2016). Measuring oxytocin and
vasopressin: bioassays, immunoassays and random 167
b. Desmopressin
numbers. J Neuroendocr 28, 1–13.
Christ-Crain M & Fenske W. (2016). Copeptin in the

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170
Chapter
An Introduction to Sellar Masses
10
Sellar masses (SM) are tumors of pituitary and non- Table 10.1 A list of common SM based on origin
pituitary origin that account for approximately 15% Pituitary SM
of all intracranial neoplasms (Dolecek et al., 2012).
Non-functioning adenoma
Although mostly benign, SMs can cause significant Prolactinoma
morbidity and even mortality, either due to hormo- Growth hormone-secreting adenoma
nal dysfunction or a mass effect on the surrounding Adrenocorticotrophin-secreting
adenoma
structures. Tumors of pituitary origin (pituitary Gonadotropin-secreting adenoma
adenomas; PAs) account for the vast majority of Thyrotropin-secreting adenoma
these lesions, that are further subdivided into non- Hypophysitis
Pituitary carcinoma/metastatic lesions
functioning adenomas (NFAs) – which do not
Non-pituitary SM
secrete pituitary hormones – or functioning adeno-
mas, which secrete one or more active hormones. Rathke’s cleft cyst
Craniopharyngioma
Based on size, SMs are arbitrarily defined as either Meningioma
microadenomas (<1cm) or macroadenomas Chordoma
(≥1 cm). Glioma
Histiocytosis
A detailed description of various SM lies outside Arachnoid cyst
the scope of this book. Nevertheless, we shall briefly Germinoma
discuss the epidemiological characteristics of various Sarcoidosis
Aneurysm
SM that are commonly encountered in clinical prac-
tice, key diagnostic criteria, clinical features, imaging
and principles of management.
10.1 History and Assessment of physician to the possibility of other rare SM,
like inflammatory or metastatic lesions. Many
Patients with an SM drugs, such as oral contraceptives, anti-psycho-
A thorough history and physical examination should tics, opioids and immunotherapy agents can
be conducted in all patients presenting with SM. PAs cause significant pituitary hormonal dysfunction
account for over 80% of all SMs (Al-Dahmani et al., and the clinician must keep them in mind while
2016). Key elements of history include features of conducting the hormonal evaluation of SM.
hypopituitarism, hormonal over secretion and fea-
tures of mass effect, other health disorders, medica- Baseline Hormonal Assessment of SM
tions and a careful family history should be obtained A thorough history and physical examination should
(Table 10.2). enable the physician to tailor the investigations.
Several inherited conditions are associated Baseline hormonal screening tests are necessary in
with PAs, such as multiple endocrine neoplasia all patients with SM at initial presentation and further
type 1, McCune–Albright syndrome, Carney com- hormonal assessment is based on the suspected dis-
plex and familial isolated PA. A history of other order. A list of recommended baseline tests, obtained
health conditions such as sarcoidosis, malignancy at 0800-0900 h, after an overnight fast is shown in
and autoimmune disorders should alert the Table 10.3.
171
Chapter 10: An Introduction to Sellar Masses
Table 10.2 Effects of SMs

Table 10.3 Baseline hormonal assessment of SM
Key features of pituitary insufficiency
Serum cortisol: A value of <130 nmol/L confirms secondary
Low prolactin: inability to breastfeed
adrenal insufficiency, whereas a value of >250 nmol/L in
Low growth hormone (GH): short stature in children, fatigue, adults generally indicates adequate hypothalamic–pituitary–
increased adiposity and reduced exercise capacity adrenal function. An intermediate value should be further
Low luteinizing hormone/follicle stimulating hormone: assessed by dynamic test such as ACTH test or insulin stress
low libido, sexual dysfunction, menstrual irregularities, test (Yip et al., 2013).
vasomotor symptoms, infertility and osteoporosis Serum thyroid stimulating hormone (TSH): Low or normal
Low cortisol: weight loss, fatigue, muscle weakness, postural in patients with secondary hypothyroidism except in TSH
dizziness and salt craving adenoma where it may be elevated.
Low thyroid stimulating hormone (TSH): fatigue, weight Serum thyroxine: Below normal in patients with secondary
gain, cold intolerance, constipation and bradycardia hypothyroidism and elevated in TSH adenoma.
Low VP: polyuria and polydipsia Prolactin: Elevated in hyperprolactinemia or patients with
pituitary stalk damage, and low in destructive pituitary lesions
Key features of common hormone over secretion or diffuse pituitary damage.
disorders
Luteinizing hormone (LH)/Follicle stimulating hormone
Hyperprolactinemia: sexual dysfunction, infertility and (FSH): Low or normal in patients with secondary
galactorrhea hypogonadism. Rare gonadotropin-producing adenomas can
GH (acromegaly): sweating, excessive snoring, voice change, lead to elevated FSH or LH levels.
acral enlargement, nerve entrapment, coarse features, Estradiol/testosterone: Low in patients with secondary
diabetes, hypertension and sexual dysfunction hypogonadism.
TSH (secondary hyperthyroidism): features of Insulin-like growth factor 1 (IGF-1): Elevated IGF-1 suggests
thyrotoxicosis including tachycardia, palpitations, tremor, excessive growth hormone (GH) production and low IGF-1
heat intolerance, sweating, diarrhea, weight loss and indicates the possibility of GH deficiency requiring additional
nervousness dynamic tests.
Features of mass effect In case of suspected diabetes insipidus (DI):
Headache (a) Serum and urine osmolality: Uncontrolled DI leads to
Vision loss a concentrated serum with high serum osmolality and a
Double vision dilute urine with low urine osmolality.
Seizures
Personality change (b) Electrolytes: Uncontrolled DI leads to a high–normal or
above normal serum sodium.
structural changes – such as PAs – is a sella protocol

Imaging of SM that visualizes an area comprising the pituitary gland,
The pituitary gland lies within a bony cavity called the pituitary stalk, hypothalamus, optic chiasm and the
sella turcica. The sellar region and surrounding tissue cavernous sinus. MRI scans generate images based on
is anatomically complicated, consisting of vascular, the hydrogen (or proton) content, and tissues with
pituitary and neural structures in close proximity to higher hydrogen content appear bright on MRI. The
one another. With respect to sellar and parasellar images are further adjusted to emphasize different
pathology, imaging of this region requires high reso- tissue densities into either T1 weighted – where fat
lution and high contrast. Imaging studies were trans- appears bright and the water content of cerebrospinal
formed with the advent of magnetic resonance fluid (CSF) appears dark – or T2 weighted – where
imaging (MRI). MRI provides a sharper resolution water (and CSF) appears bright and fat appears
of the pituitary gland compared with other imaging lighter. Thinner cuts (<3 mm) provide a better resolu-
techniques. Although the computed tomography(CT) tion of the pituitary gland. The use of gadolinium
scan is superior in visualizing the bony structures of contrast medium with T1-weighted sequences greatly
the sella, or to occasionally characterize certain SMs improves the clarity of the images. Gadolinium is
such as craniopharyngiomas that may show distinct taken up by pituitary tissue revealing the adenoma
calcification, MRI is by far the best technique to as a darker area (Figure 10.1A & B). Nevertheless,
visualize the pituitary gland (Lucas and Zada, 2012; certain microadenomas and pituitary cysts might be
Bonneville, 2016). The ideal approach to assess difficult to discern and may be better visualized on T2-
172
Figure 10.1 Different imaging modalities to differentiate types of pituitary lesions. (A) and (B) illustrate the use of gadolinium contrast in T1-
weighted images to reveal an adenoma as a darker area compared to normal pituitary tissue. (C) shows an unenhanced CT scan revealing the
bony structure (bright) and an SM. (D) and (E) are MRI scan images showing the same SM with improved resolution. The post-contrast T1
sagittal image (D) shows a hypodense lesion, which appears bright on the T2 coronal image (E), confirming this to be a cyst. (F) is a combined
PET/CT image, after yttrium 90 infusion, showing a bright signal typical of a cystic pituitary mass.
173
Figure 10.2 CT and MRI scans of a non-

functioning macroadenoma. (A) A contrast-
enhanced CT scan and (B and C) subsequent
MRI images show a large SM. Confirmed by
pathology, this is a large macroadenoma,
extending superiorly to compress the optic
chiasm and cause bitemporal visual field
defects.
weighted images (Figure 10.1 C, D & E). In addition, MRI or CT scans. Occasionally PET scans done for
the signal intensity of certain pituitary tumors on T2 other reasons might pick up an area of increased
images provides clues to the underlying pathological uptake in the sella, which is generally due to a PA
characteristics; for example, hyperintensity of growth but other possibilities like metastatic and inflamma-
hormone (GH) adenomas on T2 images correlates tory lesions (such as hypophysitis and sarcoidosis)
with the sparse granulation pattern on immunocyto- should also be considered. PET scan images may be
chemistry (Heck et al., 2012), which has implications superimposed on CT or MRI to provide better over-
on the choice of management. all anatomic details. Figure 10.1E shows a combined
Although not routinely used in day-to-day pitui- PET/CT scan of the same patient in other panels of
tary care, positron emission tomography (PET) scans Figure 10.1, but following stereotactic implantation
are frequently used in patients for detection of can- of yttrium 90.
cer. For example, a positron-emitting radionuclide
tracer, such as [18 F] fluorodeoxyglucose (FDG), is
injected intravenously. Tissue uptake of FDG and 10.2 Nonfunctioning Adenomas
release of positrons produces gamma ray emissions, NFA are the commonest PA and account for almost
which are imaged by a scanning camera that pro- 40% of all SMs (Al-Dahmani et al., 2016). Although
duces three-dimensional (3D) images. Tissues with a NFA typically do not secrete any hormone,
higher glucose uptake, such as tumor cells, avidly most NFA stain positive for LH and FSH on immu-
take up the tracer. PET scans with FDG assess tissue nostaining (Chanson and Brochier, 2005). The
function (i.e., glucose metabolism) rather than struc- gender distribution shows a slightly higher prepon-
174 ture, especially where tumors might not be visible in derance (55%) in females (Al-Dahmani et al., 2016).
A B Figure 10.3 MRI images of a solid/

Cystic portion of adenoma cystic PRLoma. Pre-treatment
Cystic portion of adenoma images of a giant cystic PRLoma
showing (A) coronal and (B) sagittal
views. (C) and (D) are post-treat-
ment scans following 18 months of
dopamine agonist (cabergoline)
therapy. A marked reduction of the
solid and cystic portions of the
tumor are shown in (C) coronal and
(D) sagittal views.
Solid portion of adenoma Solid portion

Solidofportion
adenomaof adenoma
C D
Pituitary stalk
Pituitary stalk
Residual tumor
Residual tumor
These tumors are either found incidentally, on ima- In a large series of NFA and non-pituitary SM
ging of the head, or with clinical features of their that did not require immediate surgery, over 90%
physical mass such as headache, loss of vision, diplo- of the tumors remained stable over 3 years (Imran
pia and hormonal dysfunction due to compression of et al., 2016). However, life-long follow-up of these
the adjacent pituitary gland. The risk of hormonal tumors is mandatory through serial imaging with
dysfunction in NFA is significant and in a large MRI (or CT if MRI is contraindicated) and
series, over 40% of patients on presentation had hormonal assessment because new onset hormo-
evidence of secondary hormonal dysfunction (Al- nal dysfunction can develop in around 20% of
Dahmani et al., 2016). These included secondary patients over 5 years (Vaninetti et al., 2018). In
hypogonadism (34.3%), secondary hypothyroidism patients with residual tumor post-surgery, with
(23.9%), GH deficiency (13.9%), secondary hypoa- evidence of enlargement, either repeat surgery
drenalism (10.8%) and diabetes insipidus (1.2%). or stereotactic radiation or both should be con-
Many patients had more than one hormonal sidered. The rate of tumor control after radiation
deficiency. therapy with newer techniques is over 95%
Management of NFA depends upon the size and (Minniti et al., 2016). Although some studies
whether or not there is evidence of a mass effect. Most have shown a beneficial effect of dopamine ago-
incidental smaller NFA do not require any interven- nist therapy, such as cabergoline (Greenman et
tion except replacement therapy in case of hormonal al., 2005), the effect is relatively limited in our
deficiency. Larger tumors with evidence of optic nerve experience and medical therapy should not be
compression on presentation (see Figure 10.2) or used as an alternative to surgery in enlarging
enlarging tumors require surgical excision. tumors. 175
10.3 Prolactinomas if a clear discrepancy between tumor size and serum

PRL levels is suspected in a patient with clinical fea-
Prolactinomas (PRLomas) are the commonest func-
tures of a PRLoma, then the PRL sample should be
tioning adenomas, accounting for 32–34% of all PAs
diluted before being re-assayed.
(Al-Dahmani et al., 2016; Tjörnstrand et al., 2014).
Another potential diagnostic pitfall is that of macro-
(For the underlying pathophysiological principles
prolactinemia, which is caused by the formation of a
governing PRL secretion, please refer to Chapter 7.)
large complex between PRL and immunoglobulin G
PRLomas are commoner in women than in men (70
(mostly anti-PRL antibody), which delays its clearance
vs. 30%, respectively) and typically present in younger
and increases measured serum PRL (cf. Chapter 7). The
individuals between the ages of 20–40. (Al-Dahmani
biological activity of macroprolactin is low and these
et al., 2016). In our own series (Al-Dahmani et al.,
patients are typically asymptomatic and may account
2016) almost 60% were microadenomas, the remain-
for as much as 10–25% of patients with hyperprolacti-
ing being macroadenomas. PRLomas have a peculiar
nemia (Samson et al., 2015). Therefore, in patients with
infrasellar growth pattern (see Figure 10.1A) com-
an elevated serum PRL without symptoms of hyperpro-
pared with NFAs, which have a predominant supra-
lactinemia, this possibility should be considered, and
sellar growth (Imran et al., 2017; see Figure 10.2).
the sample should be screened by the polyethylene
PRLomas typically present with features of gonadal
glycol precipitation method.
deficiency such as loss of libido, menstrual irregularity
Management of PRLoma is mostly medical in the
or amenorrhea in women, and erectile dysfunction in
form of dopamine agonist therapy. The commonly
men, as well as infertility in both. Another common
used drugs are bromocriptine, cabergoline and qui-
feature of PRLomas is galactorrhea, more common in
nagolide. Bromocriptine (taken daily) and cabergo-
women than in men. Due to their peculiar inferiorly
line (taken once or twice a week) are ergot derivatives
extending growth pattern, PRLomas seldom cause
whereas quinagolide (taken daily) is a non-ergot
visual field defects through compression of the optic
dopamine agonist. Cabergoline is typically used as
nerve, but giant PRLomas (Figure 10.3) tend to be
first-line therapy and we recommend patients to take
invasive and can cause significant compression of the
the tablet at bedtime with a light snack to improve
surrounding structures and loss of vision.
tolerability, as otherwise these medications can cause
Occasionally, these large tumors can extend into the
headache, nausea, dizziness and nasal stuffiness.
brain, leading to personality changes and even
Between 10 and 25% of patients fail to normalize
seizures.
PRL with medical therapy and are deemed resistant
The diagnosis is based on an elevated serum PRL
to medical treatment (Webster et al., 1994; Verhelst et
level in the presence of typical symptoms. Serum PRL
al., 1999). Resistant tumors may occasionally require
levels tend to correlate with the size of the tumor, with
surgery and, in case of recurrence, radiation therapy.
large PRLomas demonstrating serum PRL, which is
several-fold above the normal range. When a large
pituitary tumor is associated with only mildly elevated 10.4 GH Adenomas (Gigantism and
serum PRL (two to three times the upper limit of
normal) the clinician should be alerted to the possi- Acromegaly)
bility of stalk compression causing obstruction to the GH adenomas are the second commonest functioning
flow of inhibitory dopamine (thereby increasing PAs, constituting 6.5% of all SM and around 8% of
serum PRL) rather than a PRLoma. However, smaller PAs (Al-Dahmani et al., 2016; see Figure 10.4). Most
PRLomas typically present with a modest elevation of patients are in their third or fourth decade at the time
serum PRL (two to five times the upper limit of of diagnosis (Al-Dahmani et al., 2016) and, due to the
normal). insidious nature of the disease, there is a 10–12-year
In patients with large tumors, serum PRL may delay in diagnosis from the onset of symptoms (Colao
reach as much as 100 times the upper limit of normal et al., 2004). (For a detailed review of the underlying
or higher (see Section 7.11.1 A Case of Prolactinoma; pathophysiological aspects of GH secretion, please
Chapter 7; Figure 7.8). In some cases, a high PRL can refer to Chapter 8.)
saturate the assay antibodies such that serum PRL Excessive GH secretion from a GH-producing PA
may appear only modestly elevated. This condition leads to a constellation of symptoms, including
176 is known as the “hook effect” (Frieze et al., 2002) and increased linear height (in childhood-onset disease,
Figure 10.4 MRI images of a GH macroadenoma. Post-gadolinium contrast views of a macroadenoma in a patient with acromegaly showing
(A) coronal and (B) sagittal views. Note that the pituitary stalk is deviated to the opposite side of the tumor. Note that the normal pituitary tissue,
after contrast, appears brighter than the adenoma.
called gigantism; see Section 8.7.1 A Case of The goal of treatment is to normalize GH and
Gigantism; Chapter 8), soft-tissue enlargement (skin IGF-1 and to remove the tumor. Surgery is the first-
thickening, visceromegaly, snoring and sleep apnea line therapeutic option for most patients with GH-
etc.), enlargement of bones and cartilage tissue (enlar- producing adenoma. In patients with microadenoma
gement of hands and feet, thickening of the skull, or smaller macroadenomas, the rate of remission is
prominence of the jaw and forehead), metabolic con- almost 80–90%, whereas in larger macroadenomas it
ditions (hyperglycemia due to an anti-insulin effect of is under 50% (Melmed, 2006). Although some studies
GH, excessive sweating and hypopituitarism), among suggest initiating medical therapy before surgery to
others. If untreated, acromegaly is associated with reduce tumor size for better surgical remission, the
significant mortality and early death due to cardiovas- benefit of this approach remains controversial and
cular or respiratory conditions and an increased rate most experts suggest surgery without delay (Jacob
of malignancy such as colonic and thyroid cancer and Bevan, 2014; Katznelson et al., 2014). In patients
(Melmed, 2006). The systemic manifestations of acro- where surgery is not feasible, or those with persistent
megaly are predominantly mediated by insulin-like disease after surgery, medical therapy is initiated.
growth factor 1 (IGF-1), which is produced in the Three classes of medical therapy are currently avail-
liver under the influence of GH (Chapter 8). able: somatostatin analogs (lanreotide, octreotide and
Diagnosis of acromegaly is based on clinical fea- pasireotide), dopamine agonists (cabergoline,
tures and biochemical evidence of excessive GH. bromocriptine) and a GH receptor antagonist (pegvi-
Serum GH is produced in a pulsatile fashion, and somant). The rate of remission with the first-genera-
therefore an isolated random GH measurement is tion somatostatin analog therapy (octreotide and
not suitable as a single diagnostic test. The initial lanreotide) is around 50% (Carmichael et al., 2014),
biochemical diagnosis of acromegaly is based on an whereas the second-generation somatostatin analog,
elevated serum IGF-1 compared with an age and pasireotide, has slightly better efficacy but is asso-
gender-matched normal range. This should be con- ciated with a significant risk of hyperglycemia
firmed with a GH measurement during a 75 g oral (Gadelha et al., 2014). Pegvisomant is a GH receptor
glucose tolerance test (OGTT). Typically, serum GH antagonist, which lowers serum IGF-1 by blocking
suppresses to <1 mcg/L (preferably <0.4 mcg/L using GH binding in the liver. The real-life efficacy of peg-
a sensitive GH assay) in normal individuals. An ele- visomant in normalizing IGF-1 has been reported to
vated serum IGF-1 and failure to suppress GH with be around 60% (van der Lely et al., 2012). Dopamine 177
OGTT confirms acromegaly. agonist therapy is generally used in patients with mild
disease or for those tumors that co-secrete both GH Several tests have been proposed, such as 24-hour
and PRL. The efficacy of dopamine agonist therapy is urinary free cortisol, late night serum, or salivary
low and only a small proportion of acromegaly cortisol and overnight or 48-hour low-dose dexa-
patients achieve normalization of IGF-1 (Sandret et methasone suppression test (DST; Nieman et al.,
al., 2012). Radiation therapy is an effective adjunct 2008). The sensitivity and specificity of these tests
modality of treatment in patients who fail to achieve vary, and different cut-off values have been suggested
biochemical control. However, the response is slow in the literature.
and around 50% of patients over a 2–3-year treatment For increased accuracy, two or three samples of
period achieve biochemical remission (Imran et al., 24-hour urinary free cortisol should be obtained.
2009; Abu Dabrh et al., 2015). Mildly elevated (less than two to three times the
Management of other co-morbid conditions – upper limit of normal) levels are seen in patients
including diabetes, hypertension, sleep apnea and with depression, polycystic ovary syndrome and
arthritis as well as screening for cardiac dysfunction, with excessive alcohol intake, and normal levels
colonic and thyroid cancer – should be undertaken. may be seen in patients with mild disease or those
Many acromegaly patients develop psychiatric pro- with cyclical Cushing’s syndrome. Typically, in
blems, personality disorders and body image disor- patients with symptomatic Cushing’s, 24-hour
ders (Imran et al., 2016), which should be carefully urine cortisol levels are several-fold higher than nor-
assessed. mal and a value of more than three times the upper
limit of normal is highly suggestive of Cushing’s
10.5 ACTH Adenomas (Cushing’s syndrome.
Although a late evening serum or salivary cortisol
Disease) test has been recommended (Nieman et al., 2008),
ACTH adenomas are relatively rare and account these tests are cumbersome. Testing late evening
for around 4% of PAs, with women constituting serum cortisol requires hospitalization, which may
around 80% of all cases (Al-Dahmani et al., 2016). or may not be feasible, and salivary cortisol is assay-
Most patients present in their third or fourth dec- specific and universally applicable cut-off values have
ade of life with features of cortisol excess (Al- not been established. For the late evening serum cor-
Dahmani et al., 2016). These include: rapid weight tisol, the cut-off cortisol value of <50 nmol/L in
gain, hypertension, proximal muscle weakness, patients while asleep excludes Cushing’s syndrome
excessive bruising, thinning of the skin, facial (Newell-Price et al., 1995) and a value of over
plethora and increased abdominal adiposity (see 207 nmol/L in patients resting but not asleep indicates
Section 5.7.1 A Case of Cushing’s Disease; Cushing’s syndrome with 96% sensitivity
Chapter 5). In addition, many patients also (Papanicolaou et al., 1998).
develop psychological problems including depres- A more standardized and routinely used approach
sion, anxiety, mania and sleep disorders. It is is to perform a dexamethasone suppression test (DST)
noteworthy that these features may be mild or instead of the late evening serum or salivary test. Again,
absent in patients with subclinical Cushing’s dis- various protocols have been reported including giving
ease and in a series of 124 patients presenting with 1 mg dexamethasone at 2300 h and testing serum
suspected nonfunctioning pituitary macradeno- cortisol at 0900 h next morning (overnight DST; con-
mas, without overt features of excessive cortisol venient and sensitivity up to 90%) or 0.5 mg dexa-
production, an estimated 16% were ACTH adeno- methasone at 0900 h and then every 6 hours for
mas, of which half had biochemical evidence of 48 hours and measuring serum cortisol 6 hours after
autonomous cortisol production (Guttenberg et the last dose (48-hour low-dose DST; complex but
al., 2016). sensitivity up to 98%). A post-DST cortisol value of
The diagnosis of patients with suspected ACTH <50 nmol/L rules out Cushing’s syndrome (Nieman et
adenoma starts with screening tests. These screening al., 2008). It is important to note that several factors can
tests do not differentiate between hypercortisolemia interfere with the measurement of serum cortisol
due to other endogenous causes including pituitary, levels. For example, estrogen can falsely elevate total
adrenal or ectopic causes that produce clinical fea- serum cortisol due to an estrogen-dependent increase
178 tures of hypercortisolism (Cushing’s syndrome). in serum cortisol-binding globulin.
Once the diagnosis of excess cortisol is confirmed, 10.6 TSH Adenoma

the next step is to measure serum ACTH, which is
TSH adenomas are extremely rare tumors accounting
typically either mildly elevated or detectable (i.e.,
for <1% of PAs (Al-Dahmani et al., 2016). These
inappropriately normal) in patients with ACTH ade-
tumors generally present with features of thyrotoxi-
noma. This is followed by an MRI of the sella; ACTH
cosis because excess TSH production leads to hyper-
adenomas are generally small microadenomas (see
stimulation of the thyroid, causing elevated
Figure 5.15) and in some cases may be undetectable
concentrations of thyroid hormones (T4 and/or T3)
(Sharma et al., 2015). A detectable tumor >6 cm is
and goiter (see Section 6.8.1 A Case of
highly suggestive of ACTH adenoma, but if the tumor
Hyperthyroidism; Chapter 6). The diagnosis is based
is small or undetectable then additional localizing
on clinical features of thyrotoxicosis (see Chapter 6),
studies are needed before surgery. Typically, this
elevated T4/T3 and a non-suppressed (inappropriately
would include inferior petrosal sinus sampling with
normal) or elevated TSH concentration. TSH, LH and
either CRH or vasopressin (see Chapter 5) and a
FSH are all comprised of α-subunits and β-subunits.
central-to-peripheral ACTH gradient of >2.0 without
TSH adenomas typically produce a higher concentra-
CRH and >3.0 after CRH is diagnostic of pituitary
tion of the TSH α-subunit, resulting in a high α-sub-
ACTH production.
unit/TSH molar ratio, which can help in diagnosing
The goal of treatment is to remove the ACTH
these rare tumors. However, interpretation of this
adenoma and reverse symptoms of hypercortiso-
ratio can be complex as the α-subunit test is only
lism. Trans-sphenoidal surgery to remove the ade-
available in specialized laboratories and it is impor-
noma is the treatment of choice for patients with
tant that both α-subunit and TSH levels should be
ACTH adenoma. Depending upon the size of the
tested in the same sample. The cut-off values may
tumor, the remission rate is as high as 60–80% for
vary; for instance, in men the α-subunit/TSH molar
small adenomas (Woo et al., 2005). However, risk
ratio may be as low as 0.3 whereas in post-menopausal
of recurrence is high and around 15–20% of
women it can be as high as 29.1 (Beck-Peccoz et al.,
patients with initial remission eventually develop
1992).
recurrence (Petersenn et al., 2015). Medical ther-
The primary management of TSH adenomas is
apy is generally used for symptom control while
surgical removal of the tumor. However, in patients
awaiting surgery. Various medical therapeutic
with persistent disease, long-acting somatostatin ana-
options are available, including: (a) drugs inhibit-
log therapy (lanreotide, octreotide) is given, which
ing synthesis of glucocorticoids (ketoconazole,
leads to normalization of thyroid levels in almost
metyrapone, etomidate and LCI699); (b) drugs
90% of patients and tumor shrinkage in 40% of
reducing ACTH production by targeting the
patients (Beck-Peccoz et al., 2013).
ACTH adenoma (cabergoline, pasireotide); (c)
agents causing adrenal lysis (mitotane) and (d)
glucocorticoid receptor blocker (mifepristone). A 10.7 Non-pituitary SM
commonly employed strategy for ACTH adenomas Non-pituitary SMs constitute around 20% of all SM
is to start with ketoconazole and then add cabergo- (Al-Dahmani et al., 2016) of which Rathke’s cleft cyst
line; but newer agents like osilodrostat or LCI699, (RCC), craniopharyngiomas and meningiomas form
which act through reducing glucocorticoid synth- the main bulk of the disease. These tumors typically
esis by inhibiting 11β-hydroxylase, seem promising present either as incidental abnormalities or with
and studies are underway to assess the efficacy of evidence of mass effect and loss of pituitary hormonal
these agents. function.
In patients who are unable to achieve remission
through pituitary surgery, radiation therapy may be Rathke’s Cleft Cyst (RCC)
used but generally its role is limited because small RCC constitute almost 40% of all non-pituitary SM
adenomas are hard to localize. In patients with persis- and 6.5% of all SM with a higher prevalence (60%)
tent disease, bilateral adrenalectomy is the definitive among women (Al-Dahmani et al., 2016). These cysts
treatment. These patients then require life-long repla- arise from the remnant of Rathke’s pouch and mostly
cement with glucocorticoid and mineralocorticoid present in the third and fourth decade of life. The
therapy. commonest mode of presentation is incidental 179
Figure 10.5 MRI images, (A) weighted T1 and (B) T2 of a cystic craniopharyngioma. Cystic lesions such as craniopharyngioma, and RCCs exhibit
a variety of MRI signal intensities. This figure illustrates that the cystic fluid and the CSF appear bright on T2.
finding in almost 70% of cases or with mass effect conservatively, but enlarging lesions require surgery
causing headache or vision loss (Al-Dahmani et al., and in some cases radiation therapy. These tumors
2016). In a large series (Al-Dahmani et al., 2016), can be both solid and cystic (see Figure 10.5), and the
around 20% of patients with RCC had evidence of cystic portion may require intracavitary radiation
pituitary insufficiency at presentation. Smaller and such as yttrium 90 (Burrell et al., 2017) or intracavi-
otherwise stable RCC generally do not require any tary chemotherapy (Hukin et al., 2007).
intervention, but an enlarging cyst would require
surgical management. Excision of the cyst with partial 10.8 Less Common SM
removal of the wall is the commonly used surgical
A number of uncommon pituitary and non-pituitary
approach, but re-accumulation of fluid and thus
SM are encountered. These account for approxi-
recurrence of the cyst occurs in almost 40 % patients
mately 0.5% of SM (Al-Dahmani et al., 2016) and
(Kinoshita et al., 2016). Our own approach is to use
include: meningiomas, arachnoid cysts, hypophysitis,
radiation therapy by injecting yttrium 90 into the cyst
histiocytosis, malignant neoplasms like germinoma
with no evidence of early recurrence (unpublished
and metastatic lesions, among others. These SM are
data).
uncommon and a detailed discussion is outside the
Craniopharyngiomas scope of this book.
Craniopharyngiomas account for around 4.5% of all
SM and typically present early in life up to the third 10.9 Chapter Summary
decade and can also arise from the remnants of SM are mostly benign growths of pituitary or non-
Rathke’s pouch (Al-Dahmani et al., 2016). The most pituitary origin that are increasingly encountered in
common mode of presentation during adult life is clinical practice. These tumors constitute 15% of all
headache and vision loss or as incidental abnormal- central nervous system tumors and the population
ities (Al-Dahmani et al., 2016). These tumors are prevalence is around 0.1%. In a large, comprehensive,
highly likely to cause pituitary insufficiency and as population-based study of 1005 SM, 837 (83%) had
much as 70% of patients have some degree of pituitary PAs and 168 (17%) had non-pituitary sellar lesions.
insufficiency at presentation (Al-Dahmani et al., The relative prevalence of various SMs was: NFAs
180 2016). Small tumors are generally followed (38.4%), PRLomas (34.3%), RCCs (6.5%), GH-
secreting adenomas (6.5%), craniopharyngiomas intervention. PRLomas mostly respond to medical

(4.5%), ACTH-secreting adenomas (3.8%), meningio- therapy with dopamine agonist agents, whereas pri-
mas (1.9%) and others (3.9%). mary treatment for both GH and ACTH adenomas is
Evaluation of SM includes assessment of pituitary surgical excision followed by medical therapy in case
insufficiency, hormonal oversecretion, mass effect, of non-remission.
other medical condition, drugs and family history. A
baseline screening hormonal evaluation should be 10.10 Review Questions
conducted in all patients at presentation and then as
needed. 1. With regard to imaging of the sella, which of the
Although the CT scan is superior in visualizing the following statements are correct?
bony structures of the sella, MRI is by far the best a. A computed tomography (CT) scan is ideal for
technique to visualize the pituitary gland. MRI scans visualizing the soft tissue structures around the
generate images based on the hydrogen (or proton) sella.
content, and tissues with higher hydrogen content b. Cerebrospinal fluid appears bright on T2-
appear brighter on MRI. The images are further weighted magnetic resonance imaging (MRI).
adjusted to emphasize different tissue densities into c. Gadolinium is taken up by the normal
either T1 weighted – where fat appears bright and the pituitary tissue.
water content of CSF appears dark – or T2 weighted – d. MRI is the ideal technique to study the bony
where water (and CSF) appears bright and fat appears structures of the sella.
lighter. The use of gadolinium contrast medium with e. Tissues with higher glucose uptake avidly take
T1-weighted sequences greatly improves the clarity of up [18 F] fluorodeoxyglucose tracer.
the images. Some microadenomas and cystic pituitary
2. Nonfunctioning adenomas (NFA) are associated
lesions are better visualized on T2-weighted images.
with which of the following features?
Although not routinely used in day-to-day pituitary
care, PET scans using a radionuclide tracer such as FDG a. Most NFA stain positive for growth hormone
are frequently used in patients for detection of cancer. (GH).
Tissue uptake of tracers produces gamma ray emissions, b. Monitoring of hormonal function can be
which are imaged by a scanning camera that produces discontinued after 1 year of follow-up.
3D images. Occasionally PET scans done for other c. Dopamine agonist therapy shrinks 90% of
indications might pick up an area of increased uptake NFA tumors.
in the sella, which is generally due to PAs, metastatic or d. Radiation therapy is the first-line treatment for
inflammatory lesions. PET scan images may be super- enlarging tumors.
imposed on CT or MRI to provide better overall ana- e. NFAs typically present with either features of
tomic details. mass effect or as incidental lesions.
The specific pathologies and their most common 3. Which of the following statement are true for
presenting features are: NFA (incidental, headaches prolactinomas (PRLomas)?
and vision loss); PRLomas (galactorrhea, sexual a. PRLomas are the commonest functional
dysfunction and headache); GH adenomas (enlar- pituitary tumors.
ging extremities, excessive snoring and sweating); b. A mildly elevated serum prolactin (PRL) with a
ACTH adenomas (easy bruising, muscle wasting large tumor may be due to stalk compression.
and weight gain); TSH adenomas (tachycardia, c. Patients with macroprolactinemia typically do
excessive sweating, nervousness and weight loss); not have symptoms of elevated PRL.
and non-pituitary lesions (incidental, headaches d. Galactorrhea is commoner in female PRLoma
and vision problems). patients compared with males.
Smaller NFA and other non-pituitary SM may not e. PRLoma tend to grow inferiorly.
require any intervention except hormone replacement
in case of hormonal deficiency and regular monitor- 4. Which of the following statements are correct with
ing. Larger lesions require surgical excision and even regard to thyroid stimulating hormone (TSH)
radiation therapy. Functioning PAs cause considerable adenomas?
morbidity and even mortality and require urgent a. May present with features of thyrotoxicosis 181
b. Produce an excess of α-subunit compared with c. Surgery is the first-line therapy for these
TSH patients.
c. Despite an elevated TSH, serum T4 and T3 d. Screening for colonic cancer should be
levels are generally normal undertaken in all patients with acromegaly.
d. Somatostatin analog therapy can induce tumor e. Patients with mixed GH/PRL tumors may
shrinkage respond to dopamine agonist therapy.
e. Surgery is the first-line treatment 9. ACTH adenomas may present with which of the
5. Features of craniopharyngioma include which of following features?
the following? a. As incidental abnormalities
a. Hormonal deficiency is common in these b. Rapid weight gain
patients c. Mood disorders
b. Typically present in older individuals d. Postural dizziness
c. May show distinct calcification pattern on CT e. Salt craving
scan 10. Which of the following statements are correct for
d. May show up as bright lesions on T2-weighted Rathke’s cleft cysts (RCCs)?
MRI
a. RCCs are the commonest of all non-pituitary
e. Can lead to loss of vision
SM
6. With regard to the baseline hormonal assessment b. Most present as incidental findings
of pituitary tumors: c. Reaccumulation of the cyst is common after
a. Blood can be drawn at any time during the day. surgical drainage
b. A subnormal serum PRL is typically seen in d. All patients should undergo surgical drainage
patients with stalk compression. followed by intracavitary radiation therapy
c. Despite a low fasting serum osmolality, urine e. Can be malignant in a small number of
is highly concentrated in patients with diabetes patients
insipidus (DI).
d. A morning basal serum cortisol of 400 nmol/L
excludes cortisol deficiency. Further Reading
e. Hypernatremia may occur in untreated DI Babic N, Yeo K-T J, Hannoush Z C & Weiss R E. (2017).
patients. Endocrine testing protocols: hypothalamic pituitary adrenal
axis. www.endotext.org
7. Which of the following statements regarding the
clinical history of sellar masses (SMs) are correct?
a. A family history of pituitary adenomas might
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184
Appendix
Answers to Review Questions
Chapter 1 Chapter 2
1. Correct answer: phospholipase C (PLC) pathway 1. Answers: a and e are no longer in use; ELISA and
and JAK/STAT pathway. associated assays are the methods of choice in
2. Correct answer: Neurotransmitters bind to terms of automation and large sample numbers;
G protein-coupled receptors, whereas peptides, mass spectrometry is also a valuable technique,
such as prolactin, bind to tyrosine kinase able to determine multiple hormones in small
receptors. sample volumes.
3. Answers: Any of the releasing hormones (e.g.,
2. Possible answers:
corticotropin releasing hormone, GnRH, TRH or
somatostatin); also circulating hormones such as a. Monthly (e.g., LH or FSH)
leptin, GH, TSH or oxytocin. b. Circadian (e.g., ACTH or cortisol)
4. Answer: b and d bind to intracellular receptors. c. Sleep (e.g., GH)
5. Answers: a, c and d are correct. Estradiol receptors d. Pulsatile (ultradian; e.g., PRL or LH)
are predominantly found in the cytosol, not the 3. Answers: Nighttime maximum secretion is seen,
cell membrane, and do not activate G proteins. for example, for PRL, TSH, leptin and vasopressin.
6. Answer: true. The receptor is only biologically A typical daytime maximum is seen for cortisol
active when bound to the hormone. The hormone- and ACTH.
receptor complex acts as a transcription factor, 4. Answer: The stimulatory proteins are CLOCK and
modifying gene expression. BMAL1, and the inhibitory ones are PER and CRY.
7. Answer: GHRH and ghrelin activate stimulatory 5. Possible answers: Shift work, jet lag, artificial
G proteins that signal through cAMP and PLC, lighting at night, aging, Cushing’s syndrome.
respectively, to synergistically increase GH release. 6. Possible answers: LH, GH, ACTH, cortisol, PRL,
Somatostatin acts through an inhibitory G protein oxytocin.
to reduce cAMP production and inhibit GH 7. Answers: (a) pituitary receptors for GnRH would
secretion. be downregulated, shutting off the release of
8. Answers: a. Delayed puberty; b. hypothyroidism; gonadotropins; and (b) inhibition of LH secretion
c. obesity and hyperphagia; d. dwarfism; would prevent ovulation.
e. nephrogenic diabetes insipidus. 8. Correct answers: all statements are correct.
9. Correct answer is c. An activating mutation of the 9. Correct answers are: a and b. c is incorrect because
LH receptor stimulates high testosterone levels. long-acting GnRH analogs downregulate GnRH
The high testosterone, in turn, reduces LH and receptors and thus reduce gonadotropin secretion,
FSH through negative feedback. causing hypogonadism. d is incorrect because
10. Correct answers are: b, c and d. An activating TSH longstanding hypogonadism, with reduced
receptor mutation typically leads to excessive gonadal steroids, increases the risk of
stimulation of the thyroid gland and high levels of osteoporosis. e is also incorrect because GnRH
T4. This produces goiter, low TSH (negative analogs suppress gonadotropins and thus reduce
feedback) and features of hyperthyroidism. the production of sex steroids, arresting the
185
Appendix
pubertal process. These agents are actually used in incorrect because GLP-1 is rapidly degraded
some cases of precocious puberty. following injection, leading to inconsistent results.
10. Correct answers are: b, c and d. a is incorrect 6. Correct answers are: a, b, d and e.
because, unlike blood, tissues like hair, saliva and 7. Correct answers are: b, c and d. Food-induced
urine provide an estimation of the average Cushing’s is due to GIP (gastric inhibitory
hormonal secretion over hours, days or even polypeptide). e is incorrect because several long-
weeks. e is also incorrect because immunoassays acting formulations are available requiring weekly
are based on the use of antibodies, whereas mass injections.
spectrometry is based on the differences in 8. Correct answer is c. a, b and d cause weight loss
molecular weight. and hyperprolactinemia does not exert significant
effect on weight.
Chapter 3 9. Correct answers are: c, d and e.
10. Correct answers are: a, c and d. b is incorrect, as
1. Correct answers are: a, b, c and e. Hypothalamic weight gain due to HO is resistant to caloric
opioid receptors have affinity for both endogenous restriction, and e is incorrect because
and exogenous opioids. hyperglycemia can occur with any weight gain.
2. Correct answers are: a, b, d and e.
3. Correct answer is c because due to the Chapter 5
hypothalamic dysfunction in patients with
anorexia nervosa, both LH and FSH secretion is 1. Correct answer is: corticotropin releasing
reduced. hormone (CRH) and vasopressin (VP; antidiuretic
4. Correct answers are: a, b and e. c is incorrect hormone).
because opioids have a central effect on the 2. Correct answer is: c. The pituitary tumor secretes
hypothalamic–pituitary system, and d is incorrect ACTH that stimulates the adrenal cortex to increase
because the effect is seen with oral as well as cortisol output. However, this type of tumor does
injectable opioids. not respond in the normal way to cortisol negative
5. All are correct. feedback, so ACTH secretion remains high.
6. Correct answer is e. This is the only treatment that An adrenal tumor would give high cortisol but low
will induce ovulation. The GnRH will stimulate ACTH, via negative feedback. a would give low
the pituitary to produce FSH, which in turn will blood ACTH via negative feedback. b would give
produce estradiol from the ovary followed by low cortisol and high ACTH; that is, no negative
a midcycle release of LH. Ovulation will ensue feedback. d is inappropriate except for possible
7. Correct answers are: b, d and e. obesity in both cases.
8. Correct answers are; b, c, d and e 3. Correct answer is: a. b, c, d and e are typical
symptoms seen in untreated Addison’s patients
and are due to the loss of adrenal hormones
Chapter 4 cortisol and aldosterone. These patients are
1. Correct answer is d. Ghrelin is secreted from the normally hypotensive; thus, a is incorrect.
empty stomach. 4. Correct answers are: b is correct, but the diurnal
2. Correct answer is e, all of the above. increase occurs toward the end of sleep; c is
3. Correct answers are: b, c and d. a is incorrect correct; and d and e are incorrect. Glucocorticoid
because LH pulses are largely absent. e is incorrect treatment reduces ACTH via negative feedback,
because these patients are often underweight. whereas in e the removal of negative feedback (low
4. Correct answer: High levels of leptin, consistent cortisol) elevates ACTH levels.
with diet-induced obesity, are ineffective in 5. Correct answer is: These three peptides are
reducing food intake because of a state of leptin derived from the same precursor propeptide, pro-
resistance; that is, hypothalamic leptin receptors opiomelanocortin (POMC). They are thus all
do not respond to leptin. However, in the presence present in the same secretory vesicles and are
of amylin, leptin is able to reduce body weight. therefore co-released from corticotrophs.
5. Correct answers are: b, c and e. a is incorrect 6. Correct answers are: a, b and c. d is incorrect
186 because levels are lower in obese individuals. d is because dexamethasone suppresses ACTH
Appendix
through negative feedback. e is also incorrect Chapter 7

because congenital adrenal hyperplasia causes
1. Correct answers are: b and d. a is incorrect because
reduced cortisol production thereby reducing
PRL induces milk production whereas milk
negative feedback on ACTH. This stimulates
ejection is induced by oxytocin; and c is incorrect
ACTH production and secretion.
because dopamine agonists lower PRL and thus
7. Correct answers are: a, c and d. b and d are
inhibit lactation. A dopamine antagonist would
typically seen in hypocortisolism.
elevate PRL
8. Correct answers are: a and e. b and c reduce ACTH
2. Correct answers are: a, c, d and e. Cabergoline is
release from the pituitary adenoma, and
a dopamine agonist that lowers PRL.
mifepristone is an adrenal receptor blocker.
3. Correct answer is: c.
9. Correct answer: all of the above
4. Correct answers are: a, b, c and e.
10. Correct answers are: c, d and e. a reduces
5. Correct answers are: b and e. Option a is incorrect
ACTH production via a direct hypothalamic
because most Prolactinomas respond to medical
effect, and b suppresses ACTH through
therapy. Quinagolide is a non-ergot D2 agonist
negative feedback.
whereas bromocriptine and cabergoline are ergot
derivatives and dopamine therapy can worsen
Chapter 6
psychosis.
1. Correct answer is: c. Her TSH levels should be very 6. Correct answers are: a, b and c.
low because of the negative feedback effect of 7. Correct answers are: a and b. c is incorrect because
thyroxine. increased PRL leads to excessive lactation
2. Correct answers are: c and d, because TSH levels (galactorrhea); d is also incorrect because tongue
fall after fasting or starvation, and d because hCG enlargement (macroglossia) occurs due to
acts like TSH thus lowering endogenous TSH excessive growth hormone production. e is
secretion. incorrect because with hypogonadism there is
3. Correct answers are: a, c and d. b is incorrect because testicular shrinkage rather than enlargement.
moist hands and feet are due to thyrotoxicosis. e is 8. Correct answer is: all are correct.
incorrect because weight gain, rather than weight
loss, is typical in hypothyroid patients.
4. Correct answers are: a, b, c and e. Replacement is Chapter 8
typically given as T4 due to its long half-life compared 1. Correct answers are: b, c and d. Ghrelin stimulates
to T3. Iodine is required for thyroid hormone GH secretion as does hypoglycemia.
synthesis and deficiency of iodine makes women 2. Correct answer is: all are correct, except
more prone to hypothyroidism during pregnancy e. Somatostatin inhibits GH secretion.
when thyroid hormone requirement increases. 3. Correct answers are: b, c and e. Gigantism and
5. Correct answer is: c because with the removal acromegaly both increase serum IGF-1 but
of the thyroid gland, both T4 and T3 levels will gigantism occurs in prepubertal children before
drop allowing TSH to rise, free of negative the closure of the epiphyseal plates.
feedback. 4. Correct answers are: a, b, d and e. IGF-1 is
6. Correct answers are: b, c and d. The half-life of T3 produced by the liver under the influence of GH.
is less than 24 hours and it is the bound T4 that 5. Correct answers are: c and e. a and d are incorrect
constitutes the largest portion of the T4 pool. as neither of these conditions cause GHD and
7. Correct answer is: all are correct. b suggests familial short stature.
8. Correct answers are: a, b and e. c is incorrect 6. Correct answer is: all are correct.
because these patients typically develop a goiter. 7. Correct answers are: b, d and e. a is incorrect as
d is also incorrect because heart muscle GH typically drops after glucose and a failure of
predominantly expresses THRα which remains GH to suppress indicated acromegaly and GHD is
sensitive to high circulating thyroid hormone associated with a low IGF-1 level.
levels, causing tachycardia. 8. Correct answers are: b and d. Acromegaly leads to
9. Correct answers are: b, c, d and e. excessive sweating and failure of GH to suppress
10. Correct answers are: b and c. after oral glucose test. 187
Appendix
9. Correct answer is: c. partially sensitive to desmopressin. c and e are

10. Correct answers are: a, b and e. c is incorrect because incorrect as both cause nephrogenic DI.
ghrelin synergizes with GRH, and d is incorrect 9. Correct answers are: b, c and d. a and e are
because somatostatin is an agonist at SSTR. incorrect as it is oxytocin, which leads to uterine
contraction and milk letdown during lactation.
Chapter 9 10. Correct answers are: a, b and c. d and e are
1. Correct answer is: c. Oxytocin is biosynthesized in incorrect as SIADH leads to fluid retention rather
supraoptic and paraventricular hypothalamic than dehydration, and polydipsia is associated
neurons and then transported to nerve terminals with diabetes insipidus.
in the posterior lobe of the pituitary, from which it
is secreted. Chapter 10
2. Correct answers are: a, b and d. c is incorrect; VP 1. Correct answers are: b, c and e. A CT scan is ideal
increases when osmolality increases. e is incorrect; for visualizing the bony structures, whereas MRI
copeptin and VP are derived from the same pre- better visualizes the soft tissue.
propeptide and are secreted together in equimolar 2. Correct answer is e. Most NFA stain for
amounts. gonadotropins and long-term monitoring is
3. Correct answer is: e. a, b, c and d are incorrect. VP required as a significant proportion of patients
and oxytocin are biosynthesized in separate develop hormonal dysfunction over the years.
neurons. VP and oxytocin are bound to different In enlarging tumors, or those with evidence of
neurophysins (I and II). VP is released from the mass effect, surgery is the first-line treatment.
posterior pituitary by action potentials, not by Medical therapy with dopamine agonists has
a releasing hormone. An oral water load inhibits limited efficacy in terms of tumor shrinkage and
VP secretion. radiation therapy is used in patients with
4. Correct answers are: a, c and d. a is correct because significant or enlarging residual tumor after
the mutation reduces VP secretion and prevents surgery.
anti-diuresis. b is incorrect because release is 3. Correct answer is: all answers are correct.
regulated by action potentials. c is correct because 4. Correct answers are: a, b, d and e. These patients
VP synergizes with CRH to increase ACTH typically present with elevated T4 and T3 levels and
release. d is correct because the aquaporin a non-suppressed or elevated TSH.
channels are activated (phosphorylated) by 5. Correct answers are: a, c, d and e. These tumors
stimulation of V2 receptor. e is incorrect because typically present at a younger age and are less
the frequency of oxytocin pulses is critical for common in older individuals.
initiation of labor, not the magnitude. 6. Correct answers are: d and e. A blood sample
5. Correct answers are: a, c and d. b is incorrect; should be drawn around 2 hours after awakening
oxytocin release is stimulated by running. e is to check basal hormone levels and to avoid
incorrect; oxytocin receptors are also found in interference of the diurnal rhythm. In patients
many areas of the human brain. with stalk compression, serum PRL is mildly
6. Correct answers are: a, d and e. b is incorrect as elevated and in patients with untreated DI, fasting
DDAVP will lead to further fluid retention. serum osmolality is high but urine remains dilute.
A rapid normalization of serum sodium can lead 7. Correct answer is: all are correct.
to permanent neurological damage and must be 8. Correct answers are: c, d and e. Most systemic
avoided. manifestations of acromegaly are mediated by
7. Correct answers are: a and b. c is incorrect because IGF-1 and the predominant causes of mortality
serum osmolality is typically high in untreated DI are cardiovascular and respiratory disorders.
patients, indicating hemoconcentration. d is 9. Correct answers are: a, b and c. Both d and e are
incorrect as lithium therapy leads to nephrogenic features of cortisol deficiency.
DI and e is also incorrect as VP is low in central DI 10. Correct answers are: a, b and c. RCC are benign
due to reduced production of VP. lesions and surgical management is only needed in
8. Correct answers are: a, b and d. It is noteworthy a large cyst with evidence of mass effect, whereas
188 that some patients with nephrogenic DI remain small cysts simply require monitoring.
Index
acromegaly, 106, 140–141, 145–146, androgens, 6 arginine vasopressin. See vasopressin

172, 176–178 GC resistance and, 9, 10 aripiprazole, 120–121
treatment of, 144, 145–146, 177–178 androstenedione, 29, 31 assays, 14, 25
ACTH. See adrenocorticotropin anorexia nervosa, 53 enzyme-linked immunosorbent
ACTH adenomas, 88–89, 155–156, anamorelin treatment for, 64 assay (ELISA), 14, 15
178–179 HPA axis and, 88 immunoassays, 14–15, 16
Addison’s disease, 23–25, 85 leptin deficiency in, 56–57, 58 mass spectrometry, 15–16, 17
adenoma LH secretion in, 32, 34 multiplex immunoassays, 14–15, 16
nonfunctioning, 174–175 OXY secretion in, 159 autism, 165
pituitary (See pituitary adenoma) anorexigenic peptides, 62 autoimmune thyroid disease, 106, 108
adipokines, 55. See also leptin anosmia, 35, 36
adrenal cortex, 75. See also anti-depressants, ACTH and cortisol blood pressure, VP secretion and,
hypothalamic–pituitary– effects of, 78 164–165
adrenal cortex axis antidiuresis, 160, 161 blood samples, 14, 15–16
adrenocorticotropin (ACTH) antidiuretic hormone. See vasopressin bmal1 gene, 18–20
assay of, 14 antiestrogens, estrogen resistance body weight. See appetite and body
in Cushing’s disease, 88–89 induced by, 8 weight regulation
drugs and medications influencing, anti-psychotic drugs brain injury
32 ACTH and cortisol, effects on, 78 cortisol deficiency in, 89–90
GC resistance effects on, 9, 10, obesity induced by, 67–68 DI (diabetes insipidus) after, 163
79–81, 82 PRL, effects on, 120–121 hypothyroidism in, 111–112
in obesity, 87–88 appetite and body weight regulation, breast cancer, estrogen resistance
POMC deficiency and, 59 53–54, 68–69 in, 8
secretion of, 22–25 case studies involving breastfeeding
daily rhythm of, 75–77, 78 drug-induced obesity, 67–68 OXY secretion and, 157–158
GC negative feedback on, 79–81, hypothalamic obesity, 66–67 PRL secretion and, 122–123
82, 83 genes affecting, 58–59 bromocriptine
MRs and, 81, 83 FTO gene mutations, 61–62 GH suppression by, 145–146,
neurotransmitter/neuropeptide leptin deficiency, 55, 57 177–178
control of, 75–79, 80 MC4R deficiency, 61 PRL inhibition by, 119–120,
pulsatile rhythm of, 81–82 POMC deficiency, 59–61 127–128, 176
VP regulation of, 154–156 Prader-Willi syndrome, 61 Byetta. See exenatide
stress effects on, 82–83, 84 GI peptide role in (See
psychiatric disorders and, 85–86 gastrointestinal peptides) cabergoline
reproduction and, 83–85, 86 HPA axis and for ACTH-producing pituitary
age anorexia nervosa, 88 adenoma, 89, 179
circadian disruption associated with, food intake, 87 GH suppression by, 145–146,
21 obesity, 87–88 177–178
GH secretion and, 139–140 leptin role in, 54, 55, 56 PRL inhibition by, 119–120,
albiglutide (Tanzeum), 64–65 clinical use of leptin and gut 127–128, 176
Allan-Herndon-Dudley syndrome, peptides in body weight control, CAH. See congenital adrenal
103–104 58, 60 hyperplasia
Alzheimer’s disease, 21 obesity caused by deficiency of, 55, calcitonin, 97
amenorrhea 57 cancer anorexia-cachexia syndrome,
hypothalamic (See hypothalamic obesity caused by excess of, 57, 59 64
amenorrhea) obesity caused by leptin receptor cannabis, PRL secretion and, 121
leptin deficiency and, 56–57, 58 mutation, 55 canrenoate, 81, 83
suckling-induced, 122 neural control of, 54, 55, 56 CBG. See corticosteroid binding
amylin, 58, 60 obesity and (See obesity) globulin 189
anamorelin, 64 OXY secretion and, 159 cell membrane receptor mechanisms, 2
Index
GPCRs, 2–5 (See also G protein- GIP and, 62 resistance to, 8

coupled receptors) reproductive disturbances in, 84–85 etomidate, 89, 179
tyrosine kinase-dependent exenatide (Byetta), 64–65
receptors, 5–6 daily rhythm secretion patterns, 17–20
chest wall trauma, 122 DDAVP. See desmopressin fat mass and obesity related (FTO)
circadian rhythm. See also deiodinases, 101–102, 103, 104 gene, 61–62
suprachiasmatic nucleus delayed puberty, 35–37 female reproduction, 29, 45–46
of ACTH secretion, 75–77, 78 dermorphin, 37–38 case studies involving
of cortisol secretion, 17, 18, 19, 20, desmopressin (DDAVP), 161 delayed puberty, 35–37
75–77, 78 dexamethasone (DEX), 79–81, 82, 85 opioids and kisspeptin, 45
of hormone secretion, 17–20 dexamethasone suppression test GnRH secretion in
disruption of, 20–22 (DST), 178 kisspeptin stimulatory effects on,
of TSH secretion, 105–106, 107, 108 diabetes insipidus (DI), 154, 160–163 40–45
clock gene, 18–20 domperidone, 122–123 neural control of, 30–31, 32
congenital adrenal hyperplasia (CAH), dopamine neurochemical regulation of, 37
85, 86 PRL regulation by, 118, 119–121 opioid inhibitory effects on, 37–39
copeptin, 156, 159 TSH effects of, 99 LH secretion in, 31–33, 34
corticosteroid binding globulin (CBG), dopamine agonists absence of, 34–37
79, 81 GH suppression by, 145–146, development of, 32–33, 34
corticotrophs, 22, 75, 79, 155 177–178 kisspeptin effects on, 41–42, 43, 44
corticotropin releasing hormone (CRH) PRL inhibition by, 119–120, 121, in menstrual cycle, 32, 33
ACTH regulation by, 75–76, 77, 79 127–128, 176 necessity of, 33–34, 35
in obesity, 87–88 DST. See dexamethasone suppression menstrual cycle control in, 29, 30,
secretion of, 22–25 test 31, 32, 33
cortisol, 6 dulaglutide (Trulicity), 64–65 fentanyl, 157
deficiency of, 89–90 dynorphin (DYN), 37–38, 40–41, 42 fertility
excess of (See Cushing’s disease; LH secretion in, 31–32, 33–34, 35
Cushing’s syndrome) eating behavior. See appetite and body stress effects on, 83–85, 86
food intake and, 87 weight regulation thyroid hormones and, 110–111
GC resistance effects on, 9, 10, ELISA. See enzyme-linked FGFR1 gene, 35, 36
79–81, 82 immunosorbent assay follicle stimulating hormone (FSH), 2
GH secretion and, 141–142 endocannabinoids, PRL secretion and, drugs and medications influencing,
measurement of, 14, 15–16, 17, 75, 121 32
76–77 endogenous opioid peptides (EOP), GC effects on, 85
MR binding of, 81, 83 37–39 GnRH secretion and, 22, 23, 33–34,
in obesity, 87–88 β-endorphin, 37–38 35
secretion of energy balance, thyroid hormones and, in Kallmann syndrome, 36–37
ACTH regulation and, 75–81, 82, 107–109 in menstrual cycle, 29, 30, 31
83 energy intake. See appetite and body folliculostellate (FS) cells, 102
daily rhythm of, 17, 18, 19, 20, weight regulation food intake. See appetite and body
75–77, 78 enzyme-linked immunosorbent assay weight regulation
disrupted of, 21–22 (ELISA), 14, 15 FS cells. See folliculostellate cells
pulsatile, 22–25, 81–82 EOP. See endogenous opioid peptides FSH. See follicle stimulating hormone
stress effects on, 82–83, 84 ER. See estrogen receptor FTO gene. See fat mass and obesity
psychiatric disorders and, 85–86 estradiol, 6 related gene
reproduction and, 83–85, 86 GH secretion and, 137–139 fulvestrant, 8
synthesis of, 75 GnRH secretion and, 22, 23
craniopharyngiomas, 180 kisspeptin and, 41, 42 G protein-coupled receptors (GPCRs)
CRH. See corticotropin releasing in menstrual cycle, 29, 30, 31 clinical significance of, 3–5
hormone PRL secretion and, 123–124 desensitization of, 4
critical illness structure of, 6 mechanisms of, 2–5
HPA axis activation in, 83, 84 estradiol therapy, in Kallmann mutations in genes for, 4–5
thyroid function in, 109, 110 syndrome, 37 galactorrhea, 122–123
Cushing’s disease, 155–156, 178–179 estrogen gamma-hydroxybutyrate (GHB), 139
cortisol secretion in, 17, 18, 88–89, GH secretion and, 137–139 gastrointestinal (GI) peptides
172 OXY and VP secretion and, 157 in appetite regulation, 54, 55, 56, 62
HPA axis in, 88–89 resistance to, 8 clinical use of leptin and gut
Cushing’s syndrome structure of, 6 peptides in body weight control,
CRH and VP measurement in estrogen receptor (ER) 58, 60
190 assessment of, 77 mechanisms of, 7–8, 9, 10 ghrelin (See ghrelin)
Index
GLP-1, 62, 64–65, 66 pulsatile LH secretion induced by, GCs, 9, 10, 79–81, 82
cortisol secretion and, 87 31–32, 33–34, 35 leptin, 6, 57, 59
GCs. See glucocorticoids secretion of THR, 102–105
gender, GH secretion and, 137–139 in hypothalamic amenorrhea, 22, hormone response element (HRE),
germinomas, 66–67 23, 34 6–7, 8
GH. See growth hormone kisspeptin stimulatory effects on, hormones. See also specific hormones
GH adenomas, 145–147, 148, 176–178 40–45 assays of (See assays)
GHB. See gamma-hydroxybutyrate neural control of, 30–31, 32 secretion patterns of, 16, 25–26
GHD. See growth hormone deficiency neurochemical regulation of, 37 circadian disruption, 20–22
GHR. See growth hormone receptor opioid inhibitory effects on, 37–39 daily rhythms, 17–20
ghrelin GPCRs. See G protein-coupled pulsatile, 22–25
ACTH and cortisol effects of, 78 receptors HPA axis. See hypothalamic–
in appetite regulation, 54, 55, 56, GR. See glucocorticoid receptor pituitary–adrenal cortex axis
62–64 Graves’ disease, 106 HRE. See hormone response element
FTO gene link to, 62 growth hormone (GH), 134, 148–149 human chorionic gonadotropin
GH regulation by, 134, 135 assay of, 14–15, 16 (hCG), in Kallmann syndrome,
in obesity, 64 case studies involving 36–37
PRL secretion and, 119 GHD, 148 hydrocortisone, LH and FSH effects of,
somatotroph receptors for, 143–144, gigantism, 146–147, 148 85
145 deficiency of (See growth hormone hypercortisolism, 81. See also
GHRH. See growth hormone releasing deficiency) Cushing’s disease; Cushing’s
hormone drugs and medications influencing, syndrome
GI peptides. See gastrointestinal 32 hyperprolactinemia, 126, 172
peptides excess of, 145–147, 148, 172, chest wall trauma causing, 122
gigantism, 145–147, 148, 176–178 176–178 dopamine agonist treatment for,
GIP. See glucose-dependent insulin GPCR-dependent mechanisms 119–120, 121, 127–128, 176
releasing polypeptide regulating, 3 drugs inducing, 120–121, 126
glucagon-like peptide-1 (GLP-1) IGF-1 stimulation by, 144–145, 146 macroprolactinemia and, 118, 176
in appetite regulation, 62, 64–65, 66 insensitivity to, 6 PRLomas causing (See
cortisol secretion and, 87 secretion of prolactinomas)
glucocorticoid receptor (GR), 6–7, 75, daily rhythm of, 17–18 hyperthyroidism, 98, 111, 112, 172
79 factors influencing, 136–142 blood tests for, 99
mechanism of, 79, 81 neural control of, 142–143 fertility in, 110–111
resistance, 9, 10, 79–81, 82 pulsatile, 134–135, 136 metabolic rate in, 107
glucocorticoids (GCs). See also cortisol regulation of, 134, 135 pulsatile TSH secretion and, 106
ACTH regulation by, 79–81, 82, 83 somatotroph receptor TSH adenoma causing (See TSH
assay of, 14 mechanisms and, 143–144, 145 adenomas)
disrupted secretion patterns of, tyrosine kinase-dependent receptors hypoglycemia, insulin-induced, 82, 83
21–22 for, 5 hypogonadotropic hypogonadism
GH secretion and, 141–142 growth hormone deficiency (GHD), GnRH deficiency inducing, 34
health and disease roles of, 75, 76 140–141, 147–148 KISS1 gene mutations in, 42–43
in HPA axis (See hypothalamic- growth hormone receptor (GHR), 5, leptin deficiency and, 55, 56
pituitary-adrenal cortex axis) 144–145, 146 opioid administration causing, 38
replacement of, 23–25 growth hormone releasing hormone hypothalamic amenorrhea (HA)
resistance to, 9, 10, 79–81, 82 (GHRH) cortisol levels in, 83–84
structure of, 6 GH regulation by, 134, 135 GnRH secretion in, 22, 23, 34
glucose, GH secretion and, 140–141 receptors for, 143–144, 145 kisspeptin use in, 43–44
glucose-dependent insulin releasing gut-brain axis, 62. See also leptin deficiency in, 56–57, 58
polypeptide (GIP), 62 gastrointestinal peptides naloxone and naltrexone therapy in,
GnRH. See gonadotropin releasing 39
hormone HA. See hypothalamic amenorrhea hypothalamic obesity (HO), 66–67
GnRH agonists, uses of, 34 hair samples, 14, 15–16, 17 hypothalamic–pituitary–adrenal
GnRH secretion, in hypothalamic haloperidol, PRL effects of, 120–121 cortex (HPA) axis, 75, 76, 90–91
amenorrhea, 22, 23, 34 Hashimoto’s thyroiditis, 106 ACTH in (See adrenocorticotropin)
GnRH therapy, in Kallmann hCG. See human chorionic body weight and, 87–88
syndrome, 36–37 gonadotropin case studies involving
gonadotropin releasing hormone head injury. See brain injury cortisol deficiency, 89–90
(GnRH), 1, 2 HO. See hypothalamic obesity Cushing’s disease, 88–89
deficiency of, 34–35, 36 hormone resistance, 8 cortisol in (See cortisol)
in menstrual cycle, 29, 30, 31 estrogens, 8 food intake and, 87 191
Index
stress and, 82–83, 84 reproductive system effects of, MCT8. See monocarboxylate
psychiatric disorders and, 85–86 41–42, 43, 44 transporter 8
reproduction and, 83–85, 86 KNDy neurons, 40–41, 42 melanocortin-4 receptor (MC4R), 61
VP (vasopressin) neurons in, KP. See kisspeptin α-melanocyte stimulating hormone
154–156 KS. See Kallmann syndrome (α-MSH), 58–61
hypothalamic–pituitary–gonadal melatonin, 19, 20
system, opioid effects on, 37–39 labor, OXY secretion in, 158, 159 menopause, 8, 10
hypothalamic–pituitary–thyroid axis, lactation. See breastfeeding menstrual cycle, 29, 30, 31
98–99 lanreotide, 144, 145–146, 177–178, 179 pulsatile LH secretion in, 32, 33
hypothalamic–posterior pituitary LCI699, 89, 179 metabolic syndrome, circadian
system, 154–156 leptin disruption and, 20–21
hypothalamus, 1–2 in appetite regulation, 54, 55, 56 metastin, 40
in appetite regulation, 54, 55, 56 clinical use of leptin and gut met-enkephalin, 37–38
drugs and medications influencing, peptides in body weight control, methadone, 121
32 58, 60 methimazole, 111
GH regulation by, 134, 135 obesity caused by deficiency of, 55, metyrapone, 22, 89, 179
GnRH control by, 30–31, 32 57 mifepristone, 81, 89, 179
PRL control by, 118, 119 obesity caused by excess of, 57, 59 mineralocorticoid receptor (MR), 79
TRH neurons in, 100 obesity caused by leptin receptor ACTH secretion and, 81, 83
hypothyroidism, 97–98, 111–112 mutation, 55 mechanism of, 79, 81
blood tests for, 99 deficiency of mineralocorticoids, 6
fertility in, 110–111 amenorrhea and, 56–57, 58 mitotane, 179
metabolic rate in, 107 lipodystrophy and, 57 molecular chaperone, 6–7, 8
TSH secretion and, 106, 107 obesity and, 55, 57 monocarboxylate transporter 8
as fat-derived peptide hormone, 55 (MCT8), 98, 101, 103–104
IGD. See isolated GnRH deficiency tyrosine kinase-dependent receptors morphine, 37, 121, 157
IGF-1. See insulin-like growth factor-1 for, 5 MR. See mineralocorticoid receptor
immunoassays, 14–15, 16 leptin resistance, 6, 57, 59 α-MSH. See α-melanocyte stimulating
in vitro fertilization (IVF), 44–45 LH. See luteinizing hormone hormone
incretins, 62 lipodystrophy, 57
inhibins, 29 liraglutide, 64, 65 naloxone
insulin, 22, 56, 63 liver cells, IGF-1 production in, ACTH and cortisol effects of, 78
insulin-induced hypoglycemia, 82, 83 144–145, 146 LH secretion and, 38–39
insulin-like growth factor-1 (IGF-1) lixisenatide (Lyxumia), 64–65 TSH effects of, 99
GH regulation by, 134, 135 luteinizing hormone (LH), 1, 2 naltrexone, 38–39
receptor mechanism for GH drugs and medications influencing, neuroendocrinology, 1
stimulation of, 144–145, 146 32 neurohypophysis. See posterior
receptors for, 143–144, 145 GC effects on, 85 pituitary
intracellular receptor mechanisms, GnRH secretion and, 22, 23, 31–32, neurokinin B (NKB), 40–41, 42
6–7, 8 33–34, 35 neuropeptides/neurotransmitters
estrogen receptors, 7–8, 9, 10 kisspeptin effects on, 40–42, 43, 44 ACTH control by, 75–79, 80
isolated GnRH deficiency (IGD), leptin effects on, 56–57, 58 GH control by, 142–143
34–35, 36 in menstrual cycle, 29, 30, 31 GnRH secretion control by, 37
IVF. See in vitro fertilization naloxone effects on, 38–39 kisspeptin, 40–45
opioid effects on, 38–39 opioids, 37–39
janus kinase (JAK), 5, 144–145, 146 pulsatile secretion of, 31–33, 34 mechanisms of membrane receptors
absence of, 34–37 for, 2
KAL1 gene, 35, 36 development of, 32–33, 34 GPCRs, 2–5
Kallmann syndrome (KS), 31–32, 33, kisspeptin effects on, 41–42, 43, 44 tyrosine kinase-dependent
34–37 in menstrual cycle, 32, 33 receptors, 5–6
ketoconazole, 89, 179 necessity of, 33–34, 35 OXY and VP regulation by, 156–157
KISS1 gene, 40, 41, 42–43 Lyxumia. See lixisenatide NFA. See nonfunctioning adenoma
kisspeptin (KP) NKB. See neurokinin B
GnRH secretion stimulation by, macimorelin, 135 nonfunctioning adenoma (NFA),
40–45 macroprolactin (macroPRL), 118, 176 174–175
potential clinical uses of, 42–43 male reproduction, LH secretion in,
hypothalamic amenorrhea, 43–44 31–32, 33, 35–37 OATP1C1. See organic ion
IVF, 44 mass spectrometry, hormone transporting polypeptide
in women at high risk for OHSS, quantification using, 15–16, 17 obesity, 53–54
192 44–45 MC4R. See melanocortin-4 receptor circadian disruption and, 20–21
Index
clock gene role in, 20 parturition, OXY secretion in, 158, 159 PR. See progesterone receptor
drug-induced, 67–68 pasireotide Prader-Willi syndrome (PWS), 61
genetic forms of, 58–59 ACTH and cortisol effects of, 78 pramlintide, 58, 60
FTO gene mutations, 61–62 for ACTH-producing pituitary precocious puberty, 42–43
leptin deficiency, 55, 57 adenoma, 89, 179 pregnancy, PRL secretion in, 123–124
leptin receptor mutation, 55 GH suppression with, 144, 145–146, PRH. See PRL releasing hormone
MC4R deficiency, 61 177–178 PRL. See prolactin
POMC deficiency, 59–61 prolactinoma treatment with, PRL releasing hormone (PRH), 118–119
Prader-Willi syndrome, 61 127–128 PRLomas. See prolactinomas
ghrelin in, 64 PCOS. See polycystic ovary syndrome progesterone
HPA axis and, 87–88 pegvisomant, 145–146, 177–178 GH secretion and, 137–139
hypothalamic, 66–67 pentagastrin, 78 in menstrual cycle, 29, 30, 31
leptin and gut peptide therapy for, peptide hormones. See also PRL secretion and, 123–124
58, 60 neuropeptides/ progesterone receptor (PR), 6–7
leptin deficiency in, 55, 57 neurotransmitters progestin therapy, in Kallmann
leptin excess in, 57, 59 endogenous opioid, 37–39 syndrome, 37
leptin receptor mutation, 55 GI (See gastrointestinal peptides) PROKR2 gene, 35, 36
leptin resistance causing, 6 leptin as, 55 prolactin (PRL), 118, 128–129
OXY secretion and, 159 mechanisms of membrane receptors case studies involving,
PRL secretion and, 125 for, 2 prolactinoma, 126–128
octreotide, 144, 145–146, 177–178 GPCRs, 2–5 elevated levels of (See
prolactinoma treatment with, tyrosine kinase-dependent hyperprolactinemia)
127–128 receptors, 5–6 secretion of
for TSH adenomas, 179 pituitary adenoma (PA) breastfeeding and, 122–123
OHSS. See ovarian hyperstimulation ACTH adenomas, 88–89, 155–156, chest wall trauma and, 122
syndrome 178–179 dopamine regulation of, 118,
olanzapine, 67–68, 78, 120–121 GH adenomas, 145–147, 148, 119–121
opioid antagonists, LH secretion and, 176–178 drugs and medications
38–39 history and assessment of patients influencing, 32, 121
opioid receptors, 37 with, 171, 172 obesity and, 125
opioids baseline hormonal assessment, pulsatile, 121–122
GH secretion and, 142–143 171 regulation of, 118–119, 120
hypothalamic–pituitary–gonadal imaging, 172–174 sex hormone effects on, 123–124
system and, 37–39 NFA, 174–175 sexual activity effects on, 124
LH secretion and, 38–39 prolactinomas (PRLomas), 126–128, sleep and, 121–122
OXY and VP secretion and, 157 175, 176 stress-induced, 124–125
PRL secretion and, 121 TSH adenomas, 106, 111, 112, 179 tyrosine kinase-dependent receptors
orexigenic peptides, 62 pituitary gland, 1–2. See also for, 5
organic ion transporting polypeptide hypothalamic–pituitary– prolactinomas (PRLomas), 126–128,
(OATP1C1), 101, 103 adrenal cortex axis; 175, 176
osmoreceptors, 159–160, 161 hypothalamic–pituitary– pro-opiomelanocortin (POMC) gene,
ovarian hyperstimulation syndrome gonadal system; hypothalamic– 59–61, 77, 78
(OHSS), 44–45 pituitary–thyroid axis proprotein convertases, 77, 78
ovulation, 29, 30, 31 drugs and medications influencing, psychiatric disorders, stress and, 85–86
oxytocin (OXY), 154, 165–166 32 puberty
behavioral effects of, 165 folliculostellate cells of, 102 delayed, 35–37
breastfeeding (suckling stimulus) GH secretion by, 134, 135 precocious, 42–43
and OXY secretion, 157–158 posterior (See posterior pituitary) pulsatile LH secretion in, 32–34, 35
central regulation of, 156–157 PRL control by, 118, 119 pulsatile secretion pattern, 22–25
eating behavior effects of, 159 pituitary insufficiency PVN. See paraventricular nuclei
genes for, 156 head injury with, 89–90, 111–112 PWS. See Prader-Willi syndrome
neurohypophyseal system secretion key features of, 172
of, 154–156 plasma osmolality, 159–160, 161 quetiapine, 67–68, 78, 120–121
parturition, OXY secretion in, 158, polycystic ovary syndrome (PCOS), 39 quinagolide, 119–120, 127, 176
159 POMC gene. See pro-
receptors for, 154–156 opiomelanocortin gene radioimmunoassay, 14
stimuli inducing, 157–159 posterior pituitary, 154, 165–166 Rathke’s cleft cyst (RCC), 179–180
neuroanatomy of, 154–156 receptor mechanisms, 1–2, 9–11
PA. See pituitary adenoma OXY secretion by (See oxytocin) cell membrane receptors, 2
paraventricular nuclei (PVN), 154, 155 VP secretion by (See vasopressin) GPCRs, 2–5 193
Index
tyrosine kinase-dependent for TSH adenomas, 179 rhythmic and pulsatile, 105–106,
receptors, 5–6 somatostatin receptor (SOMR), 107, 108
hormone resistance and, 8, 9, 10 143–144, 145 thyroid hormone feedback
intracellular steroid hormone prolactinomas expressing, 127–128 regulating, 100–102, 103
receptors, 6–7, 8 somatotrophs, 3 thyroid hormone receptor (THR), 98,
estrogen receptors, 7–8, 9, 10 GH secretion from, 134 100–101, 102
reproduction receptor mechanisms controlling, mutations in, 104–105
female (See female reproduction) 143–144, 145 thyroid hormone transporters, 98, 101,
male, 31–32, 33, 35–37 SOMR. See somatostatin receptor 103–104
stress effects on, 83–85, 86 SON. See supraoptic nuclei thyroid hormones. See thyroxine;
thyroid hormones and, 110–111 STAT. See signal transducer and triiodothyronine
reserpine, 120–121 activator of transcription thyroid replacement therapy, 97, 112
resistance to thyroid hormones (RTH), steroid hormone receptor thyroid stimulating hormone (TSH)
102–105 mechanisms, 6–7, 8 critical illness effects on, 109, 110
estrogen receptors, 7–8, 9, 10 drugs and medications influencing,
saliva samples, 14, 15–16 steroid hormones, 6 32
SCN. See suprachiasmatic nucleus assay of, 14, 15 fasting effects on, 107–108
second messengers, 2 stress in hypothalamic–pituitary–thyroid
of GPCRs, 3 HPA axis and, 82–83, 84 axis, 98–99
of tyrosine kinase-dependent psychiatric disorders and, 85–86 measurement of, 99
receptors, 5 reproduction and, 83–85, 86 secretion of
secretion patterns, 16, 25–26 PRL secretion induced by, 124–125 drug/hormonal effects on, 100
circadian disruption, 20–22 suckling stimulus, 122–123, 157–158 neural control of, 99–100
daily rhythms, 17–20 suprachiasmatic nucleus (SCN), 18–20 rhythmic and pulsatile, 105–106,
pulsatile, 22–25 supraoptic nuclei (SON), 154, 155 107, 108
seizure, 125 surgery, HPA axis activation after, thyroid hormone feedback
sellar masses (SM), 171, 180–181 82–83, 84 regulating, 100–102, 103
history and assessment of patients syndrome of inappropriate thyroid stimulating hormone receptors
with, 171, 172 antidiuretic hormone secretion (TSH.R), 106, 108
baseline hormonal assessment, (SIADH), 163–164 thyrotoxicosis, 98, 99, 111, 112
171 blood tests for, 99
imaging, 172–174 T3. See triiodothyronine fertility in, 110–111
NFA, 174–175 T4. See thyroxine TSH adenoma causing (See TSH
non-pituitary, 179–180 tamoxifen, 8 adenomas)
pituitary (See pituitary adenoma) Tanzeum. See albiglutide thyrotropin releasing hormone (TRH)
uncommon, 180 TBG. See thyroid binding globulin brain localization of, 100
semaglutide, 64–65 temozolomide, 127 in hypothalamic–pituitary–thyroid
setmelanotide, 59–61 testosterone, 6 axis, 98–99
sex hormones. See also specific sex GH secretion and, 137–139 neural control of, 99–100
hormones opioid effects on, 38 PRL secretion and, 118–119
GH secretion and, 137–139 PRL secretion and, 124 thyroxine (T4), 97–98
OXY and VP secretion and, 157 testosterone therapy, in Kallmann energy balance and, 107–109
PRL secretion and, 123–124 syndrome, 36–37 fertility and, 110–111
sexual activity, PRL release and, 124 tetraiodothyronine. See thyroxine in hypothalamic–pituitary–thyroid
SIADH. See syndrome of inappropriate THR. See thyroid hormone axis, 98–99
antidiuretic hormone secretion receptor insensitivity to, 102–105
signal transducer and activator of thyroid binding globulin (TBG), 97 measurement of, 97, 99
transcription (STAT), 5 thyroid gland, 97–98, 112–113 TSH regulation by, 100–102, 103
sleep case studies involving tolvaptan, 164
aging effects on, 21 hyperthyroidism, 111, 112 traumatic brain injury. See brain injury
GH secretion and, 134–135, 136, 139 hypothyroidism, 111–112 TRH. See thyrotropin releasing
PRL secretion and, 121–122 in critical illness, 109, 110 hormone
sleep–wake cycle. See circadian rhythm energy balance and, 107–109 triiodothyronine (T3), 97–98
SM. See sellar masses fertility and, 110–111 energy balance and, 107–109
somatostatin (SOM) in hypothalamic–pituitary–thyroid fertility and, 110–111
GH regulation by, 134, 135 axis, 98–99 in hypothalamic–pituitary–thyroid
TSH effects of, 99 thyroid hormone insensitivity and, axis, 98–99
somatostatin analogues 102–105 insensitivity to, 102–105
GH suppression with, 144, 145–146, TSH secretion and measurement of, 97, 99
194 177–178 neural control of, 99–100 TSH regulation by, 100–102, 103
Index
Trulicity. See dulaglutide behavioral effects of, 165 disorders of, 160–164
TSH. See thyroid stimulating hormone case studies involving measurement of, 159
TSH adenomas, 106, 111, 112, 179 DI, 162–163 water homeostasis and, 159–160,
TSH.R. See thyroid stimulating SIADH, 164 161
hormone receptors genes for, 156 vasopressin antagonists, 164
tyrosine kinase-dependent receptors, 5–6 neurohypophyseal system secretion VP. See vasopressin
of, 154–156
urine samples, 15–16 receptors for, 154–156, 160, 161 water balance, VP role in, 159–160,
secretion of, 24 161
vasopressin (VP), 154, 165–166 baroregulation of, 164–165 weight. See appetite and body weight
ACTH regulation by, 75–76, 77, 79 central regulation of, 156–157 regulation
195

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Thyrotropin releasing hormone

Figure 1.3 Schematic diagram of GPCR signaling via G proteins

a superfamily of human membrane proteins. Drugs Desensitization is reversible by replacing continuous

Clinical features Biochemical feature GPCR aﬀected (type of

Table 1.1 (cont.)

Clinical features Biochemical feature GPCR aﬀected (type of

1.3 Tyrosine Kinase-Dependent LEPTIN

Receptors Plasma membrane

tures – in this case the leptin receptor dimer – have P P SOCS3

only two transmembrane domains. Leptin binding to STAT STAT

a single transmembrane protein induces receptor

messenger JAK/STAT pathway (for details of the GH

that are docked on the intracellular domain.

Clinical Signiﬁcance of Tyrosine insensitivity – mutations in the intracellular STAT5

Figure 1.6 Chemical

hERα NTD DBD H HORMONE BINDING DOMAIN

hERβ NTD DBD H HORMONE BINDING DOMAIN

enables the DNA binding domain (DBD) to interact Estrogen Receptors

Figure 1.8 Schematic view of a steroid

Figure 1.9 Distribution of hERα and hERβ

Glucocorticoids resistance, increasing patient vulnerability to exagger-

Figure 1.11 Changes in the HPA axis due to glucocorticoid resistance.

Manoranjan B, Salehi F, Scheithauer B W, Rotondo F, Rodriguez J M, Monsalves-Alvarez M, Henriquez S,

Increased hair cortisol Decreased hair cortisol

and peak secretion for these is illustrated in

Figure 2.3 Diurnal rhythm of human cortisol secretion: control vs.

Figure 2.4 Peak

Pineal gland Figure 2.5 Schematic representation of

Figure 2.6 Schematic outline

clock per cry PER, reach a critical level

Table 2.2 Human circadian rhythm disruption

20 Data derived from Potter et al. (2016)

Figure 2.7 Exposure to night-

Figure 2.8 Eﬀects of pulsatile

600 Figure 2.11 Subcutaneous infusion of

dose 19.9 mg). Note that the maximum

through a feedforward–feedback interaction between 8. Disruption of circadian rhythms in shift workers

OVARIAN CYCLE FOLLICULAR PHASE LUTEAL PHASE

Figure 3.2 Ovarian production of E2 by a collaborative two-cell

Anterior pituitary Stimulation Inhibition

5 Figure 3.4 Pulsatile secretion of LH in a normal male.

Normal male pulses above the background. Pulses occur

* testosterone, respectively (Grumbach, 2002). This

with the pulses being correlated with slow wave sleep

restoration of normal body weight. LH pulses are now greatly 29

Although several mutations have been asso-

neurons. FGFR1 encodes a receptor, FGFR1, which

Olfactory bulb FGFR1

Nasal GnRH neuron

to widespread opioid prescription abuse. In 2014,

Figure 3.11 Naloxone-stimulated LH

Figure 3.13 Tentative model for the role of KNDy

Figure 3.14 KP neurons mediate hypothalamic E2 feedback. This

0 50 100 150 200 250 350

Mean serum LH (iU/L)

Mean serum estradiol (pmol/L)

Table 3.3 Summary of patient response following KP triggering

secretion of LH, a pattern that is crucially important 3.6 Review Questions

Figure 4.1 Obesity and the

Leptin and Amenorrhea gonadotropin secretion. This may also be true in

human leptin increases nocturnal LH secretion in

Obesity and Leptin Excess