Introduction to the endocrine

system and pathophysiological

basis of pituitary disorders
 Pituitary
Disorders

Hypersecretion of Hyposecretion of
hormones hormones

Anterior pituitary
Posterior pituitary Anterior Pituitary Posterior Pituitary
Acromegaly
SIADH Hypopituitarism Cranial DI
Prolactinoma
What leads to pituitary disorders?
• Damage to hormone-secreting cells
• Ischaemic
• Inflammatory/ infective
• Antibody-induced
• Carcinomatous
• Head injury

• Compression of the Pituitary stalk

• Hypersecreting tumors
Case # 1
• Padma is a 41-year-old woman who has worked as a janitor for many
years.
• Her co-workers noted that her physical appearance had changed—her
features had become coarse, her lower jaw was protruding, and her
teeth had separated.
• She disclosed that her menstrual periods had suddenly stopped 5
years ago; that her slipper size had increased; and that her fingers had
enlarged so much that her wedding ring no longer fit.
• Every night, she had been getting up several times to urinate.

• Padma decided to see a physician for evaluation of these strange

symptoms.
Physical examination
revealed a woman with
coarse facial features, a
prominent jaw, and large
hands and feet. Her blood
pressure was elevated at
170/110 .
Key learning points: What is the likely diagnosis? Enumerate the features
in history and examination that support your diagnosis.
Key learning points: Explain the pathophysiological basis of the findings
of her physical examination.
Clinical Feature Pathophysiological basis

Coarse facial features

Prognathism

Large hands and feet

Amenorrhoea

Polyuria and nocturia

Hypertension
List relevant biochemical investigations and their expected findings, that
would help in her diagnosis and management
Case # 2
• Kusum, a 42-year-old mother and housewife was referred to the medical clinic for the first
time by her GP with chronic pain in bilateral upper and lower extremities (predominantly in
the proximal part) and generalized fatigue and lethargy for the past eight years, insidious in
onset and gradually progressing. The pain and fatigue worsened over the years to the extent
that it stopped her from going to work.
• On further evaluation, it was noted that her movements were sluggish, she had slow speech
with a hoarse voice, dry and thick skin, and mentioned difficulty remembering things.
• The only significant medical history that she knew and could remember was that following
her last childbirth eight years earlier, she lost consciousness and had profound vaginal
bleeding following which a hysterectomy was done and she had been sick since then. She
had five pregnancies and breastfed all her four children, except her last child whom she
could not as she did not have any breast milk despite trying several remedies. Kusum visited
several doctors in the last several years for the same and was given symptom-driven
treatment with no long-term benefits. She was unsure about the medications she had
received and the workup that was done. There were no documents with her.
• The examination was significant for a slow response to commands, facial puffiness, and loss
of a lateral third of the eyebrows. The skin was cold, thick, and dry. Blood pressure was 80-
90/50-70 mmHg. She had a postural fall in diastolic blood pressure of > 10 mmHg.
Empty sella appearance in the MRI
Abnormality Pathophysiological basis

Myalgia, fatigue,
lethargy
Slow and hoarse
speech, memory
impairment, dry skin

Inability to
breastfeed
Low BP/ Orthostatic
hypotension
Test ( Serum) Expected finding
TSH
T3
T4
Prolactin
LH
FSH
Cortisol
Somatomedin
Case # 3
• Maya is a 36-year-old executive of an Internet company. She has been
married for 10 years and has always used barrier methods for
contraception. Maya’s menstrual periods started when she was 12
years old and were regular until 18 months ago. At that time, her
periods became irregular and then ceased altogether (amenorrhea).
She was very concerned because she and her husband had been
trying to have a child. Not only had her periods stopped, but a milky
substance was leaking from her breasts.

• Maya made an appointment to see her gynecologist. Findings of the

pelvic examination were normal, but the gynecologist was able to
express milk from her breasts (galactorrhea). Results of a pregnancy
test were negative.
• The gynaecologist requested some lab tests.

• Luteinizing hormone- midcycle 5 IU/L (normal: follicular1–18 IU/L;

midcycle 24–100 IU/L)

• Prolactin 85ng/mL ( normal 5-25)

Abnormality Pathophysiological basis

Galactorrhoea

Amenorrhoea

Subfertility

Prolactin of 85ng/mL
• The laboratory results suggested that Maya had a prolactinoma. The
physician ordered a MRI of her brain. The scan showed a 1.5-cm mass
on her pituitary that was believed to be secreting prolactin.
• While Maya was awaiting surgery to remove the mass (an adenoma),
drug treatment was initiated, which decreased Maya’s serum
prolactin level to 20 ng/mL. After the adenoma was removed, Maya’s
galactorrhea stopped, her menstrual periods resumed, and she is now
pregnant with her first child.
Case #4
• Latha is a 19-year-old nursing student. Recently Latha noticed that was
urinating every hour (polyuria) and drinking more than 5 L of water daily
(polydipsia). She always carried a water bottle with her and drank almost
constantly.
• Latha’s supervising matron was concerned and wondered whether Latha
had either a psychiatric disorder involving compulsive water drinking
(primary polydipsia) or diabetes insipidus and referred her to a physician.
• The findings on physical examination were normal. Latha’s blood pressure
was 105/70, her heart rate was 85 beats/min, and her visual fields were
normal.
• Blood and urine samples were obtained for evaluation
• Plasma Na 147 mmol/L
• P. Osmolality- 301 mOsm/L and Urine Osm 70
• FBG- 90mg/dL UG- negative
Abnormality Pathophysiological basis

Polydipsia

Plasma osmolality of 301

and Urine osmolality of 70
• Because of these initial laboratory findings, Latha’s physician performed
a 2-hour water deprivation test. Latha was then injected subcutaneously
with dDAVP (an analogue of arginine vasopressin).

• Comment on the test results.

Plasma osmolality mosm/L Urine osmolality mosm/L

Baseline 301 70
After 2-hr WDT 325 70
After dDAVP 290 500
• Based on the test results and her response to vasopressin ( antidiuretic
hormone [ADH]), Latha was diagnosed with central diabetes insipidus.
Because she had no history of head injury and subsequent magnetic
resonance imaging scans ruled out a brain tumor, Latha’s physician
concluded that she had developed a form of central diabetes insipidus
in which there are circulating antibodies to ADH-secreting neurons.

• Latha started treatment with dDAVP nasal spray. As long as Latha uses
the nasal spray, her urine output is normal, and she is no longer
constantly thirsty.
Case # 5
• Kamal is a 68-year-old mechanical engineer who is being treated in
the neuro-trauma unit following a traumatic brain injury. His vital
signs are stable and the Glasgow Coma Score has improved from 10
to 13 within a course of two weeks after the injury. On the 14th day he
develops a generalized seizure.

• He does not have oedema and his blood pressure is 118/78 mmHg.
• His investigations done immediately after the seizure reveal the
following

Test Result
Plasma Na 112 mEq/L (normal: 140 mEq/L)

Plasma osmolality 230 mOsm/L (normal: 290

mOsm/L)

Urine osmolality 950 mOsm/L

• He is treated immediately with an infusion of hypertonic (3%) NaCl
after which his condition improves. The ICU doctor limits his water
intake.
SIADH
Abnormality Underlying reason

Seizures

Low sodium

Low plasma osmolality

Inappropriately high U Osm

SIADH
• What is the explanation for ( despite fluid retention)

1) Absence of oedema
2) Normal blood pressure