DEPARTMENT OF PATHOLOGY

ENDOCRINE FUNCTION TESTS

Mirjana C. Tidoso, MD
Department of Pathology
Gullas College of Medicine
 OUTLINE

Overview of the
01 Endocrine System
04 Adrenal Function

02 Pituitary Function
05 Renin-Aldosterone Axis

03 Thyroid Function
01
OVERVIEW OF THE
ENDOCRINE SYSTEM
01 OVERVIEW OF THE ENDOCRINE SYSTEM
● Consists of organs called glands
● Orchestrate a state of metabolic equilibrium among organs of the body
● Signaling – autocrine (act directly on themselves), paracrine (act on adjacent) ,
intracrine (act within the cell of origin)

ENDOCRINE GLANDS
▪ Release hormones act on distant sites
▪ Feedback inhibition
▪ Diseases are generally classified:
1. Underproduction or overproduction
2. Mass lesions
02 PITUITARY FUNCTION
02 Pituitary Gland
● Bean-shaped structure located within sella
turcica
● Controlled by hypothalamus
● Regulates function of other endocrine
glands
● Composed of two functionally distinct
components:
○ Anterior – adenohypophysis
○ Posterior – neurohypophysis
02 Pituitary Gland
02 Pituitary Gland
02 Pituitary Tumors
● Microadenomas (<1cm in greatest
diameter and confined to the sella)
● Macroadenomas (>1cm in greatest
diameter)
● Most common type if pituitary
adenoma: Prolactinoma
● Can compress optic chiasm:
bitemporal hemianopia (most frequent
presentation)
02 Anterior pituitary/ Adenohypophysis
02 Prolactin (PRL)
● Responsible for initiation and maintenance of lactation
● Inhibited by dopamine and inhibits GnRH
● Peaks during sleep and nadir between 10am and 12nn
● Reference values: 1-25ng/mL for women and 1-20ng/mL for men
● As high as 500ng/mL in pregnant women
● > 250ug/L indicates prolactinoma
● Gold standard for detecting macroprolactin: Gel filtration
chromatography
● Monomeric PRL is detected via immunoassay (ELISA)
02 Prolactin (PRL)
● Hyperprolactinemia
● Amenorrhea-galactorrhea syndrome in women
● Testicular atrophy, impotence, and gynecomastia in men
02 Growth Hormone (GH)
● Inhibited by somatostatin and
insulin-like growth factor-
1(IGF-1)
● Peaks in puberty and 70%
occurs in stage 4 (slow-wave)
sleep or 1st 2 hours.
● Measured with chemiluminescent
assay
● Normally less than 1 ng/mL and
secretory peaks typically reach
20-40 ng/mL
02 Growth Hormone (GH)
● Growth Hormone Deficiency
● Idiopathic growth hormone deficiency is the most common cause in
children
● Pituitary adenoma in adults
● Insulin tolerance test - GOLD standard for diagnosing GH deficiency
● Failure to rises above 3-5 ng/mL (adults) and >10 ng/mL
(children) when glucose drops to <40mg/dL
02 Growth Hormone (GH)
● Growth hormone excess
● Acromegaly in adults
● Gigantism in children (before closure of epiphysis)
● Screening test: randomly collected IGF-1
● Confirmatory test: OGTT
● Normal: GH suppression to <1 ng/mL at any time during the test
● Acromegaly: GH fails to drop to below 1 ng/mL
● Puberty, uncontrolled DM, malnutrition, hepatic disease and renal
disease will cause failure to suppress GH (BUT! Puberty has normal
serum IGF-1)
● Oral estrogens lower IGF-1 concentrations
02 Growth Hormone (GH)
● Growth hormone excess
● Acromegaly in adults
● Gigantism in children (before closure of epiphysis)
● Screening test: randomly collected IGF-1
● Confirmatory test: OGTT
● Normal: GH suppression to <1 ng/mL at any time during the test
● Acromegaly: GH fails to drop to below 1 ng/mL
● Puberty, uncontrolled DM, malnutrition, hepatic disease and renal
disease will cause failure to suppress GH (BUT! Puberty has normal
serum IGF-1)
● Oral estrogens lower IGF-1 concentrations
02 Follicle stimulating hormone (FSH) and Luteinizing hormone (LH)

● Stimulated by GnRH
● If GnRH receptors are continuously stimulated, GnRH soon
becomes inhibitory
● In diagnosing early menopause:
● 2 separate determinations taken >4 weeks apart
● FSH of >40 IU/L suggests ovarian failure
02 Antidiuretic Hormone (ADH)/ Arginine Vasopressin
● Function: to maintain osmotic homeostasis by regulating water balance
● ADH is maximally stimulated at serum osmolality of greater than
295mOsm/kg and is suppressed at 284mOsm/kg
● 1-2% increase in osmolality will cause a rise in ADH secretion while
5-10% drop in blood volume or blood pressure will trigger release of
ADH
● Basal levels: 0.5 to 2 pg/uL
● Normal plasma osmolality: 280-295 mOsm/kg
02 Antidiuretic Hormone (ADH)/ Arginine Vasopressin
02 Diabetes insipidus (DI)
● Inadequate ADH activity
● Decreased or absent secretion → central/neurogenic
● Renal tubules are unresponsive → nephrogenic
● Characterized by large volumes of urine (>2.5/day) in the
face of an inappropriately elevated Posm (Polyuria and
polydipsia)
● Confirmed with water deprivation test
● Primary polydipsia → dipsogenic DI vs psychogenic
polydipsia
02 Diabetes insipidus (DI)
02 Diabetes insipidus (DI)
02 Syndrome of inappropriate diuretic hormone (SIADH)

● Euvolemic hypoosmolar hyponatremia associated with hyperosmolar

urine
● Cannot be diagnosed until nonosmotic stimuli for ADH secretion and
other pathologies interfere with free water clearance have been
excluded
● Failure to excrete 80 to 90% of the administered water load within 4
hours and to suppress Uosm to <100 mOsm/kg is consistent with the
diagnosis of SIADH
● Diagnosis of exclusion
02 Syndrome of inappropriate diuretic hormone (SIADH)
02 Antidiuretic Hormone (ADH)/ Arginine Vasopressin
03 THYROID FUNCTION
03 Thyroid function tests
03 Thyroid function tests
● Active transport of iodide
● Organification
● Coupling of iodotyrosine
molecules within Tg to form
T3 and T4
● Proteolysis of Tg with
release of T4 and T3
● Deiodination of T4 to T3
03 Thyroid function tests
03 Thyroid function tests
03 Thyroid function tests
03 Thyroid function tests
● Radioactive iodine uptake (RAIU)
● Nuclear medicine test
● Given a dose of radioactive iodine then scanned for
thyroid radioactivity
● Graves disease/functioning adenoma → increased RAIU
● Thyroiditis, struma ovarii, exogenous thyroid → decreased
RAIU
03 Hyperthyroidism
● Most common cause: Graves disease
● Other causes: MNG, Toxic adenoma (Plummer
syndrome), thyroiditis of various etiologies, exogenous
thyroxine, pituitary adenoma
● Presents as a generalized hypermetabolic state:
tachycardia, palpitations, weight loss (without anorexia),
diarrhea, heat intolerance, and anxiety
● 5:1 female to male predominance
● Reduced TSH and high free T4
03 Hyperthyroidism
03 Hypothyroidism
● Generalized hypometabolic state: fatigue, cold intolerance,
slowed mentation, reflexes and speech and periorbital
edema, dyslipidemia
● Elevated TSH and low free T4
● Subclinical hypothyroidism: normal free T4 in spite of high
TSH
● MC cause: Hashimoto’s thyroiditis
● Others: previous thyroidectomy, previous radioactive iodine
therapy, drugs, recovery of both lymphocytic and
granulomatous thyroiditis
 03 Hashimoto’s Thyroiditis
• Most common cause of Hypothyroidism
• Autoimmune Disorder
• Anti-TSH (Speci c for Hashimoto’s
Thyroiditis and Graves Disease)

• Anti-Thyroid Peroxidase Antibodies

• Anti-Thyroglobulin Antibodies
• Associated with HLA-DR5 (Goitrous Form), HLA-
DR3 (Atrophic Form)

• Increased risk of Non-Hodgkin’s Lymphoma

fi
03 Neonatal Hypothyroidism
● Abnormal development of thyroid gland (complete
agenesis/ partial dysgenesis)
● Peripheral hormone resistance (Autosomal dominant
Refetoff syndrome)
● Hypopituitarism
● Maternal antibodies/medications
● Diagnosed with TSH immunoassay 48-72 hours after birth
● Second screening at 2-6 weeks of age
03 Nonthyroidal illness syndrome/Euthyroid sick syndrome

● Abnormal function tests in a euthyroid individual suffering

from a non thyroidal illness
● Usually in the critically ill, elderly, hospitalized patient with
decreased T3, T4, increased rT3 and normal or low TSH
03 Exogenous estrogens
● Causes increased TBG thus increasing bound T3 and T4
but TSH and free T3 and T4 are normal
04 ADRENAL FUNCTION
04 Normal Adrenal gland
04 Hormones of adrenal medulla
04 Hormones of adrenal medulla
04 Pheochromocytoma and Paraganglioma
● Pheochromocytomas arise
from the chromatin cells of
the adrenal medulla
● Paragangliomas are extra-
adrenal in origin
(paravertebral sympathetic
ganglia in chest,
abdomen, pelvis, and
parasympathetic chains
along the vagus and
glossopharyngeal nerves)
04 Pheochromocytoma
● 90% are benign but lethal if not diagnosed and properly
treated.
● Most are sporadic; 40% are familial (MEN 2A, MEN 2B, VHL,
NF-1)
● MC presentation: Sustained or paroxysmal hypertension
● Dx:
● Plasma concentration of free metanephrine or
normetanephrine is about 4x the upper reference limit.
● 24hr urine collection/plasma catecholamines that are
2-3x the upper limit of normal.
04 Pheochromocytoma
● Special considerations:
● Pediatric: fractionated plasma free metanephrines are
the biochemical test of choice
● Renal insufficiency/failure: plasma free metanephrines
used to dx
● CHF, surgery, Acute CV accident patients: wait to
stabilize
● Oldies: normetanephrine concentrations increase with
age➡ fractionated urinary metanephrines and
catecholamines
04 Pheochromocytoma
04 Pheochromocytoma
● Testing procedure (HPLC/MS-MS)
● 24 hour urine
● Urine should be collected in a container with 25mL of 6 N Hal
● Plasma catecholamines
● Collected after an overnight fast (water permitted)
● Patient is in a reclining position
● Quiet environment
● Heparin lock
● After 20-30 minutes, blood is collected in a pre chilled EDTA tube
● WB should be kept in ice water (4 °C) until centrifuged
● Plasma should then be frozen immediately
04 Pheochromocytoma
04 Neuroblastoma
● Arises from adrenal glands or sympathetic chain
● 2nd. Most common solid malignant tumor in childhood,
usually occurring before 3 years of age
● Sx due to tumor mass rather than hypertension
● Elevated urinary HVA (90%) and VMA (75%) levels at the
time of dx➡ screening tests
04 Normal Adrenal gland
04 Adrenal Cortex
● Chief mineralocorticoid: aldosterone
● Produced only in zone glomerulosa (CYP11B2)
● Precursor molecules 11- deoxycorticosterone (DOC)
and 11-deoxycortisol can be synthesized in zone
fasciculate and glomerulosa
● Responds to ACTH but mainly under control of renin-
angiotensin system.
04 Adrenal Cortex
● Chief glucocorticoid: Cortisol
● Produced in Z. Fasciculate (75% of cortex)
● Negative feedback inhibition to HPA axis
● Corticosterone also possesses glucocorticoid activity
04 Adrenal Cortex
04
04 Adrenal Cortex
04 Adrenal Cortex
04 Adrenal Function Tests
● 21- Hydroxylase Deficiency (MC CAH)
● Diagnosis
● Prenatal dx
● Measuring 17-OHP in amniotic fluid/ genotyping
cells obtained by chorionic villous sampling
● Mutations can be identified by PCR and
Southern blotting- MOST DEFINITIVE
● Neonatal screening - Dissociation-Enhanced
Lanthanide Fluoroimmunoassay (DELFIA)
04 Adrenal Function Tests
● 11β Hydroxylase Deficiency (2nd MC CAH)
● Congenital lipoid adrenal hyperplasia (lipoid CAH)
● Most sever for of CAH
● Defect in StAR- controls rate-limiting step in
steroidogenesis
● Diagnosis is made by the presence of extremely low
cortisol and aldosterone concentrations and elevated
ACTH and plasma renin activity
04 Adrenal Function Tests
● Cortisol
● Secreted in intermittent small surges throughout the
day with a relative trough around midnight and a peak
at approx 8am
● A single elevated midnight cortisol ➡ Cushing
syndrome
● A single reduced 8AM cortisol ➡ Adrenal insufficiency
● 90% bound to transcortin/CBG and albumin
04 Adrenal Function Tests
● Cortisol
● Measured by HPLC/MS-MS
● Collected in a no-additive tube
● Reference values: 5-25ug/dL at 8-10am
● 3-12 ug/dL by 4pm
● Most useful to measure when evaluated in the context
of dynamic manipulation (adrenal stimulation/
suppression)
04 Adrenal Function Tests
● Cortisol tests
● Dexamethasone suppression test (DST)
● Low dose DST
● High dose DST
● Cortisol releasing hormone (CRH) stimulation test
● Insulin tolerance test
● Cosyntropin administration
● Metyrapone stimulation test
04 Cushing syndrome
● MC cause in developed
world: Iatrogenic (tx of
inflammatory disease)
● Spontaneous cause: 70%
➡ pituitary adenoma, 20%
➡ adrenal cortical
hyperplasia/neoplasia
● Dx: demonstration of
persistent
hypercortisolism.
04 Cushing syndrome
04 Addison’s disease
● Aka primary adrenal insufficiency
● Caused by autoimmune
adrenalitis
● Drugs: ketoconazole etomidate,
mitotane
● Dx: demonstration of low 8am
serum cortisol and/or blunted
increase in cortisol following
cosyntropin stimulation
06
RENIN-
ALDOSTERONE AXIS
06
05 Primary Hyperaldosteronism
● Screening test: Plasma aldosterone concentration/plasma
renin activity ratio via immunoassay/HPLC/MS-
● A PAC/PRA ratio greater than 30 is suggestive but
greater than 50 is diagnostic
● Confirmatory test: Oral sodium loading test, saline infusion
test, fludrocortisone suppression test, or captopril
challenge test
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 Thank you!
References: 1. 24e Henry’s Clinical Diagnosis and Management by Laboratory Methods
2. 4e ASCP Quick Compendium of Clinical Pathology