Symposium for Patients & Caregivers

1. Symposium for Patients & Caregivers

2. Hormonal Imbalances Laura Knecht, MD Adult EndocrinologistMedical Director, Barrow Pituitary Center

3. Functions of the Hypothalamus • Secretes hormones-releasing and inhibitory effects on the pituitary gland • Anti diuretic hormone (ADH) • Dopamine • Oxytocin • Somatostatin • Corticotropin Releasing Hormone (CRH) • Thyrotropin Releasing Hormone (TRH) • Gonadotropin Releasing Hormone (GnRH) • Growth Hormone Releasing Hormone (GHRH)

4. Anti Diuretic Hormone (ADH) • ADH (vasopressin) made in the hypothalamus • ADH stored in posterior pituitary gland • Works at kidney to resorb water • Reabsorbing water regulates sodium levels in the blood • Lack of ability to reabsorb water leads to increased thirst and urination

5. Dopamine • Released by the Hypothalamus • Travels down the pituitary stalk • Continuous release inhibits the release of prolactin from pituitary

6. Oxytocin • Acts at breast for milk let-down • Acts at uterus to aid in contractions

8. Somatostatin • Inhibits growth hormone release from pituitary • Inhibits TSH release from pituitary

9. Corticotropin Releasing Hormone (CRH) • Acts at pituitary to release adrenocorticotropic hormone (ACTH) • ACTH acts at adrenal glands to secrete cortisol (stress hormones)

11. Thyrotropin Releasing Hormone (TRH) • Acts at thyroid to secrete TSH (Thyroid Stimulating Hormone) • Acts at pituitary to release prolactin • TSH acts at thyroid to release T4, T3 which controls metabolic activities

13. Gonadotropin Releasing Hormone (GnRH) • Acts at pituitary to secrete FSH (Follicular Stimulating Hormone) and LH (Luteinizing Hormone) • Acts at ovaries and testicles to secrete Estrogen, Progesterone, and Testosterone

15. Growth Hormone Releasing Hormone (GHRH) • Acts at pituitary to secrete Growth Hormone • Growth hormone acts at liver to produce IGF-1 • Acts at bones, muscles, cartilage

18. Growth Hormone Deficiency • In children, short stature • Diminished muscle mass • Increased fat mass • Increased LDL • Increased inflammatory markers (IL-6, CRP) • Increased cardiac disease • Decreased bone mineral density • Diminished quality of life

19. Treatment • Growth hormone deficiency • Recombinant human growth hormone • Increased muscle mass • Decreased fat • ? Improvement in bone mineral density • Improved quality of life

20. Hypogonadism • Causes hypogonadism • In women • Inability to ovulate • Oligo/amenorrhea • Estradiol deficiency • Decreased bone mineral density • In men • Testicular hypofunction • Infertility • Decreased testosterone (energy/libido) • Decreased bone mineral density

21. Treatment • LH/FSH deficiency • Men - testosterone replacement if not interested in fertility • Cannot follow LH • If interested in fertility, can be treated w/ gonadotropins or GnRH, HCG • Check sperm count • Women - estradiol-progestin replacement if not interested in fertility • If interested in fertility, can be treated w/ pulsatile GnRH or gonadotropins • Effects of testosterone still being studied

22. Prolactin/Oxytocin Deficiency • Inability to lactate after delivery • Difficulty with uterine contractions

23. Treatment • Not available • Not indicated

24. Hypothyroidism • Central hypothyroidism • Fatigue • Heat/cold intolerance • Decreased appetite • Puffy face • Dry skin • Bradycardia • Relaxation of deep tendon reflexes • Anemia

25. Treatment • TSH deficiency • Levothyroxine (synthroid, levoxyl, unithroid, armour) • Normalize free T4 – mid range (TSH not helpful) • Treat adrenal insufficiency first

26. Adrenal Insufficiency • Cortisol deficiency • Mild • Fatigue • Anorexia • Weight loss • Decreased libido • Hypoglycemia • Eosinophilia • Severe • Vascular collapse • Loss of peripheral vascular tone • Death

27. Treatment • ACTH deficiency • Administer hydrocortisone • 20-30 mg/d in varying regimens • Dexamethasone/prednisone (0.5-1mg, 5-7.5mg) have longer action • Increase in times of stress • Cannot measure serum ACTH, cortisol, urinary cortisol • Mineralocorticoid replacement unnecessary • Can unmask central DI w/ polyuria • Can increase blood pressure, renal flow, and decrease bone mineral density

28. Diabetes Insipidus • Can occur prior to surgery, around time of surgery, after surgery • Can be temporary or permanent

29. Diabetes Insipidus - Symptoms • Increased thirst • Craving ice water • Increased urination • Every 30-60 minutes • Night time urination 5-6x/night • Increased sodium levels • Above upper limit of normal

30. Diabetes Insipidus - Treatment • If intact thirst center, can drink • Can drink to thirst • Usually desire ice water • Avoid significantly increased sodium loads • Tomato juice, V8, pickles, high salt foods

31. Diabetes Insipidus - Treatment • If hypothalamus damaged, may not have desire to drink • Can schedule drinking times • With meals, at mid-morning (10am), mid-afternoon (3pm)

32. Diabetes Insipidus – TreatmentDDAVP (Desmopressin) • Oral • 0.1-0.2mg by mouth 2-3x/day • Half-life of 8-12 hours • Intranasal • 10mcg spray 1-2 sprays 2-3x/day • Longer half-life of 12 hours • More potent • Need to coordinate inhalation

33. Diabetes Insipidus – TreatmentDDAVP (Desmopressin) • Subcutaneous • Rarely necessary as outpatient • Avoids absorption issues • IV • Avoids absorption issues • Used in hospital around time of surgery

34. A Special Thanks to our Sponsors • Aesculap • Barrow Neurological Institute @ St. Joseph’s Hospital • Barrow Neurological Institute @ Phoenix Children’s Hospital • Great Council for the Improved • Hope for Hypothalamic Hamartoma Foundation • KARL STORZ Endoskope