Care of Client with Endocrine Alterations

• Hypothalamus


  • Very small but extremely important in mediation of endocrine, autonomic and behavioral functions
  • Controls the release of 8 major hormones
  • Involved in temperature regulation
  • Control of food and water intake, hunger, thirst
  • Sexual behavior and reproduction
  • Control of daily cycles in physiological state and behavior (circadian rhythm)
  • Mediation of emotional responses
• Pituitary gland


  • Master gland located on the inferior aspect of the brain, regulates the secretion of hormones by other endocrine glands
  • Controlled by the hypothalamus
  • About the size of a pea and consists of two parts (often called lobes): a front part called the anterior pituitary and a back part called the posterior pituitary

  
• Anterior pituitary hormones


  • Prolactin
  • Growth hormone (GH)
  • Adrenocorticotropin (ACTH)
  • Thyroid-stimulating hormone (TSH)
  • Luteinizing hormone (LH)
  • Follicle-stimulating hormone (FSH)

  
• Posterior pituitary hormones


  • Antidiuretic hormone (ADH)
  • Oxytocin
• Anterior pituitary


  • Major hormones: FSH,LH, prolactin, ACTH, TSH, GH
  • Hypothalamus secretes releasing factors that stimulate the secretion of major hormones by the pituitary
• Posterior pituitary


  • Major hormones synthesized in hypothalamus and stored in posterior pituitary: vasopressin/ADH, oxytocin
• Alterations in the pituitary gland


  • Over- or under-secretion of any of the hormones
  • Anterior and posterior gland abnormalities are independent

  
• Anterior pituitary over-secretion


  • Cushing syndrome (ACTH)
  • Acromegaly (GH)
  • Excess GH in adults– enlargement of peripheral body parts without an increase in height
  • Excess GH in children– gigantism
• Anterior pituitary under-secretion


  • Dwarfism: Insufficient GH in children
  • Hypo-pituitarism includes decreased secretion of all hormones
  • Thyroid, adrenal, and gonads atrophy due to loss of stimulating hormones
  • May lead to destruction of the anterior lobe of pituitary
• Acromegaly


  • Often diagnosed in middle-aged adults
  • Treatable in most patients, but because of its slow and often "sneaky" onset, it often is not diagnosed early or correctly
  • If not treated, acromegaly can result in serious illness and premature death
  • Most serious health consequences: type 2 diabetes, HTN, increased risk of cardiovascular disease, and arthritis
• Symptoms of acromegaly


  • Abnormal growth of the hands and feet (early feature)
  • Gradually, bone changes alter the patient's facial features: The brow and lower jaw protrude, the nasal bone enlarges, and the teeth space out
  • Overgrowth of bone and cartilage often leads to arthritis
  • When tissue thickens, it may trap nerves, causing carpal tunnel syndrome
  • Body organs, including the heart, may enlarge
  • Joint aches
  • Thick, coarse, oily skin
  • Enlarged lips, nose, and tongue
  • Deepening of the voice
  • Sleep apnea
  • Excessive sweating and skin odor
  • Fatigue and weakness
  • Headaches
  • Impaired vision
  • Abnormalities of the menstrual cycle and sometimes breast discharge in women
  • Erectile dysfunction in men
  • Decreased libido
• Posterior pituitary dysfunction


  • Diabetes insipidus (DI): underproduction of vasopressin
  • May also occur as after brain surgery, nervous system infections, traumatic brain injury
• Diabetes insipidus (DI)


  • Most common condition of the posterior lobe of pituitary
  • Deficiency of production ADH (vasopressin)
  • Types: Central, Nephrogenic, Dipsogenic, Gestational
• Central diabetes insipidus


  • Damage to hypothalamus or pituitary gland causes disruptions in the normal production, storage, and release of vasopressin
  • Result: disruption of vasopressin causes the kidneys to remove too much fluid from the body, leading to an increase in urination
  • Damage can be from surgery, infection, inflammation, tumor, head injury, inherited defect, or unknown cause
• Nephrogenic diabetes insipidus


  • Kidneys do not respond normally to vasopressin and continue to remove too much fluid from bloodstream
  • Cause: inherited gene changes, or mutations, that prevent the kidneys from responding to vasopressin, or other causes like chronic kidney disease, certain medications, low potassium, high calcium, blockage of the urinary tract, or unknown cause
• Dipsogenic diabetes insipidus


  • Defect in the thirst mechanism, located in hypothalamus
  • Causes: abnormal increase in thirst and liquid intake that suppresses vasopressin secretion and increases urine output, certain medications or mental health problems
  • Same events and conditions that damage the hypothalamus or pituitary can also damage the thirst mechanism
• Clinical manifestations of diabetes insipidus

  • Enormous amounts of dilute urine output (> 250 mL/hr; SG 1.001-1.005)
  • Intense thirst– drinking 2-20 L/ day– crave for cold water
  • Main complication: Dehydration if fluid loss is greater than liquid intake
• Assessment of diabetes insipidus

  • Medical and family history, physical assessment
  • Fluid deprivation test (withhold fluids and test body weight + plasma and urine osmolality)
  • Plasma levels of ADH, serum Na, plasma and urine osmolality, MRI brain
• Management of diabetes insipidus

  • Replace ADH– long term
  • Ensure fluid replacement
  • Identify and correct underlying cause
  • Desmopressin: synthetic vasopressin intranasally
  • Caution with cardiac patients (due to vasoconstriction)
  • Chlorpropamide (Diabinese) and thiazide diuretics– potentiate action of vasopressin in early stages of DI
  • Nephrogenic (renal): thiazide diuretic, mild salt deprivation, prostaglandin inhibitors (Ibuprofen, indomethacin, aspirin)
• Pituitary tumors


  • 95% of pituitary tumors are benign (pituitary adenomas)
  • They don't grow very large, but they can have a big impact
  • Pituitary adenomas are also classified by whether excess of a hormone and the type they make
  • The kind of hormone an adenoma produces strongly affects what signs and symptoms the patient has
• Types of functional pituitary adenomas

  • Prolactin-producing adenomas (prolactinomas)
  • Growth hormone-secreting adenomas
  • ACTH-secreting adenomas
  • Gonadotropin (LH and FSH)-secreting adenomas
  • TSH-secreting adenomas
  • Some adenomas secrete more than one type of hormone
• Non-functional pituitary adenomas


  • Don't make excess hormones
  • Usually detected as macroadenomas, causing symptoms because of their size as they press on surrounding structures
• Risk factors for pituitary tumors

  • Family history
  • Genetic predisposition
• Assessment and diagnostics for pituitary tumors

  • Family history
  • Physical examination
  • CT, MRI
  • Serum levels of pituitary hormones
  • Serum levels of hormones of target organs (e.g., thyroid, adrenal)

  
• Clinical manifestations of pituitary tumors

  • Blurred or double vision
  • Loss of peripheral vision
  • Sudden blindness
  • Headaches
  • Facial numbness or pain
  • Dizziness
  • Loss of consciousness
  • Lower basal metabolic rate
  • Nausea, Weakness
  • Unexplained weight loss or weight gain
  • Feeling cold, Feeling tired or weak
  • Menstrual changes or loss of menstrual periods in women
  • Erectile dysfunction or decreased interest in sex in men
  • Diabetes insipidus: tumor pressing on posterior pituitary
  • Acromegaly (GH secreting adenoma)
  • Cushing syndrome (ACTH secreting adenoma)
  • Hyperthyroidism (TSH-secreting adenomas)
  • Irregular menstrual periods in women or low testosterone levels and decreased interest in sex in men (gonadotropin-secreting adenomas)
  • Menstrual periods become less frequent or to stop, abnormal breast milk production (prolactinomas in women before menopause)
  • Breast growth, erectile dysfunction and loss of interest in sex (prolactinomas in men)
• Medical management of pituitary tumors

  • Surgery to remove the tumor: transsphenoidal resection approach (most common)
  • Radiation therapy
  • Medications to control hormone production
• Pituitary Tumors


  Clinical manifestation
• Clinical manifestations of pituitary tumors

  • DI: tumor pressing on posterior pituitary
  • GH secreting adenoma: acromegaly (adults) or gigantism (children)
  • ACTH secreting adenoma: Cushing syndrome
  • Thyrotropin (TSH)-secreting adenomas: hyperthyroidism
  • Gonadotropin-secreting adenomas-- irregular menstrual periods in women or low testosterone levels and decreased interest in sex in men
  • Prolactin-secreting adenomas (prolactinomas)-- most common in young women and older men
• Prolactin-secreting adenomas (prolactinomas) in women before menopause


  Menstrual periods become less frequent or to stop, abnormal breast milk production
• Prolactin-secreting adenomas (prolactinomas) in men


  Breast growth, erectile dysfunction and loss of interest in sex
• Prolactin-secreting adenomas (prolactinomas) in females who don't have periods


  Might not be noticed
• Pituitary Tumor Medical Management: Surgery

  1. Transsphenoidal resection approach (most common)

  2. Craniotomy may also be an option

  3. Surgery is done through the sphenoid sinus, an incision is made beneath the patient's upper lip to enter the nasal cavity

  4. Nasal pack (for 4 days) to stop bleeding

  5. A urinary catheter is placed to monitor urine output

  6. Do NOT blow nose or insert anything in the nose
• Pituitary Tumor Surgery Complications


  • Postoperative hemorrhage & CSF leak which may result in meningitis
• Pituitary Tumor Medical Management: Gamma Knife Stereotactic Radiotherapy (radiosurgery)


  1. Delivers a large, precise radiation dose to the tumor area in a single session (radiosurgery) or in a few sessions (radiotherapy)

  2. Targets the tumor more precisely than standard radiation, causing less harm to the remaining normal pituitary gland

  3. A light-weight metal frame is often attached to the head with small pins or screws to help aim the radiation beams very precisely and radiation is focused at the tumor from many different angles
• Pituitary Tumor Medical Management: Radiation Therapy

  1. Proton beam therapy (not common)

  2. External radiotherapy (5x/ wk for 4-6 wks)
• Pituitary Tumor Medical Management: Pharmacology for Prolactin-secreting tumors (prolactinomas)

  Cabergoline and bromocriptine (Parlodel) decrease prolactin secretion and often reduce tumor size
• Possible side effects of medications for prolactin-secreting tumors


  Drowsiness, dizziness, nausea, vomiting, diarrhea or constipation, confusion, and depression. Some people develop compulsive behaviors, such as gambling, while taking these medications.
• Pituitary Tumor Medical Management: Pharmacology for Growth hormone-secreting tumors

  1. Somatostatin analogs (Sandostatin, Somatuline Depot, others): causes decrease in growth hormone production and may shrink the tumor

  2. Pegvisomant (Somavert): blocks the effect of excess growth hormone on the body
• Somatostatin analogs side effects

  Nausea, vomiting, diarrhea, stomach pain, dizziness, headache and pain at the site of injection. Many of these side effects improve or even go away with time. They can also cause gallstones and may worsen diabetes mellitus.
• Pegvisomant side effects


  May cause liver damage in some people