Symposium for Patients & Caregivers

Hormonal Imbalances

Laura Knecht, MD

Adult EndocrinologistMedical Director, Barrow Pituitary Center

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)

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

Dopamine

• Released by the Hypothalamus• Travels down the pituitary stalk• Continuous release inhibits the release of

prolactin from pituitary

Oxytocin

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

Somatostatin

• Inhibits growth hormone release from pituitary• Inhibits TSH release from pituitary

Corticotropin Releasing Hormone (CRH)

• Acts at pituitary to release adrenocorticotropic hormone (ACTH)

• ACTH acts at adrenal glands to secrete cortisol (stress hormones)

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

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

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

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

Treatment

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

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

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

Prolactin/Oxytocin Deficiency

• Inability to lactate after delivery• Difficulty with uterine contractions

Treatment

• Not available• Not indicated

Hypothyroidism

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

Treatment

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

Adrenal Insufficiency

• Cortisol deficiency• Mild

• Fatigue• Anorexia• Weight loss• Decreased libido• Hypoglycemia• Eosinophilia

• Severe• Vascular collapse• Loss of peripheral vascular tone• Death

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

Diabetes Insipidus

• Can occur prior to surgery, around time of surgery, after surgery

• Can be temporary or permanent

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

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

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)

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

Diabetes Insipidus – TreatmentDDAVP (Desmopressin)

• Subcutaneous• Rarely necessary as outpatient• Avoids absorption issues

• IV• Avoids absorption issues• Used in hospital around time of surgery

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