St.
Paul University Philippines- School of Medicine- MED II
LAB DX – FINAL S |ENDOCRINE FUNCTION TESTS – Dr. CAUAN
ENDOCRINE FUNCTION TESTS Pituitary tumors – classification
• Endocrine system – finely integrated system – • Microadenomas (< 1cm in greatest dia and
-hypothalamus, pituitary and target glands confined to sella)
continually communicate through feedback • Macroadenomas (>/= 1 cm in greatest dia)
inhibition and stimulation to control all aspects of • secretory and nonsecretory varieties
metabolism, growth and reproduction • compress the optic chiasm - visual field defects -
• Prolactin level bitemporal hemianopia (most frequent
• elevated –variety of pharmacologic and presentation)
physiologic stimuli • Invasion -cavernous sinus
• > 200 ng/ml – associated with presence -compression of cranial nerves III, IV, VI, V1,
of pituitary tumor and V2 and the intracavernous portion of the
• Initial screening for acromegaly – serum insulin internal carotid artery
growth factor-I • hydrocephalus - obstruction of the third
• day 2–3 follicle-stimulating hormone ventricle
• good indicator of follicular reserve
• day 21–22 progesterone - assess whether cycles PROLACTIN
are ovulatory • polypeptide - lactotrophs of the pituitary
• initiation and maintenance of lactation
Pituitary • secretion normally kept at low levels by the
• hormone - acts at a site distant from its place of inhibitory actions of dopamine produced by the
origin hypothalamus
-autocrine (act directly upon themselves) • secreted in a circadian fashion
-paracrine (act adjacent to the cells of origin) • highest levels - sleep
-intracrine (act within the cells of origin without • secreted in a pulsatile fashion
ever exiting the cells) -amplitude and frequency - influenced
• Pituitary gland – hypophysis by a variety of physiologic (e.g., stress,
-located within the sella turcica postprandially, exercise)
-connected by the infundibular stalk to the • Serum half-life: 26–47 minutes
median eminence of the hypothalamus -screening for hyperprolactinemia -
-divided into anterior lobe (adenohypophysis) three specimens with 20- to 30-minute intervals
and posterior lobe (neurohypophysis) • PRL is measured by immunometric assay
-Weight: 0.6 g • reference value:
-Size: about 12 mm (transverse); 8 mm -1–25 ng/mL (1–25 μg/L) - women
(anteroposterior) diameter -1–20 ng/mL (1–20 μg/L) - men
PRL deficiency
• pituitary necrosis
• infarction
• some cases of pseudohypoparathyroidism
Other tool for DX
• CT or MRI of the sella with and without contrast
• better for visualizing microadenomas
• formal visual field examination - done at least
yearly in patients with stable disease
GROWTH HORMONE
• single-chain polypeptide
• 191 amino acids synthesized, stored
1 GERDANO
St. Paul University Philippines- School of Medicine- MED II
LAB DX – FINAL S |ENDOCRINE FUNCTION TESTS – Dr. CAUAN
• secreted by the somatotrophs of the • screening test for clinically suspected
pituitary in response to the secretion of acromegaly - randomly collected IGF-1
growth hormone–releasing hormone • If IGF-1 is elevated (appropriate age- and
(GHRH) by the hypothalamus gender-related reference range)
• Somatostatin - produced by the -confirm the diagnosis - oral glucose
hypothalamus, inhibits GH release tolerance test (OGTT)
• IGF-I (somatomedin C) – intermediary – -normal response is suppression of GH
indirectly mediates anabolic and to <1 ng/mL (1 μg/L) at any time during the test
metabolic action -fails to drop to below 1 ng/mL (1 μg/L)
-synthesized in the liver and in certain – acromegaly
target tissues, in response to stimulation by GH
• Secretion - pulsatile fashion Posterior pituitary hormone
• frequency and amplitude of the peaks - greatest OXYTOCIN AND VASOPRESSIN
during puberty
• up to 70% of GH secretion occurs during stage 4 OXYTOCIN
(slow wave) sleep -STIMULI: STRETCHING OF UTERUS
• diagnosis of GH deficiency AND VAGINA – PARTURITION
-measured following pharmacologic (FERGUSSON REFLEX)
stimulation -STIMULATES THE MYOEPITHELIAL
• GH excess - confirmed by failure of GH CELLS SURROUNDING THE MAMMARY
suppression following an oral glucose load GLANDS AND LACTIFEROUS DUCTS TO
• commonly measured by chemiluminescent CONTRACT, RESULTING IN MILK
immunoassay EJECTION
• Normal values: -MEASUREMENT OF OXYTOCIN
-70%–80% - below 1 ng/mL (<1 μg/L) LEVELS IS EXTREMELY RARE
-secretory peaks typically reach 20–40 -HALF-LIFE: 3–5 MINUTES;
ng/mL (20–40 g/L) SUBJECT TO RAPID DEGRADATION BY
OXYTOCINASE
Growth hormone deficiency
• Idiopathic growth hormone deficiency VASOPRESSIN/ANTIDIURETIC HORMONE
-most common cause of GH deficiency
(GHD) - children -VASOPRESSOR EFFECTS -
• pituitary adenoma MEDIATED BY CONTRACTION OF THE
-most common etiology - adult-onset GHD SMOOTH MUSCLE
• Insulin Tolerance Test (ITT) - “gold standard” for -ANTIDUIRETIC EFFECTS –
diagnosing GHD MEDIATED BY PROMOTING RENAL
-Failure of GH to rise above 5 ng/mL - adults WATER REABSORPTION FROM THE
-above 10 ng/mL in children – abnormal CORTICAL COLLECTING DUCTS
• IGF-1- screening for GHD in children
-IGF-I levels decline in malnutrition, ARGININE
VASOPRESSIN/ANTIDIURETIC HORMONE
hypothyroidism, hepatic disease, uncontrolled
diabetes mellitus, and with age DIABETES INSIPIDUS
• CENTRAL
GROWTH HORMONE EXCESS • ABSENT OR DECREASED ADH
• Growth hormone overproduction – acromegaly SECRETION FROM THE
• condition develops before closure of the HYPOTHALAMUS OR
epiphyses – gigantism NEUROHYPOPHYSIS
2 GERDANO
St. Paul University Philippines- School of Medicine- MED II
LAB DX – FINAL S |ENDOCRINE FUNCTION TESTS – Dr. CAUAN
• NEPHROGENIC (DUE TO RENAL Syndrome of Inappropriate Secretion of ADH
RESISTANCE TO THE ACTIONS
OF ADH) euvolemic hypoosmolar hyponatremia
associated with hyperosmolar urine (result
WATER DEPRIVATION TEST - of continued inappropriate natriuresis)
PREFERRED DIAGNOSTIC TEST Water Load Test:
Thyroid
• normal thyroid gland - 15–25 g
• divided into lobules, each composed of 20–40
follicles
• Follicles: ring-shaped structures
• single cell band of follicular cells
- colloid, thyroid hormone
(tetraiodothyronine (T4) and
some triiodothyronine (T3)),
thyroglobulin (Tg), and a variety
of other glycoproteins
• Almost all circulating T4 and T3 – bound to
protein
• Unbound T4 or free T4 – biologically active form
3 GERDANO
St. Paul University Philippines- School of Medicine- MED II
LAB DX – FINAL S |ENDOCRINE FUNCTION TESTS – Dr. CAUAN
• Sustained or paroxysmal hypertension -
most common manifestation
• Measurement:
• Plasma free metanephrines:
• Urine fractioned metanephrines
• CT scan – first line imaging technique
• TSH - most important test of thyroid function
• Thyroglobulin – dx of well-differentiated
carcinoma
• FT4 - biologically active fraction of thyroxine in
circulating blood
• Serum total T3 measurement - confirming the
diagnosis of hyperthyroidism (patients with no
or minimally elevated T4 or ambiguous clinical
manifestation)
• Thyroxine-Binding Globulin (TBG)
-patients who have serum T4 and T3 levels
that do not agree with other laboratory parameters Neuroblastoma
of thyroid function, or not compatible with clinical • neural crest origin, arising within the adrenals
findings or the sympathetic chain
• pyramidal structures located above each kidney • second most common solid malignant tumor in
• Divided into two distinct parts: childhood, before the age of 3
• medulla (inner layer) • 90% of patients have elevated urinary
• cortex (outerlayer) homovanillic acid (HVA) levels at the time of
• medulla diagnosis
-neural crest origin (ectoderm) • almost 75% have increased urinary
-stores and secretes catecholamines vanillylmandelic acid (VMA) levels
• cortex
-mesenchymal origin; 80%–90% of the Adrenal cortex
adrenal gland Mineralocorticoid Axis
-divided into three zones: • Aldosterone - promotes the reabsorption of
-outermost zona glomerulosa - sodium and water by the kidney
produces mineralocorticoids • help maintain blood pressure and tonicity
-zona fasciculata - responsible for
glucocorticoid production
-inner zona reticularis - synthesizes
androgens
Adrenal medulla
Pheochromocytoma
• rare catecholamine-producing tumors
• Most pheochromocytomas - sporadic
4 GERDANO
St. Paul University Philippines- School of Medicine- MED II
LAB DX – FINAL S |ENDOCRINE FUNCTION TESTS – Dr. CAUAN
• stimulated by:
• ACTH
• Diurnal variation
• Stress
• ACTH
• synthesized in the adenohypophysis
• 39 amino acid residues
• secreted in response to several factors - CRH
and AVP are the most important
• ACTH level – useful for differentiating primary
from secondary adrenal insufficiency
• Hypercortisolism: Cushing’s Syndrome
• group of clinical and metabolic
disorders
• most common findings: central obesity,
hypertension, and hirsutism
Adrenal cortex • adrenocortical hyperfunction
Congenital Disorders of Adrenal Cortical • associated with excess production of
Enzyme Deficiencies glucocorticoids, or glucocorticoids and
androgens
• Laboratory findings in Cushing’s syndrome
include:
(1) excessive and persistent production of
cortisol measured as elevated serum cortisol,
urinary free cortisol, midnight salivary cortisol
or 17-OHCS
(2) loss of circadian rhythm of ACTH and
cortisol
(3) loss of suppression of cortisol production by
administration of the synthetic glucocorticoid
dexamethasone
(4) hyperglycemia
Diagnosis: • Algorithm for the evaluation of Cushing’s
-Prenatal diagnosis - important syndrome
-suppressive treatment with • All screening tests must be followed by a
steroids can abrogate the development of confirmatory test
virilization of the female fetus • Screening:
• level of 17-OHP in amniotic fluid or by • 11 pm salivary cortisol
genotyping cells obtained chorionic • 24-hr urine free cortisol
villous sampling • Overnight 1 mg dex suppression
• PCR and Southern blotting on chorionic • Confirmatory:
villous samples • 0.5 mg dex every 6 hr for 48hrs
• Neonatal screening – mandatory • Midnight plasma cortisol
•
Adrenal cortex
(Cortisol and the Glucocorticoids)
Cortisol
• Secreted by adrenal cortex
5 GERDANO
St. Paul University Philippines- School of Medicine- MED II
LAB DX – FINAL S |ENDOCRINE FUNCTION TESTS – Dr. CAUAN
-most commonly due to autoimmune
adrenalitis (70%–90% of all cases)
-other – tuberculosis (most common cause
worldwide), granulomatous disorders, metastatic
disease, hemorrhage, human immunodeficiency virus,
acquired immunodeficiency syndrome, and infection
• most common cause of central adrenal
insufficiency
-HPA (hypothalamic-pituitary-adrenal)axis
suppression due to prolonged treatment with
pharmacologic doses of steroids
• Tests:
• Basal Hormone Measurements
-8 am to 9 am plasma cortisol: <3
μg/dL (83 nmol/L) - indicative of adrenal
insufficiency
• ACTH Stimulation Test
-most convenient procedure
-administering 250 μg of
Cosyntropin (commercially available
ACTH analog) intravenously or
intramuscularly - failure of aldosterone
to increase by more than 4 ng/dL over
baseline suggests primary adrenal
dysfunction
• Corticotropin-Releasing Hormone Test -
to localize the site of damage
Pseudo-Cushing’s Syndrome
• Excess activity of the hypothalamic-pituitary RENIN AND HYPERTENSION
axis • About 15% of patients with essential
• Patients with alcoholism, major depression, and hypertension have high-renin hypertension
obesity • Hyperreninemia - from renal parenchymal
• not suppress on a low-dose DST and may have disease or renal vasculopathy leads to increased
elevated UFC (urine free cortisol) aldosterone production and retention of
• combined dexamethasone-oCRH test: sodium and enhanced potassium excretion
-more definitive test for distinguishing it • hypervolemic, intensely
from Cushing syndrome vasoconstrictive, and more prone to
-IV bolus injection of synthetic ovine CRH – ischemic injury
dose: 1 mcg (200nmol)/kg • Renin-secreting tumors are extremely rare
-Serum cortisol level: >30 nmol/L after 15
min if injection – true Cushing
Adrenal Insufficiency
• key site of dysfunction
• primary (adrenal)
• secondary (pituitary)
• tertiary (hypothalamic)
• primary adrenal insufficiency (Addison’s
disease)
6 GERDANO
St. Paul University Philippines- School of Medicine- MED II
LAB DX – FINAL S |ENDOCRINE FUNCTION TESTS – Dr. CAUAN
Causes of Hyperaldosteronism
PRIMARY HYPERALDOSTERONISM—SCREENING CAUSES OF HYPOALDOSTERONISM
AND CONFIRMATION TESTS
• plasma aldosterone concentration/plasma renin
activity (PAC/PRA) ratio
• remained upright for at least 2 hours
• patient should have stopped
spironolactone and eplerenone for 4–6
weeks and other diuretics for at least 2
weeks before testing
• PAC/PRA ratio > 30 - suggestive of
primary hyperaldosteronism
• Confirmed by: GONADOTROPINS AND SEX
• oral sodium loading test
• saline infusion test KEY POINTS
• fludrocortisone suppression test • Reproductive function and pregnancy are
• captopril challenge test regulated by the complex interaction of a
• variety of hormones
ALDOSTERONE MEASUREMENTS • synthesized and secreted by the:
• Aldosterone assays - performed on plasma • testis (testosterone)
using extraction to remove aldosterone from • ovary (estradiol and progesterone)
plasma proteins, followed by chromatography • pituitary (follicle-stimulating hormone
and immunoassay [FSH] and luteinizing hormone [LH])
• Urine is assayed following acid hydrolysis and • hypothalamus (gonadotropin-releasing
extraction hormone
• HPLC with tandem mass spectrometry affords • placenta (human chorionic
greater consistency and is gradually replacing gonadotropin [hCG], estrogens, and
older methods progesterone)
GNRH
RENIN MEASUREMENTS • Decapeptide
• current methods – PRA (plasma renin activity) • Synthesized and secreted by neuroendocrine
and RIA cells of the hypothalamus (arcuate nucleus)
7 GERDANO
St. Paul University Philippines- School of Medicine- MED II
LAB DX – FINAL S |ENDOCRINE FUNCTION TESTS – Dr. CAUAN
diagnostic algorithm for amenorrhea
Approximate gestational weeks for laboratory
evaluation of major disease states in pregnancy
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