1
Q
Hypofunction d/t
A
- loss of reserve, hyposecretion, agenesis, atrophy, or active destruction
- Lack/loss of gland function (i.e. DM I, diminished erythropoiesis in CRF)
- Inappropriate response to signals (i.e. hypothyroidism or hyperthyroidism)
2
Q
Hyperfunction d/t
A
- hypersecretion, loss of suppression, hyperstimulation, or hyper/neoplastic changes
- Structural enlargement in a critical site (i.e. hyperthyroidism)
- Dysregulation of hormone release (i.e. productive pituitary adenoma)
- Inappropriate response to signals (i.e. hypothyroidism or hyperthyroidism)
3
Q
Hyperpituitarism
Definition
A
- Primary hypersecretion of pituitary hormones
- MC cause: a functional pituitary adenoma
- Can most commonly cause increased release of GH, prolactin, or ACTH
- GH: Gigantism or acromegaly
- Prolactin: Hyperprolactinemia (prolactinoma)
- ACTH: Cushing’s Disease
4
Q
Hyperpituitarism
Shared Signs and Symptoms
A
- visual field disturbances
- headaches
- SSx that are specific to the hormone that is being oversecreted
5
Q
Gigantism
Definition
Occurs if hypersecretion…
A
- Gigantism occurs if hypersecretion is before growth plates close
- excessive growth and height significantly above average
6
Q
Acromegaly
Definition
Occurs if hypersecretion…
A
- Acromegaly occurs if hypersecretion is after growth plates close
- excessive thickening of the appendages
- Hands, feet, forehead, jaw, nose
- Change in height does not occur
7
Q
Gigantism
Definition
A
- Overproduction of growth hormone (GH) during
childhood years, before the closing of the epiphyseal plate - extremely rare, approximately 3 to 4 reported cases per million
8
Q
Gigantism
Etiology
A
- Most common cause is a GH secreting pituitary adenoma
9
Q
Gigantism
Signs and Symptoms
A
- Abnormal and accelerated growth, mainly in the long bones
- Complications are numerous and lead to reduced life expectancy
- Mobility issues due to muscle weakness
- Cardiomegaly and valve disorders
- Sleep apnea
- Osteoarthritis
10
Q
Gigantism
Treatment
A
- Surgical resection of adenoma or radiation
- GH antagonists
11
Q
Gigantism
Massage and Gigantism
A
- You are very unlikely to encounter anyone with gigantism since it is so rare
- No contraindications
12
Q
Acromegaly
Definition
A
- Overproduction of growth hormone (GH) during adult years, after the closing of the epiphyseal plate
- Less rare than gigantism, but still rare
- One case per 25000 adults
13
Q
Acromegaly
Etiology
A
- Most common cause is a GH secreting pituitary adenoma
14
Q
Acromegaly
Signs and Symptoms
A
- Excessive growth in the hands, feet, and face
- Bones become thicker and heavier
- Common changes:
- Protruding jaw
- Thick fingers
- Number and size of glands in the skin increased
- Thick, coarse skin
- Increased body odour
15
Q
Acromegaly
Epidemiology
A
- Uncommon, one per 25000 adults
- Occurs equally in men and women
16
Q
Acromegaly
Diagnosis
A
- Laboratory tests
- Serum IGF-1
- GH suppression test (gold standard) = GH levels taken 2 hours after oral glucose load
- Sensitive test for dx of acromegaly
- GH levels should fall after glucose administration
17
Q
Acromegaly
Treatment
A
- Surgical resection of adenoma or radiation
- GH antagonists
18
Q
Acromegaly
Prognosis
A
- People with acromegaly have a decreased life expectancy
- With successful surgery, some may lead a relatively normal life
19
Q
Massage and Acromegaly
A
- No contraindications
- Inquire about pain
20
Q
Prolactinoma
Definition
A
- A benign, functioning pituitary tumour that secretes prolactin causing hyperprolactinemia
- Most common type of pituitary adenoma
- Tumors range from microadenomas to large, expansile lesions and have a tendency to calcify
- Classification is based on efficiency (ability to create prolactin) and proportionality (size is generally congruent with serum prolactin)
21
Q
Prolactinoma
Etiology
A
- Risk factors are unknown, genetics may play a factor is some cases
22
Q
Prolactinoma
Epidemiology
A
- occur most commonly in people under the age of 40
- more common in people assigned female at birth
- rarely occur in children and adolescents.
23
Q
Prolactinoma
Signs and Symptoms
A
- SSx of increased prolactin are similar, regardless of cause
- MC: H/A, amenorrhea, galactorrhea, infertility,
hypogonadism, gynecomastia, loss of libido, impotence,
decreased bone density - Other SSx: visual disturbances, vertigo, vomiting
24
Q
Prolactinoma
Diagnosis
A
- Laboratory tests: serum PRL
- Thyroid testing and medication review to r/o other causes
- Imaging: MRI (most sensitive), CT
25
# Prolactinoma
Differential Diagnosis
* Stress: can increase prolactin and mimic prolactinoma
* Rx drugs: dopamine antagonists and opiate & estrogen agonists can also mimic prolactinoma
* Pregnancy and breastfeeding increase prolactin
26
# Prolactinoma
Treatment
* Goals: return serum PRL to normal, reduce tumor size, correct visual disturbances, and restore pituitary function
* Maintenance of stress and elimination of prolactin inducing medications
* Medications: dopamine agonists
* Surgical removal and radiation
27
# Prolactinoma
Prognosis
* Generally good
* Surgery corrects prolactin levels in about 90% of people with small prolactinomas and in 50% of people who have large tumors
28
Massage and Prolactinoma
* No contraindications
29
# Hypercortisolism
Cushing’s syndrome
* is a collection of signs and symptoms due to prolonged exposure to cortisol or corticosteroids (hypercortisolism)
* Most common cause is medications
* We will cover this more and other causes with the adrenal glands
30
# Hypercortisolism
Cushing’s disease
* is a particular type of Cushing’s syndrome, resulting from an ACTH secreting pituitary tumor
31
# Cushing’s Disease
Definition
* Benign pituitary adenoma that secretes excess adrenocorticotropic hormone (ACTH), causing adrenal hypersecretion of cortisol
32
# Cushing’s Disease
Etiology
* No known risk factors
33
# Cushing’s Disease
Epidemiology
* Rare, 5 to 25 cases per million people per year
* Most prevalent between the ages of 20 and 50
34
# Cushing’s Disease
Signs and Symptoms
* Round face called “moon face”
* Central or truncal obesity
* Striae
* Upper back fat deposition, ”buffalo hump”
* Acne
* Puffy eyes
* Thinning hair
* Reduced immune function
* Thinning of skin
35
# Cushing’s Disease
Diagnosis
* Laboratory tests
* Examine cortisol levels in either blood, saliva, or urine
* dexamethasone suppression test
* Synthetic glucocorticoid administered and cortisol and ACTH response monitored
* Imaging (MRI)
36
# Cushing’s Disease
Treatment
* Surgical excision of tumor with or without radiation
* Cortisol antagonists
37
Massage and Cushing’s Disease
* Much more likely to see patient’s with Cushing’s
syndrome, but the management is similar
* No contraindications, unless bone density also
affected
38
# Hypopituitarism
Definition
* Decreased secretion of one or more the pituitary hormones due to partial or complete loss of function
* can be caused by pituitary or hypothalamus disorders
* Various clinical symptoms arise, depending on the specific hormone deficiency and the underlying cause
39
# Hypopituitarism
Causes
* Tumors
* Stroke or hemorrhage
* Sheehan syndrome
* Surgery or radiation
* Infection
40
# Hypopituitarism
Signs and Symptoms
* SSx are specific to the hormones that are decreased and the underlying
cause
* May be one or more hormones
* Often have slow, vague, insidious onset
* Decreases in TSH and ACTH are rare
41
# Hypopituitarism
Diagnosis
* Clinical picture can be confusing d/t multiple gland involvement
* Imaging and basal/provocative laboratory tests needed to confirm
* Basal: morning, baseline testing
* Dynamic: injection of stimulatory substance
42
# Hypopituitarism
Treatment
* Depends on cause
* In general, removal of tumour and replacement of hormones
43
# Empty Sella Syndrome
Description
* rare condition in which your pituitary gland becomes
flattened or shrinks due to issues with the contents
within the sella turcica
44
# Empty Sella Syndrome
Etiology
* gland or the sella turcica is somehow damaged as a result of another condition or incident
* tumors
* Radiation therapy or surgery
* Head trauma (injury), such as a traumatic brain injury
* Idiopathic intracranial hypertension (IIH)
* Sheehan’s syndrome
45
# Empty Sella Syndrome
Signs and Symptoms
* SSx are specific to the hormones that are decreased and underlying cause
* May be one or more hormones
* Frequent headache is a common symptom (unsure of connection)
46
# Empty Sella Syndrome
Diagnosis
* Often found incidentally on imaging MRI or CT
* Blood tests to check hormone levels
47
# Empty Sella Syndrome
Treatment
* Hormone replacement therapy
48
Massage and Empty Sella Syndrome
* Causes and side effects may vary, consult with patient
49
# Pituitary Dwarfism
Definition
* An underproduction of growth hormone (GH) in childhood, causing short stature
* Causes proportionate dwarfism
50
# Pituitary Dwarfism
Epidemiology
* Affects 750 people per million
51
# Pituitary Dwarfism
Etiology
* Idiopathic
* Trauma (head injury)
* Pituitary tumours
* Infections
52
# Pituitary Dwarfism
Signs and Symptoms
* **Short in stature**
* Average male: 4 feet, 3.8 inches
* Average female: 4 feet, 0.6 inches
* **Proportionate**
* Head, trunk, and limbs proportionate to each other
* **Other SSx include:**
* A younger-looking face than what’s expected for their age
* Impaired hair and nail growth
* Delayed tooth development
* Delayed puberty
53
# Pituitary Dwarfism
Diagnosis
* Suspected due to lack of growth compared to peers
* Confirmatory tests include:
* X-rays of bone, specifically growth plates
* Blood tests: GH and IGF-1
* Growth hormone stimulation test
* MRI of pituitary
54
# Pituitary Dwarfism
Treatment
* Hormone replacement therapy
55
Massage and Pituitary Dwarfism
* No contraindications
56
# Diabetes Insipidus
Definition
* Lack of or lack of a response to antidiuretic hormone (ADH; vasopressin) resulting in dilute urine and polyuria
57
# Diabetes Insipidus
There are two types of DI:
* **Central diabetes insipidus**
* The posterior pituitary does not release enough ADH
* **Nephrogenic diabetes insipidus**
* The posterior pituitary makes ADH, but the kidney does not respond to it
58
# Diabetes Insipidus
Etiology
| Central DI
* Idiopathic lack of production by hypothalamus
(50%)
* primary, secondary tumors, infiltrative disease
* trauma
59
# Diabetes Insipidus
Etiology
| Nephrogenic DI
* defect in structures of kidneys so kidneys are
unable to respond appropriately to ADH
* Defect can be caused by CKD, genetics
60
# Diabetes Insipidus
Signs and Symptoms
Massive polyuria with dilute urine
* > 12L of urine per day
* Especially at night
* Dehydration
* Polydipsia (3-30 L/day)
* d/t initial elevation in serum Na
* Low blood pressure
* Shock
61
# Diabetes Insipidus
Diagnosis
* Suspected in persons who produce large amounts of urine (24hr urine volume assessment) > 3L/day in adults
* Serum chemistry lab tests, especially sodium and GTT and blood sugar tests to r/o DM
62
# Diabetes Insipidus
Treatment
* Vasopressin/desmopressin nasal spray
* Dose is frequently changed to meet body’s requirements
* Can cause fluid retention and edema
* Does not work on nephrogenic DI – WHY?
63
# Diabetes Insipidus
Prognosis
* Prognosis for central DI is generally good
* usually doesn’t cause serious problems if treated
properly and managed properly
64
Massage and Diabetes Insipidus
* No contraindication
65
# Cushing’s Syndrome
Definition
* A collection of signs and symptoms due to prolonged exposure to cortisol or corticosteroids (hypercortisolism)
66
# Cushing’s Syndrome
Etiology
* Administration of exogenous glucocorticoids or ACTH (most common)
* Pituitary adenoma (Cushing’s Disease)
* Adrenal tumor or hyperplasia
* Paraneoplastic syndrome
67
# Cushing’s Syndrome
Signs and Symptoms
* Same as Cushing’s disease
* Round face called “moon face”
* Central or truncal obesity
* Striae
* Upper back fat deposition, ”buffalo hump”
* Acne
* Puffy eyes
* Thinning hair
* Reduced immune function
* Thinning of skin
68
# Cushing’s Syndrome
Diagnosis
* Suspicion based on characteristic symptoms
* **Confirmation via three common tests**
* **Dexamethasone suppression test**
* No suppression of ACTH w/ administration of cortisol if pituitary issue
* Cortisol levels rise even more and ACTH stays low if adrenal issue
* **24hr urinary cortisol excretion**
* **Late night serum/salivary cortisol**
69
# Cushing’s Syndrome
Treatment
* Reduction of exogenous cortisol
* Cortisol inhibiting medications
* Surgical removal and/or radiation of tumors
70
Massage and Cushing’s Syndrome
* No contraindications, unless bone density also affected
71
# Adrenal Insufficiency
Definition
| and two main types
* Rare endocrine disorder wherein the adrenal glands do not produce enough glucocorticoids and mineralocorticoids
* **There are two main types:**
* Primary adrenal insufficiency (the cause is in the adrenal gland)
* This is known as Addison’s Disease
* Secondary adrenal insufficiency (the causes is in the pituitary)
72
# Adrenal Insufficiency
Epidemiology
* Can affect any age (MC is 30-50) and effects all sexes equally
73
# Adrenal Insufficiency
Etiology
| Primary and secondary
* Primary AI
* Congenital hypoplasia/hyperplasia
* Infection
* Autoimmune polyendocrinopathy
* Metastatic carcinoma
* Secondary AI
* Inflammation (TB) or neoplasm of hypothalamus/pituitary gland
* Long-term steroid administration/steroid-producing neoplasm (causes
hypothalamic-pituitary suppression)
74
# Adrenal Insufficiency
Signs and Symptoms
* Initial SSx
* progressive weakness, easy fatigability, anorexia, weight loss, N/V/D
* Potential for hypoglycemia
* hyperkalemia, hyponatremia, volume depletion, dehydration, and hypotension
* Addison’s: hyperpigmentation (bronzing)
* Any stress (infection/trauma/surgery) can evoke adrenal (Addisonian) crisis:
* intractable vomiting, abdominal pain, hypotension, vascular collapse, coma, and death
* Medical emergency
75
# Adrenal Insufficiency
Diagnosis
* Usually late dx d/t ambiguous SSx
* Physical stressors make SSx more obvious and may cause a crisis
* Serum chemistry blood tests: low sodium, high potassium and altered
kidney function tests (GFR, BUN, Cr)
* Serum cortisol and ACTH levels
* Primary: low cortisol, high ACTH
* Secondary: low cortisol, low ACTH
* Corticotropin provocation test to DDX primary vs secondary
76
# Adrenal Insufficiency
Treatment
* **Corticosteroids and IV fluids**
* Start w/ PO hydrocortisone or prednisone
* IV or IM synthetic steroids if severe disease
* Doses are divided throughout day
* Increased dosage during illness or physical stress
* **Fludrocortisone**: both mineralocorticoid and glucocorticoid properties
* Restore normal Na+/K+ excretion and fluid balance
* Androgen replacement is not necessary
* Treatment is lifelong
77
# Massage and Adrenal Insufficiency
* No contraindications
78
# Hyperaldosteronism
Definition
| and two main types
* Chronic, excessive secretion of aldosterone resulting in sodium and water retention and potassium excretion
* Hypertension, hypernatremia and hypokalemia
* There are two main types:
* Primary aldosteronism (the cause is in the adrenal gland)
* This is known as Conn’s Syndrome
* Secondary aldosteronism (the causes is elsewhere)
79
# Hyperaldosteronism
Etiology
| Primary Aldosteronism
* Benign adrenal neoplasm
* Idiopathic adrenal hyperplasia: bilateral nodular hyperplasia
* Glucocorticoid-remediable hyperaldosteronism: genetic disorder of increased cortisol and aldosterone
80
# Hyperaldosteronism
Etiology
| Secondary Aldosteronism
* Decreased renal perfusion
* Arterial hypovolemia and edema: CHF, cirrhosis, nephrotic syndrome
* Pregnancy: increased estrogen causes increase in plasma renin
81
# Hyperaldosteronism
Signs and Symptoms
* Hypertension and hypokalemia
* Muscle weakness
* Muscle cramps
* Tingling and temporary paralysis
* H/A
* Metabolic alkalosis
* Dyspnea, H/A, weakness
* High pH leads to hypocalcemia
* Convulsions, arrhythmia, tetany, paresthesia
82
# Hyperaldosteronism
Diagnosis
* Serum aldosterone and renin ratio
* Primary: increased aldosterone, decreased renin
* Secondary: increased aldosterone and renin
* CT scan to confirm adrenal neoplasm
83
# Hyperaldosteronism
Treatment
* Based on underlying cause
* Surgical adrenalectomy is curative for adrenal adenomas
* If bilateral adrenal involvement, aldosterone blocking drugs are used
* K+ sparing diuretics: spironolactone
84
# Hyperaldosteronism
Prognosis
* HTN and hypokalemia increase burden on heart
* Cardiac decompensation (CHF) and arrhythmias
* Increased risk of stroke, heart disease, kidney failure
* Proper Tx and management results in excellent prognosis
85
# Hyperaldosteronism
Massage and Hyperaldosteronism
* No contraindications
86
# Pheochromocytoma
Definition
* Uncommon neoplasms of chromaffin cells, resulting in
overproduction of catecholamines
* MC symptom: hypertension
87
# Pheochromocytoma
Epidemiology
* Rare, 0.66 cases per 100,000 people per year
88
# Pheochromocytoma
Etiology
* Most cases are idiopathic, some have a genetic link
89
# Pheochromocytoma
Signs and Symptoms
* Abrupt elevation of BP
* Tachycardia, palpitations, tachypnea
* Headache
* Excessive sweating
* High blood sugar
* Tremor
* Constipation
* Chest or abdominal pain
* Nervousness/sense of impending doom
90
# Pheochromocytoma
Diagnosis
* Suspected when HTN is seen in young children, when it is intermittent, or when there are other SSx of pheochromocytoma
* Serum and urine tests
* Increased catecholamines and their metabolites
* Increased HTN when given a beta-blocker
* Would not intentionally be given if pheochromocytoma is suspected
* CT or MRI with contrast to visualize tumour
91
# Pheochromocytoma
Treatment
* Surgical removal
* Requires pre-surgical treatment with catecholamines
* If too high, they can cause HTN crisis during surgery
* If malignant, chemotherapy or radioisotope therapy may be required
* Once tumour is gone, beta-blockers can be given to control SSx
92
# Pheochromocytoma
Prognosis
* 95% 5-year survival rate if diagnosed with a cancerous form of pheochromocytoma that hasn’t spread to other parts of the
* If the tumors have spread or come back after treatment, about 34% to 60% of people live at least 5 years after diagnosis
93
Massage and Pheochromocytoma
* Depends on the patient’s current condition
* A hypertensive crisis is a medical emergency
94
# Hyperparathyroidism
Definition
* Overproduction of parathyroid hormone, causing high levels of calcium in the blood, or hypercalcemia
* Osteoclast activity in bone increases
95
# Hyperparathyroidism
Epidemiology
Incidence in the US is 100,000 cases per year
* Females are more affected than males (2:1)
96
# Hyperparathyroidism
Etiology
* Primary = parathyroid tumor
* Secondary = vitamin D deficiency or kidney disease
97
# Hyperparathyroidism
Signs and Symptoms
* Some SSx are related to reduced bone density or osteoporosis
* Pathologic fractures
* Bone deformities
* Muscle weakness and joint pain
* Hypertension
* Kidney damage and kidney stones
98
# Hyperparathyroidism
Treatment
* Hormone replacement therapy (estrogen) in postmenopausal women
* Correcting deficiencies (vit D supplementation)
* Surgery or radiation if tumor is the cause
99
Massage and Hyperparathyroidism
* Possible contraindication due to reduced bone
density
* Consider lowering pressure
100
# Hypoparathyroidism
Definition
* Underproduction of parathyroid hormone, causing low levels of calcium in the blood, or hypocalcemia
101
# Hypoparathyroidism
Epidemiology
* Incidence in the US is about 30 per 100,000 persons per year
102
# Hypoparathyroidism
Etiology
* Some cases are idiopathic
* MC causes is thyroidectomy
* Radiation therapy
103
# Hypoparathyroidism
Signs and Symptoms
* Mild cases are asymptomatic
* Paresthesia, muscle spasms, cramping, twitching
* Fatigue
104
# Hypoparathyroidism
Treatment
* Hormone replacement therapy (parathyroid hormone)
* Calcium and vitamin D supplementation
105
Massage and Hypoparathyroidism
* No contraindications
700 - Sys Path
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