- the hthe hormones which ormones which respond to respond to ‘stress’ ‘stress’ (ACTH, cortisol, (ACTH, cortisol, growth hormone, growth hormone, prolactin)prolactin) -
- different kidifferent kinds of ‘nds of ‘stress’; the stress’; the kind whikind which affects ch affects these hormones ithese hormones is not s not exactly definableexactly definable Know about the common syndromes of deficiency and excess in detail:
Know about the common syndromes of deficiency and excess in detail:
-
- adrenal iadrenal insufficiency (Addison’s) nsufficiency (Addison’s) - primary - primary adrenal failure, adrenal failure, pluriglandular syndrome, pluriglandular syndrome, hypoadrenalism due hypoadrenalism due toto pituitary failure and its compensation by the intact renin-aldosterone system.
pituitary failure and its compensation by the intact renin-aldosterone system.
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- excess excess of adrenal of adrenal hormones Cushings hormones Cushings syndrome: adrenal syndrome: adrenal tumours, pituitary tumours, pituitary Cushing’s, ectopic Cushing’s, ectopic ACTHACTH syndrome; Conn’s syndrome
syndrome; Conn’s syndrome -
- excess of excess of growth hormone - growth hormone - acromegaly, interpretation of acromegaly, interpretation of growth hormone levels growth hormone levels in diagnosis; in diagnosis; use of GTT use of GTT withwith growth hormone assay as a confirmatory test; use of IGF1 and IGFBP3
growth hormone assay as a confirmatory test; use of IGF1 and IGFBP3 -
- deficiency of deficiency of growth hormone - growth hormone - methods of methods of screening children screening children and adults and adults for growth for growth hormone deficiency;hormone deficiency;
confirmatory tests including clonidine (children), insulin tolerance test, glucagon test.
confirmatory tests including clonidine (children), insulin tolerance test, glucagon test.
-
- prolactin prolactin excess- excess- prolactinoma; other prolactinoma; other factors factors which which raise raise prolactin hypothyroidiprolactin hypothyroidism, phenothiazines sm, phenothiazines pregnancy,pregnancy, lactation prolactin deficiency - Sheehan’s syndrome
lactation prolactin deficiency - Sheehan’s syndrome -
- FSH and FSH and LH ‘excess’- LH ‘excess’- revise the changes revise the changes of hormone levels of hormone levels in the normal in the normal menstrual cycle menstrual cycle - revise the - revise the changeschanges of hormone levels in the menopause know that primary gonadal failure is marked by raised FSH and LH of hormone levels in the menopause know that primary gonadal failure is marked by raised FSH and LH -understand that the effect of primary gonadal failure in children is only manifested as raised FSH and LH after understand that the effect of primary gonadal failure in children is only manifested as raised FSH and LH after the time for puberty has arrived - know a little about polycystic ovary syndrome - the effect of excess FSH and the time for puberty has arrived - know a little about polycystic ovary syndrome - the effect of excess FSH and LH (hyper stimulation of ovulation) in causing multiple ovulation - be aware that tumours secreting FSH and or LH (hyper stimulation of ovulation) in causing multiple ovulation - be aware that tumours secreting FSH and or LH occur but are very rare indeed
LH occur but are very rare indeed -
- FSH FSH and LH and LH deficiency - deficiency - hypogonadotrophic hypogonadism hypogonadotrophic hypogonadism - reversible - reversible hypothalamic effects hypothalamic effects causingcausing
hypogonadism such as occur in low body weight – hypopituitarism - know that in progressive pituitary disorders, hypogonadism such as occur in low body weight – hypopituitarism - know that in progressive pituitary disorders, the order in which hormone systems are ablated is usually: first FSH, LH and GH; last TSH and ACTH
the order in which hormone systems are ablated is usually: first FSH, LH and GH; last TSH and ACTH -understand how LHRH-analogues cause hypogonadism
understand how LHRH-analogues cause hypogonadism -
- oestrogen oestrogen deficiency deficiency states states and and the the effect effect on on bone bone turnover turnover - - tachyphylaxis tachyphylaxis in in HRT HRT - - androgen eandrogen excess, xcess, itsits causes and diagnosis
causes and diagnosis -
- catecholamine catecholamine excess excess in in phaeochromocytoma phaeochromocytoma and and neuroblastomaneuroblastoma Know about congenital adrenal hyperplasia (in outline only):
Know about congenital adrenal hyperplasia (in outline only):
-
- a compound a compound heterozygote condition heterozygote condition and hence and hence variable expression variable expression - an - an enzyme defect enzyme defect causing cortisolcausing cortisol deficiency which is compensated for by high ACTH in turn causing adrenal hyperplasia and excess of other deficiency which is compensated for by high ACTH in turn causing adrenal hyperplasia and excess of other steroids such as androgens
steroids such as androgens -
- 21-hydroxylase 21-hydroxylase defect is defect is by far by far the the commonest type commonest type - presentation - presentation and diagnosis and diagnosis of the of the acute ‘acute ‘classical’ formclassical’ form -
- presentation and presentation and diagnosis of diagnosis of the ‘non-classical’ the ‘non-classical’ or late or late onset form; onset form; - diagnosis - diagnosis by measuring by measuring 17 hydroxy17 hydroxy progesterone
progesterone -
- methods methods of of monitoring monitoring of of replacement replacement therapytherapy
THYROID FUNCTION THYROID FUNCTION
Main topics:
Main topics: thyroid hormones and TSH, pituitary negatithyroid hormones and TSH, pituitary negative feed-back system, synthesis and metabolive feed-back system, synthesis and metabolism of thyroid hormones,sm of thyroid hormones, effects of antithyroid drugs, thyroid
effects of antithyroid drugs, thyroid failure, hyperthyroifailure, hyperthyroidism, thyroid antibodies, thyroid function in dism, thyroid antibodies, thyroid function in pregnancy,pregnancy, binding of thyroid hormones to serum pro
binding of thyroid hormones to serum pro teins, iodine deficiency, sick euthyroiteins, iodine deficiency, sick euthyroid syndrome, thyroid hormoned syndrome, thyroid hormone replacement therapy, treatment of
replacement therapy, treatment of hyperthyroidismhyperthyroidism Objectives: Gaini
Objectives: Gaining facility in understanding the use ong facility in understanding the use o f the pituitary negative feedback system in the context of f the pituitary negative feedback system in the context of thyroid function. Know about the different causes of hypothyroidism and hyperthyroidism. Know the scientific and thyroid function. Know about the different causes of hypothyroidism and hyperthyroidism. Know the scientific and medical issues underlying diagnosis and management
medical issues underlying diagnosis and management of thyroid disease. Know how to interpret thyroid functionof thyroid disease. Know how to interpret thyroid function tests in various clinical contexts.
tests in various clinical contexts.
Know about thyroid hormones and TSH (thyroid stimulating hormone, thyrotrophin) Know about thyroid hormones and TSH (thyroid stimulating hormone, thyrotrophin)
-
- thyroxine thyroxine (T4), (T4), tri-iodothyronine tri-iodothyronine (T3), (T3), reverse reverse T3T3 -
- know know that that TSH TSH is is pulsatile pulsatile and and has has diurnal diurnal rhythm.rhythm.
-
- know the know the main thyroid main thyroid biosynthetic and mbiosynthetic and metabolic pathways and etabolic pathways and the effect on the effect on them of: them of: TSH, odine, antithyroidTSH, odine, antithyroid drugs (PTU and carbimazole), TSH-receptor stimulating antibody
drugs (PTU and carbimazole), TSH-receptor stimulating antibody
Understand the pituitary negative feedback system Understand the pituitary negative feedback system
-
- be able be able to understand to understand and manipulate and manipulate data related data related to the to the negative feedback negative feedback system to system to make clinical make clinical deductionsdeductions in a clinical context of thyroid disorders
in a clinical context of thyroid disorders
Understand peripheral conversion of T4 to T3 or reverse T3 Understand peripheral conversion of T4 to T3 or reverse T3
-
- factors whifactors which affect ch affect peripheral conversion peripheral conversion (fasting and illne(fasting and illness, drugs ss, drugs (PTU and (PTU and amiodarone); TSH is amiodarone); TSH is not a not a factor factor affecting peripheral conversion
affecting peripheral conversion
Know the main causes of and use of diagnostic tests in thyroid failure Know the main causes of and use of diagnostic tests in thyroid failure
-
- Hashimoto’s Hashimoto’s thyroiditisthyroiditis -
- pluriglandular syndrome pluriglandular syndrome - treatment - treatment of thyrotoxicosis of thyrotoxicosis - dyshormonogenesis - dyshormonogenesis (in outline (in outline only)only) -
- interpretation interpretation of of TSH TSH levelslevels -
- interpretation interpretation of of T4 T4 and and T3 T3 (Free T(Free T4 4 and and Free Free T3) T3) levelslevels -
- pituitary fpituitary failure and ailure and the interpretation the interpretation of T4 of T4 and TSH and TSH levels levels in hypopituitarismin hypopituitarism -
- use use of of TRH TRH testtest
-- neonatal hypothyroidismneonatal hypothyroidism
Know the main causes of and use of diagnostic tests in hyperthyroidism Know the main causes of and use of diagnostic tests in hyperthyroidism
-
- Grave’s Grave’s disease disease - nodular - nodular and multi-nodular and multi-nodular goitre - goitre - viral thyroiditiviral thyroiditiss -
- interpretation interpretation of of TSH TSH levelslevels -
- interpretation interpretation of of T4 T4 and and T3 T3 (Free T(Free T4 4 and and Free Free T3) T3) levelslevels -
- use use of of TRH TRH test test - - thyrotropinomathyrotropinoma -
- hypercalcaemia hypercalcaemia of of thyrotoxicosisthyrotoxicosis -
- neonatal neonatal thyrotoxicosisthyrotoxicosis
Know about TSH-receptor stimulating antibodies (TRAB) Know about TSH-receptor stimulating antibodies (TRAB)
-
- be aware of be aware of the multiple the multiple names used: LATS, TBII, names used: LATS, TBII, TRAB etc TRAB etc - be aware - be aware of the diffiof the difficulty and multiple culty and multiple methods of methods of measuring TRAB (not in detail) - use of TRAB in predicting the occurrence of neonatal thyrotoxicosis
measuring TRAB (not in detail) - use of TRAB in predicting the occurrence of neonatal thyrotoxicosis Thyroid function and dysfunction in pregnancy
Thyroid function and dysfunction in pregnancy -
- pregnancy-associated pregnancy-associated hyperthyroidism hyperthyroidism - - post-partum post-partum thyroiditisthyroiditis -
- neonatal neonatal thyrotoxicosisthyrotoxicosis
Know about diagnostic thyroid antibodies Know about diagnostic thyroid antibodies
-
- Thyroid Thyroid Peroxidase antibodPeroxidase antibody (TPO, y (TPO, also known also known as thyroid as thyroid microsomal microsomal antibody)antibody) -
- thyroglobulin thyroglobulin antibodyantibody -
- know know that positive that positive TPO together TPO together with mildly with mildly raised TSH raised TSH predicts future predicts future thyroid failthyroid failureure Know the nature and prognosis of thyroid tumours
Know the nature and prognosis of thyroid tumours -
- use use of of thyroglobulin thyroglobulin as as a a tumour tumour marker marker -
- ‘hot’ ‘hot’ and and ‘cold’ ‘cold’ nodulesnodules
Understand the nature of binding of thyroid hormones to serum proteins;
Understand the nature of binding of thyroid hormones to serum proteins;
-
- serum free serum free T4 and T4 and free T3 free T3 and the and the difference between totdifference between total T4 al T4 and free Tand free T44 -
- binding of binding of T4 and T4 and T3 to T3 to Thyroxine-Binding Globulin Thyroxine-Binding Globulin (TBG), albumin (TBG), albumin and prealbumin and prealbumin the factors the factors which affect which affect TBGTBG levels
levels -
- understand that understand that the practthe practice of ice of use of use of tests of tests of thyroid function thyroid function varies from varies from country to country to country.country.
-
- use use of of ‘T3-uptake’ ‘T3-uptake’ teststests -
- the effect the effect of drugs of drugs which bind which bind to TBG to TBG displacing T4 displacing T4 (phenytoin, salicylate, (phenytoin, salicylate, NSAIDs)NSAIDs) Know about iodine deficiency in a world-wide context
Know about iodine deficiency in a world-wide context -
- World World – – Europe Europe – – UK UK - - the the consequences consequences for for population population and and individual individual thyroid thyroid pathology pathology - - know know wherewhere iodine comes from in the UK diet;
iodine comes from in the UK diet;
-
- know that know that Grave’s disease Grave’s disease causes iodine deficiency causes iodine deficiency and hence the and hence the mechanism of Tmechanism of T3 toxicosis 3 toxicosis - know the - know the effecteffect of supplying iodine to someone with Grave’s Disease (Jod-Basedow effect) - effects of amiodarone on thyroid of supplying iodine to someone with Grave’s Disease (Jod-Basedow effect) - effects of amiodarone on thyroid
Understand sick euthyroid syndrome Understand sick euthyroid syndrome
-
- the effects the effects of fasting and of fasting and illness on tillness on thyroid hormones - hyroid hormones - the effect of the effect of raised serum lipase raised serum lipase and free fatty and free fatty acids onacids on free T4 levels
free T4 levels -
- understand why understand why thyroid function thyroid function tests tests can can be misleading be misleading in ilin ill or l or fasting fasting patientspatients Understand screening for thyroid disease
Understand screening for thyroid disease -
- know know the approximate the approximate prevalences at prevalences at different ages different ages - strengths - strengths and weaknesses and weaknesses of the of the strategies of strategies of use of use of thyroid function tests - know how to manage a patient with a borderline raised or borderline low TSH
thyroid function tests - know how to manage a patient with a borderline raised or borderline low TSH Understand thyroid hormone replacement therapy
Understand thyroid hormone replacement therapy -
- consequences consequences of of giving giving thyroxine thyroxine in in patients patients with with hypoadrenalismhypoadrenalism -
- need to need to start on start on a low a low dose and idose and increase the dose ncrease the dose slowly - the slowly - the need to need to avoid too frequent avoid too frequent biochemical testing -biochemical testing -the potential consequences of over or under-treating hypothyroidism - how to interpret thyroid function tests in the potential consequences of over or under-treating hypothyroidism - how to interpret thyroid function tests in patients taking replacement therapy
patients taking replacement therapy
Understand methods and monitoring of treatment of thyrotoxicosis Understand methods and monitoring of treatment of thyrotoxicosis
-
- antithyroid antithyroid drugs drugs (carbimazole, (carbimazole, propylthiourea) - propylthiourea) - radio-iodine - radio-iodine - surgerysurgery -
- the more the more rapid rate of rapid rate of change in T3 change in T3 than T4 than T4 because of T3’because of T3’s shorter half-life s shorter half-life - the - the refractory nature of arefractory nature of a suppressed TSH
suppressed TSH -
- detecting detecting recurrence recurrence of of hyperthyroidismhyperthyroidism -
- detecting detecting over-treatment resulting over-treatment resulting in hypothyroidism in hypothyroidism - the - the effects of effects of hyperthyroidism on hyperthyroidism on bonebone