SysPath: Endocrine System

• Endocrine system diseases are common and can include diabetes mellitus (DM), hypothyroidism, and obesity.

Hypofunction

• Results from loss of reserve, hyposecretion, agenesis, atrophy, or active destruction.
• Can involve a lack or loss of gland function, such as in DM I or diminished erythropoiesis in chronic renal failure (CRF)
• Inappropriate response to signals, like hypothyroidism or hyperthyroidism can cause it

Hyperfunction

• Hypersecretion, loss of suppression, hyperstimulation, or hyper/neoplastic changes underlie hyperfunction
• Structural enlargement in a critical site, like in hyperthyroidism is an example
• Hormone release deregulation such as a productive pituitary adenoma can cause it
• Inappropriate response to signals similar to hyperthyroidism or hyperthyroidism can cause it

Disorders of the Pituitary

• Disorders classified as hyperpituitarism and hypopituitarism can occur

Hyperpituitarism Definition

• Primary hypersecretion of pituitary hormones occurs
• Functional pituitary adenomas are the most common cause
• There can be increased release of growth hormone (GH), prolactin, or adrenocorticotropic hormone (ACTH)

Hyperpituitarism Hormone Specific

• GH increase can cause gigantism or acromegaly
• Prolactin release can trigger hyperprolactinemia or a prolactinoma
• ACTH production can cause Cushing's Disease

Shared Signs & Symptoms of Hyperpituitarism

• Includes visual field disturbances and headaches
• Symptoms specific to the hormone being oversecreted can occur

Gigantism and Acromegaly Definition

• Conditions involve excessive growth due to inappropriate release of GH
• A pituitary adenoma is the most common cause

Gigantism

• When hypersecretion occurs before growth plates close, often resulting in excessive growth and height significantly above average

Acromegaly

• Hypersecretion after growth plate closure is associated with excessive thickening of the appendages (hands, feet, forehead, jaw, nose)
• A change in height does not occur

Gigantism Details

• Definition: overproduction of GH during childhood before epiphyseal plate closure
• Gigantism is extremely rare, with approximately 3 to 4 reported cases per million
• Etiology: most common cause is a GH-secreting pituitary adenoma

Gigantism Signs & Symptoms and Treatment

• Signs and Symptoms: include abnormal and accelerated growth, mainly in the long bones
• Complications can lead to reduced life expectancy, mobility issues (muscle weakness), cardiomegaly, valve disorders, sleep apnea, and osteoarthritis
• Treatment: surgical resection of adenoma or radiation and/or GH antagonists

Gigantism and Massage

• Due to its rarity, massage therapists are unlikely to encounter a client with gigantism
• There are no contraindications for massage

Acromegaly Details

• Definition: overproduction of growth hormone (GH) during adult years after the closing of the epiphyseal plate
• Acromegaly is less rare than gigantism, with one case per 25,000 adults
• Most common cause is a GH-secreting pituitary adenoma
• Signs and Symptoms: excessive growth in hands, feet and bones which become thicker and heavier and common changes like protruding jaw and thick fingers

Acromegaly Diagnostics and Treatment

• Lab tests include serum insulin-like growth factor 1 (IGF-1)
• GH suppression tests involve GH levels being taken 2 hours after oral glucose load; if GH levels don't fall after glucose, it could be a sign of the issue
• Treatment: surgical resection of adenoma, radiation, or GH antagonists

Acromegaly Prognosis and Massage

• People with acromegaly experience decreased life expectancy; successful surgery may lead to a relatively normal life
• Treatment also includes surgical resection of adenoma or GH antagonists

Acromegaly and Massage contn'd

• No contraindications, but therapist should inquire about any pain

Prolactinoma Definition

• A benign, functioning pituitary tumour that secretes prolactin, leading to hyperprolactinemia
• It is the most common type of pituitary adenoma

Prolactinoma Details

• Tumors range from microadenomas to large, expansile lesions with a tendency to calcify
• Classification based on efficiency with which it causes prolactin and proportionality (size relative to serum prolactin)
• Risk factors are unknown, although genetics may be a factor

Prolactinoma Epidemiology and Signs & Symptoms

• Most common in people under age 40, more common in people assigned female at birth and rarely occurs in children and adolescents
• Signs and symptoms of increased prolactin regardless of the underlying cause
• Amenorrhea, galactorrhea, infertility, hypogonadism, gynecomastia, loss of libido, impotence, decreased bone density and and other symptoms such as visual disturbances, vertigo, vomiting

Prolactinoma Diagnosis and Differential Diagnosis

• Diagnosis: laboratory tests (serum prolactin) and thyroid testing or medication review to rule out other causes with MRI being the most sensitive and CT scan as an alternative diagnostic imaging
• Differential Diagnosis: Stress, certain Rx drugs, pregnancy and breastfeeding can increase prolactin

Prolactinoma Treatment and Prognosis

• Treatment: the goals include restoring serum prolactin to normal levels, decreasing tumor size, as well as correcting visual disturbances
• Maintenance includes stress reduction and elimination of prolactin-inducing medications, dopamine agonists, and surgical removal or radiation
• Prognosis is generally good; surgery can correct prolactin levels in ~90% with small prolactinomas and ~50% with large tumours

Prolactinoma and Massage

• No contraindications for massage

Hypercortisolism: Cushing's Disease vs. Cushing's Syndrome

• Hypercortisolism includes Cushing's disease and syndrome are forms and Cushing's syndrome is a collection of signs and symptoms due to prolonged exposure to cortisol or corticosteroids (hypercortisolism)
• Cushing's Disease is a particular type of Cushing's syndrome due to an ACTH secreting pituitary tumor
• Other causes of Cushing's syndrome are more common than Cushing's disease

Cushing's Disease Details

• Benign pituitary adenoma secretes excess adrenocorticotropic hormone (ACTH), resulting in adrenal hypersecretion of cortisol
• No known risk factors, rare impacting 5 - 25 cases per million people per year, most prevalent between 20 - 50 yr old

Cushing's Disease Signs & Symptoms and Diagnosis

• Signs and Symptoms include a round face ("moon face"), central/truncal obesity, striae, upper back fat deposition ("buffalo hump"), acne, puffy eyes, thinning hair, reduced immune function, thinning of skin
• Diagnosis: look at cortisol levels in blood, saliva, or urine and dexamethasone suppression test that is synthetic glucocorticoid administration to monitor cortisol/ACTH

Cushing's Disease Treatment and Massage

• Treatment: surgical excision of tumor or radiation and/or cortisol antagonists
• Since seeing a client with Cushing's Syndrome is more likely, management is similar

Hypopituitarism Definition and Causes

• Decreased secretion of one or more pituitary hormones occurs due to partial/complete function loss, be a pituitary/hypothalamus cause, and can lead to different clinical symptoms dependent on hormone deficiency and underlying cause
• Causes: tumors, stroke or hemorrhage, Sheehan syndrome, surgery or radiation, infection

Other Causes of Hypopituitarism

• Hypothalamic diseases: mass lesions, radiation, infiltrative lesions, infections (tuberculous meningitis), traumatic brain injuries or stroke
• Pituitary diseases: mass lesions, pituitary surgery/radiation, infiltrative lesions, infections, Sheehan syndrome, apoplexy, genetic mutations or empty sella
• Note: CNS refers to the central nervous system

Hypopituitarism Symptoms

• Specific to the hormones that are decreased and the underlying cause, slow vague or insidious onset, one or more hormones and decreases in TSH and ACTH are rare
• Decreased GH before puberty causes pituitary dwarfism and a reduction in ADH output can lead to diabetes insipidus

Hypopituitarism Diagnosis and Treatment

• Diagnosis: confusing presentation from multiple gland involvement
• Imaging and basal/provocative laboratory tests needed to confirm like basal: morning, baseline testing and dynamic: injection of stimulatory substance
• Treatment depends on cause but usually includes removal of tumour and/or replacement of hormones

Empty Sella Syndrome Details

• Rare condition the pituitary gland becomes flattened or shrinks due to issues with the contents within the sella turcica
• Gland or sella turcica is damaged or tumor, radiation or surgery, head trauma, idiopathic intracranial hypertension (IIH), or Sheehan's syndrome

Empty Sella Signs and Symptoms and Treatment

• Signs and Symptoms: specific as the underlying cause for hormone decrease and often manifest as frequent headaches
• Often found incidentally on imaging such as MRI or CT scan and blood tests confirm hormone levels
• Treatment is hormone replacement therapy

Empty Sella Syndrome and Massage

• Massage should start with a consultation with the patient about any side effects

Pituitary Dwarfism Details

• An underproduction of GH in childhood, resulting in short stature that affects 750 people per million and idiopathic or trauma, tumors or infections cause

Pituitary Dwarfism Signs and Symptoms and Diagnosis and Treatment

• Signs and Symptoms: short stature that proportional that appears as younger than their age with growth impairments and delayed puberty
• Suspected when lack of growth is observed in the peers on an X-Ray
• Treatment is hormone replacement therapy

Pituitary Dwarfism Massage

• No massage contraindications

Diabetes Insipidus

• Is the lack or of a response to antidiuretic hormone (ADH; vasopressin) resulting in dilute urine and polyuria

Types of Diabetes Insipidus

• Central diabetes insipidus is where the posterior pituitary isn't releasing adequate ADH
• Nephrogenic diabetes insipidus is where the posterior pituitary makes ADH, but the kidney does not respond

Diabetes Insipidus Etiology

• Central DI with idiopathic lack of production via the hypothalamus often due to tumor or trauma
• Nephrogenic DI is a defect in the kidney that limits their response to ADH and can be caused by CKD or genetics

Diabetes Insipidus Signs and Symptoms

• Massive polyuria with dilute urine, exceeding 12L daily, especially at night.
• Followed by dehydration and Polydipsia (3-30 L/day) that manifests low blood pressure and dehydration

Diabetes Insipidus Diagnosis and Treatment

• Large urine output with (24hr urine volume assessment) > 3L/day in adults that confirmed with serum chemistry lab tests in blood such as glucose and sodium
• Vasopressin/desmopressin nasal spray is common and prognosis is good is treated and managed

Diabetes Insipidus and Massage

• No contraindications

Adrenal Glands

• Refresh on the Anatomy and Hormones of the Adrenal Gland

Adrenal Glands Anatomy

• Two regions: outer cortex (zona glomerulosa, zona fasciculata (75%), and zona reticularis), and inner medulla, regulated by hormones

Review of Adrenal Hormone

• The Zona glomerulosa secretes Aldosterone
• The Zona fasciculata secretes Cortisol
• Zones reticularis secretes a type of Adrogens

Adrenal Physiology and Hormone Effects

• Adosterone increases Na+ abs
• Cortisol increase glucose absorption
• Androgens create secondary sex characteristics

Adrenal Glands: Medulla

• Hormone secretions are Epinephrine and/or Norepinephrine
• Increases heart rate, contractility, gluconeogenesis, dilation of airway

Cushing's Syndrome Definition

• A collection of signs and symptoms due to prolonged exposure to cortisol or corticosteroids (hypercortisolism)
• Most common is the result long term ACTH or glucocorticoids that impacts most ages but is more common in women over 40
• Other less frequent Etiology can be Pituitary adenoma (Cushing's Disease) and Adrenal tumor or hyperplasia

Cushing’s Syndrome Signs and Symptoms

• Same as Cushing's Disease a round face called "moon face” manifests to the arms and legs that may express increased weight
• Diagnosis is suspicion based on characteristic symptoms that's confirmed by lab tests like Dexamethasone suppression

Cushing's Syndrome Treatment and Massage

• Treatment: the reduction of exogenous glucocorticoids, Cortisol inhibiting medications, and Surgical removal and/or radiation of tumors

Adrenal Insufficiency

• Occurs when rare the adrenal glands stop producing glucocorticoids and mineralocorticoids and can be divided into Primary the in adrenal gland and secondary in the pituitary that affects most adults 30-50 with equal sex probability
• Causes or can be the disorder itself like Addison's Disease

Etiology of Adrenal Insuffficinecy

• Primary Al results from congenital hypoplasia/hyperplasia, infection, autoimmune polyendocrinopathy or metastatic carcinoma while secondary al or hypothalamus results from Steroid admin that suppress hypothalamus output

Signs and Symptoms of Adrenal Insufficiency

• Can cause weakeness, fatigue an N/V and hyperkalemia, hyponatremia, volume depletion, dehydration and hypotension and increased Any stress can induce the condition more

Diagnosis and Treatment

• Diagnosed with an inspection such as GFR, BUN and CR from blood tests that also check sodium and pottassium lever and if its secone or primary
• Treatment starts with Steroids for physical stress that the Fludrocortisone balances blood and androgen

Adrenal Insufficiency and Massage

• Massage is not

Hyperaldosteronism

• A result of chronic, excessive secretion of aldosterone resulting in sodium and water retention and potassium excretion

Type of Hyperaldosteronism

• Primary is from gland and secondary from is elsewhere
• Is most likely from adrenal neoplasm that results in edema

Sign and Symptom and Diagnois

• Diagnosed the sodium ratio in the blood wit CT for tumor observation and is characterized by hypertension and hypokalemia
• Large amounts of licorice can mimc it

Hyperaldosteronism Treatmennt

• Is based the underlying cause as the adrenalectomy to remove adrenal denomas but in severe case aldesterone blockers wit proper mangement

Massage

• No

Pheochromocytoma

• Definition are Uncommon neoplasms of chromaffin cells resulting in overproduction of catecholamines

Signs and Symptom and Diagnois

• The BP is the first symptom that's associated high blood pressure and the tumor presence confirmed wit contrasting CT

Treatment and Massage

• Requires pre-surgical treatment with catecholamines but requires is removal by surgery wit a 95% survivale rate for cancer

  - Is based the underlying cause as the adrenalectomy to remove adrenal denomas but in severe case aldesterone blockers wit proper mangement No