MED 1103 (Sem.

3, 2017)
Endocrinology Case Study:
A Lady with Multiple Problems

Learning Outcomes:

At the end of the session, the students should be able to

1. Describe with the aid of a diagram, the anatomy and histology of the hypothalamus and
the pituitary with respect to their endocrine functions.
2. Describe the two general types of tumour of the pituitary and analyse the clinical
consequence of each type.
3. List the hormones related to the pituitary gland (upstream releasing/inhibiting
neurohormones from the hypothalamus, the pituitary hormones, and the downstream
hormones secreted from other glands that are influenced by the pituitary hormones.
4. Relate the functions of the above hormones to the signs and symptoms of patients with
panhypopituitarism.

Class protocol:
Pre-class
All students should have done the pre-class assignment (see pg. 3) in your own handwriting and
drawing before the case study session. The pre-class assignment will be inspected and marks
will be awarded appropriately. Please e-mail the scanned answers to Dr Hafiz before the
session.

In class
Students will be divided into groups of 4 (please refer to grouping arrangement
provided).
Each group will be given a set of questions piecemeal to answer based on the case
provided. Students are free to discuss among team mates but each student will write
his/her own answer. Students are encouraged to supplement answers with as many
drawings/diagrams as possible.
Any answer that is obtained from reference materials shall be written in different
coloured ink.
At the end of the session, a discussion will be held. Again, any answer obtained from
the discussion with the lecturer shall be written in another coloured ink.
At the end of class, each group will submit the scanned copy of the answer from each
member.
Grades will be given based on the effort to answer all questions satisfactorily.

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The Case: A lady with multiple endocrine problems

Mrs A, a 52-year-old housewife had noticed that her periods have been irregular. She consulted a
friend who worked as a nurse and was told that she could be experiencing menopausal symptoms.
She accepted the explanation and regarded it as part of ageing process. A few weeks later, she
noticed that she was getting fatigued easily and the power in her muscle was not as strong as before.
For example, she found it difficult to lift pots of plants while doing her favourite hobby of gardening. As
the months progressed, she noticed that she started to feel cool even when the day was rather warm.
She even had to use a blanket at night even though her husband kept complaining that he felt warm.
She went back to see her friend and wanted to know why she felt cool most of the time when she was
supposed to be feeling warm and flushed as part of her menopausal symptoms. Her friend suggested
that her basal metabolic rate may be low and advised her to consult a doctor.

One day while gardening, she experienced a severe headache. She also felt too lethargic to even
move about. When she stood up to walk, she noticed that she consistently bumped into objects and
cannot see objects on her sides. Her husband took her to the nearest clinic. The doctor noted that she
looked pale, with a slow pulse and was hypotensive. On looking at her retina using a fundoscope the
doctor noticed a pale-looking optic disc. The doctor suspected something sinister and referred her to
the nearest hospital. An urgent CAT scan of the brain showed a growth in the pituitary fossa. The
doctor decided to do more tests and requested the endocrine laboratory to assist in coming out with
the final diagnosis.

CASE SUMMARY

This is a case of panhypopituitarism due to a non-secretory tumour which has enlarged out of the
sella turcica compressing the optic chiasm. The tumour has destroyed functioning glandular tissues
and had caused pituitary deficiency. The classical description of hormonal deficiency which ensues
normally affects gonadotropins first followed by TSH and last ACTH although it may not always
happen in that sequence. ADH deficiency is rare in pituitary disease but common with stalk and
hypothalamic lesion.

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Pre-class assignment:
Note: all students should do the following pre-class assignment in your own handwriting and
drawing before the case study session. The pre-class assignment will be inspected and marks
will be awarded appropriately.

1. Draw the location of the pituitary gland in the brain. Label sella turcica. Your sketch should
also show how the pituitary is related to the optic nerve and the hypothalamus. What
structural changes would you expect to see if there is hyperplasia of the non-secretory cells in
the pituitary gland?

2. Draw and describe the vascular system of the hypothalamus and pituitary. Explain the
significance of the double capillary beds. Does this blood flow have any influence on the
condition of the patient? Justify your answer. On the diagram, indicate factors that would
influence the secretion of the hypothalamic neurohormones. Which of these factors (if any)
affect the hypothalamic secretion in this patient?

3. Draw a diagram to demonstrate the endocrinological relationship between the

Label your diagram: hypothalamus, anterior pituitary, posterior pituitary, superior hypophysial
artery, medial hypophysial artery, and inferior hypophysial artery that provide arterial blood
supply to the median eminence, the primary plexus, the secondary plexus, the portal veins,
parvocellular nucleus with a few axons terminating at the primary capillary plexus,
magnocellular nucleus with a few neurons terminating at the posterior pituitary, pituitary fossa,
sphenoid bone, lactotrophs, corticotrophs, thyrotrophs, gonadotrophs, somatotrophs.

4. List the neurohormones secreted by the hypothalamus. Briefly describe their chemical nature.
Which cells of the pituitary do these neurohormones act on? Briefly describe the mechanism
of action of these nurohormones. Do you expect to see changes in the secretion of the
hypothalamic neurohormones in this patient? Justify your answer.

5. Draw and describe the histology of the pituitary. Name the specific cells that secrete
specific hormones. Describe the consequence if these cells develop into a tumour.
Compare and contrast between functional tumours and non-functional tumours.
What would be the effects of these tumours (functional and non-functional tumours)?
Which type of tumour does the patient have? Justification?

6. In a Table, list down all the hormones of the hypothalamus and pituitary, their chemical
nature, the target organ and the effect on the target organs. Concentrate on the pituitary
hormones and relate the effects of hyposecretion of these hormones on other endocrine
glands and on other tissues. Hint: include the negative feedback effects.

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Pre-class assignment:
Note: all students should do the following pre-class assignment in your own handwriting and
drawing before the case study session. The pre-class assignment will be inspected and marks
will be awarded appropriately.

1. Draw the location of the pituitary gland in the brain. Label sella turcica. Your sketch should
also show how the pituitary is related to the optic nerve and the hypothalamus. What
structural changes would you expect to see if there is hyperplasia of the non-secretory cells in
the pituitary gland?

2. Draw and describe the vascular system of the hypothalamus and pituitary. Explain the
significance of the double capillary beds. Does this blood flow have any influence on the
condition of the patient? Justify your answer. On the diagram, indicate factors that would
influence the secretion of the hypothalamic neurohormones. Which of these factors (if any)
affect the hypothalamic secretion in this patient?

3. Draw a diagram to demonstrate the endocrinological relationship between the

Label your diagram: hypothalamus, anterior pituitary, posterior pituitary, superior hypophysial
artery, medial hypophysial artery, and inferior hypophysial artery that provide arterial blood
supply to the median eminence, the primary plexus, the secondary plexus, the portal veins,
parvocellular nucleus with a few axons terminating at the primary capillary plexus,
magnocellular nucleus with a few neurons terminating at the posterior pituitary, pituitary fossa,
sphenoid bone, lactotrophs, corticotrophs, thyrotrophs, gonadotrophs, somatotrophs.

4. List the neurohormones secreted by the hypothalamus. Briefly describe their chemical nature.
Which cells of the pituitary do these neurohormones act on? Briefly describe the mechanism
of action of these nurohormones. Do you expect to see changes in the secretion of the
hypothalamic neurohormones in this patient? Justify your answer.

5. Draw and describe the histology of the pituitary. Name the specific cells that secrete
specific hormones. Describe the consequence if these cells develop into a tumour.
Compare and contrast between functional tumours and non-functional tumours.
What would be the effects of these tumours (functional and non-functional tumours)?
Which type of tumour does the patient have? Justification?

6. In a Table, list down all the hormones of the hypothalamus and pituitary, their chemical
nature, the target organ and the effect on the target organs. Concentrate on the pituitary
hormones and relate the effects of hyposecretion of these hormones on other endocrine
glands and on other tissues. Hint: include the negative feedback effects.