HYPOTHALAMUS-PITUITARY-THYROID AXIS
PRESENTERS: DR: Nyangaresi justine
DR: Mitchelle
FACILITATOR: DR:
H- P- T AXIS
TRH is secreted by the hypothalamus and stimulates the secretion of TSH
by the anterior pituitary.
TSH increases both the synthesis and the secretion of thyroid hormones
by the follicular cells via an adenylate cyclase–cAMP mechanism.
T3 and T4 down-regulate TRH receptors in the anterior pituitary; and
paraventricular neurons in the hypothalamus
REGULATION OF THYROID HOMORNES
TRH synthesis
hypothalamus
+ TRH
-
TRH receptor
- T3/T4
pituitary
-
TSH synthesis
ANATOMY
HYPOTHALAMUS: NUCLEI
PITUITARY: LOC
PARS INTERMEDIA
PARS NERVOSA
PARS DISTALIS
Cells: Chromophils
(a) Basophilic
(b) acidophils(prolactin and GH)
chomophils
Thyroid gland anatomy
INACTIVE
histology Flat follicular cells
More colloid
Large follicles
ACTIVE
Cuboidal to tall columnar
Less colloid
Smaller follicles
NB: Also has parafollicular cells that secrete
calcitonin
THYROID HORMONE SYNTHESIS
THYROID HORMONE ACTIONS
CNS
Growth and development
Increase catecholamine activity on cns
Alertness
CVS
Permissive effects of catecholamines
Increase α myosin, a atpase, nak atpase β adrenergic
Decrease peripheral resistance
INCRE. CONTRACTILITY, HR, CO
THYROID HORMONE ACTIONS
BONE
Increase osteoblastic and osteoclastic activity
Linear growth
Enhances growth hormone effect in bone
GUT
Increased motility and MMC
Increased neutrient absorption
LIVER
Increased gluconeogenesis and glycolysis
Increase cholesterol uptake thr LDL receptors
THYROID HORMONE ACTIONS
ADIPOSE TISSUE
Increased lipolysis
MUSCLE
Increased protein catabolism
KIDNEY
Increased EPO synthesis
ENERGY METABOLISM
Increased BMR, Inc O2 consumption, Incr heat
PATHOLOGY
Hyperthyroidism
Hypothyroidism
Goitre
Thyroid disorders with normal profiles
HYPERTHYROIDISM
Excessive amount of thyroid hormone
CLASSIFIED TO
(A) TSH Dependent (RARE)
-TSH secretion by tumours of trophoblastic origin
anterior pituitary
-Over secretion of TRH
(B) TSH INDEPENDENT
Graves disease
Toxic multinodular goitre
Single/solitary functioning nodule
Carcinoma
Ingestion of thyroid hormones
Excessive T3/T4 ingestion
Exogenous administration of iodine or iodine containing drugs
HYPOTHYROIDISM
Structural or functional derangement that interferes with production of
thyroid hormone
(A) Major causes
Hashimotos thyroiditis
Surgical treatment of hyperthyroidism
HYPOTHYROIDISM CONTINUED
(B) MINOR CAUSES
TSH deficiency
Congenital defects
Transient hypothyroidism to drugs
Severe iodine deficiency
HYPOTHYROIDISM CONT...
(C) OTHER CAUSES
Hashimotos disease
Atrophic autoimmune thyroiditis
Drugs
Treatment of hyperthyroidism
Post radioactive treatment
GOITRE
TYPES
A. PHYSIOLOGICAL:
B. EUTHRYOID
(i) Simple goitre (sporadic, colloidal and diffuse)
(ii) Iodine Deficiency (nodular or multinodular)
(iii) enzymatic defects
NEOPLASMS
Benign: Benign adenoma
Malignant: Papillary
follicular
medullary
anaplastic
HYPERTHYROIDISM
Symptoms Signs
Weight loss Fine hair, thin skin
Increased appetite Onycholysis
Fatigue Muscle weakness
Menstrual irregularities Low cholesterol
Heat intolerance
Glucose intolerance
Increased sweating
Tachycardia
Nervousness
Widened pulse pressure
Restlessness
Panic attacks Tremor
Loss of libido Brisk tendon reflexes
HYPOTHRYROIDISM
Symptoms Signs
Weight gain Growth retardation
Easy fatigue Deep hoarse voice
Lethargy Dry coarse skin
Cold intolerance Myxedema
Hair loss High cholesterol
Constipation Bradycardia
Hypertension
Slow reflex relaxation
THYROID FUNCION TESTS
1. Hormonal concentrations (TFT –Thyroid function tests
Serum/ plasma TSH =0.25-5 uIU/ml
Serum /plasma TT4 =60-120 nmol/l
Serum /Plasma TT3 =0.9-2.8 nmol/l
Serum /plasma FT4 =9-20 pmol/l
Serum/Plasma FT3 =4-8 pmol/l
Ratio of T4/T3 =100
2. Serum proteins
Thyroxine binging Globulin (TBG)
Thyroxine binding prealbumin (TBPA)/ Transthyretin
Increased in
Pregnancy, increased estrogens/ estrogen therapy/newborn /inherited TBG
Decreased in
Severe illness
Nephrotic syndrome( loss of low molecular weight proteins)
Androgen administration
Inherited TBG deficiency (rare)
3.Test for Autoimmune diseases/Antibodies
i. Thyroid Stimulating Immunoglobulin (TSI) – Graves’ disease
ii. Antimicrosomal antibodies (TmAb)
iii.Antithyroglobulin antibodies (TgAb)
80-100 % of patients with Hashimoto’s thyroiditis or chronic thyroiditis
60-70% of patients with Graves disease
Thyroid peroxidase antibodies (TPO)
Present in almost all patients with Hashimoto’s thyroiditis
70% in Graves’ Disease
4. Dynamic /Provocative test
TRH dynamic test
Hypopituitarism
Primary hypothyroidism
Secondary hypothyroidism
Primary hyperthyroidism
Secondary hyperthyroidism
1. Other hormones or related proteins
Thyroglobulin(Tg): Increased in -
Thyroid follicular carcinoma
Thyroid edema
Subacute thyroiditis
Hashimoto’s thyroiditis
Graves ’ disease
1. Radiological and Histological Tests
-FNA
-US Scan, MRI
-Radioactive iodine uptake test (RAIU) I131
I131 uptake within 24hrs- specimens are taken for blood/urine/scan the thyroid
gland for concentration and thigh for background radioactivity
Thyroid scintiscanning
Etiology of congenital hypothyroidism
- Ectopic
- Aplasia
- Nodules of the thyroid
- Goitres and ability to uptake iodine
1. RBS. FBS,OGTT
2. Lipid profile
3. FNA
TSH TT4N FT4 TT3 FTT3
Euthyroid normal Normal Normal Normal Normal
Primary hyperthyroidism Low High High High High
Secondary hyperthyroidism High High High High High
Primary hypothyroidism High Low Low Low Low
Secondary hypothyroidism Low Low Low Low Low
Sick Euthyroid/Non thyroid illness Normal Low Low Low Low
Compensated states
Subclinical hypothyroidism High Normal Normal Normal Normal
Subclinical Hyperthyroidism Low Normal Normal Normal Normal
Case1
42 year old female patient was admitted in the hospital and thyroid function
showed the following:
TSH - 0.00 uIU/ml (0.25-5.00)
FT4 >250pmol/ml (9-20)
FT3 >300pmol/ml (4-8)
List the signs and symptoms
Describe the management and biochemical tests you would order
Role of Surgeon In Management
1. Euthyroid Goiter – Surgery if very large due to cosmetic reasons,
pressure symptoms, patient anxiety, retrosternal goiter
2. Iodine deficiency – goiter – surgery
3. Neoplasm
a) Benign – surgical intervention when large for cosmetic reasons, pressure
symptoms, solitary ‘hot’nodule. NB: Consider medical treatment before
surgical intervention
