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
 Weight loss
 Increased appetite
 Fatigue
 Menstrual irregularities
 Heat intolerance
 Increased sweating
 Nervousness
 Restlessness
 Panic attacks
 Loss of libido
Signs
 Fine hair, thin skin
 Onycholysis
 Muscle weakness
 Low cholesterol
 Glucose intolerance
 Tachycardia
 Widened pulse pressure
 Tremor
 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