- Osteoporosis
- Medical Weight LossPheochromocytomas are a rare cause of hypertension, being the underlying cause of only about.01% of cases of high blood pressure. The manifestations of pheochromocytoma are varied and often not particularly specific and it is easy to understand why such a rare tumor may not be diagnosed immediately by even the most astute physician. Headache, perspiration or palpitation are symptoms found in 90% of such patients. Anxiety, tremor, high blood sugar, nausea, thoracic or abdominal pains, weakness, weight loss, shortness of breath, visual disturbances and heat intolerance are other occasional symptoms. Patients can also sometimes present with confusion or psychosis, constipation, tingling sensations, seizures, or high blood counts as well as Raynaud’s phenomenon. Ironically, patients can also have a slow heart beat (bradycardia) or hypotension, particularly when standing up suddenly.
- Sleep DisordersIn premenopausal women, serum testosterone levels decline with age. Between 25 and 45 years of age, women’s testosterone levels fall 50%. After natural menopause, the ovaries remain a significant source for testosterone and serum testosterone levels do not fall abruptly. In contrast, very low serum testosterone levels are found in women after bilateral oophorectomy, autoimmune ovarian failure, or adrenalectomy, and in hypopituitarism. Testosterone deficiency contributes to hot flushes, loss of sexual hair, muscle atrophy, osteoporosis, and diminished libido, also known as hypoactive sexual desire disorder. Flibanserin (Addyi) is a centrally acting drug that stimulates serotonin 5-HT1A receptors and blocks other brain receptors. Flibanserin is modestly effective for treating premenopausal women with acquired hypoactive sexual desire disorder. It is administered orally 100 mg at bedtime; side effects may include hypotension, appendicitis, nausea, xerostomia, sleep disorders, and fatigue. If there is no improvement within 8 weeks, it is discontinued.
- High Cholesterol
- Constipation
- Erectile Dysfunction
- Pneumonia
- GlaucomaSome hypothyroid individuals who receive thyroxine replacement continue to have symptoms typical of hypothyroidism (particularly fatigue), despite having serum levels of TSH and FT4 that are solidly normal. In such cases, it is important to screen for other conditions, such as concurrent illness (eg, anemia, diabetes, hypercalcemia, electrolyte abnormalities, celiac disease, adrenal insufficiency, hypogonadism, depression). Medications can cause fatigue (eg, oral statin drugs for treatment of high cholesterol, oral beta blockers, beta blocker eye drops for glaucoma, etc). In the absence of such conditions, a serum T3 or FT3 can be checked. If the serum T3 or FT3 level is low or low-normal and there are no contraindications (eg, angina, atrial fibrillation), a careful increase in thyroxine replacement is reasonable and may be continued if symptomatic relief is obtained. But if thyroxine is given such that serum TSH levels are suppressed, the serum T3 or FT3 levels should be monitored, keeping them in the lower half of the normal reference range. Careful clinical monitoring is also required for symptoms or signs of hyperthyroidism. Periodic bone mineral densitometry may be followed, thyroid hormone replacement does not cause osteoporosis as long as they are clinically euthyroid (no signs of excess thyroid). Individuals receiving doses of thyroxine that suppress serum TSH below 0.1 mIU/L, as a group, have been found to be at an increased risk for clinical hyperthyroidism (eg, atrial fibrillation), particularly with menopause or withdrawal of oral estrogen therapy.
- GynecologyFitzgerald PA: Competitive Protein Binding Radioassay for Progesterone. National Institutes of Health student research grant. Department of Obstetrics and Gynecology, Jefferson Medical College. Philadelphia, PA 1970.
- Menopause
- Obstetrics
- Pregnancy
- Internal MedicineFitzgerald PA: Cushing’s Syndrome. Pitfalls in Diagnosis, Imaging and Treatment. Advances in Internal Medicine. Department of Medicine Extended Programs in Medical Education UCSF, Hyatt Regency, Embarcadero Center, June 14, 1989. Cole Hall, UCSF Campus, June 28, 1989.
- Kidney StonesThus, an endocrinologist has special expertise in the evaluation and treatment of diseases caused by an excess or deficiency of hormones normally secreted by the pituitary, adrenals, thyroid, parathyroids, ovaries, testicles, or pancreatic islet cells (eg, diabetes, hypoglycemia). The endocrinologist also treats cancers arising out of these glands. Additionally, the endocrinologist treats diseases of calcium metabolism (eg, osteoporosis, osteomalacia, kidney stones), and lipid metabolism (eg, hypercholesterolemia).
- Ovarian CancerLong-term conventional-dose unopposed estrogen increases the mortality risk from ovarian cancer, although the absolute risk is small. The annual age-adjusted ovarian cancer death rates for women taking estrogen replacement for 10 years or longer are 64:100,000 for current users, 38:100,000 for former users, and 26:100,000 for women who had never taken estrogen. Lower-dose estrogen replacement is believed to confer a negligible increased risk for ovarian cancer.
- Prostate CancerAggravation of benign prostatic hypertrophy (BPH), although it does not commonly worsen voiding problems in younger men. In younger men, testosterone replacement therapy does not appear to increase the incidence of prostate cancer. However, in elderly men, testosterone appears to increase the risk of prostate-related symptoms and may possibly increase the risk of clinically significant prostate cancer, compared to elderly peers with low testosterone. Needless to say, testosterone is contraindicated in the presence of active prostate cancer. Therefore, it is reasonable to obtain a serum PSA before beginning testosterone. Men with an elevated or high-normal PSA or who have had a prior prostatectomy for low-grade prostate cancer, should not receive testosterone replacement therapy unless they are followed carefully for increasing PSA levels that can signal the the emergence of prostate cancer or prostate-related symptoms.
- Carpal Tunnel SyndromeAcromegaly refers to the clinical syndrome caused by excessive growth hormone (GH) in adulthood, after the closure of epiphyses (bone growth plates). GH produces many of its effects through the stimulation of insulin-like growth factor (IGF-I), produced in the liver and at epiphyses. Symptoms of acromegaly typically include the growth of hands and feet, the growth of jaw and brow, with coarsening of facial features. Bones grow thicker and the growth of spinal bone can cause spinal stenosis and serious neurologic problems. Affected individuals are usually very sweaty, and also have increased muscle mass and reduced subcutaneous fat. Carpal tunnel syndrome is common. Diabetes and hypertension commonly occur. Untreated patients have a reduced life expectancy due to cardiovascular complications.
- Epilepsy
- Depression
- PsychiatrySchmidt PJ et al. Effects of estradiol withdrawal on mood in women with past perimenopausal depression: a randomized clinical trial. JAMA Psychiatry. 2015 Jul;72(7):714-26. [PMID: 26018333]
- Anxiety
- Diabetes Care
- EndocrinologyEndocrinology is a specialty in medicine dealing with hormone-secreting glands. The endocrine glands secrete hormones into the bloodstream. These hormones are molecular signals sent to other cells that have receptors which can receive their signal. Hormones regulate a variety of critical metabolic functions.
- HypothyroidismThe following discussion of hypothyroidism is intended to be understandable and practical. I’ll first present a glossary of terms and then a description of hypothyroidism in adults: symptoms, causes, testing, and treatment. Then I have sections on special groups with hypothyroidism: pregnant women, newborn infants, and children. I first published this online as a Google “Knol”.
- Thyroid
- Thyroid CancerGraves disease is the most common cause of hyperthyroidism in the United States. Other causes of hyperthyroidism include multinodular goiter, toxic solitary nodules of the thyroid, and functioning thyroid cancer. Rare causes for hyperthyroidism include TSH-secreting pituitary tumors, struma ovarii, and hCG-secreting trophoblastic tumors of the ovary or testis. All of the latter conditions cause increased thyroid radioactive iodine uptake on scanning. Hyperthyroidism without increased thyroid radioiodine uptake can be caused by subacute thyroiditis, an acute phase of Hashimoto thyroiditis, thyroid hormone intake, and iodide-induced hyperthyroidism (due to kelp, amiodarone, x-ray contrast, or potassium iodide).
- UltrasoundTreatment of primary hyperparathyroidism has been neck surgery, ideally by a surgeon specializing in endocrine surgery. Preoperatively, parathyroid adenomas can often be visualized in the neck with ultrasound and sestamibi scanning. With such identification, a limited neck exploration can be performed, with an introperative serum iPTH measurement being done to confirm the removal of all the abnormal tissue. Postoperatively, serum calcium levels can drop very low, resulting in paresthesias or severe muscle spasms (“tetany”), since the remaining normal parathyroid glands have been suppressed by the hypercalcemia and require time to recover. Therefore, it is prudent to admit patients overnight following parathyroid surgery and administer calcium supplements prophylactically, once hypercalcemia has resolved.
- MRIMagnetic resonance imaging (MRI) of the pituitary is obtained after the biochemical confirmation of acromegaly. The MRI is quite sensitive (about 90%) in identifying a GH-secreting pituitary adenoma.
- RadiologyFitzgerald PA: Pituitary Radiology. Advances in Endocrinology and Metabolism. Department of Medicine Postgraduate Program, University of California, San Francisco. October 19, 1986.
- X-Rays
- Nuclear MedicineGoldsby RE, Fitzgerald PA: Meta[131I]iodobenzylguanidine therapy for patients with metastatic and unresectable pheochromocytoma and parganglioma. Nuclear Medicine and Biology 35: S149-62, 2008.
- ChemotherapyThere is a very strong genetic predisposition to autoimmune thyroiditis. http://www.jautoimdis.com/content/2/1/1 Â Hashimoto thyroiditis can also occur during treatment with lithium, amiodarone, interferon therapy, and immuno-chemotherapy with immune checkpoint inhibitors. Dietary iodine supplementation also appears to increase the risk of autoimmune thyroiditis. http://www.ncbi.nlm.nih.gov/pubmed/12849065?dopt=Abstract
- Radiation TherapyPeople with Graves eye disease may have involvement of one or both eyes to variable degrees. Occasionally, thyroid eye disease occurs without noticeable enlargement of the thyroid gland or any hyperthyroidism. Although nearly 50% of patients with Graves disease have some eye complaints, only about 5% develop exophthalmos that is serious enough to warrant treatment. Thyroid eye disease is not particularly helped by removing the thyroid gland or by treatment with radioactive iodine. In fact, radioactive iodine can aggravate Graves eye disease. Once hyperthyroidism is treated, the eyes can appear improved, since achieving normal thyroid levels reduces the stare and retraction of the eyelid muscles. For mild-to-moderate Graves eye disease, selenium supplementation 200 mcg/d has been shown to improve outcome. But when Graves exophthalmus becomes very noticeable or affects vision, aggressive treatment with prednisone must be commenced immediately. For patients with active prednisone-resistant Graves eye disease, off-label use of other drugs, such as the IL-6 inhibitor Actemra (tocilizumab) may slow the disease. Some patients require additional therapy with radiation therapy to the retro-orbital muscles. If eye protrusion becomes permanent and to correct diploplia (double vision), orbital decompression surgery can be performed.
- Neurosurgery
- HysterectomyHormone replacement needs to be individualized. Ideally, in women with an intact uterus, very low-dose transdermal estradiol may be used alone or with intermittent progestin or a progesterone-eluting intrauterine device, in order to reduce the risk of endometrial hyperplasia, while avoiding the need for daily oral progestin. Vaginal estrogen can be added if low-dose systemic estradiol replacement is insufficient to relieve symptoms of vulvovaginal atrophy. Women who have had a hysterectomy may receive transdermal estrogen at whatever is the lowest dose that adequately relieves symptoms. However, some women cannot find sufficient relief with transdermal estradiol and must use an oral preparation.
- LaparoscopyTreatment of pheochromocytomas involves blocking the effect of catecholamines with an alpha adrenergic blocker such as doxazosin or phenoxybenzamine. We also use calcium channel blockers, such as nifedipine. After adequate block, it then becomes safe to surgically remove the pheochromocytoma or paraganglioma. Even relatively large pheochromocytomas have been successfully removed at UCSF Medical Center, usually via laparoscopy. Patients with metastatic or recurrent pheochromocytoma or paraganglioma present a difficult problem. Chemotherapy has not been particularly successful. Radiation therapy can be given to bone metastasis. An alternative is I-131 MIBG therapy. For many years, I was the principal investigator for a UCSF phase II clinical trial (later a compassionate use protocol) for I-131 MIBG therapy. This involves treating patients with metastatic or recurrent pheochromocytoma (and similar tumors) which take up MIBG (metaiodobenzylguanadine). I-131 MIBG can be given to such patients in high doses. The tumor takes up the isotope and delivers a dose of
- GynecomastiaEnlargement of the breasts (gynecomastia). Such enlargement is usually mild and may regress spontaneously; switching from testosterone injections to other treatments may help this condition. Male breast cancer can be stimulated by testosterone therapy.
- Acne Treatment
- LesionsCauses of hyperprolactinemia: Hyperprolactinemia refers to serum levels of prolactin that are above the normal range for sex. The most common cause of hyperprolactinemia is pregnancy. Other causes for hyperprolactinemia include a variety of medications, nipple stimulation, chest wall lesions, hypothyroidism, renal failure, liver disease, anterior pituitary adenomas (tumors), and anything that damages the hypothalamus or pituitary stalk (inflammation, other tumors, etc.).