Endocrine finding intb full details for md exams 15marks with dosage and treatment

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🧬 Endocrine Findings — Complete MD Exam Notes (15-Mark Format)

1. HYPOTHYROIDISM

Definition

Deficiency of thyroid hormones (T3/T4) leading to slowing of all metabolic processes.

Classification

Type	Cause	TSH	FT4
Primary	Hashimoto's, post-RAI, post-surgery, iodine deficiency	↑	↓
Secondary (Central)	Pituitary TSH deficiency	↓/N	↓
Tertiary	Hypothalamic TRH deficiency	↓/N	↓
Subclinical	Early/compensated	↑	Normal

Clinical Features

Symptoms: Fatigue, cold intolerance, weight gain, constipation, dry skin, hair loss, bradycardia, hoarse voice, menorrhagia, depression
Signs: Periorbital puffiness, non-pitting edema (myxedema), delayed relaxation of deep tendon reflexes, bradycardia, carpal tunnel syndrome, macroglossia
Labs: ↑TSH (primary), ↓FT4, ↑cholesterol, ↑CK, normocytic/macrocytic anemia, hyponatremia

Myxedema Coma (Emergency)

Triggered by cold, infection, drugs
Features: Hypothermia, bradycardia, hypotension, hypoventilation, altered consciousness
Treatment:
- IV T4 (Levothyroxine) 200–400 mcg IV loading dose, then 1.6 mcg/kg/day
- IV T3 (Liothyronine) 10–20 mcg IV if severe
- IV hydrocortisone 100 mg q8h (rule out concurrent adrenal insufficiency first)
- Supportive: warming, ventilatory support, IV fluids

Treatment — Hypothyroidism

Drug	Dose	Notes
Levothyroxine (T4)	1.6 mcg/kg/day PO (average 100–150 mcg/day)	Take fasting, 30–60 min before meals
Elderly/CAD patients	Start 25–50 mcg/day, titrate slowly	Avoid precipitating angina/MI
Central hypothyroidism	Monitor FT4, NOT TSH	TSH unreliable for monitoring

Goal: TSH 0.5–2.5 mIU/L (primary); FT4 mid-normal (central)

2. HYPERTHYROIDISM / THYROTOXICOSIS

Causes

Graves' disease (most common, autoimmune — TSH-receptor antibodies/TRAb)
Toxic multinodular goiter (Plummer's disease)
Toxic adenoma
Thyroiditis (subacute, silent, postpartum)
Exogenous thyroid hormone

Clinical Features

Symptoms: Heat intolerance, weight loss with increased appetite, palpitations, tremors, anxiety, diarrhea, oligomenorrhea
Signs: Tachycardia/AF, warm moist skin, fine tremor, hyperreflexia, lid lag, lid retraction
Graves'-specific: Exophthalmos (proptosis), pretibial myxedema, thyroid acropachy
Labs: ↓TSH, ↑FT4/FT3, ↑TRAb (Graves'), ↑radioiodine uptake (Graves', toxic nodule); ↓uptake (thyroiditis, exogenous)

Thyroid Storm (Thyrotoxic Crisis) — Emergency

Burch-Wartofsky score >45 = thyroid storm likely

Features: Hyperthermia >41°C, tachycardia, AF, vomiting, diarrhea, psychosis, coma

Treatment Protocol (ABCDE):

Drug	Dose	Purpose
Propylthiouracil (PTU)	600 mg loading, then 200–250 mg q4h	↓ synthesis + ↓T4→T3 conversion
OR Methimazole	20–25 mg q4h	↓ synthesis
Lugol's iodine	5–10 drops q8h (1 hour AFTER PTU/MMI)	Wolf-Chaikoff — ↓ hormone release
Propranolol	60–80 mg PO q4h or 0.5–1 mg IV	↓ sympathomimetic effects
Hydrocortisone	100 mg IV q8h	↓T4→T3 conversion + adrenal support
Supportive	Cooling, IVF, treat precipitant	—

Treatment — Hyperthyroidism

Modality	Drug/Dose	Notes
Antithyroid drugs	Methimazole 20–40 mg/day (1st line)	Remission in 30–50% after 12–18 months
	PTU 100–200 mg TID	Used in 1st trimester pregnancy, thyroid storm
Beta-blockers	Propranolol 20–40 mg TID-QID	Symptomatic relief only
Radioactive Iodine (RAI)	¹³¹I: 10–15 mCi	Definitive; avoid in pregnancy/severe ophthalmopathy
Surgery	Thyroidectomy	Preferred in large goiter, compressive symptoms, pregnancy 2nd trimester

⚠️ PTU vs. Methimazole: PTU preferred in pregnancy 1st trimester (MMI → aplasia cutis/choanal atresia), thyroid storm. MMI preferred otherwise (once-daily, better compliance, lower hepatotoxicity risk).

3. DIABETES MELLITUS

Type 1 DM

Autoimmune β-cell destruction → absolute insulin deficiency
Anti-GAD, anti-IA2, anti-insulin antibodies
HLA-DR3/DR4 association

Type 2 DM

Insulin resistance + progressive β-cell failure
Risk: Obesity, sedentary lifestyle, family history

Diagnostic Criteria (ADA)

Test	Diabetes	Pre-diabetes
FPG	≥126 mg/dL	100–125 mg/dL
2-hr OGTT	≥200 mg/dL	140–199 mg/dL
HbA1c	≥6.5%	5.7–6.4%
Random PG + symptoms	≥200 mg/dL	—

Treatment — Type 2 DM

Oral/Injectable Agents

Drug Class	Drug	Dose	Mechanism	Key Notes
Biguanides	Metformin	500–2000 mg/day	↓ hepatic glucose production	1st line; hold if eGFR <30; B12 deficiency
SGLT2 inhibitors	Empagliflozin	10–25 mg/day	Glucosuria	CV & renal protective; risk: DKA, UTI
	Dapagliflozin	5–10 mg/day		HFrEF indication
GLP-1 agonists	Semaglutide SC	0.5–2 mg/week	↑ insulin, ↓ glucagon, ↓ appetite	Weight loss, CV benefit; GI SE
	Liraglutide	1.2–1.8 mg/day SC
DPP-4 inhibitors	Sitagliptin	100 mg/day	↑ incretin activity	Weight neutral; dose-adjust in CKD
Sulfonylureas	Glipizide	5–20 mg/day	↑ insulin secretion	Hypoglycemia risk; weight gain
	Glibenclamide	2.5–15 mg/day
Thiazolidinediones	Pioglitazone	15–45 mg/day	↑ insulin sensitivity	CI: HF, bladder cancer risk
Alpha-glucosidase inhibitors	Acarbose	50–300 mg TID with meals	↓ carb absorption	GI flatulence; dose with food

Insulin Therapy

Insulin Type	Onset	Peak	Duration	Example
Rapid-acting	5–15 min	1–2 hr	3–5 hr	Lispro, Aspart, Glulisine
Short-acting	30–60 min	2–4 hr	5–8 hr	Regular (Actrapid)
Intermediate	1–2 hr	4–10 hr	14–18 hr	NPH
Long-acting (basal)	1–4 hr	Peakless	20–24 hr	Glargine, Detemir
Ultra-long	6 hr	Peakless	42 hr	Degludec

Standard Insulin Regimen: Basal (Glargine 0.2 U/kg/day at bedtime) + Bolus (Aspart/Lispro 0.1 U/kg/meal or 1U per 10g carbohydrate)

Type 1 DM: Total daily dose ~0.5–0.7 U/kg/day; 50% basal, 50% bolus

DKA vs HHS

Feature	DKA	HHS
Type	T1DM (mostly)	T2DM (mostly)
Blood glucose	>250 mg/dL	>600 mg/dL
pH	<7.3	>7.3
Bicarbonate	<18 mEq/L	>18 mEq/L
Ketones	Present (3+)	Absent/trace
Osmolality	<320 mOsm/kg	>320 mOsm/kg
Mortality	1–5%	5–20%

DKA Management:

IV Fluids: 0.9% NS 1L in first hour → 500 mL/hr × 4 hr → 250 mL/hr
Insulin: Regular insulin 0.1 U/kg/hr IV infusion (after K⁺ ≥3.5 mEq/L)
Potassium replacement: If K⁺ 3.5–5.0 → add 20–40 mEq KCl/L of fluids
Dextrose: Add D5W when glucose <250 mg/dL
Bicarbonate: Only if pH <6.9 — 100 mEq NaHCO₃ over 2 hours
Monitoring: Hourly glucose, q2–4h electrolytes, anion gap

4. ADRENAL DISORDERS

A. Primary Adrenal Insufficiency (Addison's Disease)

Causes: Autoimmune (most common in developed countries), TB, metastases, bilateral adrenalectomy, hemorrhage (Waterhouse-Friderichsen)

Clinical Features:

Weakness, fatigue, weight loss, nausea, vomiting, abdominal pain
Hyperpigmentation (pathognomonic — due to ↑ACTH/MSH) — buccal mucosa, palmar creases, pressure areas
Salt craving, postural hypotension
Labs: ↓Na⁺, ↑K⁺, ↓glucose, ↑BUN, ↓cortisol, ↑ACTH, eosinophilia

Diagnosis:

8 AM cortisol <3 mcg/dL (highly suggestive)
ACTH (Synacthen) stimulation test: Cortisol <18 mcg/dL at 30–60 min = diagnostic
↑ACTH (primary) vs ↓ACTH (secondary/central)

Adrenal Crisis (Emergency):

Precipitants: Infection, surgery, missed doses, trauma
Features: Severe hypotension, vomiting, altered consciousness, fever
Treatment:
- Hydrocortisone 100 mg IV bolus, then 50–100 mg IV q6–8h
- 0.9% NS + D5W IV fluids (1–2L rapid)
- Identify and treat precipitant
- Fludrocortisone NOT needed acutely (hydrocortisone has mineralocorticoid activity at high doses)

Maintenance Treatment:

Drug	Dose	Notes
Hydrocortisone	15–25 mg/day (10 mg AM + 5 mg PM)	Mimics diurnal rhythm
OR Prednisolone	3–5 mg/day	Once daily
Fludrocortisone	0.05–0.2 mg/day	Primary AI only (mineralocorticoid replacement)
Sick day rules	Double/triple dose for fever/illness	Educate patient; MedicAlert bracelet

B. Cushing's Syndrome

Causes:

Cause	ACTH	Notes
Cushing's disease (pituitary ACTH adenoma)	↑	70% of endogenous cases
Ectopic ACTH (SCLC, carcinoid)	↑↑	Rapid onset, severe hypokalemia
Adrenal adenoma/carcinoma	↓	Unilateral mass
Exogenous steroids	↓	Most common cause overall

Clinical Features (Mnemonic: CUSHINGS):

C — Central obesity, moon face, buffalo hump
U — Urinary free cortisol ↑
S — Striae (purple/violaceous), Skin thinning
H — Hypertension, Hyperglycemia, Hypokalemia (ectopic)
I — Infections (immunosuppressed)
N — Neuropsychiatric (depression, psychosis)
G — Gonadal dysfunction, Growth retardation (children)
S — Supraclavicular fat pads, Osteoporosis

Diagnostic Workup:

Screening: 24-hr urinary free cortisol (>3× upper limit), late-night salivary cortisol ×2, or overnight 1 mg dexamethasone suppression test (failure to suppress <1.8 mcg/dL)
ACTH level: ↑ → ACTH-dependent; ↓ → ACTH-independent (adrenal)
High-dose DST (8 mg overnight): Suppression → Cushing's disease (pituitary); No suppression → ectopic
MRI pituitary: For Cushing's disease
Bilateral inferior petrosal sinus sampling (BIPSS): Gold standard to distinguish pituitary vs. ectopic

Treatment:

Cause	Treatment
Cushing's disease	Transsphenoidal pituitary adenomectomy (1st line)
Adrenal adenoma	Unilateral adrenalectomy
Ectopic ACTH	Treat primary tumor; bilateral adrenalectomy if uncontrollable
Medical (pre-op/recurrence)	Metyrapone 0.25–1g QID, Ketoconazole 200–400 mg TID, Mifepristone (GR antagonist)
Nelson's syndrome (post-bilateral adrenalectomy)	Pituitary irradiation

C. Primary Hyperaldosteronism (Conn's Syndrome)

Causes: Bilateral adrenal hyperplasia (60%), Aldosterone-producing adenoma (35%)

Clinical: Hypertension (often resistant), muscle weakness, polyuria/polydipsia (hypokalemia-induced nephrogenic DI) Labs: ↓K⁺, ↑Na⁺, metabolic alkalosis, ↑aldosterone, ↓renin

Diagnosis:

Aldosterone-to-Renin Ratio (ARR) >30 with aldosterone >15 ng/dL = screen positive
Confirmatory: Salt loading test, fludrocortisone suppression test
CT adrenals → adrenal vein sampling to lateralize

Treatment:

Cause	Treatment
Unilateral adenoma	Laparoscopic adrenalectomy
Bilateral hyperplasia	Spironolactone 25–400 mg/day (1st line)
	Eplerenone 25–50 mg BD (fewer anti-androgenic SE)
	Amiloride 5–20 mg/day (alternative)

D. Pheochromocytoma

The "10% tumor": 10% bilateral, 10% extra-adrenal (paraganglioma), 10% malignant, 10% children, 10% familial (MEN2, VHL, NF1, SDH mutations)

Clinical (5 H's): Hypertension (paroxysmal or sustained), Headache, Hyperhidrosis, Heart palpitations, Hyperglycemia

Diagnosis:

24-hr urine metanephrines/catecholamines (sensitivity >95%)
Plasma free metanephrines (most sensitive — used for hereditary)
CT/MRI adrenals (MIBG scan for extra-adrenal/metastatic)
⚠️ Do NOT biopsy without alpha-blockade — risk of hypertensive crisis

Treatment:

Alpha-blockade FIRST (mandatory, ≥14 days pre-op):
- Phenoxybenzamine (non-selective, irreversible): 10 mg BD → titrate to 20–40 mg TID
- OR Doxazosin 2–16 mg/day (selective α1, better tolerated)
Beta-blockade AFTER alpha (to control reflex tachycardia):
- Propranolol 20–40 mg TID or Atenolol 25–50 mg/day
- ⚠️ NEVER give beta-blocker before alpha — unopposed α causes severe hypertension
High-salt/fluid diet (counteract volume depletion from alpha-blockade)
Definitive: Laparoscopic adrenalectomy

Hypertensive Crisis: IV Phentolamine 2–5 mg bolus or IV Sodium nitroprusside

5. PITUITARY DISORDERS

A. Hyperprolactinemia

Causes: Prolactinoma (most common), dopamine antagonists (metoclopramide, antipsychotics), hypothyroidism, stalk compression, pregnancy

Clinical:

Women: Oligomenorrhea/amenorrhea, galactorrhea, infertility
Men: Hypogonadism, ED, infertility, galactorrhea (rare), large tumors → visual field defects
Bitemporal hemianopia (large tumor compressing optic chiasm)

Diagnosis: Serum prolactin >200 ng/mL → strongly suggests prolactinoma; MRI pituitary

Treatment:

Drug	Dose	Notes
Cabergoline (1st line)	0.25–1 mg twice weekly	Better tolerated, higher remission rate
Bromocriptine	1.25–2.5 mg daily → 2.5–7.5 mg/day	Used in pregnancy (more data)
Surgery	Transsphenoidal	Resistant/intolerant to dopamine agonists
Radiotherapy	Adjunct	Residual/recurrent tumor

B. Acromegaly (GH Excess in Adults)

Cause: GH-secreting pituitary adenoma (99%)

Clinical Features:

Acral enlargement: Hands (ring size ↑), feet (shoe size ↑), jaw (prognathism, malocclusion)
Coarse facial features, frontal bossing, macroglossia, widely spaced teeth
Systemic: Hypertension, DM, carpal tunnel, arthropathy, sleep apnea, cardiomegaly
Visual: Bitemporal hemianopia (if macroadenoma)
Skin tags (↑ colonic polyp risk)

Diagnosis:

↑IGF-1 (best screening test)
Oral glucose tolerance test (OGTT): Failure of GH suppression to <1 ng/mL (gold standard)
MRI pituitary

Treatment:

Modality	Drug/Dose	Notes
Surgery (1st line)	Transsphenoidal adenomectomy	Cure in 80–90% (microadenoma)
Somatostatin analogues	Octreotide LAR 20–40 mg IM monthly	If surgery fails/contraindicated
	Lanreotide 90–120 mg SC monthly
GH receptor antagonist	Pegvisomant 10–30 mg SC daily	Most effective medically; doesn't reduce tumor size
Dopamine agonists	Cabergoline 0.5–3.5 mg/week	Mildly effective (if GH+PRL co-secreting)
Radiotherapy	Stereotactic radiosurgery	Adjunctive; takes years to work

C. Diabetes Insipidus (DI)

Feature	Central DI	Nephrogenic DI
Cause	ADH deficiency (head trauma, surgery, tumors)	ADH resistance (lithium, hypercalcemia, hypokalemia, congenital)
Urine osmolality	Very low (<200 mOsm/kg)	Very low (<200 mOsm/kg)
Response to desmopressin	↑ (responds)	No response
Plasma ADH	↓	↑

Diagnosis: Water deprivation test → urine concentration failure → desmopressin challenge

Treatment:

Type	Drug	Dose
Central DI	Desmopressin (DDAVP)	0.1–0.2 mg PO BD–TID or 10–20 mcg intranasal BD
Nephrogenic DI	Remove cause (stop lithium)	—
	Hydrochlorothiazide	25–50 mg/day (paradoxical)
	Indomethacin	50–150 mg/day
	Low-solute, low-sodium diet	—

6. PARATHYROID / CALCIUM DISORDERS

A. Primary Hyperparathyroidism

Cause: Single adenoma (85%), hyperplasia (15%), carcinoma (<1%)

Clinical (Painful Bones, Renal Stones, Abdominal Groans, Psychic Moans):

Bones: Osteitis fibrosa cystica, subperiosteal resorption (radial aspect of middle phalanx), salt-and-pepper skull, brown tumors
Stones: Nephrolithiasis (calcium oxalate/phosphate), nephrocalcinosis
Abdomen: Nausea, constipation, pancreatitis, peptic ulcer (MEN1)
Psychic: Depression, confusion, coma (if severe)

Labs: ↑Ca²⁺, ↓PO₄, ↑PTH, ↑urine Ca²⁺, ↑ALP (if bone disease), ↑1,25-OH₂D₃

Treatment:

Indication	Treatment
Symptomatic / Serum Ca >1 mg/dL above normal / Age <50 / Osteoporosis / Renal complications	Parathyroidectomy (curative)
Asymptomatic, not meeting criteria	Surveillance
Medical (inoperable)	Cinacalcet 30–90 mg BD (calcimimetic — ↓PTH)
Hypercalcemic crisis (Ca >14 mg/dL)	IV 0.9% NS + IV Furosemide 40–80 mg, IV Zoledronic acid 4 mg, Calcitonin 4–8 IU/kg IM/SC q6–12h

B. Hypoparathyroidism

Cause: Post-thyroidectomy/parathyroidectomy (most common), autoimmune, DiGeorge syndrome

Clinical (Hypocalcemia):

Chvostek's sign: Facial twitch on tapping facial nerve
Trousseau's sign: Carpal spasm on BP cuff inflation (more specific)
Perioral numbness, paresthesias, tetany, seizures
↑QTc on ECG, cataracts (chronic)
Labs: ↓Ca²⁺, ↑PO₄, ↓PTH

Treatment:

Setting	Drug	Dose
Acute tetany/seizure	Calcium gluconate 10% — 10–20 mL IV over 10–20 min	Monitor ECG
Maintenance	Calcium carbonate	1–3 g/day elemental calcium
	Calcitriol (1,25-OH₂D₃)	0.25–2 mcg/day
	Thiazide diuretics	Reduce urine calcium
Recombinant PTH	Natpara (PTH 1-84) 50–100 mcg SC daily	Severe/refractory cases

7. MULTIPLE ENDOCRINE NEOPLASIA (MEN) SYNDROMES

Feature	MEN 1	MEN 2A	MEN 2B
Gene	MEN1 (Menin)	RET proto-oncogene	RET
Tumors	Pituitary + Parathyroid + Pancreas ("3 P's")	MTC + Pheo + Parathyroid	MTC + Pheo + Mucosal neuromas + Marfanoid
Pituitary	Prolactinoma, GH, ACTH	—	—
Pancreas	Gastrinoma (Zollinger-Ellison), insulinoma, VIPoma, glucagonoma	—	—
Parathyroid	Hyperparathyroidism	Hyperparathyroidism (mild)	—
Screening	Genetic + biochemical	RET mutation → prophylactic thyroidectomy

8. DIABETIC COMPLICATIONS — KEY EXAM POINTS

Complication	Screening	Target	Treatment
Nephropathy	Urine ACR annually	ACR <30 mg/g	ACE inhibitor/ARB (1st line), SGLT2i
Retinopathy	Ophthalmology exam annually	—	Laser photocoagulation, anti-VEGF (bevacizumab)
Neuropathy	10g monofilament, VPT	—	Pregabalin 75–300 mg/day, Duloxetine 60–120 mg/day, Gabapentin
Foot ulcer	Wagner classification	—	Debridement, offloading, antibiotics, revascularization
Autonomic	Postural BP, gastric emptying scan	—	Metoclopramide, Fludrocortisone

9. THYROID NODULE & CANCER

Workup Algorithm

TSH → if ↓, radionuclide scan (hot nodule = functioning, unlikely malignant)
Ultrasound (all nodules) → suspicious features: hypoechoic, irregular margins, microcalcifications, taller-than-wide, absent halo
FNAC (Fine Needle Aspiration Cytology) — gold standard for nodules >1 cm

Bethesda Classification (FNAC)

Category	Malignancy Risk	Management
I — Nondiagnostic	1–4%	Repeat FNAC
II — Benign	0–3%	Follow-up USS
III — AUS/FLUS	10–30%	Repeat FNAC / molecular testing
IV — FN/SFN	25–40%	Hemithyroidectomy
V — Suspicious	50–75%	Surgery
VI — Malignant	97–99%	Surgery

Thyroid Cancer Treatment

Type	Frequency	Treatment
Papillary (PTC)	80%	Total thyroidectomy + RAI + TSH suppression (Levothyroxine to keep TSH <0.1)
Follicular (FTC)	10%	Total thyroidectomy + RAI
Medullary (MTC)	5–8%	Total thyroidectomy + central neck dissection; screen for MEN2/RET; Vandetanib/Cabozantinib for metastatic
Anaplastic	1–2%	Very poor prognosis; combined chemoradiation; Dabrafenib+Trametinib (BRAF V600E)

10. SIADH (Syndrome of Inappropriate ADH)

Causes: CNS disorders, pulmonary diseases (TB, pneumonia, SCLC), drugs (carbamazepine, SSRIs, cyclophosphamide), hypothyroidism, adrenal insufficiency

Diagnostic Criteria (Schwartz-Bartter):

Serum Na⁺ <135 mEq/L + Serum osmolality <275 mOsm/kg
Urine osmolality >100 mOsm/kg (inappropriately concentrated)
Urine Na⁺ >20 mEq/L (euvolemic, no edema)
Normal thyroid and adrenal function (exclude these first)

Treatment:

Serum Na⁺	Management
Mild/asymptomatic	Fluid restriction <800–1000 mL/day
Moderate	Fluid restriction + Salt tablets; Demeclocycline 300–600 mg BD
Severe (Na⁺ <120 + symptoms)	3% Hypertonic saline 0.5–1 mL/kg/hr → correct at max 8–10 mEq/L in 24hr (risk of osmotic demyelination if corrected too fast)
Chronic	Tolvaptan (V2 receptor antagonist) 15–60 mg/day PO; Urea 15–60 g/day

⚠️ Correction rate: Never exceed 10–12 mEq/L in first 24 hours (risk of central pontine myelinolysis/osmotic demyelination syndrome)

QUICK REVISION TABLE — HORMONES & REPLACEMENT

Deficiency	Replacement Drug	Dose
Hypothyroidism	Levothyroxine	1.6 mcg/kg/day
Adrenal (glucocorticoid)	Hydrocortisone	15–25 mg/day
Adrenal (mineralocorticoid)	Fludrocortisone	0.05–0.2 mg/day
Hypoparathyroidism	Calcium + Calcitriol	1–3g + 0.25–2 mcg/day
GH deficiency	Somatropin	0.2–0.6 mg/day SC
ADH deficiency (CDI)	Desmopressin	0.1–0.2 mg BD–TID PO
Hypogonadism (male)	Testosterone	250 mg IM q3 weeks or 50 mg gel daily
Hypogonadism (female)	Estradiol + Progesterone	Cyclical HRT

Key exam tip — Primary vs. Secondary endocrine disorders: In primary disease, the gland itself fails → the trophic hormone (TSH, ACTH, LH/FSH) rises (negative feedback loss). In secondary disease, the pituitary fails → trophic hormones fall. As per Management of Immune-Related Adverse Events (p. 14), always replace cortisol (hydrocortisone) before thyroid hormone in panhypopituitarism to prevent precipitating adrenal crisis.

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