> Measurement of TSH

•In hyperthyroidism and secondary (pituitary) hypothyroidism, TSH level

is expected to decrease while in primary hypothyroidism, TSH is
increased.
•This parameter is extremely useful for the diagnosis of hypothyroidism
in borderline cases.

>Thyroid-Releasing Hormone (TRH) Stimulation Test

•This test measures pituitary TSH stores.
•It can also differentiate between secondary (pituitary) from
tertiary (hypothalamic) hypothyroidism.
•This increases the diagnostic accuracy in patients with symptoms
suggesting hypothyroidism but have normal results of basal thyroid
function tests.
•Typical results of the test are the following:
VII. Other Special Thyroid Function Tests
1. Reverse T3 (rT3)
*rT3 is metabolically inactive.
•Increased rT3 occurs in impaired conversion of T4 to T3. It
can be measured by RIA.
•Increased rT3 is seen in serum of newborns (where there
is decreased T3) and in amniotic fluid at early stages of
pregnancy.
•It is used to diagnose fetal hypothyroidism where the
sample examined is amniotic fluid.
2. Thyroid-binding proteins (TBP)

•Examples of these are TBG, TBPA, and TBA.

•These are measured by immunoradiometric assay
(IRMA).
•Increased TBP is seen in pregnancy, use of oral
contraceptives, and in hepatitis.
•Decreased TBP occurs in anabolic steroid therapy
congenital deficiency, and advanced liver or kidney
disease.
3. Thyroid antibodies
•These are antibodies against thyroid follicles
• These accompany Grave’s disease and Hashimoto’s disease.

4. Thyroglobulin antibodies
•Thyroglobulin is the storage form of thyroid hormones.
• Antibodies to this protein are usually IgG (or IgA or IgM).
•They do not fix the complement. (Complement Fixation: The
binding of active serum complement to an antigen-antibody
pair.)
•They are seen in Hashimoto’s thyroiditis, Grave’s disease,
thyroid cancer, and subacute thyroiditis.
•Thyroglobulin antibodies are used to monitor patient with
thyroid cancer.
5. Microsomal antibodies
•These are antibodies directed against antigen in the cytoplasm.
•They are usually IgG and they can fix the complement.
•They are also seen in Hashimoto’s disease, primary myxedema,
and thyrotoxicosis.

6. Colloid antibodies
•The colloid antigen (CA-2) represents about less than 1% of the
proteins in the thyroid colloid.
•Antibodies to this antigen are predominantly IgG.
•They can be detected by immunofluorescence.
•They are seen in subacute thyroiditis, and Hashimoto’s
disease.

7. Thyroid stimulating immunoglobulins (TSI)

• These are a variety of 7S γ-globulins.
•They may displace TSH from its receptor on the thyroid cell or
they may stimulate the receptor.

8. Anti-TSH-receptor antibodies - are also known as LATS (long-

acting thyroid stimulating antibodies)
•TSH-binding immunoglobulin (TBI), LATS-protector (LATS-P),
TSAb (Thyroid Stimulating antibodies).

8. Radioactive Iodine Uptake (RAIU) Test

•The patient is given radioactive iodine by mouth.
•The radioactivity over thyroid gland is counted at various
intervals of time, usually 4-6 hours and again at 24 hours.
•This test is not useful for hypothyroidism.
•It is used to differentiate many causes of hyperthyroidism.
9. T3 Suppression Test
•This is used to diagnose mild hyperthyroidism and
differentiate thyrotoxicosis from other causes of increased
radioactive iodine uptake.
•It evaluates the response of patients with hyperthyroidism to
anti-thyroid drug therapy.
•The procedure is as follows:
oDo RAIU test
oAdminister T3
oRepeat RAIU
•T3 suppresses TSH causing RAIU.
•In a normal person or in iodine deficiency, T3 is suppressed by
at least 50% as compared by first RAIU test.

10. Thyroid Scan

*This uses Iodine-123 (123I) or pertechnetate (99mTc).

*This procedure defines areas of increased or decreased uptake
within the gland.

11. Needle biopsy

* This involves the removal by needle aspiration of cytologic
samples from thyroid masses to screen for possible malignancy.
 PARATHYROID DISEASES
HYPERPARATHYROIDISM
Primary (Parathyroid pathology)
Adenoma( 85-95%) (Solitary)
Hyperplasia (5-1-%) (Multiglandular)
Carcinoma (~1%)
Secondary (Compensation to chronic hypocalcemia)
Renal failure (most common)
Inadequate Ca intake, steatorrhea, Vit. D deficiency
Tertiary (Persistent PTH section after correction of hypocalcemia)

Clinical manifestations of PRIMARY HYPERPARATHYROIDISM

Osteoporosis → microfractures with hemorrhages→ repair in the form a brown fibrous
ingrowth “brown tumor” (may sometimes undergo cystic change)

Von Recklinghausen disease of bone: 1. Increases osteoclast activity;

2. Peritrabecular fibrosis;
3. Cystic brown tumors
SYSTEM MANIFESTATION
Renal  Nephrolithiasis, nephrocalcinosis
Gastrointestinal  Constipation, nausea, peptic ulcers, pancreatitis, gallstones
CNS  Depression, lethargy, seizures
Neuromuscular  Weakness, fatigue
Cardiac  Aortic and/or Mitral valve calcifications
SECONDARY HYPERPARATHYROIDISM
Most common cause: renal failure
Compensatory increase in PTH (due to calcium wasting in CKD) with reactive parathyroid hyperplasia
Bone changes usually milder than primary (renal osteodystrophy)
Metastatic calcification in blood vessels→ ischemic injury (“calciphylaxis”)

PARATHYROID ADENOMA
Most common cause of primary hyperparathyroidism: Adenoma
Adenomas and carcinomas can be grossly (well-encapsulated) and cytologically similar(uniform, polygonal
cell with centrally located nuclei)
Metastases and local invasion: reliable criteria for malignancy

HYPOPARATHYROIDISM
Causes:
Surgically-induced (most common)
Autoimmune
Single gene defects
Congenital absence (part of DiGeorge syndrome)
Pseudohypoparathyroidism: end organ resistance to PTH (genetic defects); normal PTH levels with
symptoms of PTH deficiency
 CLINICAL MANIFESTATION of HYPOPARATHYROIDISM

SYSTEM MANIFESTATION
Neuromuscular  Tetany (neuromusculat irritability); Chvostek and Trosseau
sign
Mental  Emotional instability, anxiety and depression, confusional
states, hallucinations, frank psychosis
CNS  Calcifications of basal ganglia, Parkinsonian-like
movement disorders, increased ICP with papilledema
 (Decreased PTH leads to increased phosphate→
calcifications)
Ocular  Calcification of lens, cataract formation
Cardiac  Conduction defect (QT prolongation)

Chvostek's sign is the twitching of the facial muscles in response to

tapping over the area of the facial nerve.

Trousseau's sign is carpopedal spasm caused by inflating the blood-

pressure cuff to a level above systolic pressure for 3 minutes.
INTRODUCTION
•Steroids are hormones derived from
cholesterol.

•As such, they possess the

cyclopentano-phenanthrene nucleus
in their structure.

•There are two organs in the body

that produce steroid hormones.

*These are the adrenal glands

(cortex) and the gonads.
• In pregnant
women, the
placenta also
contributes to the
steroid pool in the
body.
*Once synthesized, steroids are metabolized in the liver and then
excreted principally in the urine.
*The metabolic reactions that occur in the liver include reduction of
unsaturated bonds and introduction of additional hydroxyl groups.
*The byproducts are then conjugated with glucuronic acid or sulfate to
make them more soluble.
*Moreover, some fractions of steroid hormones are often bound to
transport proteins.
*About 30% of the metabolites are excreted through bile and feces.
*The rest returns to the blood and are excreted through the urine.
HORMONES OF THE ADRENAL CORTEX

*Histologically, the adrenal cortex is layered into three different

zones.

*From the outside, these are the zona glomerulosa, zona

fasciculata, and zona reticularis.

*Each of these layers is specialized to produce a particular set of

steroid hormones.

*These hormones are the mineralocorticoids, glucocorticoids,

and androgens or sex hormones, respectively.
MINERALOCORTICOIDS

•These hormones are produced by the zona glomerulosa.

*These hormones are involved in electrolyte and water

balance.

*The major mineralocorticoid is the hormone aldosterone.

*About 30% of the aldosterone released by the adrenal cortex

is bound to cortisol-binding globulin (CBG) or transcortin; 42%
is bound to albumin, while 28% remains free in the blood.
*Aldosterone is inactivated and excreted by formation of
glucoronides (via conjugation with glucuronic acid) in the
liver.

*The level of aldosterone in the blood is regulated

primarily by the renin-angiotensin aldosterone (RAA)
system.

*To a lesser extent, the pituitary ACTH could also trigger

the release of aldosterone from the zona glomerulosa.
GLUCOCORTICOIDS

*Specifically, glucocorticoids are 21-carbon-steroids with a

hydroxyl group in carbon-17.

*As such, they are most often referred to as 17 hydroxy-

corticosteroids (17-OHCS).

•They are involved in glucose metabolism by increasing

gluconeogenic activity and protein breakdown.

*These groups of steroids are also immunosuppressive and

anti-inflammatory.
*The major glucocorticoid in humans is cortisol.

*The release of cortisol by the zona-fasciculata exerts a negative

feedback to ACTH production from the anterior pituitary.

*That is, the release of cortisol is largely controlled by the

hypothalamo-pituitary-adrenal cortex axis.

*About 83 to 90% of cortisol is bound to CBG (transcortin).

*Only 12-20% is bound to albumin while 5-10% is free (i.e;

active).
*Levels of cortisol in the blood are also controlled by diurnal
rhythm.

•The diurnal pattern is due to circadian pattern of ACTH

release.

*Cortisol levels are usually high between 4:00 AM to 8:00 AM.

•They are low the rest of the day.

•In normal sleep wake schedule, ACTH is lowest shortly after

midnight.
*Stress is also an important factor for the release of
cortisol.
*Among the stressful stimuli for cortisol release are
surgical trauma, pyrogens, hypoglycemia, and
hemorrhage.

*Cortisone is less important glucocorticoid.

*Both cortisol and cortisone may be inactivated by

conversion to tetrahydro- derivatives via reduction
reactions.
SEX HORMONES
*These hormones are produced by the zona reticularis of the adrenal
cortex.

*Sex hormones produced by the adrenal cortex are also responsible

for the development of secondary sexual charactaristics of humans.

*These include androgens (19-C steroids with saturated A rings) and

estrogens (18-C steroids with unsaturated A rings).

*The major androgen produced by the adrenal cortex is the

dehydroepiandrosterone (DHEA).
 ADRENAL GLAND DISEASES
HYPERADRENALISM Cushing syndrome
glucocorticoids: Cushing Most common cause overall: Exogenous steroids
syndrome (“latrogenic”)
mineralocorticoids:
Most common endogenous cause: ACTH-secreting
Hyperaldosteronism
sex steroids: Androgenital/ pituitary adenoma (Cushing disease) (70%)
virilising syndromes Common clinical presentation: abdominal striae,
TYPES obesity, dorsocervical fullness (buffalo hump), moon
PARAMETER facies
ACTH-INDEPENDENT ACTH-DEPENDENT
Adrenal morphology  Adenoma/ CA: Cells resembling  Bilateral diffuse or nodular
normal zona fasciculata; adjacent hyperplasia
parenchyma and contralateral
adrenal atrophic
 Iatrogenic: Bilateral atrophy
Pituitary morphology  Crooke- hyline change (homogenous, paler cytoplasm of ACTH-secreting cells)
24-hour urine free cortisol Increased
Plasma ACTH  Decreased  Increased
Dexamethasone  No suppression  Pituitary ACTH
suppression test o Low-dose: No suppression
o High-dose: Suppression
 Ectopic ACTH
o No suppression
 HYPERALDOSTERONISM
PARAMETER PRIMARY SECONDARY
Etiology  Bilateral idiopathic hyperplasia  Decreased renal
(Most common cause) perfusion
 Neoplasm (aldosterone- (nephrosclerosis, renal
secreting adrenal adenoma/ artery stenosis)
Conn syndrome) (more  Arterial hypovolemia and
common) or carcinoma edema (CHF, cirrhosis,
 Glucocorticoid-remediable nephrotic syndrome)
hyperaldosteronism (rare)  Pregnancy (estrogen-
induced increases in
plasma renin substrate)
Plasma aldosterone Increased
Plasma renin activity  Decreased  Increased
Fludrocortisone  Suppression  Not suppressed
suppression test
Clinical manifestation
Most common and most important: Hypertension
Investigate for hyperaldosteronism in treatment-resistant hypertension
Hypokalemia
Potassium wasting
CONGENITAL ADRENAL HYPERPLASIA: FORMS

PARAMETER SALT-WASTING SIMPLE VIRILIZING LATE-ONSET

Degree of 21-  Total deficiency  Can produce  Partial deficiency
hydroxylase sufficient (most common)
deficiency mineralo-
corticoids
Hormonal  Mineralo-corticoid,  glucocorticoid  Partial
deficiencies  Glucocorticoid
Clinical findings  Salt-wasting  virilization  virtually
cardiovascular asymptomatic;hir
collapse, sutism, acne and
Virilization menstrual
abnormalities
Adrenal morphology  Bilaterally enlarged, brown, with thickened cortex
 Lipid-depleted cells
Pituitary  Corticotroph hyperplasia
morphology
 virilization
 (DHEAS) Dehydroepiandrosterone Sulfate
> DHEAS:
1) Plays a role in developing male secondary sexual characteristics at puberty
2) Can be converted by the body into more potent androgens, such
as testosterone and androstenedione
3) Can be converted into the female hormone estrogen
> Well-vascularized endocrine theca
interna = steroid-producing cells secreting
androstenedione
= diffuses into the follicle through the
basement membrane,
= enzyme aromatase in the
granulosa cells converts it to estradiol, an
FSH-dependent function.

> Estrogen returns to the thecae and stroma

around the follicle, enters capillaries, and is
distributed throughout the body.
Why Test?
a) To help evaluate whether the adrenal glands are working
properly;
b) to detect adrenal tumors or cancers;
c) to help determine the cause of masculine physical characteristics
(virilization) in girls and women or early puberty in boys
When To Test?
a) When a girl or woman has excess facial and body hair (hirsutism),
acne, absence of menstrual periods (amenorrhea),
b) or when a woman is unable to get pregnant (infertility);
c) when a boy shows signs of very early (precocious) puberty such
as deeper voice, pubic hair, or muscle development

> The blood DHEAS concentration, is stable

anytime, unlike Testosterone.
Interpreting the test result:
= A normal DHEAS level, in addition to other normal male hormone levels, likely indicates that
your adrenal glands are functioning normally. Rarely, DHEAS may be normal when an adrenal
tumor or cancer is present but is not producing excess hormones.
= A high DHEAS blood level may indicate that excess DHEAS production is causing or contributing
to your symptoms (but not diagnostic of a specific condition). It usually indicates the need for further
testing to pinpoint the cause of the hormone imbalance.
> An ELEVATED DHEAS may indicate:
•Congenital adrenal hyperplasia
•A tumor of the adrenal gland, which may be benign or cancerous
•Polycystic ovary syndrome (PCOS)—about 25% to 50% of women with POCS have
elevated DHEAS
•Rarely, an ovarian tumor that produces DHEAS

A LOW level of DHEAS may be due to:

•Adrenal insufficiency or Addison disease
•Adrenal dysfunction
•Hypopituitarism, a condition that causes low levels of the pituitary hormones that
regulate the production of adrenal hormones
> MEASUREMENT OF ADRENAL CORTICAL STEROID HORMONES

*Adrenal cortex function is usually assessed by measuring the levels

of the steroid hormones produced by the gland as well as the levels
of their metabolites.

*Either plasma or urine sample may be utilized.

I. Levels of corticosteroids in the urine serve as an important index

of the functional status of the adrenal cortex.

*Levels are increased in Hyperadrenalism (Cushing’s syndrome) and

decreased in Hypoadrenalism (Addison’s disease).
 II. Plasma ACTH. Measurement of adrenocorticotrophic
hormone (ACTH)in the blood is used to differentiate between
primary (adrenal cortex defect) and secondary (pituitary
defect) adrenal insufficiency.
The following table shows the difference between the two.

Primary hypocortisolism Secondary hypocortisolism

Plasma ↓ ↓
Cortisol
Plasma ↑ ↓
ACTH
 In the measurement of plasma ACTH, there are important
precautions that one has to observe.
1. Don’t use glass when collecting blood; ACTH release is
adsorbed onto the glass.
2. Timing is important due to the Circadian rhythm of ACTH
release from the pituitary. Collect between 8:00AM-10:00 AM.
3. Store samples at -20oC when there is delay.
Normally, plasma ACTH does not go beyond 50ng/L.

*In stressful conditions however, levels as high as 500 ng/L may be

observed.
*Other applications of the measurement of ACTH levels in the
blood are as follows:
1. Establishing a diagnosis of Cushing ‘s syndrome
characterized by a decreased ACTH levels.
*For this purpose, obtain blood between 9:00 PM and midnight
to best discriminate patients with Cushing’s syndrome from
healthy individuals.

*In Cushing’s syndrome there is loss of circadian rhythm

of ACTH and cortisol.
 2. Establishing a diagnosis of adrenal adenomas or
carcinomas where ACTH is also decreased.

3. Determining the adequacy of cortisol replacement in

congenital adrenal hyperplasia.

III. Plasma Cortisol. Plasma cortisol is used to evaluate

adrenal stimulation or suppression test.

*In fluorometry, the assay is interfered by corticosterone

and birth control pills containing estrogens.
 IV. Urinary Free Cortisol. Urinary cortisol is used as
adjunct in the diagnosis of adrenal cortical disease.
*A 24-hour-urine collection is the best specimen for
this purpose.
*In adrenal insufficiency e.g; Addison’s disease, there
is decreased urinary free cortisol.
*In adrenal hyperfunction e.g; Cushing’s syndrome
urinary free cortisol is increased.
 V. Total 17-ketosteroids. These metabolites are also
referred to as 17-ketogenic steroids.

*They usually include androsterone, dehydroepiandrosterone

(DHEA) and other androgens except testosterone and
dihydroxytestosterone.

*Measurement of total 17-ketosteroids is used to assess

androgen production by the adrenal cortex.
*There are actually two categories of Cushing’s syndrome. The
distinguishing feature has to do with what causes the overproduction:
1. Cushing’s disease. This is characterized by increased cortisol
production due to excessive development and activity of the pituitary
gland.
2. Cushing’s syndrome. Here, there is increased cortisol production
due to tumors which produce either excessive ACTH or cortisol.

VI. Dexamathasone Suppression Test. This test has been used to

establish the cause of hypercortisolism.
*Dexamethasone is a synthetic glucocorticoid which suppresses ACTH
output from the anterior pituitary gland.
*It acts like a negative feedback at the level of the pituitary.

*If the cause of hypercortisolism is a pituitary problem, there is

50% suppression of cortisol.

*This is due to suppression of the pituitary ACTH.

*If the cause is ectopic, there is no suppression of ACTH

production.
*Note that ectopic ACTH is not suppressed unlike pituitary
ACTH.
• If the cause is adrenal adenoma or cancer, there is no
suppression since ACTH is already low.
VII. Metyrapone Inhibition Test. Metyrapone inhibits the
conversion of 11-deoxycortisol to cortisol.
*The result is decreased cortisol and increased ACTH.
*The adrenal gland then produces more steroids.
*Normally, after the metyrapone challenge, the plasma
cortisol is decreased, the 11-deoxyprecursors are increased,
the total 17-OHCS excretion is increased, and the urine cortisol
is decreased .
ADRENOCORTICAL INSUFFICIENCY
(HYPOADRENALISM)
Primary/ Secondary
Primary: Adrenal pathology
Secondary: Extra-adrenal pathology
Acute/ Chronic

I. PRIMARY ACUTE ADRENOCORTICAL INSUFFICIENCY

Crisis in patients with chronic adrenal insufficiency
Rapid withdrawal of steroids in patients maintained on
steroids
Massive adrenal hemorrhage
Waterhouse- Friedrichsen syndrome: bilateral adrenal
haemorrhage; complication of disseminated bacterial
infection (usually N. meningitidis)
Addison’s Disease (Hypoadrenalism)
*This condition is characterized by decreased aldosterone, plasma
cortisol, and other steroids.
*Urine free cortisol is decreased and 17-OHCS is also decreased.

*The causes of hypoadrenalism can be determined by the

administration of synthetic ACTH analogs e.g; dexamethasone.
•If the defect is in the adrenal cortex there will be no change in
plasma or urine cortisol before and after challenge.
*If the defect is in the hypothalamus or pituitary gland, there will be
increased plasma and urine cortisol.
PHEOCHROMOCYTOMA
Cytogenetic origin: chromaffin cells of medulla
Releases cathecolamines
Rare cause of surgically correctible hypertension

“Rule of 10s”
10% are extra-adrenal
10% are bilateral
10% are biologically malignant
10% are not assiociated with hypertension
Additional: 25% have a germline genetic mutations in RET, Nf1, VHL and SDH genes

Morphology
Zellballen (nests of cells surrounded by sustentacular cells)
Salt and pepper chromatin
Rich vascular network

ONLY criteria for malignancy: METASTASES

•INTRODUCTION

•Catecholamines are
hydrophilic hormones
produced by the adrenal
medulla which is a neuro-
endocrine gland, and the
neurons of the central
nervous system.
•It is derived from the amino acid tyrosine.
•Catecholamines include the hormones dopamine,
epinephrine, and norepinephrine.
•Adrenals secrete catecholamines in response to stressful fight
or flight situations.

•They posses α and β adrenergic effects with a net effect of

increasing the blood pressure.

•Other effects include dilatation of the pupils of the eyes,

lipolysis (to preserve the levels of glucose in case of
hypoglycemia), and hyperglycemia.

•These hormones are primarily synthesized and stored in

the vesicles of chromaffin cells in adrenal medulla; other
site is the sympathetic neuron (synaptic vesicles).
•REGULATION OF CATECHOLAMINE RELEASE

•Stressful conditions favor the release of these hormones.

•Another important trigger for the release of catecholamines
especially epinephrine is low glucose concentration.

•Epinephrine stimulates the liver to undergo glycogenolysis

and restore the level of glucose back to normal.
•It also acts as a positive modulator that triggers the
hormone-sensitive lipase to breakdown triglycerides into fatty
acid and glycerol in the adipose tissues.
•The adrenal cortex hormone, cortisol, may also profoundly affect the
conversion of norepinephrine to epinephrine.
•Decreased levels of cortisol stimulate the breakdown of
phenylethanolamine-N-methyltransferase (PENMT) thereby decreasing
the epinephrine levels.
•The metabolites of catecholamines are important diagnostic tools in
assessing the function of the adrenal medulla and the nervous tissues.

*Among these metabolites are:

1. Homovanillic acid (HVA).
* This is the principal end-product of dopamine metabolism.
 2. Dihydroxy-phenylacetic acid (DOPAc).
* This is a metabolite in the pathway of dopamine degradation.

3. Metanephrines.
*Metanephrines refer to the metabolites formed from
norepinephrine and epinephrine using the enzyme COMT
(Catechol-O-methyltransferase).
*They are measured in the urine as total metanephrines
(metanephrine from epinephrine and normetanephrine from
norepinephrine).
 4. Vanillyl Mandelic Acid (VMA).
*This is the final product of epinephrine and norepinephrine
degradation specifically as a result of further oxidation of
metanephrines by MAO
(L-Monoamine oxidases ).

5. Sulfated or Glucuronide Derivatives.

*They are formed by the action of phenolsulfotransferase.

6. Methoxy-hydroxy-phenyl glycol (MHPG).

*This is preferentially produced in the brain instead of VMA.
•MEASUREMENT OF CATECHOLAMINES
• In the measurement of catecholamines, the physician must be aware
of certain precautions important in ensuring an accurate result:
1. Platelets may bind readily and metabolize catecholamines
through MAO and COMT enzymes.
Thus, prolonged exposure to platelets and increased platelet
counts may lower the values of catecholamines.
2. Standing increases norepinephrine levels markedly.
* The patient should be in recumbent position or
should be lying down for 15 to 30 minutes prior to
collection.
*Sitting also causes increases in catecholamine values but only to a
lesser extent.
3. Avoid elevation related to stress of venipuncture.
4. Samples must be cooled on ice during transport and
centrifuged immediately.
5. Use antioxidants e.g., glutathione or ascorbic acid to stabilize
the catecholamines.
6. The preferred sample is a 24-hour urine sample since
some secretory bursts of catecholamines are sporadic.
7. The container must be opaque to light because sunlight can
increase the breakdown of catecholamines.
7. Urine samples must be placed in tubes with 10 ml 6N
HCl and cooled with ice or refrigerated until collection is complete.
* Adjust the pH to pH 5 with 6N HCl after collection is complete.
8. Restrict intake of bananas, chocolates, coffee, tea,
cocoa, citrus fruits and vanilla prior to collection of samples,
since these can increase catecholamine levels.

URINE CATECHOLAMINES
•Dopamine is the major intact catecholamine in urine.
•Measuring urinary dopamine is most useful in the diagnosis of
neuroblastoma.
•Measurement of HVA, normetaphrine and VMA in the urine can
also be used for neuroblastoma.
•When using VMA, however, try to differentiate between excess
epinephrine and norepinephrine by testing for normetanephrine or
metanephrine.

URINE METANEPHRINES

•Measurement of urine metanephrines is the assay of choice

especially for Pheochromocytoma since catecholamines are easily
degraded in the circulation once released from adrenal medulla.
DISORDERS CHARACTERIZED BY CHANGES IN CATECHOLAMINE
LEVELS

Adrenal Medullary Insufficiency

•This may be caused by surgery, bilateral lesions, sympathectomy,
neuropathies, and dopamine β hydroxylase deficiency.
•These conditions are characterized by hypoglycemia.
•A soluble protein called chromogranin A is usually secreted along
with catecholamines from chromaffin cells.
•It was found out that this protein increases in renal insufficiency and
is decreased after surgical resection of the adrenal medulla.
•It can therefore be used as a marker to follow the response
of the patient to treatment.

•Neuroblastoma (Malignant) and Ganglioneuroma

•Increased norepinephrine and dopamine but not
epinephrine are seen in neuroblastoma.
•In ganglioneuromas, there is an exclusive increase in
norepinephrine.
*The hormones of the gonads are responsible for regulating
the reproductive processes in humans.

*The menstrual cycle, for example, is largely controlled by

hormones released not only by ovaries but also by anterior
pituitary.

*The menstrual cycle is divided into three phases namely

follicular or proliferative phase, the ovulatory phase, and
the luteal or secretory phase.
PROGESTERONE.

>This is produced principally by the ovary especially during

the second half of the menstrual cycle.

>It is also produced by the adrenal cortex as precursor for

the formation of other adrenal cortical steroids.

>In pregnant patients, the placenta takes over the role of

the corpus luteum in the synthesis of the progesterone.
>The three important groups of progesterone are
pregnanediones, pregnanolone, and pregnanediols.

>The last is considered the major metabolite of

progesterone.

>Determination of progesterone levels is important to

demonstrate anovulatory cycles.

>No cyclical rise in pregnanediol excretion in the urine is

observed if ovulation does not occur.
ESTROGENS.

>The primary source of estrogen is the ovary.

>There are three major estrogens in the human female:
1. estrone (E1)
2. estradiol-17 β (E2)
3. estriol (E3)

>Estradiol is the major estrogen that regulates the menstrual cycle

in women of reproductive age.

>Estrone is seen in post-menopausal women while estriol

predominates in pregnant women.
ANDROGENS.
>Androgens are synthesized by the testes and small amounts are
contributed by the adrenal cortex.

>These include testosterone, androstenedione, and

dehydroepiandrosterone (DHEA).

>The major androgen produced by the testis is testosterone.

>Testosterone is highest at about 7:00 AM and lowest at about
8:00 PM.
>In the circulation, 98% of testosterone is bound to either
albumin or SHBG (Sex hormone-binding globulin).
>Testosterone carries the following important functions:

1. Facilitate the development of secondary male sexual

characteristics, and

2. Enhance protein synthesis leading to growth in both

skeletal muscle and bone (especially during puberty).
Anti-Mullerian Hormone (AMH)
= a protein hormone produced by cells within the ovary.
= used to assess ovarian egg reserve and therefore
fertility.

*AMH levels are naturally lower in older women

(particularly over the age of 40)
and higher in women with Polycystic Ovaries
(PCO) or Polycystic Ovary Syndrome (PCOS).
Optimal fertility 40.04-67.9pmol/l
Satisfactory fertility 21.98-40.03pmol/l
Low fertility 3.08-21.97pmol/l
Very low/undetectable 0.0-3.07pmol/l