Vitamin D is very important for overall health and well-being. A major source of vitamin D comes from exposure to sunlight. However, with fear of skin cancers in the last decade, people did significantly reduce their sun exposure and with the use of sunscreens mainly in the west have dramatically reduced the vitamin D levels leading to major health problems. Although the evidence with skin cancer relate to excessive unprotected sun exposure and not to moderate exposure to the sun in early morning or late afternoon away from noon time, the peak of the harmful ultraviolet rays. There is now substantial evidence of high rate of Vitamin D deficiency reaching more than 90 percent of young women and to a lesser extent among males. This led to increased risk of bone disorders like Rickets in kids (bowing of the bone and disrupted bone growth leading to deformities), osteoma Lacia (softening of the bone) and osteoporosis in adults.

Moreover, there is evidence of increase pain in osteoarthritis patients with low vitamin D status. There is also very strong evidence of increased risk for diabetes, thyroid disorders, neurological diseases like multiple sclerosis, other autoimmune disorders like rheumatoid arthritis, inflammatory bowel diseases, and even certain kinds of cancer are more among those with low levels. Cancers of the colon, prostate, breast and ovary have been linked to low levels of Vitamin D. Recently, there was evidence of increased heart diseases in large scale studies, hypertension, stroke and this week another study confirmed increased artery diseases of the extremities.

Age related memory problems have been linked to lower vitamin D levels as well as poor mental health and symptoms of seasonal affective disorder, premenstrual syndrome, and depression.

It is almost impossible to consume adequate vitamin D through diet alone and while supplements are an important alternative, most people don’t get the recommended amount.

We dispel the myth that women with osteoporosis living in sunnier latitudes do not have to worry about vitamin D. The clothing, use of sunscreen, and avoidance of sun exposure, particularly in hot climates like the Gulf areas, could explain the high prevalence of vitamin D inadequacy observed in the studies. We live in houses that have tinted glass windows, drive our car from a covered garage going to another covered garage with our car windows all tinted. Most of our activities are scheduled after sunset and focus more on the indoor activities due to the hot weather. It isn’t natural or healthy to live that way!

Although the initial results clearly show that, regardless of age, geographic region, or latitude, many women with osteoporosis are not getting enough vitamin D. now we know that even those without osteoporosis have low values and at risk of having other more serious disorders.

In review of the studies in most parts of the world, vitamin D was deficient in almost 50-90% of the population regardless of the geographical areas more in the elderly making them prone to serious disorders. The Gulf area had one of the highest rates of vitamin D deficiency. In institutionalized patients and elderly patients, it was up to 100%. Correcting vitamin D deficiency could significantly lower the risk of several types of cancer, autoimmune diseases and improve bone health.

Vitamin D is made by out body as the main source by the exposure of the skin to UV-B of the solar spectrum of sunlight which is then activated along with the dietary vitamin by the liver and kidneys into the active form. Dietary supply of vitamin D could be found in fortified milk and orange juice, Swiss cheese, fortified cereals, salmon, mackerel, sardines and codfish. Also, multivitamins do include vitamin D supply.

Your pituitary gland is about the size of a pea and is situated in a bony hollow in the base of the brain, just behind the bridge of your nose. It is attached to the base of your brain by a thin stalk. The hypothalamus, which controls the pituitary by sending messages, is situated immediately above the pituitary gland. The pituitary gland is often called the master gland because it controls several other hormone glands in your body, including the thyroid and adrenals, the ovaries and testicles. The hormones of the pituitary gland send signals to other endocrine glands to stimulate or inhibit their own hormone production. The anterior lobe releases hormones upon receiving releasing or inhibiting hormones from the hypothalamus. These hypothalamic hormones tell the anterior lobe whether to release more of a specific hormone or stop production of the hormone.

Anterior Lobe Hormones:

1. Adrenocorticotropic hormone (ACTH): ACTH stimulates the adrenal glands to produce hormones.
2. Follicle-stimulating hormone (FSH): FSH works with LH to ensure normal functioning of the ovaries and testes.
3. Luteinizing hormone (LH): LH works with FSH to ensure normal functioning of the ovaries and testes.
4. Growth hormone (GH): GH is essential in early years to maintaining a healthy body composition and for growth in children. In adults, it aids healthy bone and muscle mass and affects fat distribution.
5. Prolactin: Prolactin stimulates breast milk production.
6. Thyroid-stimulating hormone (TSH): TSH stimulates the thyroid gland to produce hormones.

The posterior lobe contains the ends of nerve cells coming from the hypothalamus. The hypothalamus sends hormones directly to the posterior lobe via these nerves, and then the pituitary gland releases them.

Posterior Lobe Hormones:

1. Anti-diuretic hormone (ADH): This hormone prompts the kidneys to increase water absorption in the blood.
2. Oxytocin: Oxytocin is involved in a variety of processes, such as contracting the uterus during childbirth and stimulating breast milk production.

Diseases and Disorders of the Pituitary Gland

Pituitary tumors are the most common pituitary disorder, and many adults have them. However, they are not, in the great majority of cases, life threatening. But that doesn’t mean they’re harmless—pituitary tumors can disrupt the gland’s normal ability to release hormones. There are two types of pituitary tumors—secretory and non-secretory. Secretory tumors secrete too much of a hormone, and non-secretory tumors don’t secrete excess hormone. These hormonal imbalances can cause problems in many different areas of the body. If you have a secretory tumor that is overproducing thyroid-stimulating hormone, for instance, you will experience hyperthyroidism. The pituitary gland is immensely important to the overall function of your endocrine system—and to your overall health. By working with the hypothalamus, the pituitary gland ensures that all your body’s internal processes work as they should. If you think you may have a problem with your pituitary gland, you should talk to an endocrinologist. He or she will help diagnose and treat your hormone-related condition.

The under-diagnosed endocrine disorder Thyroid diseases are one of the most common endocrine disorders that is easily diagnosed and treated. However, the disease is usually under-diagnosed and under-treated affecting high percentage in the population.

A quick overview of the common thyroid disorders Thyroid disorders are broadly divided into thyroid function disorders (hypothyroidism and hyperthyroidism) and thyroid gland size disorders (goiters and nodules) which could be present both in a single patient. The disorders are more prevalent with age, with family history of thyroid disease and autoimmune disorders, and much more common in females. Thyroid disorders occur in a significant proportion of the general population and increasingly being diagnosed but still with more than half of the cases undiagnosed.

In one of the largest studies to date, the Colorado study, revealed around 10 % of population do suffer from hypothyroidism and 3% hyperthyroidism. Thyroid nodules are very common and were found in multiple studies to reach 50% of population without a history of clinically detectable thyroid disease. The natural history of thyroid diseases usually evolves but with early diagnosis and appropriate management by a specialized Endocrinologist, most disorders are treatable.

Hypothyroidism

Hypothyroidism is a clinical syndrome resulting from a deficiency of thyroid hormones which in turn results in a generalized slowing down of the metabolic process.

Whether hypothyroidism results from hypothalamic-pituitary disease or primary thyroid disease, symptoms and signs of the disease vary in relation to the magnitude of the thyroid hormone deficiency, and the acuteness with which the deficiency develops. Hypothyroidism is less prominent clinically and better tolerated when there is a gradual loss of thyroid function (as in most cases of primary hypothyroidism) than when it develops acutely after thyroidectomy or abrupt withdrawal of exogenous thyroid hormone. The symptoms are mostly related to the generalized slowing of metabolic processes. This can lead to abnormalities such as fatigue, slow movement and slow speech, cold intolerance, constipation, weight gain, delayed relaxation of deep tendon reflexes, and bradycardia.

However, the accumulation of matrix glycosaminoglycans in the interstitial spaces of tissues can lead to coarse hair and skin, puffy facies, enlargement of the tongue, and hoarseness. These changes are often more easily recognized in young patients, and they may be attributed to aging in older patients. This hypometabolism that is associated with hypothyroidism results in a decrease in cardiac output that is mediated by reductions in heart rate and contractility that could worsen cardiac failure. Hypertension, hyperlipidemia and hyperhomocysteinemia could complicate hypothyroidism thus leading to atherosclerosis.

Hypothyroidism in infants and children results in marked slowing of growth and development, with serious permanent consequences including mental retardation. In adult females, hypothyroidism may cause menstrual changes and these menstrual changes result in decreased fertility and hyperprolactinemia may occur. If pregnancy does occur, there is an increased likelihood for early abortion and decreased IQ of the fetus. However, many cases are asymptomatic or have non-specific signs and symptoms like in post-partum depression, fatigue, anemia, or with GI symptoms. The American Thyroid Association recommends every one to test their thyroid function at 35 years of age.

Adult primary hypothyroidism is caused most frequently by chronic autoimmune thyroiditis (Hashimoto thyroiditis) and is present in up to 10 % of the population. Women older than 40 years of age and elderly individuals of both sexes are affected most frequently but could occur at any age. Other causes of hypothyroidism include thyroidectomy, radioactive iodine therapy, antithyroid drugs, head and neck irradiation, certain medications and congenital defects.

Hyperthyroidism

It results from excess thyroid hormone and is present in a variety of conditions that are mainly caused by intrinsic thyroid disease, including hyperthyroidism due to toxic diffuse goiter (Graves’ disease), toxic multinodular goiter, toxic adenoma and thyroiditis (painful and subacute, or silent).

Thyrotoxicosis may also be associated with excessive pituitary TSH production, a trophoblastic tumor, or excessive ingestion of iodine or thyroid hormone.

A wide range of signs and symptoms is associated with hyperthyroidism but manifestations and severity depend on the extent of thyroid hormone excess, age of the patient, and duration of the condition.

They usually present with symptoms related to the higher metabolism like sweating, tremor, palpitations, unexplained weight loss, hyperdefecation, heat intolerance, insomnia, and muscle weakness. They also could have significant eye symptoms with dermopathy or be only as a cardiac presentation especially in older populations presenting only with atrial fibrillations, tachycardias and/or heart failure. Children may present with height and growth related problems or just hyperactivity. They tend to have more weight gain than weight loss.The condition may be diagnosed during pregnancy and could present with abortion, failure to gain weight during pregnancy or weight loss, and fetal tachycardia as thyroid stimulating antibodies can cross the placenta to stimulate the fetal thyroid.

Careful assessment should be done with proper laboratory data and thyroid scan before treatment as Thyrotoxicosis could be a simple thyroiditis that resolves or one of the toxic thyroid disorders requiring appropriate treatment.

Goiters

Goiter, which is an enlargement of the thyroid gland, may be diffuse or nodular, and may or may not be associated with hypothyroidism or hyperthyroidism. Diffuse goiter may result from iodine deficiency, exposure to environmental or pharmacologic goitrogens, or autoimmune processes such as Graves’ disease or autoimmune thyroiditis (Hashimoto thyroiditis). Patients with goitrous autoimmune thyroid disorders usually have measurable titers of thyroid autoantibodies and may be

euthyroid or hypothyroid. Nontoxic goiter is often a precursor to toxic multinodular goiter; the toxic form generally is associated with signs and symptoms of hyperthyroidism. If thyroid function is abnormal, then the treatment most likely will help decrease the size of the goiter in most cases. However, if the function was normal, then a careful assessment to consider suppressive therapy depending on the age, level of TSH, size of the goiter and the size response in the first 6 months.

After assessing the function of the thyroid, Patients should have a thyroid scan and/or ultrasound. If nodules are found and are greater than 1.0 cm, the physician should consider performing ultrasound-guided fine-needle aspiration (FNA), or without in ultrasound if nodule is large enough, to rule out malignancy.

Thyroid nodules

A thyroid nodule is a discrete lesion within the thyroid gland that is palpable and/or ultrasonographically distinct from the surrounding thyroid parenchyma. The nodules could be with or without a goiter, and could be solitary or multinodular. A nodule could be solid, cystic or a mixed nodule. Clinically apparent solitary thyroid nodules occur in up to 7% of the general population and more than 50% by thyroid ultrasound studies. The disorder is more common in women than in men. A history of head or neck irradiation is a major risk factor for the development of thyroid nodules and thyroid cancer. Family history of thyroid cancer could be also a risk factor in certain thyroid cancer syndromes. Although thyroid nodules occur less frequently in children than in adults, the diagnostic and therapeutic approach to one or more thyroid nodules in a child should be the same as it would be in an adult. Evaluation during pregnancy is the same as for a non-pregnant patient, except that a radionuclide scan is contraindicated.

Thyroid nodules generally are classified as benign (colloid or follicular adenomas), suspicious, or malignant. The principal diagnostic tool used is fine-needle aspiration (FNA) for cytology. Most nodules are benign and the risk of malignancy is small but still significant to justify FNA. If FNA results indicate that the nodule is malignant or suspicious for malignancy, surgical excision is indicated; the extent of surgery varies depending on factors such as nodule size, location, and the presence of lymph nodes. Thyroid cancer is the commonest malignant endocrine tumour but comprises only about 1% of all malignancies. Over 90% of thyroid cancers are of the follicular or papillary variants often termed differentiated thyroid cancer. The rare forms of thyroid cancer comprise medullary thyroid cancer arising form parafollicluar C-cells, thyroid lymphoma, anaplastic carcinoma, Hurthle-cell carcinoma, squamous cell carcinoma and the very rare intrathyroid sarcoma. A number of factors are associated with an increased risk for thyroid carcinoma; age 40 years, nodule size > 2 cm, regional adenopathy, presence of distant metastasis, prior head and neck irradiation, rapidly growing lesion, development of hoarseness, progressive dysphagia, or shortness of breath, family history of papillary or medullary thyroid carcinoma or Multiple Endocrine Neoplasia (MEN type 2).

Thyroid cancers usually caries good prognosis and is one of the curable cancers when diagnosed, treated early and carefully by a qualified Endocrinologist.

Osteoporosis, which means “porous or spongy bones,” is a condition that causes formerly strong bones to gradually thin and weaken, leaving them susceptible to fractures.

The National Institutes of Health (NIH) Consensus Conference definition of osteoporosis is: “a skeletal disorder characterized by compromised bone strength, predisposing to an increased risk of fracture.” Bone strength in this definition reflects the integration of 2 main features: Bone density and a term that’s evolving more as we define it better both in science and clinically”Bone quality.”This chronic, prevalent and could be a debilitating disease, presents a major public health concern in contemporary societies.

It is the world’s most common bone disease, affecting one out of three women and one out of five men over age 50 years.The risk of suffering such a fracture over the course of life is about 40% for women, and 13% for men. Fractures at an older age can result in pain, loss of movement, inability to perform daily chores, and may cause death.

The most common fractures associated with osteoporosis are fractures of the hip and the vertebrae. With the predicted increase in aging population worldwide, the number of hip fractures could rise from 1.7 million in 1990 to 6.3 million by 2050. It is estimated that 71% of these fractures will occur in developing countries including those in the Middle East.

The most devastating consequence of osteoporosis is fractures, especially hip fractures. Up to 90% of all fractures in the elderly can be attributed to osteoporosis. Adults who have one fracture are 50-100% more likely to have another fracture. Mortality rates among the elderly, one year after a hip fracture, range from 14% to 36%. Compared with the general population, elderly women and men are two and three times as likely to die, respectively, after a hip fracture. There is also evidence that women who suffer a clinical vertebral fracture have a lower survival rate. Morbidity data show that, after a hip fracture, only 33-40% of people regain the ability to perform basic activities of daily living, 20% are Non ambulatory, and 10-60% are unable to return home. Although two thirds of vertebral fractures can remain asymptomatic, others may cause significant back pain, kyphosis, and height loss. These psychosocial consequences can adversely impact overall health and quality of life. Osteoporosis is often undetected until a fracture occurs. The spine, hip, and wrist are the common sites for fractures. The US Preventive Services Task Force notes that One-half of all postmenopausal women will have an osteoporosis-related fracture during their lives, including 25% who will develop a vertebral deformity and 15% who will suffer a hip fracture. Hip fractures are more worrisome, as the subsequent mortality rate is approximately 25% for those greater than 65 years of age. One of the most dangerous myths about osteoporosis is that only women need to worry about bone health. Men with osteoporosis have more severe osteoporosis and higher rates of fracture than women because the illness is often diagnosed later in the disease process. Osteoporosis is underdiagnosed in both sexes, but the underdiagnosis in men is worse because clinicians aren’t looking for it. And many men refuse to believe they have a woman’s disease. However, Osteoporosis isn’t just women’s or grandmother’s disease. Osteoporosis affects men and women of all races. The overall health of a person’s bones is a function of many things ranging from how well the bones were formed as a youth, to the level of exercise the bones have seen over the years. Early in life, bone is broken down and replaced continuously, a process known as bone remodeling. During the first 20 years of life, the formation of bone is the most important factor, but after that point it is the prevention of bone loss, which becomes more important. Anything, which leads to decreased formation of bone early in life, or loss of bone structure later in life, will lead to osteoporosis and fragile bones subject to fracture.

Risk factors for developing osteoporosis

A number of factors increase the likelihood of developing osteoporosis and can be classified as “modifiable” and “nonmodifiable” risk factors. Nonmodifiable factors among women include female sex, ethnicity (white and Asian), advanced age, family history (fracture in first-degree relative), prior fracture in adulthood, and poor health/dementia with frailty. Emphasis should be placed on identifying modifiable risk factors. These include smoking, thinness ( 127 lb or 60 Kg), early menopause ( 40 years of age, either natural or surgical), excessive alcohol intake, sedentary lifestyle, low calcium intake, and poor general health. Prolonged immobility due to paralysis or illness can also cause bone loss. Recurrent falls and poor eyesight increase the risk for subsequent fracture and should be addressed when assessing the patient. Nulliparous women have higher rates of hip fracture than parous women. Pregnancy may induce biomechanical changes in the hip that later protect women from fracture. Elderly are more prone to falls (impaired vision, dementia, physical frailty).

Bone loss begins at a rate of approximately 0.5% per year late in the fourth decade. During the perimenopausal period and for up to seven years after menopause, women can experience a variable and potentially dramatic increase in the rate of bone loss of up to 3% per year that is directly related to estrogen deficiency. Thereafter, bone loss slows to a steady rate of 0.5-1% per year.

Approximately 20% of postmenopausal women have secondary causes of osteoporosis examples include rheumatoid arthritis, multiple myeloma, hyperparathyroidism, Cushing’s syndrome, hyperthyroidism, hyperprolactinemia, inflammatory bowel disease, chronic kidney disease, and organ transplantation. Oral glucocorticoids are the most common contributor to drug-induced osteoporosis. Other drugs that have been associated with detrimental effects on bone are excessive thyroid hormone, anticonvulsant medications, heparin, gonadotropin-releasing-hormone agonists, neuroleptic agents, methotrexate, and lithium.

The most important risk factors are a personal history of fractures as an adult 40 years of age or older and low BMD. A low-trauma fracture as an adult is significant because it establishes an unusual susceptibility to fractures and strongly predicts future fracture potential. For example, patients who have had a previous vertebral fracture are five times as likely to have a new vertebral fracture within one year as patients who have not.

Diagnosis

A person is usually not aware they have osteoporosis until a fracture occurs. Backache, loss of height, with gradual curvature of the back (caused by vertebral compression fractures), may be the only physical sign of osteoporosis. An x-ray examination of the spine may be obtained to confirm any suspicion. In many affected people, bone loss is gradual and without warning signs until the disease is advanced. Osteoporosis is also known as “the silent crippler” because a person usually doesn’t know they have it until it’s too late. Unfortunately, in many cases, the first real “symptom” is a broken bone.

Several common methods can measure the bone density, including Dual-energy X-ray Absorptiometry (DXA), single-energy absorptiometry, quantitative CT, and quantitative ultrasonography of the heel. DXA has been the most extensively validated method and is considered to be the “gold standard” for assessing bone mineral density (BMD). This is because of its high precision, short scan time, and low radiation dose (less than a chest radiograph). In most cases, the hip is the preferred site for diagnosing osteoporosis, and the spine is preferred for monitoring changes due to drug therapy. Therefore, a baseline DXA scan is needed to confirm the diagnosis of osteoporosis and for monitoring of the response to drug therapy.

Vitamin D is very important for overall health and well-being. A major source of vitamin D comes from exposure to sunlight. However, with fear of skin cancers in the last decade, people did significantly reduce their sun exposure and with the use of sunscreens mainly in the west have dramatically reduced the vitamin D levels leading to major health problems. Although the evidence with skin cancer relate to excessive unprotected sun exposure and not to moderate exposure to the sun in early morning or late afternoon away from noon time, the peak of the harmful ultraviolet rays. There is now substantial evidence of high rate of Vitamin D deficiency reaching more than 90 percent of young women and to a lesser extent among males. This led to increased risk of bone disorders like Rickets in kids (bowing of the bone and disrupted bone growth leading to deformities), osteoma Lacia (softening of the bone) and osteoporosis in adults.

Moreover, there is evidence of increase pain in osteoarthritis patients with low vitamin D status. There is also very strong evidence of increased risk for diabetes, thyroid disorders, neurological diseases like multiple sclerosis, other autoimmune disorders like rheumatoid arthritis, inflammatory bowel diseases, and even certain kinds of cancer are more among those with low levels. Cancers of the colon, prostate, breast and ovary have been linked to low levels of Vitamin D. Recently, there was evidence of increased heart diseases in large scale studies, hypertension, stroke and this week another study confirmed increased artery diseases of the extremities.

Age related memory problems have been linked to lower vitamin D levels as well as poor mental health and symptoms of seasonal affective disorder, premenstrual syndrome, and depression.

It is almost impossible to consume adequate vitamin D through diet alone and while supplements are an important alternative, most people don’t get the recommended amount.

We dispel the myth that women with osteoporosis living in sunnier latitudes do not have to worry about vitamin D. The clothing, use of sunscreen, and avoidance of sun exposure, particularly in hot climates like the Gulf areas, could explain the high prevalence of vitamin D inadequacy observed in the studies. We live in houses that have tinted glass windows, drive our car from a covered garage going to another covered garage with our car windows all tinted. Most of our activities are scheduled after sunset and focus more on the indoor activities due to the hot weather. It isn’t natural or healthy to live that way!

Although the initial results clearly show that, regardless of age, geographic region, or latitude, many women with osteoporosis are not getting enough vitamin D. now we know that even those without osteoporosis have low values and at risk of having other more serious disorders.

In review of the studies in most parts of the world, vitamin D was deficient in almost 50-90% of the population regardless of the geographical areas more in the elderly making them prone to serious disorders. The Gulf area had one of the highest rates of vitamin D deficiency. In institutionalized patients and elderly patients, it was up to 100%. Correcting vitamin D deficiency could significantly lower the risk of several types of cancer, autoimmune diseases and improve bone health.

Vitamin D is made by out body as the main source by the exposure of the skin to UV-B of the solar spectrum of sunlight which is then activated along with the dietary vitamin by the liver and kidneys into the active form. Dietary supply of vitamin D could be found in fortified milk and orange juice, Swiss cheese, fortified cereals, salmon, mackerel, sardines and codfish. Also, multivitamins do include vitamin D supply.

Your pituitary gland is about the size of a pea and is situated in a bony hollow in the base of the brain, just behind the bridge of your nose. It is attached to the base of your brain by a thin stalk. The hypothalamus, which controls the pituitary by sending messages, is situated immediately above the pituitary gland. The pituitary gland is often called the master gland because it controls several other hormone glands in your body, including the thyroid and adrenals, the ovaries and testicles. The hormones of the pituitary gland send signals to other endocrine glands to stimulate or inhibit their own hormone production. The anterior lobe releases hormones upon receiving releasing or inhibiting hormones from the hypothalamus. These hypothalamic hormones tell the anterior lobe whether to release more of a specific hormone or stop production of the hormone.

Anterior Lobe Hormones:

1. Adrenocorticotropic hormone (ACTH): ACTH stimulates the adrenal glands to produce hormones.
2. Follicle-stimulating hormone (FSH): FSH works with LH to ensure normal functioning of the ovaries and testes.
3. Luteinizing hormone (LH): LH works with FSH to ensure normal functioning of the ovaries and testes.
4. Growth hormone (GH): GH is essential in early years to maintaining a healthy body composition and for growth in children. In adults, it aids healthy bone and muscle mass and affects fat distribution.
5. Prolactin: Prolactin stimulates breast milk production.
6. Thyroid-stimulating hormone (TSH): TSH stimulates the thyroid gland to produce hormones.

The posterior lobe contains the ends of nerve cells coming from the hypothalamus. The hypothalamus sends hormones directly to the posterior lobe via these nerves, and then the pituitary gland releases them.

Posterior Lobe Hormones:

1. Anti-diuretic hormone (ADH): This hormone prompts the kidneys to increase water absorption in the blood.
2. Oxytocin: Oxytocin is involved in a variety of processes, such as contracting the uterus during childbirth and stimulating breast milk production.

Diseases and Disorders of the Pituitary Gland

Pituitary tumors are the most common pituitary disorder, and many adults have them. However, they are not, in the great majority of cases, life threatening. But that doesn’t mean they’re harmless—pituitary tumors can disrupt the gland’s normal ability to release hormones. There are two types of pituitary tumors—secretory and non-secretory. Secretory tumors secrete too much of a hormone, and non-secretory tumors don’t secrete excess hormone. These hormonal imbalances can cause problems in many different areas of the body. If you have a secretory tumor that is overproducing thyroid-stimulating hormone, for instance, you will experience hyperthyroidism. The pituitary gland is immensely important to the overall function of your endocrine system—and to your overall health. By working with the hypothalamus, the pituitary gland ensures that all your body’s internal processes work as they should. If you think you may have a problem with your pituitary gland, you should talk to an endocrinologist. He or she will help diagnose and treat your hormone-related condition.

The under-diagnosed endocrine disorder Thyroid diseases are one of the most common endocrine disorders that is easily diagnosed and treated. However, the disease is usually under-diagnosed and under-treated affecting high percentage in the population.

A quick overview of the common thyroid disorders Thyroid disorders are broadly divided into thyroid function disorders (hypothyroidism and hyperthyroidism) and thyroid gland size disorders (goiters and nodules) which could be present both in a single patient. The disorders are more prevalent with age, with family history of thyroid disease and autoimmune disorders, and much more common in females. Thyroid disorders occur in a significant proportion of the general population and increasingly being diagnosed but still with more than half of the cases undiagnosed.

In one of the largest studies to date, the Colorado study, revealed around 10 % of population do suffer from hypothyroidism and 3% hyperthyroidism. Thyroid nodules are very common and were found in multiple studies to reach 50% of population without a history of clinically detectable thyroid disease. The natural history of thyroid diseases usually evolves but with early diagnosis and appropriate management by a specialized Endocrinologist, most disorders are treatable.

Hypothyroidism

Hypothyroidism is a clinical syndrome resulting from a deficiency of thyroid hormones which in turn results in a generalized slowing down of the metabolic process.

Whether hypothyroidism results from hypothalamic-pituitary disease or primary thyroid disease, symptoms and signs of the disease vary in relation to the magnitude of the thyroid hormone deficiency, and the acuteness with which the deficiency develops. Hypothyroidism is less prominent clinically and better tolerated when there is a gradual loss of thyroid function (as in most cases of primary hypothyroidism) than when it develops acutely after thyroidectomy or abrupt withdrawal of exogenous thyroid hormone. The symptoms are mostly related to the generalized slowing of metabolic processes. This can lead to abnormalities such as fatigue, slow movement and slow speech, cold intolerance, constipation, weight gain, delayed relaxation of deep tendon reflexes, and bradycardia.

However, the accumulation of matrix glycosaminoglycans in the interstitial spaces of tissues can lead to coarse hair and skin, puffy facies, enlargement of the tongue, and hoarseness. These changes are often more easily recognized in young patients, and they may be attributed to aging in older patients. This hypometabolism that is associated with hypothyroidism results in a decrease in cardiac output that is mediated by reductions in heart rate and contractility that could worsen cardiac failure. Hypertension, hyperlipidemia and hyperhomocysteinemia could complicate hypothyroidism thus leading to atherosclerosis.

Hypothyroidism in infants and children results in marked slowing of growth and development, with serious permanent consequences including mental retardation. In adult females, hypothyroidism may cause menstrual changes and these menstrual changes result in decreased fertility and hyperprolactinemia may occur. If pregnancy does occur, there is an increased likelihood for early abortion and decreased IQ of the fetus. However, many cases are asymptomatic or have non-specific signs and symptoms like in post-partum depression, fatigue, anemia, or with GI symptoms. The American Thyroid Association recommends every one to test their thyroid function at 35 years of age.

Adult primary hypothyroidism is caused most frequently by chronic autoimmune thyroiditis (Hashimoto thyroiditis) and is present in up to 10 % of the population. Women older than 40 years of age and elderly individuals of both sexes are affected most frequently but could occur at any age. Other causes of hypothyroidism include thyroidectomy, radioactive iodine therapy, antithyroid drugs, head and neck irradiation, certain medications and congenital defects.

Hyperthyroidism

It results from excess thyroid hormone and is present in a variety of conditions that are mainly caused by intrinsic thyroid disease, including hyperthyroidism due to toxic diffuse goiter (Graves’ disease), toxic multinodular goiter, toxic adenoma and thyroiditis (painful and subacute, or silent).

Thyrotoxicosis may also be associated with excessive pituitary TSH production, a trophoblastic tumor, or excessive ingestion of iodine or thyroid hormone.

A wide range of signs and symptoms is associated with hyperthyroidism but manifestations and severity depend on the extent of thyroid hormone excess, age of the patient, and duration of the condition.

They usually present with symptoms related to the higher metabolism like sweating, tremor, palpitations, unexplained weight loss, hyperdefecation, heat intolerance, insomnia, and muscle weakness. They also could have significant eye symptoms with dermopathy or be only as a cardiac presentation especially in older populations presenting only with atrial fibrillations, tachycardias and/or heart failure. Children may present with height and growth related problems or just hyperactivity. They tend to have more weight gain than weight loss.The condition may be diagnosed during pregnancy and could present with abortion, failure to gain weight during pregnancy or weight loss, and fetal tachycardia as thyroid stimulating antibodies can cross the placenta to stimulate the fetal thyroid.

Careful assessment should be done with proper laboratory data and thyroid scan before treatment as Thyrotoxicosis could be a simple thyroiditis that resolves or one of the toxic thyroid disorders requiring appropriate treatment.

Goiters

Goiter, which is an enlargement of the thyroid gland, may be diffuse or nodular, and may or may not be associated with hypothyroidism or hyperthyroidism. Diffuse goiter may result from iodine deficiency, exposure to environmental or pharmacologic goitrogens, or autoimmune processes such as Graves’ disease or autoimmune thyroiditis (Hashimoto thyroiditis). Patients with goitrous autoimmune thyroid disorders usually have measurable titers of thyroid autoantibodies and may be

euthyroid or hypothyroid. Nontoxic goiter is often a precursor to toxic multinodular goiter; the toxic form generally is associated with signs and symptoms of hyperthyroidism. If thyroid function is abnormal, then the treatment most likely will help decrease the size of the goiter in most cases. However, if the function was normal, then a careful assessment to consider suppressive therapy depending on the age, level of TSH, size of the goiter and the size response in the first 6 months.

After assessing the function of the thyroid, Patients should have a thyroid scan and/or ultrasound. If nodules are found and are greater than 1.0 cm, the physician should consider performing ultrasound-guided fine-needle aspiration (FNA), or without in ultrasound if nodule is large enough, to rule out malignancy.

Thyroid nodules

A thyroid nodule is a discrete lesion within the thyroid gland that is palpable and/or ultrasonographically distinct from the surrounding thyroid parenchyma. The nodules could be with or without a goiter, and could be solitary or multinodular. A nodule could be solid, cystic or a mixed nodule. Clinically apparent solitary thyroid nodules occur in up to 7% of the general population and more than 50% by thyroid ultrasound studies. The disorder is more common in women than in men. A history of head or neck irradiation is a major risk factor for the development of thyroid nodules and thyroid cancer. Family history of thyroid cancer could be also a risk factor in certain thyroid cancer syndromes. Although thyroid nodules occur less frequently in children than in adults, the diagnostic and therapeutic approach to one or more thyroid nodules in a child should be the same as it would be in an adult. Evaluation during pregnancy is the same as for a non-pregnant patient, except that a radionuclide scan is contraindicated.

Thyroid nodules generally are classified as benign (colloid or follicular adenomas), suspicious, or malignant. The principal diagnostic tool used is fine-needle aspiration (FNA) for cytology. Most nodules are benign and the risk of malignancy is small but still significant to justify FNA. If FNA results indicate that the nodule is malignant or suspicious for malignancy, surgical excision is indicated; the extent of surgery varies depending on factors such as nodule size, location, and the presence of lymph nodes. Thyroid cancer is the commonest malignant endocrine tumour but comprises only about 1% of all malignancies. Over 90% of thyroid cancers are of the follicular or papillary variants often termed differentiated thyroid cancer. The rare forms of thyroid cancer comprise medullary thyroid cancer arising form parafollicluar C-cells, thyroid lymphoma, anaplastic carcinoma, Hurthle-cell carcinoma, squamous cell carcinoma and the very rare intrathyroid sarcoma. A number of factors are associated with an increased risk for thyroid carcinoma; age 40 years, nodule size > 2 cm, regional adenopathy, presence of distant metastasis, prior head and neck irradiation, rapidly growing lesion, development of hoarseness, progressive dysphagia, or shortness of breath, family history of papillary or medullary thyroid carcinoma or Multiple Endocrine Neoplasia (MEN type 2).

Thyroid cancers usually caries good prognosis and is one of the curable cancers when diagnosed, treated early and carefully by a qualified Endocrinologist.

Osteoporosis, which means “porous or spongy bones,” is a condition that causes formerly strong bones to gradually thin and weaken, leaving them susceptible to fractures.

The National Institutes of Health (NIH) Consensus Conference definition of osteoporosis is: “a skeletal disorder characterized by compromised bone strength, predisposing to an increased risk of fracture.” Bone strength in this definition reflects the integration of 2 main features: Bone density and a term that’s evolving more as we define it better both in science and clinically”Bone quality.”This chronic, prevalent and could be a debilitating disease, presents a major public health concern in contemporary societies.

It is the world’s most common bone disease, affecting one out of three women and one out of five men over age 50 years.The risk of suffering such a fracture over the course of life is about 40% for women, and 13% for men. Fractures at an older age can result in pain, loss of movement, inability to perform daily chores, and may cause death.

The most common fractures associated with osteoporosis are fractures of the hip and the vertebrae. With the predicted increase in aging population worldwide, the number of hip fractures could rise from 1.7 million in 1990 to 6.3 million by 2050. It is estimated that 71% of these fractures will occur in developing countries including those in the Middle East.

The most devastating consequence of osteoporosis is fractures, especially hip fractures. Up to 90% of all fractures in the elderly can be attributed to osteoporosis. Adults who have one fracture are 50-100% more likely to have another fracture. Mortality rates among the elderly, one year after a hip fracture, range from 14% to 36%. Compared with the general population, elderly women and men are two and three times as likely to die, respectively, after a hip fracture. There is also evidence that women who suffer a clinical vertebral fracture have a lower survival rate. Morbidity data show that, after a hip fracture, only 33-40% of people regain the ability to perform basic activities of daily living, 20% are Non ambulatory, and 10-60% are unable to return home. Although two thirds of vertebral fractures can remain asymptomatic, others may cause significant back pain, kyphosis, and height loss. These psychosocial consequences can adversely impact overall health and quality of life. Osteoporosis is often undetected until a fracture occurs. The spine, hip, and wrist are the common sites for fractures. The US Preventive Services Task Force notes that One-half of all postmenopausal women will have an osteoporosis-related fracture during their lives, including 25% who will develop a vertebral deformity and 15% who will suffer a hip fracture. Hip fractures are more worrisome, as the subsequent mortality rate is approximately 25% for those greater than 65 years of age. One of the most dangerous myths about osteoporosis is that only women need to worry about bone health. Men with osteoporosis have more severe osteoporosis and higher rates of fracture than women because the illness is often diagnosed later in the disease process. Osteoporosis is underdiagnosed in both sexes, but the underdiagnosis in men is worse because clinicians aren’t looking for it. And many men refuse to believe they have a woman’s disease. However, Osteoporosis isn’t just women’s or grandmother’s disease. Osteoporosis affects men and women of all races. The overall health of a person’s bones is a function of many things ranging from how well the bones were formed as a youth, to the level of exercise the bones have seen over the years. Early in life, bone is broken down and replaced continuously, a process known as bone remodeling. During the first 20 years of life, the formation of bone is the most important factor, but after that point it is the prevention of bone loss, which becomes more important. Anything, which leads to decreased formation of bone early in life, or loss of bone structure later in life, will lead to osteoporosis and fragile bones subject to fracture.

Risk factors for developing osteoporosis

A number of factors increase the likelihood of developing osteoporosis and can be classified as “modifiable” and “nonmodifiable” risk factors. Nonmodifiable factors among women include female sex, ethnicity (white and Asian), advanced age, family history (fracture in first-degree relative), prior fracture in adulthood, and poor health/dementia with frailty. Emphasis should be placed on identifying modifiable risk factors. These include smoking, thinness ( 127 lb or 60 Kg), early menopause ( 40 years of age, either natural or surgical), excessive alcohol intake, sedentary lifestyle, low calcium intake, and poor general health. Prolonged immobility due to paralysis or illness can also cause bone loss. Recurrent falls and poor eyesight increase the risk for subsequent fracture and should be addressed when assessing the patient. Nulliparous women have higher rates of hip fracture than parous women. Pregnancy may induce biomechanical changes in the hip that later protect women from fracture. Elderly are more prone to falls (impaired vision, dementia, physical frailty).

Bone loss begins at a rate of approximately 0.5% per year late in the fourth decade. During the perimenopausal period and for up to seven years after menopause, women can experience a variable and potentially dramatic increase in the rate of bone loss of up to 3% per year that is directly related to estrogen deficiency. Thereafter, bone loss slows to a steady rate of 0.5-1% per year.

Approximately 20% of postmenopausal women have secondary causes of osteoporosis examples include rheumatoid arthritis, multiple myeloma, hyperparathyroidism, Cushing’s syndrome, hyperthyroidism, hyperprolactinemia, inflammatory bowel disease, chronic kidney disease, and organ transplantation. Oral glucocorticoids are the most common contributor to drug-induced osteoporosis. Other drugs that have been associated with detrimental effects on bone are excessive thyroid hormone, anticonvulsant medications, heparin, gonadotropin-releasing-hormone agonists, neuroleptic agents, methotrexate, and lithium.

The most important risk factors are a personal history of fractures as an adult 40 years of age or older and low BMD. A low-trauma fracture as an adult is significant because it establishes an unusual susceptibility to fractures and strongly predicts future fracture potential. For example, patients who have had a previous vertebral fracture are five times as likely to have a new vertebral fracture within one year as patients who have not.

Diagnosis

A person is usually not aware they have osteoporosis until a fracture occurs. Backache, loss of height, with gradual curvature of the back (caused by vertebral compression fractures), may be the only physical sign of osteoporosis. An x-ray examination of the spine may be obtained to confirm any suspicion. In many affected people, bone loss is gradual and without warning signs until the disease is advanced. Osteoporosis is also known as “the silent crippler” because a person usually doesn’t know they have it until it’s too late. Unfortunately, in many cases, the first real “symptom” is a broken bone.

Several common methods can measure the bone density, including Dual-energy X-ray Absorptiometry (DXA), single-energy absorptiometry, quantitative CT, and quantitative ultrasonography of the heel. DXA has been the most extensively validated method and is considered to be the “gold standard” for assessing bone mineral density (BMD). This is because of its high precision, short scan time, and low radiation dose (less than a chest radiograph). In most cases, the hip is the preferred site for diagnosing osteoporosis, and the spine is preferred for monitoring changes due to drug therapy. Therefore, a baseline DXA scan is needed to confirm the diagnosis of osteoporosis and for monitoring of the response to drug therapy.