National License: Infectious disease

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NL: Endocrine system..

Endocrine Circulation Blood vessels Target cell hormone 2

1) Steroid hormone Sex hormone target nucleus receptor cytoplasm (cytoplasmic receptor) steroid hormone lipid cell membrane cytoplasmic receptor nuclear receptor DNA transcription protein estrogen receptor nucleus protein cell breast tissue proliferation mammillary gland

2) Peptide hormone Insulin, Glucagon hormone anterior pituitary cell membrane receptor cell membrane hormone receptor secondary messenger phosphorylation activate enzyme

Hormone Axis Hypothalamus-Pituitary axis Target organ axis Adrenal axis Thyroid axis function Hypothalamus

Hypothalamus Releasing Inhibiting peptide Anterior pituitary hormone Hypothalamus hormone axon Posterior pituitary ADH Vasopressin ( Supra-optic nucleus) Oxytocin ( Paraventricular nucleus)

Releasing Inhibiting peptide Hypothalamus Hypothalamo-hypophyseal portal system anterior pituitary hormone Hypothalamus Pituitary hormone Portal system Hormone

Pituitary gland structure function hypophyseal fossa sella turcica neurosecretory cell hypothalamus axon hormone paraventricular nucleus supraoptic nucleus hypothalamus posterior pituitary gland ADH Oxytocin releasing inhibiting factors hormone anterior pituitary gland factor portal system

Pituitary gland 2 Adenohypophysis Neurohypophysis hormone hypothalamus glandular structure hormone hormone cell specific hormone

Somatotroph Growth hormone (GH)

Lactotroph Prolactin

Thyrotroph Thyroid stimulating hormone (TSH)

BasophilGonadotroph FSH LH

Corticotroph ACTH ( MSH)

Cell Hyperactivity hormone tumor somatotroph GH effect GH acromegaly gigantism

Lactotroph prolactin dopamine prolactin lactotroph dopamine hypothalamus pituitary stalk hypothalamus irritate inflammation stalk dopamine inhibit prolactin hyperprolactinemia dopamine antagonist

thyrotroph clinical hyperthyroidism hypothyroidism

Pituitary gland sella turcica Sphenoid sinus sphenoid sinusitis tumor sphenoid Infection sphenoid sinus Pituitary gland

Pituitary gland Optic chiasma pituitary Optic chiasma Visual field defect Bitemporal hemianopia

histology cell posterior pituitary cell neuroectoderm anterior pituitary cell gland Rathkes pouch remnant oral ectoderm anterior tumor embryo CraniopharyngiomaHypopituitarism

Hypopituitarism pituitary gland 1. Tumor Normal functioning cells cell (Necrosis ) common cause of hypopituitarism

2. (postsurgical) (cranial radiation)

3. Head injury 4. Hypothalamic dysfunction craniopharyngioma suprasellar tumor extend sella turcica pituitary pituitary necrosis 5. Sheehans syndrome postpartum bleeding Pituitary gland bleeding hypovolemia shock Pituitary gland ischemic infarction cell Pituitary gland Pituitary massive blood loss vital organs Pituitary gland structure cell dysfunction necrosis Sheehans syndrome hormone deficit hypopituitarism hormone 1. TSH Basal metabolic rate body temperature 2. prolactin lactation breast atrophy 3. ACTH adrenal insufficiency stress glucocorticoid stress adrenal crisis adrenal shock

4. Gonadotrophin amenorrhea,loss of libido,infertility

5. growth hormone

epiphyseal plate ( ) muscle mass Hyperpituitarism

Hyperprolactinemia

Most common hyperpituitarism hyperprolactinemia prolactinoma hormone prolactin lactotroph dopamine prolactin dopamine hypothalamus stalk portal system anterior pituitary hypothalamus head injury prolactin ( hypothalamus higher center cerebral cortex )

dopamine Antipsychotic Haloperidol , Antidepressant Tricyclic antidepressant ,H2 blocker cimetidine dopamine dopamine lactotroph prolactin : prolactin sex hormone hypogonadism amenorrhea, oligomenorrhea, infertility (Delayed secondary sexual characteristic) Clinical galactorrhea breast tissue (Gynecomastia) Hirsutism (), Acne () Osteoporosis osteopenia prolactin estrogen estrogen : decrease of libido (), impotence, infertility ( hypogonadism ) sexual intercourse problem prolactinoma late presentation mass effect bitemporal hemianopia hyperprolactinemia physiological condition rule out hyperprolactinemia

1. Pregnancy amenorrhea sexual intercourse urine pregnancy test estrogen Lactotroph prolactin 2. Post-partum stage Hormone cycle [ prolactin 3-4 - Lecture .]

3. Stress stress dopamine Higher center Cerebral cortex Hypothalamus inhibit dopamine galactorrhea () amenorrhea exclude pregnancy medication sexual intercourse urine pregnancy test antipsychotic, antidepressant, H2 blocker renal failure hypothyroidism hyperprolactinemia TRH hypothalamus dopamine hyperprolactinemia exclude Pregnancy, Medication, Renal failure, Hypothyroidism mass effect visual field defect prolactin level ( 150 ng/ml) pituitary adenoma ( prolactinoma ) MRI 10 mm Microprolactinoma 10 mm Macroprolactinoma

Prolactinoma microprolactinoma tumor function hyperprolactinemia galactorrhea prolactinoma prolactin level prolactin Growth hormone

Hypothalamus GHRH anterior pituitary GH IGF-1 (Insulin growth factor 1) organ somatic growth GH 1-5 GH

inhibit GH somatostatin hormone inhibit hormone pancreas pituitary gland

IGF-1 Insulin-like growth factor binding protein target organ membrane receptor signal stromal cell growth

GH tumor cell GH Growth factor cell Growth hormone membrane receptor Secondary messenger nucleus cell proliferation

GH epiphyseal plate Gigantism ( ) epiphyseal plate longitudinal horizontal

GH Insulin resistance Atherosclerosis Hypertension Cardiomegaly

GH Hypertension (Arthrosis) Insulin resistance DM Polyuria Sinus () supra-orbital ridge prominence visual field defect stalk hyperprolactinemia ( stalk dopamine prolactin )

Acromegaly macroadenoma macroadenoma mass effect hyperfunction ( prolactinoma hyperfunction mass effect microadenoma )

tissue bone nerve neuropathy most common Carpal tunnel syndrome thenar muscle atrophy median nerve ( )Thyroid disease

T3 T4 Bioactivity T3 Half life T4 T3 (Conversion) tissue

Thyroid hormone iodine thyroid follicular cell iodide trapping Tyrosine molecule thyroglobulin iodide oxidation Peroxidase Monoiodotyrosine (MIT) Diiodotyrosine (DIT) (coupling) T3 (MIT+DIT) T4 (DIT+DIT) colloid thyroid follicle release

TSH pituitary thyroid hormone autoregulation thyroid iodine uptake hormone

Thyroid hormone hypothalamus TRH anterior pituitary thyrotroph TSH thyroid follicular cell thyroid hormone (T3 T4) target cell

Bone target organ thyroid hormone Bone growth thyroid hormone (congenital hypothyroidism - cretinism) growth thyroid hormone IQ mental retardation screening detect congenital hypothyroidism TSH Primary hypothyroidism TSH

Thyroid hormone Hyperthyroid thyroid Levothyroxine hormone replacement hormone thyroid hormone Osteoclast resorption Osteopenia Osteoporosis Hyperthyroidism

1. Graves disease : autoimmune thyroid stimulating immunoglobulin receptor hyperfunction thyroid TSH diffuse thyroid goiter ( autoantibodies cell ) hyperthyroidism ( autoimmune disease ) Iodine uptake 2. Toxic multinodular goiter : thyroid (multinodular) hyperthyroidism thyroid iodine thyroid hormone TSH follicular cell cell fibrosis cell necrosis fibrosis healing process nodule fibrosis hyperfunction Toxic multinodular goiter3. Toxic adenoma : hyperfunction tumor thyroid hormone TSH Normal follicular cell hyperfunction normal cell TSH ( negative feedback thyroid hormone )4. Transient painless thyroiditis Subacute painful thyroiditis : thyroid Infection Hashimotos thyroiditis release thyroid hormone follicular cell hyperthyroidism Iodine uptake

Hyperthyroidism toxic adenoma toxic multinodular goiter diffuse Graves disease thyroiditis ( thyroiditis Infection )

Radioactive iodine uptake Iodine uptake Graves disease, toxic multinodular goiter toxic adenoma hyperfunction Iodine uptake thyroiditis

Hyperthyroidism system GI, CVS, Neuromuscular Nervous system

1. Cardiovascular system

Thyroid hormone sympathetic overactivity (palpitation) tachycardia arrhythmia atrial fibrillation arrhythmia tachyarrhythmia thyroid function Heart failure

- Edema: Heart failure matrix substance Pretibial area ( Pretibial myxedema)

- Catecholamine sensitivity cardiac output Vascular resistance hypertrophy Left ventricle Atrial fibrillation

2. Neuromuscular system

- Muscle weakness: myopathy muscle atrophy muscle contraction

- Hypokalemia: thyroxine sympathetic Na+-K+ ATPase K+ shift cell Na+ K+

- Thyrotoxic periodic paralysis: acute muscle weakness thyroxine myopathy Na+-K+ ATPase Hypokalemia muscle contraction

3. Nervous system

- Neuropsychitis sympathetic overactivity agitation

- ( Focus Parasympathetic)

4. GI system ( .. CM II)

- diarrhea thyroid hormone GI motility Thyroiditis

Thyroiditis Infection Trauma Hashimotos thyroiditis lymphocyte antibody thyroid cell hyperthyroidism follicular cell thyroid hormone release hormone normal hypothyroidism ( follicular cell ) histopathology lymphocyte infiltration germinal center lymphoma

Hashimotos thyroiditis antilysosomal antibody (80% antibody thyroid peroxidase enzyme) hormone supplement (Levothyroxine)

Subacute painless thyroiditis antithyroid drug -blocker Thyroxicosis Eltroxine thyroid replacement

Thyroid crisis

Thyroid hormone crisis sympathetic overactivity agitation () Tachycardia heart failure GI dysfunction diarrhea jaundice

case

67 2 Schizophrenia (Chlorpromazine) 2 () 1 3 vital sign body temperature Pulse rate Hypothyroidism

hypothyroidism general appearance pulse rate Body temperature mucopoly-saccharide Myoedema reflex relax phase

Hypothyroid Periorbital edema 1 3 lateral mucopolysaccharide (macroglossia) thyroid metabolism Tyrosine Carotemia mucopolysaccharide carpal tunnel bilateral carpal tunnel syndrome

Hypothyroid Thyroid function test TSH ( 0.2-3.2), T3 (80-200), Free T4 (0.78-2.1) case TSH >100, T3 19, FT4 0.04 TSH T3 FT4 Primary hypothyroidism Thyroid gland

TSH 0.01 secondary hypothyroidism pituitary gland postpartum bleeding tumor pituitary gland hormone

Primary hypothyroidism most common Chronic autoimmune thyroiditis Hashimotos thyroiditis 131I radiation Graves disease 131I cell hyperfunction hypothyroidism transient thyroiditis

Antithyroid antibodies Antithyroglobulin Antithyroid peroxidase titer 102400 positive

Myxedema coma

hypothyroid Thyroid hormone (Decreased mental status), hypothermia (), hypotension, bradycardia electrolyte imbalance hyponatremia SIADH hypoglycemia

Tumor of thyroid gland

Benign tumor thyroid Follicular adenoma Malignant 5 Most common Papillary carcinoma Follicular carcinoma, Medullary carcinoma, Anaplastic carcinoma Lymphoma Follicular adenoma: Function Follicular carcinoma: follicular adenoma histopathology tumor invade capsule Follicular carcinoma evidence Metastasis hemogenous route Bone metastasis Pulmonary metastasis Papillary carcinoma: lymphatic route thyroid cervical lymph node papillary carcinoma of thyroid gland Medullary carcinoma: neoplasia parafollicular (C) cell calcitonin serotonin Carcinoid syndrome MEN II

Carcinoid syndrome: Serotonin Flushing secretion diarrhea Metabolite Serotonin HIAA Paraneoplastic ACTH Cushings syndrome ]

Anaplastic carcinoma: Prognosis (Hard consistency) Lymphoma: Hashimotos thyroiditis Adrenal gland

Anatomy and Histology of adrenal gland

Adrenal gland upper pole 2 histology 2 cortex medulla ( Chromaffin cell adrenaline Noradrenaline)

Adrenal cortex 3

1) Zona glomerulosa mineralcorticoid Aldosterone Na+ K+ H+ distal tubule aldosterone Renin-Angiotensin system Aldosterone Hyperaldosteronism

2) Zona fasiculata cholesterol Glucocorticoids ACTH Cushings syndrome

3) Zona reticularis sex hormone menopause sex hormone gonad ( adrenal gland androgen)

Hypothalamus-pituitary-adrenal axis stress Hypothalamus CRH anterior pituitary ACTH ACTH Adrenal cortex Zona fasiculata glucocorticoid steroid hormone immune function candida Cushings syndrome Oral thrush (oral candidiasis) glucocorticoid physiological function feedback CRH

Mineralcorticoids Renin-Angiotensin system potassium

Adrenal cortex cholesterol SER Adrenal steroid hormone pathway cortex

Zona reticularis sex hormone tumor androgen (Hirsutism) Virilization

Tumor chromaffin cell adrenal medulla Pheochromacytoma tumor chromaffin cell Paraganglioma neuroblastoma

Adrenal gland endocrine hypertension hypertension endocrine disease Adrenal gland 2 hyperaldosteronism Pheochromocytoma

Hyperaldosteronism

Hyperaldosteronism aldosterone hypertension with hypokalemia most common Aldosterone-producing adenoma adrenal gland Conns syndrome hypertension hypokalemia proximal muscle weakness nephrogenic DI (hypokalemia ADH renal tubule polyuria ) bilateral adrenal hyperplasia rare Adrenal carcinoma serum aldosterone renin

Secondary Hyperaldosteronism renin renal artery stenosis blood flow juxtaglomerular apparatus renin Aldosterone serum aldosterone renin

Aldosterone-producing adenoma (Conns syndrome)

Conns syndrome most common cause primary hyperaldosteronism benign tumor 2 cm Aldosterone hypertension with hypokalemia BP atherosclerosis

Aldosterone Na+ K+ HT Na+ retention cardiac output BP hypertension K+ K+ aldosterone H+ metabolic alkalosis

Primary aldosteronism most common Conns syndrome hypertension with hypokalemia and metabolic alkalosis

Pheochromocytoma

Tumor adrenal medulla catecholamine sympathetic overactivity (palpitation) tachycardia flushing catecholamine Paroxysm ( ) adrenal medulla tumor chromaffin cell extra-adrenal sympathetic ganglion Rules of 10 10% ; 10% ganglion adrenal gland; 10% ; 10% malignancy; 10% familial disease

Pheochromocytoma Paroxysm hypertension metabolite catecholamine VMA metanephrin catecholamine amino acid Tyrosine tyrosine hydroxylase , DOPA decarbosylase Noradrenaline MAO COMT metabolite VMA urine VMA imaging

Clinical triad Pheochromocytoma1. Paroxysmal throbbing headache

2. Sweating

3. palpitation

hyperglycemia sympathetic overactivity

Pheochromocytoma familial disease MEN II (Multiple endocrine neoplasia type 2) VHL gene ( von Hippel-Lindau disease) Neurofibromatosis 1 (NF-1) Pheochromocytoma (VHL gene renal cell carcinoma )

antihypertensive of choice Conns syndrome K+-sparing diuretics spironolactone Aldosterone

Cushings syndrome

cortisol

Cortisol bone calcium calcium excretion osteoclast activity on steroid Cushings disease hypocalcemia PTH osteoclast vicious cycle osteoporosis

Signs & Symptoms Cushings syndrome buffalo hump moon face muscle weakness abdominal striae emotion psychosis, depression

pituitary gland sella turica cortisol salt-water retention hypertension insulin-resistance Cushings syndrome DM fat distribution truncal obesity extremities muscle atrophy cortisol proteolysis protein Cortisol fibroblast collagen glycosaminoglycan bleeding immune function cortisol WBCs lymphoid organ infection hypersensitivity phospholipase A2

(moon face) purplish striae steroid acne ( Cushings syndrome phase ) Salt-water retention, buffalo hump, moon face, cardiac hypertrophy polyuria, polydypsia DM

Cushings syndrome 2 exogenous endogenous

1) Exogenous Cushings syndrome steroid hormone Prednisolone ( steroid )2) Endogenous Cushings syndrome cortisol 2 ACTH dependent pituitary microadenoma, ectopic ACTH tumor adrenal gland ACTH small cell carcinoma of lung pancreatic tumor paraneoplastic syndrome ** ectopic ACTH skin pigmentation ACTH independent adrenal adenoma cortisol ACTH ( Ectopic function Eutopic )

Adrenal insufficiency

hypofunction adrenal gland primary secondary

1) Primary adrenal insufficiency adrenal gland autoimmune adrenalitis Addisons disease, enzyme , Adrenal hemorrhage, Adrenal infarction Hyperpigmentation ACTH structure MSH Melanocyte melanin pigment Hyperkalemia aldosterone Conns syndrome Metabolic acidosis hypotension

Cortisol lung surfactant adrenal insufficiency neonatal respiratory distress syndrome

2) Secondary adrenal insufficiency [ pituitary gland] Sheehans syndrome, Mass effect pituitary tumor, Craniophayngioma, empty-sella syndrome pituitary gland ACTH (vitiligo)

Orthostatic hypotension hypoglycemia hyponatremia SIADH lymphocytie lymphocytosis cortisol PMN predominanat PMN dysfunction cortisol lymphocyte

Polyglandular autoimmune syndrome (PGA)

PGA autoimmune disease involve endocrine gland 2 type

PGA type I Autosomal recessive hypoparathyroidism mucocutaneous candidiasis

PGA type II 20-60 DM type 1 ( autoimmune disease islets of Langerhans)Sex hormones

sex-related Y chromosome testis testosterone testosterone active form dihydrotestosterone 5-reductase dihydrotestosterone Androgen receptor male phenotype testis Anti-Mullerian hormone regression Mllerian duct Ambiguous sex sex hormone

Sex hormone hypothalamic-pituitary-ovarian axis FSH LH anterior pituitary gland GnRH hypothalamus

FSH follicles ovary LH secondary sexual characteristics LH epididymis anabolism FSH spermatogenesis

Estrogen Osteoblastic activity estrogen ( menopause) osteoclast bone resorption osteoporosis

Testosterone ( Side effect )Congenital adrenal hyperplasia

Adrenal steroid hormone enzyme 3-hydroxysteroid dehydrogenase 21-hydroxylase (21-OH) 11-hydroxylase (11-OH) enzyme -21-hydroxylase deficiency (21-OHD) : (90%) cortisol Aldosterone hypotension, hyperkalemia adrenal insufficiency stress hypoglycemia testosterone metabolite shift testosterone testosterone female virilization muscle mass -11-hydroxylase deficiency (11-OHD) : (5%) 21-OHD Deoxycorticosterone (DOC) metabolite Aldosterone hypertension estrogen clinical Primary adrenal insufficiency (hyperpigmentation) hypoglycemia stress virilization

21-OHD glucocorticoid minerocorticoid androgen hyperkalemia aldosterone Alkalosis BP metabolite 17-OHP metabolite 21-hydroxylase 11-OHD cortisol mineralocorticoid DOC BP Na+ K+ Adrenal gland hyperfunction Conns syndrome, Adrenal cushings syndrome Pheochromocytoma

hypofunction adrenal insufficiency Addisons disease Congenital adrenal hyperplasia (21-OHD 11-OHD BP) 3 hyperthyroidism, DM, pheochromocytoma

endocrine hypertension acromegaly, hyperthyroid, adrenal Cushings syndrome, Conns syndrome, adrenal hyperplasia, DM, pheochromocytomaParathyroid gland

Parathyroid gland calcium phosphate metabolism Parathyroid hormone (PTH) calcium phosphate osteoclast bone osteoclast activity PTH calcium phosphate fracture hypoparathyroidism calcium phosphate

Calcium absorb hormone calcium vitamin D PTH calcium ( GI vitamin D ) PTH

phosphate 1) cell lysis 2) phosphate vitamin D PTH

Vitamin D phosphate calcium phosphate PTH phosphate calcium phosphate

Hyperparathyroidism

1. PTH osteoclast osteopenia skull salt and pepper skull ( skull) long bone cyst osteitis fibrosa cystica

2. Calcium peptic ulcer

3. Calcium pancreatic enzyme pancreatitis

4. Calcium nephron nephrocalcinosis calcium phosphate stone renal failure

5. Calcium calcification metastatic calcification

6. Calcium nephrogenic DI ADH renal tubule hypokalemia hypercalcemia

DI 2 Central DI hypothalamus ADH

Nephrogenic DI ADH

Hyperparathyroidism

1. Primary hyperparathyroidism

- Most common adenoma

- 5% hyperplasia 4

- 2% carcinoma

2. Secondary hyperparathyroidism calcium - chronic renal failure hydroxyl vitamin D ( vitamin D hydroxyl ) inactive vitamin D- malabsorption syndrome calcium Capillaria philippinensis Crohns disease -Vitamin D deficiency

3. Tertiary hyperparathyroidism parathyroid gland autonomous nodule PTH

chronic renal failure calcium phosphate () parathyroid gland PTH PTH parathyroid gland autonomous nodule calcium phosphate

electrolyte primary calcium phosphate secondary tertiary calcium phosphate ( )

Humoral hypercalcemia of malignancy

Malignant tumor small cell type Parathyroid hormone-related peptide (PTHrP) PTH hypercalcemia paraneoplastic syndrome paraneoplasm

MEN syndromes (Multiple endocrine neoplasia)

MEN syndromes endocrine glands Autosomal dominant genetic familial history

MEN I (Wermer syndrome) mutation MEN I gene 11 clinical syndrome 3P ( Para-Pan-Pit)

1. Parathyroid adenoma hypercalcemia

2. Pancreatic islet cell tumor most common Insulinoma (-cell tumor) hypoglycemia

3. Pituitary adenoma Prolactinoma , acromegaly Cushings disease

MEN IIA (Sipples disease) point mutation RET oncogene 10 Medullary carcinoma of Thyroid gland, Parathyroid adenoma hyperplasia Pheochromocytoma ( Med-Par-Phe)

MEN IIB (Gorlins syndrome) RET oncogene tyrosine kinase domain medullary carcinoma of Thyroid gland, Pheochromocytoma MEN IIA Mucosal neuroma Ganglioneuroma of gut

Practice Endocrine disease 1.

Prolactinoma

Galactorrhea MRI pituitary gland Prolactinoma functional pituitary tumor pathologic hyperprolactinemia Prolactin 2.

Addisons disease

Hyperpigmentation gum, oral mucosa, ACTH Primary adrenal insufficiency blood electrolyte hyperkalemia Addisons disease (hypoglycemia, orthostatic hypotension, loss of libido, hyperpigmentation)

adrenal gland ACTH ACTH ACTH MSH 3.

Cushing syndrome Clinical Cushings syndrome (Cushinoid appearance) Phase Purplish striae collagen structure (fibroblast activity ) vascular tissue 4.

general appearance Reflex Pathological finding Pheochromocytoma tumor adrenal cortex

5.

3-4 Na+ Myxedema general appearance 1/3 bradycardia, body temperature , , , suggest Hypothyroidism

- Primary: Hashimotos thyroiditis, Postsurgical or postradiation

- Secondary: Hypopituitarism Sheehans, empthy sella syndrome, craniopharyngioma hormone

6.

Addisons disease hypopigmentation vitiligo autoimmune disease

7.

Gross pathology adrenal cortical adenoma

8.

Grave disease pretibial myxedema specific sign Graves disease

9.

MRI Acromegaly carpal tunnel syndrome endocrine disease acromegaly MRI Tumor

10.

Skin lesion endocrine disease 37.19 acanthosis nigricans skin hyperpigmentation insulin resistance DM, Cushings syndrome, acromegaly

11.

Graves disease

starring eye exophthalmos substance retrobulbar space12.

Grave disease pretibial myxedema clinical endocrine 3 1. Hyperthyroid metabolism2. Pheochromocytoma sympathetic activity

3. DM

13.

Grave disease starring eye exophthalmos diffuse thyroid enlargement myedema

14.

Bradycardia Hypothyriod

mucopolysaccharide 15.

Addisons disease (Primary adrenal insufficiency)

hyperpigmentation postural hypotension cortisol potassium mineralocorticoid

Primary adrenal insufficiency acute primary adrenal insufficiency meningococcemia adrenal gland adrenal insufficiency adrenal hemorrhage Waterhouse-Friderichsen syndrome16.

Cushing syndrome

Purplish striae sign specific Cushing syndrome obesity 17.

Addisons disease

18.

Addisons disease

19.

Acromegaly nasolabial fold tumor pituitary

Acidophil

Thyroid hormone (T3) nuclear receptor

Neurohypophysis

Adenohypophysis

Overview of Endocrine system

Hormone negative feedback hormone pituitary hypothalamus

Hormone Central + Peripheral