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Access to Democracy
Dr. William Young
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Hosted by Dr. Geoff Thompson. The pituitary gland, albeit the size of an acorn, sitting on the underside of the brain, embedded in the base of the skull, is critical to numerous essential bodily functions. It produces hormones that regulate virtually every other endocrine gland in the body (thyroid, adrenal, ovaries and testes) to maintain health and wellness, growth and development, reproduction, and life itself. Tumors of the pituitary gland are common, but most are small and inconsequential. When enlarged, they can put pressure on the optic nerves, leading to partial blindness. When producing uncontrolled amounts of their own hormones, they can alter normal bodily functions, leading to potentially dangerous and life-threatening syndromes ( Cushing’s disease, acromegaly, hyperthyroidism). In a similar fashion, deficiencies of pituitary hormones can also cause bodily harm. Most pituitary tumors are amenable to removal via transnasal, minimally invasive surgery.
Welcome everyone to Access to Democracy. I'm Dr. Jeff Thompson, and pleased today to provide a medical segment. We'd like to first thank our sponsors, Recaliber Health, 45th Parallel Distillery, Sheraton, and Dulas PA law firm, and Truestone Financial. We have today with us Dr. William Young, who is the Tyson Family Professor of Medicine and the past chair of the Division of Endocrinology, Metabolism and Nutrition at Mayo Clinic in Rochester, Minnesota. Dr. Young's clinical and research expertise is in the area of the pituitary and adrenal disorders. He's published over 300 manuscripts and has spoken around the world, pretty much in every country, with regard to these topics. And we're delighted to have Dr. Young here with us today. And Dr. Young, thank you for being with us. Why don't we go ahead and get started? And I thought we'd start off with before we delve into the pituitary gland, maybe talk a little bit about what endocrine glands are and what they produce and how they work.
SPEAKER_02Yeah, you bet, Jeff. Happy to be here today. So the endocrine glands in the body are most of them are fairly small structures, and they all make one or more hormones. None of us would be alive today if we didn't have the endocrine glands, and you'll learn a lot more about the pituitary gland in a few minutes. But the glands, the highest gland in the body is the pituitary gland, which is at the base of the brain, thyroid glands in the neck, along with the parathyroid glands that sit next to the thyroid. And then as we go down, there's the pancreas, and that makes insulin. And without insulin, that's patients get diabetes. And next to the pancreas are the adrenal glands, and then further down are the gonets, so the ovaries in women and the testicles in men. And all these make very specific hormones unique to each of those glands.
SPEAKER_01Okay. And why why do people talk about the pituitary gland as being the master gland?
SPEAKER_02Yeah. So it it's called the master gland. You know, it's I think this phrase small but mighty is kind of overused, you know, across all sorts of disciplines. But it's actually true for the pituitary gland. Uh the pituitary gland is really small. Um, it's about the size of your thumbnail.
SPEAKER_01And I think we have some some pictures for the audience, so we could we could put those up now.
SPEAKER_02Yeah, so so those images, first is uh a graphic showing uh across a skull um where the pituitary gland sits. It's basically straight behind the bridge of the nose and just in front of the ears, and it's uh at the base of the brain, and there's a lot of structures, important structures around it. Right above it are the nerves that go to the eyes, which can become important uh if a patient has a pituitary tumor that's enlarging. Um, on one of the other images uh are shown some scans. Uh, these are MRI scans that show uh the location of the pituitary and tumors within the pituitary gland. One shows kind of an average size pituitary tumor that's extending a little bit to one side of where the pituitary gland cysts. And then another one shows a much larger pituitary tumor that actually is pushing on the nerves of the eyes. It raises them up. So what happens is patients lose vision on the sides, so we call it in the periphery. So they might not be able to see a stop sign, for example. Um, and then another image shows a small pituitary cis, and pituitary cis are are quite common. And there's another image that shows a small benign pituitary adenoma, which actually also is quite common.
SPEAKER_01Great. And so how does the how does the pituitary go about controlling all of these other organs? And what does it produce?
SPEAKER_02Yeah, so you know, you you mentioned the master gland, and um it it makes six hormones that are all very important and control other glands in the body. So the the pituitary doesn't directly control any process in the body um uh except for a couple. Um it actually works through other glands. So I'll just give you some examples. Um none of us would be as tall as we are if the pituitary didn't make growth hormone. So the reason humans grow is it makes growth hormone, as it's important in childhood, and if you don't make growth hormone in childhood, that causes dwarfism, so short stature. Um that's very important as we're growing up through our teenage years. Um the way growth hormone works, it tells the liver to make something called insulin-like growth factor one, and that's what actually causes humans to grow. Um another uh hormone that has some direct effects is a hormone called prolactin. So prolactin is only important in women, and it prepares the breast for breastfeeding, and then it maintains breastfeeding after a woman delivers a baby. Um that's its only function in humans. Men make prolactin, but there's no function in men. And then the other four hormones are all critical to everything we do every day. Um there's a hormone from the pituitary called ACTH. It tells the adrenal glands, it sit on top the kidneys, uh, to make cortisone. And we all need cortisone to live. Without cortisone, we wouldn't survive. So when we see patients, for example, who don't make ACTH, we have to give them cortisone so that they can survive. Um does that have a name, that disorder? Well, uh primary adrenal failure is called Addison's disease, named after uh uh a British dermatologist, um uh Thomas Addison. Uh he's the one that discovered it. And when the adrenal glands themselves fail, um the pituitary makes more of its ACTH to tell the adrenal glands, come on, get going, get going, you're not making enough cortisol. And uh what happens then is the skin gets very dark. So patients who have failure of the adrenal glands themselves, ACTH levels are very high, the um the skin gets very dark, and it's one of the tip-offs to doctors that their patient may have Addison's disease. When the pituitary itself can't make ACTH, well then there's there's no increased skin pigmentation. It's more just the signs and symptoms of lack of cortisol, which typically are weight loss, nausea, uh, extreme fatigue, um, there's some lab tests that can become abnormal, sodium and and potassium. Um so that's that's a really important pituitary hormone, um ACTH. Another important one is called TSH. It's thyroid stimulating hormone, and it tells our thyroid gland to make thyroid hormone. Now, if right now my thyroid gland is not making enough thyroid hormone, the pituitary is like a thermostat. It's constantly measuring thyroid hormone in our body. And if I'm not making enough, the pituitary will make more thyroid stimulating hormone, telling my thyroid to make more thyroid hormone. Um What if your thyroid is producing too much now? Ah. So if if it's let's say it's overproducing, then the thyroid stimulating hormone will go down. If the overproduction is temporary, then thyroid stimulating hormone will be down temporarily. There are some disorders where the thyroid gland itself is overactive, uh, a most common one called Graves disease. And in that situation, the thyroid stimulating hormone is very low all the time because the thyroid itself is automatically making too much thyroid hormone. And then patients present with uh weight loss, um, they tend to have a tremor in their hands, um, they can be uh easily uh sweat more easily. Um the heart's kind of going fast all the time, and that's called hyperthyroidism, and the most common form is is Graves disease. Um and for that you actually have to do something directly to the thyroid gland to treat it. And it's not a pituitary problem.
SPEAKER_01Does the does the pituitary play any role in in reproduction?
SPEAKER_02Absolutely. If if if you didn't have a pituitary gland, none of us could have babies. You know, it would be the end of the human race. So um, right. So the the pituitary makes two hormones, luteinizing hormone and follicle stimulating hormone. We abbreviate them LH and FSH, and they tell the ovaries what to do throughout the month. Um, and this is why women will typically have a menstrual cycle every month. That's because of how the pituitary is sending messages to the ovaries. And for a woman to become pregnant, the pituitary halfway through the month has to spend send a special signal to the ovaries so that they release an egg, and then that woman could be fertile. And uh for men, uh the pituitary tells the testicles to make testosterone and sperm. And without those messages, men would be infertile. So when there's uh a couple that's having trouble with fertility, you have to look on both sides. Is it a problem with a woman, a problem with a man? And is it the problem at the gonad, the ovary or testicle, or is it a problem with the pituitary gland?
SPEAKER_01Now, if I understand there's a front and a back to the pituitary. Yeah, but what about the back of the pituitary? Does that do anything?
SPEAKER_02Yeah, the back of the pituitary is critical. Um and this is what tells our kidneys how to concentrate urine. Um and if it the hormone from the back part of the pituitary is called antidiuretic hormone or vasopressin. Um and if someone doesn't make any antidiuretic hormone, they have to drink between eight to ten gallons of water a day just to stay hydrated because the kidneys won't concentrate the urine. So everything they drink goes right out through the kidneys. So if you have no uh antidiuretic hormone, these patients are constantly drinking. They especially like ice cold water. So the the whatever they're drinking from uh typically has a lot of ice in it. I know a patient will have this when I walk in the office and there's a big jug of ice water on the desk. That that's a tip-off because ice water quenches thirst better than anything else. Um and they have to drink day and night. They have to get up throughout the night to urinate and to drink. Um, fortunately, all these hormones we've been talking about we can replace. That's what endocrinologists like I do. Um, we figure out if there's a deficiency in these hormones and then how to replace the hormones.
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SPEAKER_01Young, we're just going to take a brief break here for our sponsors, and we'll be back in a minute.
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SPEAKER_01We're back now with Dr. William Young from Mayo Clinic, and we're talking about the master gland, the pituitary gland, and let's continue our discussion.
SPEAKER_02Yeah, so um we've we've talked about the hormone in the back part of the pituitary, antidiuretic hormone, ACTH, TSH, thyroid stimulating hormone, LH and LH, FSH that tell the ovaries and testicles what to do, and uh prolactin, which tells the breast to make breast milk. So those are all the good things the pituitary gland does. There are some bad things it does. For example, um pituitary tumors, tumors of the pituitary gland, are fairly common. Fortunately, they're almost always benign. Um they can be very small, as shown in some of those images, uh, or they can be very big. Um, if you took a hundred people off the street and did an MRI scan on their head, 10% would have a little pituitary tumor. And we call these pituitary incidentalomas. Usually the MRI scan is done for headaches or some other reason, um, but you stumble over these little pituitary tumors. So many times, as an endocrinologist, I'm I'm reassuring patients that these are very common, and most people can live their whole life uh with it without it ever being a problem. But what I have to do is to make sure that little tumor is not making a hormone. If it's making one of those powerful pituitary hormones we talked about, it can cause a whole different disease. For example, if ACTH, which tells the adrenals to make cortisol, if you have a tumor that makes ACTH, that causes another syndrome called Cushing syndrome. And this is where uh it tells the adrenals to make too much cortisol. And with that, patients gain a lot of weight, mostly central. Uh the skin gets very thin, so you get these purple-red stretch marks across the abdomen. The face gets quite round and red. Uh women can get excess facial hair with this. Uh, the arms and legs, uh, you actually lose muscle, so the arms and legs get skinny. It's a very unique uh clinical presentation. Uh typically it's associated with high blood pressure and with high blood sugar diabetes. Um it's very rare, fortunately, but when patients present with this, our job is to figure out if they have it and what's causing it. Usually it's caused by that small pituitary tumor that we can take out. A neurosurgeon can uh take it out with an operation. Um other types of pituitary tumors. You could remember that hormone we talked about that tells the breast to make breast milk. Well, you can get a pituitary tumor that makes prolactin. And if this occurs in a woman, one of her symptoms she may come come in with is that she's producing breast milk and without any recent pregnancy. Um and so we simply measure the prolactin. And if it's high, then we image the pituitary with an MRI scan to find out how big the tumor is. Fortunately, for most of these patients with prolactin-producing tumors, we have a very good medication that tells it to stop making prolactin and shrinks the tumor. Um the most common type of pituitary tumor is it's a non-functioning tumor. It doesn't make any hormone. And the only way we find out a patient has it is if they have an MRI for headaches or some other reason, or if they're starting to lose vision. I mentioned before that the visual tracts are right above the pituitary and you can lose peripheral vision. And patients can sense that, that hey, I'm not seeing things as well out the sides. And many times they'll go to an optometrist and they'll figure out that you know the reason for vision loss is not because the vision straight ahead is poor, it's the peripheral vision that's a problem.
SPEAKER_01What about um if there's too much growth hormone?
SPEAKER_02Yeah. So growth hormone, it has two different names. If it if the tumor develops in childhood, uh it's called gigantism. And the reason it's called gigantism is because it tells these children to grow. And they'll keep growing, and they can get very tall. Um the tallest person ever recorded was eight foot eleven and a half inches, I believe. Um was it your patient? That was not my patient. Okay. Um but it the the the important thing when when children are growing that fast is you know to figure out why, and if they do have a pituitary tumor, to remove it and and correct the growth disorder.
SPEAKER_01Um can you always remove it?
SPEAKER_02Well, uh if they get very large, like one of those images I shared on the MRI scan, um, it may not be possible to entirely remove it. So we can call what's called debulk it, where we take out maybe 80% of it or 90% of it, and then what remains, we have some medications, for example, that can lower growth thermone. And we can also use radiation therapy, very targeted radiation therapy called gamma knife radiation, uh, uh, which is um it's kind of like a a magnifying glass, uh, you know, in the summer on a sidewalk with a dry leaf, you can focus the sun's rays and burn a hole in the leaf. Well, it doesn't burn a hole in the pituitary tumor, but a very target, very targeted way of um damaging the pituitary tumor, so it stops making grow thermone. In adults, when they have a grow throman screen tumor, it has a different name. It's called acromegly. Acromegaly gets its name because adults can't grow taller because uh the bones are fused, but the acral parts of their body, which are the tips, so the fingers, the feet, the nose, the lips, uh, all can get larger. Um and this happens really slowly. And this isn't something that usually patients recognize, they just think it's normal aging. The typical duration of the symptoms of acromeglia is about eight years before the patient's ever diagnosed. Um so some of the facial features, the lips get thicker. This bone here can grow, demandible, so it can extend. So you go from uh uh an overbite to an underbite. Uh the teeth widen, so the spacing between teeth widen, so you get gaps in the teeth. The frontal uh sinus actually can grow. Um so the frontal sinus extends out, and this is called frontal bossing. So it's a it's a unique appearance that endocrinologists uh usually can recognize quite easily. But again, patients may not recognize it, and family members may not. They think it's normal aging. Other parts, the the foot, the width of the foot enlarges and the length of the foot just slightly enlarges. So shoe size changes pretty dramatically, ring size changes dramatically because the fingers get thicker. So many of our patients, when they are diagnosed, they don't have their rings anymore because they had to get cut off because they couldn't get them off their fingers. Um especially in women, it can cause the voice to deepen because of its effect on the vocal cords. Um it's a it's a very low typical sonorous type voice.
SPEAKER_01Does it affect any other internal organs? Can it can it affect lifespan?
SPEAKER_02Yeah, it sure can. So it the this excess growth hormone can cause everything to get bigger, the heart gets bigger, the liver gets bigger, um, and it it predisposes to certain tumors like colon cancer. Um and so it absolutely can affect lifespan.
SPEAKER_01So that brings up an interesting question because a lot of people nowadays are taking various supplements, and they're taking growth hormone. Uh do adults need growth hormone and are they Putting themselves at any risk for taking growth hormone.
SPEAKER_02Yeah. So, Jeff, this drives endocrinologists crazy, okay? You know, there's these thoughts that I want to do something to make myself younger. And that doesn't exist. We all should have a healthy lifestyle, a prudent diet, but these supplements really are not very effective. And certainly agents like growth hormone, adults don't need growth hormone. We already grew. We needed it when we were kids. We don't need it as adults, and it does not extend life.
SPEAKER_01Does it build muscle?
SPEAKER_02It well, there is some evidence that it can help with muscle. So sometimes athletes inappropriately will take growth hormone supplements, for example.
SPEAKER_01And now the pituitary does control all of these things, but but there are also higher levels of control to even to the pituitary. You want to mention that? Sure, Jeff.
SPEAKER_02It you know, it can get complex. Um and one of the reasons endocrinologists go into endocrinology is it is so complicated. And it's it can be really difficult to figure out what's causing what. Is it a problem at the pituitary? Is it a problem at the target gland, or is it a problem above the pituitary gland, and that's what you're referring to? And that's called the hypothalamus. So the hypothalamus. And that's part of the brain. That's really part of the brain. It's at the very base of the brain, and it sends messages to the pituitary down the pituitary stalk. And the pituitary, again, the size of your thumbnail, isn't actually part of the brain. It it hangs down from the brain like a cherry on a stem, and it it's not brain tissue, but it's being told what to do by the hypothalamus that sits above the pituitary gland.
SPEAKER_01So we alluded a little bit about surgery, but this is really in a very tight space, in a very intricate, deep space. And how do surgeons get to it?
SPEAKER_02Yeah, it it's changed over the years. Um, you know, Cushing syndrome is named after someone named Harvey Cushing, and he was a neurosurgeon, and he developed some of the early techniques at getting to the pituitary, but that would involve uh taking part of the skull off and then going down, lifting the front of the brain up and going down and finding the pituitary. Uh fortunately, we don't do that anymore. Um, and we can we've gone through several evolutions of what we call transnasal pituitary surgery. So I mentioned the pituitary sits just behind the bridge of the nose, just in front of the ears. So the way we actually get to the pituitary these days is with something called a scope endoscope, and it goes in one nostril, and just using that, a neurosurgeon can make a hole in the floor of the cella. The cella tersca is where the pituitary sits. They can make a hole in that bone and go in and take out a pituitary tumor. It's all done under microscopic uh vision. And um it these are special neurosurgeons. This isn't just any neurosurgeon. There are neurosurgeons that are dedicated to pituitary surgery.
SPEAKER_01So if patients if patients are worried that they might have something wrong with their pituitary gland, what should they do?
SPEAKER_02Well, I think they should start with their primary care provider and share with their uh primary care provider why they think they may have uh an issue in the endocrine system or with the pituitary gland. And usually just by measuring a couple hormones, uh that initial physician or provider can figure out is there really a problem here or not. And if they find evidence that there may be a problem, well, that's the time to get referred to an endocrinologist. Okay.
SPEAKER_01Anything else you want to tell us about the pituitary gland that we haven't spoken about?
SPEAKER_02I think uh Jeff, I think you've been very thorough. Uh it yeah, I think the message is to leave folks with uh it's the master gland. It's small but mighty. Uh you you can't see it. Um and you usually can't feel it if it's if, for example, there's a pituitary tumor. Head pain is not a sign of a pituitary tumor. These grow really, really slow. And you know, if someone has a headache, it's not due to the pituitary tumor. So we a lot of time in endocrinology we reassure patients that this small pituitary tumor is not the cause of any symptoms.
SPEAKER_01So these are all fascinating entities. How how common are they?
SPEAKER_02Well, a lot of the entities I talked about, like uh adrenal gland failure, Addison's disease, or making too much ACTH Cushing syndrome, you know, we're we're talking about you know, 10 to 15 people out of a million. So a lot of these are quite rare. Uh but we think about them a lot, we search for them a lot. Um, on the other hand, little pituitary adenomas are really common. One out of ten of us, you know. One of us may have a little pituitary tumor, and we'd only know it if we had an MRI scan.
SPEAKER_01Anything else you want to share with us?
SPEAKER_02Uh let's see, Jeff. Um I think those are the most important things for people to understand about the pituitary gland. I mean, I don't think this should be top of mind. I don't I don't I don't think folks should worry, oh gee, do I have a pituitary tumor? Um but you know, if they have unexplained weight loss, unexplained weight gain, um, or if they have uh if women have milk production from the breast for no reason, you know, these are all signs that maybe we should be looking into the pituitary gland.
SPEAKER_01I'm gonna I'm gonna bring up a topic you probably don't want to hear about, and that's a term we hear a lot about in the news, adrenal fatigue.
SPEAKER_02Oh, goodness.
SPEAKER_01Is that related to the pituitary or the adrenal or is it real or what is it? Yeah. And you have 16 seconds.
SPEAKER_02Adrenal fatigue does not exist. Okay. It's a fabricated term in order for individuals to sell adrenal supplements. Okay. Please, no one should purchase adrenal supplements.
SPEAKER_01Dr. Young, on that note, thank you. We really enjoyed having you here today. Great discussion.
SPEAKER_02Thank you, Jeff.
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