Hormones of the endocrine system is a vast topic with numerous hormones involved which affect virtually every organ in the human body. Human physiologic processes such as homeostasis, metabolic demand, development, and reproduction are all possible because of hormones and the processes mediated by their actions. This review will elaborate on the organ which secretes the hormone, the actions of the hormone, and where these actions take place. In addition, it will review several of the most common endocrine diseases involving hormones. The number of diseases covered is not comprehensive due to the quantity of disease and ongoing research to help better understand less commonly occurring pathology. It is important to understand the physiology of hormones and how their actions, when even minutely disturbed, can result in serious disease and possibly even death, if not corrected.
Posterior Pituitary Hormones
Since the posterior pituitary is an extension of nervous tissue, it is maintained and activated differently than the anterior pituitary gland. An action potential from within a cell body originating in the hypothalamus travels down an axon where it synapses in the posterior pituitary. One neuronal signal, which originated in the hypothalamus and finishing in the posterior pituitary results in the release of two possible hormones: oxytocin or anti-diuretic hormone. Oxytocin is released from the posterior pituitary gland and acts on two primary areas of the body, most notably during pregnancy. The first organ oxytocin interacts with is the uterus. When the cervix and uterus begin to stretch during delivery, there is a positive feedback loop that increases the amount of oxytocin released. Activation occurs via stimulation of G-protein-coupled receptors causing an increase in intracellular calcium, resulting in smooth muscle contraction. The second function of oxytocin is in breast tissue. The process begins with nipple stimulation via suckling, triggering an afferent signal to the hypothalamus to release oxytocin. Traveling in the bloodstream oxytocin binds to its receptor on myoepithelial cells, causing contraction, and thus forcing milk into the lumen of the breast tissue. Postpartum breastfeeding results in elevated oxytocin, which as previously mentioned causes uterine contraction; these contractions result in decreased blood loss due to vessel constriction. Lastly, oxytocin studies in animals have indicated a role in behavioral effects due to oxytocin receptors located within the brain. However, insufficient data is available regarding these effects in humans.
Anti-diuretic hormone (ADH) is the other hormone released from the posterior pituitary gland and is very important in hydration and electrolyte levels especially sodium. Its primary function is to regulate serum osmolarity. When the osmolality is below 280 mOsm/kg in a normal individual ADH will be low. When levels are low, water will be excreted, in comparison when levels are high, water gets reabsorbed. This reaction occurs when the plasma osmolality rises above 280 mOsm/kg. In addition to osmoreceptor stimulation, volume-sensitive receptors can also trigger ADH release. Volume-sensitive receptors will only increase ADH if there is a sudden and significant drop in pressure, small incremental decreases will be insufficient to activate ADH – renin and norepinephrine handle these smaller changes instead. ADH acts to increase water retention and raise blood pressure via two different receptors. In the distal nephron, V2 receptors help increase water reabsorption by increasing the number of aquaporin channels in principal cells of the collecting duct. Increased ADH also stimulates V1 receptors which increase vascular resistance throughout the body.
Anterior Pituitary Affecting Hormones
The hypothalamic-pituitary-adrenal (HPA) axis is a pathway connecting the organs as mentioned above, allowing succinct control of several hormones. The hypothalamus is connected anatomically to the pituitary gland via the infundibulum. Within the infundibulum are capillaries that pour into portal veins, flowing directly to the anterior pituitary. This system ensures the hormones circulate directly into the anterior pituitary gland, never entering the general circulation. The following section will discuss the first part of the axis, the hypothalamus and the hormones it releases to stimulate the anterior pituitary gland. The hormones released from the hypothalamus include corticotropin-releasing hormone, thyrotropin-releasing hormone, gonadotropin-releasing hormone, growth hormone-releasing hormone, somatostatin, prolactin releasing hormone, and dopamine.
Gonadotropin-releasing hormone (GnRH) specifically is a hormone released from the hypothalamus and acts on the pituitary to control the reproductive axis. There are two important factors for proper GnRH function, including proper neuron migration during development and pulsatile secretion.
A small number of hypothalamic neurons release GnRH, the fetal cells migrate to the olfactory bulb and olfactory tract, from where they continue to the mediobasal hypothalamus in the preoptic area as well as the arcuate nucleus. Fetal cells in the olfactory area have the capability of detecting odorant stimuli and releasing GnRH. The importance of GnRH neuron migration received confirmation in the case of an aborted fetus diagnosed with Kallmann syndrome. The fetus had an older brother with the same X chromosome deletion; however, further neuropathologic examination revealed GnRH neurons had arrested at the cribriform plate. The fetus was old enough that these neurons should have already migrated to the hypothalamus. Additionally, the belief is that anosmia presents in GnRH deficient patients due to the close association of GnRH neurons with the olfactory bulb and tract. The pulsatile property of GnRH neurons was demonstrated when immortalized in vitro tissue continued to release GnRH in a pulsatile fashion – not only implicating a possible intrinsic hypothalamic pulse generator but emphasizes the importance of the pulse itself. The pulse generator secretes GnRH in very discrete, random, but still regular bursts. It is now well established that GnRH pulsation results in appropriate physiologic gonadotropin levels, however, when GnRH is given continuously, serum gonadotropins will increase initially, but quickly decrease as a result of desensitization. This has important clinical implications for various cancers and gynecological pathology. With the discontinuation of continuous GnRH, spontaneous GnRH pulses will return, restoring the gonadotropin response.
GnRH has a very short half-life, only 2 to 4 minutes. When secreted, it acts to stimulate the release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) – the two hormones are commonly referred to as gonadotropins. Gonadotropins and sex steroids have both negative and positive feedback loops on GnRH pulsation. How these loops work is not fully understood. However, not only sex hormones impact GnRH; multiple other molecules have been found to influence GnRH. Some of these molecules include opiates, gonadal steroids, kisspeptin, neurokinin B, catecholamines, neuropeptide Y, corticotropin-releasing hormone, galanin, dynorphin, and prolactin. GnRH, LH, and FSH regulate a variety of functions important to human sexual development, sex production, and fertility. For more information see the sections on LH and FSH.
Corticotropin-releasing hormone (CRH) is another hormone involved in the Hypothalamic-pituitary-adrenal (HPA) axis. CRH is present in the paraventricular nucleus of the hypothalamus (PVH), which is released and stimulates the anterior pituitary gland to release adrenocorticotrophic hormone (ACTH).
Growth hormone-releasing hormone (GHRH) is a hypothalamic hormone which binds to pituitary receptors to stimulate the release of growth hormone (GH). Binding to its receptor results in the activation of a linked G protein which stimulates cAMP production. This intracellular signaling results in the actual release of GH and somatotroph proliferation. It is suspected GHRH is released in a pulsatory manner, since GH is pulsatory, however, this is not yet fully understood.
Somatostatin – somatostatin has two biologically active forms – somatostatin-14 (S14) and somatostatin-28 (S28) – they are 14 and 28 amino acids, respectively. It is synthesized by delta cells of the islets of Langerhans within the pancreas and by paracrine cells scattered throughout the gastrointestinal tract. Somatostatin is found throughout the body but is notably abundant in the nervous tissue of the spinal cord, brainstem, hypothalamus, and cortex. When released somatostatin has a very short half-life, after IV administration 50% will be removed from circulation in less than three minutes. As a result, the concentration of somatostatin found within the blood is quite low, usually in sub-picomolar amounts. Somatostatin receptors are G protein-coupled receptors that when activated reduce cAMP levels. Five receptor subtypes exist, subtype 1-5. All five are present within the brain; however, each receptor has tissue specificity. Subtype 1 is present in the brain, lung, pancreas, liver, and GI tract. Subtype 2 is found in the brain and kidney. Subtype 3 is in the brain and pancreas. Subtype 4 is present in the brain and lung. Subtype 5 occurs in the brain, skeletal muscle, GI tract, heart, adrenals, and pituitary.
Once somatostatin binds to its receptor, it produces its physiologic effect, which is primarily inhibition of GH in the pituitary. In addition to inhibiting GH, somatostatin has additional physiologic properties in multiple organs. Within the brain, it has antinociception properties. In the liver/gallbladder, somatostatin decreases blood flow, inhibits gallbladder contraction, and inhibits bile duct secretion. The pancreas will have both endocrine and exocrine secretions inhibited. Finally, within the gastrointestinal system, somatostatin will inhibit salivary amylase, gastric acid, and gastrointestinal hormone secretions. It also delays gastric emptying, slows motility, inhibits absorption, and decreases splanchnic blood flow.
Dopamine is an important molecule in the human body; it plays roles in many different organs. It is most commonly discussed in psychiatric and neurological settings due to its role as a neurotransmitter. However, dopamine also serves as an endocrine hormone, secreted from the hypothalamus to the pituitary. The primary role regarding endocrine hormone physiology is to inhibit the secretion of prolactin. It has been well established and studied that pathology or medication side effects of decreased dopamine lead to hyperprolactinemia and the pathophysiology associated with this state.
Thyrotropin-releasing hormone (TRH) is composed of three peptides, pyroglutamyl-histidyl-prolineamide. TRH begins as proTRH, and through a process of peptization and cyclization of glutamine, forms a pyroglutamyl residue.  The metabolization of TRH is rapid, with a plasma half-life of approximately three minutes. TRH is another hormone involved in the HPA axis, helping determine the regulation of TSH secretion. Specifically, TRH is found in the highest concentrations in the PVH and median eminence of the hypothalamus. However, it is also present in the central nervous system, gastrointestinal tract, pancreatic islets, pituitary gland, and reproductive tracts – TRH function at these sites is not known. Lastly, high levels or exogenous administration of TRH will stimulate additional hormones besides TSH especially prolactin.
Follicle stimulating hormone (FSH) & Luteinizing hormone (LH) – see endocrine sex hormones section below.
Prolactin is a hormone produced by lactotrophs found in the anterior pituitary gland. Prolactin regulation is by the hypothalamus in an inhibitory manner – that is dopamine is released from the hypothalamus to decrease prolactin secretion. All other hormones depend on a stimulation signal from the hypothalamus to be synthesized and released. This explains why severing of the HPA axis, prolactin levels will increase, whereas other hormone levels will decrease.
When prolactin is secreted, it stimulates milk production in the mammary glands. During pregnancy elevated estrogen acts on the anterior pituitary to further increase prolactin secretion, preparing the mammary glands for breastfeeding. However, progesterone levels are also elevated, which act at the level of the breast to inhibit prolactin. This is the reason milk secretion does not begin until after birth, because postpartum physiology results in drastically decreased levels of progesterone, resulting in loss of prolactin inhibition.
In primary hypothyroidism, TRH will elevate in attempts to increase TSH levels. TRH can act on the anterior pituitary to increase prolactin levels. Anti-psychotics are dopamine antagonists, meaning the usual inhibitory hormone is lost – resulting in elevated prolactin. In either of the above scenarios in addition to several others (prolactinoma, for example) hyperprolactinemia will be present. Elevated prolactin results in inhibition of GnRH, decreased pulsation leads to decreased levels of FSH and LH. Commonly exhibited symptoms include amenorrhea and infertility in both males and females.
Thyroid stimulating hormone (thyrotropin) (TSH) – TSH is synthesized and released from cells within the anterior pituitary gland, known as thyrotrophs. This hormone is composed of two subunits, 1 alpha, and 1 beta. TSH is one of the four hormones which share the same alpha unit, the beta unit is what makes TSH unique and determines its specificity within the human body. Due to the physiologic effects of thyroxine (T4) and triiodothyronine (T3), these two hormones will help tightly control the levels of TSH released into the body. Minute increases in serum T3 and T4 will result in TSH inhibition, conversely, small decreases in serum T3 and T4 result in increased TSH. T3 and T4 levels will also work to increase/decrease TRH through a negative feedback look, another mechanism for modulating TSH levels. TSH levels will slowly change depending on several factors, such as initial TSH level, the hormone is given (T3 or T4), and the dose of hormone given. A higher TSH level will take longer to decrease and will gradually decline over several days. TSH levels will respond faster to T3 than T4. Additionally, when given a higher dose, TSH will respond more rapidly. If high doses of T3 are administered TSH levels will begin to decline over the course of several hours in hypothyroid patients. Other inhibitors of TSH include somatostatin, dopamine, and glucocorticoids. Dopamine can cause a rapid decrease in TSH levels, and accordingly dopamine antagonists can acutely raise TSH levels. Patients in the intensive care unit (ICU) often have altered TSH levels when receiving dopamine or dopamine antagonists. TSH is one of four endocrine hormones (hCG, TSH, LH, FSH) that all share same the same alpha unit. There are pathologic states, such as choriocarcinoma, where the severe elevation of hCG leads to symptoms of hyperthyroidism because TSH receptors bind hCG as a result of the shared alpha unit.
TSH is an extremely important hormone for the thyroid. It stimulates each step in hormone synthesis within the thyroid, affects the expression of multiple genes and can cause thyroid hyperplasia or hypertrophy. Action begins when TSH binds to a plasma membrane receptor, activating adenylyl cyclase which increases cyclic adenosine monophosphate (cAMP), resulting in activation of several protein kinases. Via the same receptor, TSH stimulates phospholipase C, increasing phosphoinositide turnover, protein kinase C activity, and intracellular calcium concentration. How the above steps specifically link to T3, and T4 synthesis, release and other thyroid metabolic processes are not fully understood.
Growth hormone (GH) is a hormone synthesized by pituitary somatotroph cells. It has five distinct genes which influence the final spliced mRNA hormone. The predominant form is a 22 kDa GH; the other form is a 20 kDa GH (only 10%). Many factors influence the production and release of GH, the two primary factors being GHRH and somatostatin – stimulating and inhibiting, respectively. However, gender, age, nutrition, and insulin-like growth factor-1 (IGF-1) all modulate GH levels. Its production begins in the fetus. Maternal GH levels will actually decline due to the increasing placental GH which replace maternal levels. GH levels peak during puberty, the time of extensive growth, at about 150 mcg/kg. As aging continues GH levels declines, paralleling the decline in body mass index. Every seven years GH levels decrease by about 50%, by the age of 55 years GH levels will be roughly 25 mcg/kg. GH release is pulsatile – suspected from the reduced tonic inhibition of somatostatin, and possibly bursts of GHRH. Each day there are ten pulsations, lasting 90 minutes, each one separated by 128 minutes. As previously mentioned, gender influences GH levels. In men, GH pulsations are more notable, whereas in women the GH secretion appears to be more continuous. Peak GH secretions occur within one hour of deep sleep onset. The average nighttime serum GH level is 1.0 ± 0.2 ng/mL. In contrast, average daytime GH levels are only 0.6 ± 0.1 ng/mL. IGF-1, leptin, age, obesity, and hyperglycemia are all factors which act to inhibit GH release. Conversely, ghrelin, insulin-induced hypoglycemia, estrogen, dopamine, alpha-adrenergic agonists, and beta-adrenergic antagonists all stimulate GH. While many different factors modulate GH levels, it is important to remember that ultimately GH levels will be primarily determined by GHRH and somatostatin.
Upon GH binding its receptor, primarily found in the liver, a phosphorylation cascade is activated involving the JAK/STAT pathway. The prevailing action is to stimulate the liver to synthesize and secrete IGF-1. IGF-1 is an extremely critical protein induced by GH and is believed to be responsible for most of the growth properties of GH. Some of the specific effects of GH include: stimulation of linear growth in children, increased lipolysis, increased protein synthesis, retention of phosphate, sodium, and water, and antagonism of insulin. Again, most of these actions are believed to be from GH in tandem with IGF-1.
Adrenocorticotrophic hormone (ACTH) is a hormone secreted from the anterior pituitary in response to CRH. ACTH travels through the systemic circulation to act upon the adrenal glands, specifically, the zona fasciculata and zona reticularis of the adrenal cortex. ACTH primarily acts directly in the zona fasciculata to release cortisol. ACTH stimulates the enzyme cholesterol desmolase, which is the first enzyme involved in converting cholesterol into one of the several steroid hormones. ACTH also stimulates androgen production in the zona reticularis, a byproduct of cortisol synthesis (see adrenal androgens below for more information).
Melatonin is a hormone synthesized within the pineal gland from the amino acid tryptophan. Tryptophan is hydroxylated and then decarboxylated to form 5-hydroxytryptamine or serotonin. When there is sunlight, serotonin is stored within pinealocytes, making it unavailable to monoamine oxidase – the enzyme which converts serotonin to melatonin. In the absence of light, sympathetic input increases causing a release of epinephrine. This causes the serotonin within pinealocytes to be released. Simultaneously, norepinephrine activates monoamine oxidase, serotonin-N-acetyltransferase, and hydroxyindole-O-methyltransferase. The result is a rapid increase in melatonin from 2 to 10 pg/mL to 100 to 200 pg/mL. Melatonin is highly lipid soluble, allowing it to diffuse freely across cell membranes and the blood-brain barrier. Its release sends messages throughout the body, primarily the brain, affecting synthesis of secondary messengers. Melatonin has three receptors identified M1, M2, and M3. All three express within the suprachiasmatic nucleus (SCN) of the hypothalamus. The three receptors are expressed variably depending on the tissue. However, within the SCN M1 will inhibit SCN neuron firing during nighttime. Additionally, M2 within the SCN inhibits SCN’s circadian rhythm. These effects may contribute to the sleep-promoting effects of melatonin. M1 and M2 are easily desensitized, which is why when exogenous melatonin is given chronically higher doses may be required to achieve the same effect. The melatonin cascade primarily influences sleep and circadian rhythms. Melatonin is suspected to be one of the primary drivers of sleep induction and maintenance due to its marked increase in the evening. The circadian rhythm, as alluded to earlier, is characterized by the low daylight melatonin levels and markedly increased levels at night – peaking between the hours of 11 PM to 3 AM – rapidly decreasing again before the hours of sunrise. Light from the environment has strong links with circadian rhythm; however, when people reamin in a dark room for several days, the rhythm will persist. Additionally, if a person travels across time zones to a new location where the sun rises and sets at different hours, the circadian rhythm will not change immediately. Melatonin is not produced in significant amounts in other areas of the body – post-pinealectomy humans will have virtually no melatonin and complete lack of circadian rhythm. These findings indicate the importance of melatonin in circadian rhythms and sleep induction and maintenance.
General T3/4 actions – thyroid hormones are crucial throughout the entire life of an individual. In childhood development, thyroid hormones help develop several body systems, particularly the brain. In adulthood, the thyroid hormones help drive metabolic activity and function of nearly all organs. Since it is necessary for so many different systems a constant supply of thyroid hormone is required, yet the total serum levels are always tightly controlled, if not pathology will occur. Two mechanisms control the production of thyroid hormones. The first is through hormonal pathways and negative feedback loops. Levels of TRH, TSH, T4, and T3, will signal the thyroid whether to increase or decrease thyroid hormone levels. The second is via hormone consumption by extrathyroidal tissues based on nutritional, hormonal, and illness-related factors – the effect varies depending on the tissue. The first mechanism helps protect the thyroid from hyper/hypo-secreting and the second mechanism helps respond to rapid changes within the tissue. As previously mentioned in the TSH section, there are two thyroid hormones, T3 and T4. However, before either hormone can begin synthesis Iodide must be oxidized to iodine and incorporated into tyrosine residues within the colloid. Iodide is an essential ion in thyroid physiology and will be discussed again in pathophysiology. The remaining steps of hormone synthesis include combining two diiodotyrosine (DIT) molecules to make T4 or combining one monoiodotyrosine and one DIT to create T3. Thyroglobin is a glycoprotein that incorporates into exocytotic vesicles which fuse to the apical cell membrane – only when these steps have occurred can iodination and coupling of T4 and T3 happen. To release these hormones into the extracellular fluid and eventually circulation, thyroglobulin must be resorbed into the thyroid follicular cells to create colloid droplets. These colloid droplets fuse with lysosomes to create phagolysosomes – which allow hydrolyzation of the thyroglobulin allowing hormone secretion.
Most T4 (99.95%) and T3 (99.5%) is bound within the bloodstream, preventing it from being metabolically active. The proteins that bind T4 and T3 listed in most common to least common is as follows: thyroxine-binding globulin (TBG), transthyretin (TTR), albumin, and lipoproteins. The remaining 0.02 percent of free T4 leaves only 2ng/dL within the body. Similarly 0.05 percent T3 leaves only 0.4 ng/dL. Since most T4 and T3 is bound within the serum, changes in serum concentrations of binding proteins result in drastic effects on serum total T4 and T3. However, changes in binding proteins do not affect the free hormone concentrations or the rate T4, and T3 gets metabolized.
Thyroxine (T4) - T4 is less metabolically active and produced exclusively within the thyroid. The daily production rate is 80 to 100 mcg and degraded at roughly 10% per day. Approximately 80% is deiodinated – of this, 40% converts to T3, the other 40% converts to reverse T3 (rT3). The final 20% conjugates to tetraiodothyroacetic. The conversion of in the periphery of T4 to T3 is mediated via the enzyme 5’-deiodinase. T3 is the primary metabolite of T4 which has physiologic activity; other T4 metabolites are inactive. This conversion process is regulated in extrathyroidal tissue. Thus, T3 production may change independently of the pituitary-thyroid state.
Tri-iodothyronine (T3) – T3 is the primary metabolic hormone from the thyroid and is the driver behind metabolic and organ processes. About 80% of T3 production is in extrathyroid tissue from deiodination of T4. The remaining 20% gets synthesized within the thyroid. Daily production is 30 to 40 mcg, but the extrathyroidal reserve of T3 is roughly 50 mcg. The fraction of T3 produced throughout the body from T4 varies considerably from tissue to tissue. Certain tissues like the anterior pituitary and liver contain high levels of T3 nuclear receptors, making them more responsive to serum T3.
T3 acts by modifying gene transcription. Due to the wide-reaching effects of T3, it affects nearly all tissues ability to synthesize protein and turnover substrate. The nuclear actions of T3 will depend on four factors: availability of hormone, thyroid hormone nuclear receptors (TRs), availability of receptor cofactors, and DNA regulatory elements. Within most tissue T3 enters by simple diffusion, however, in the brain and thyroid T3 is actively transported into cells. Depending on the tissue T3 will have different actions, which is determined by local production of T3 and the quantity and distribution of TR isoforms. The isoforms consist of TR-alpha-1 and 2 and TR-beta-1,2, and 3. There are insufficient studies on the TR isoforms, but due to regional or cell-specific distributions of the TRs, it is suggestive of different functions even within the same tissue. For example, TR-alpha is the dominant isoform in the brain, but TR-beta-2 is present in very high levels within the hypothalamus and pituitary. The data that does exist for TR isoforms comes primarily from knockout mice with TR gene point mutations. Mice with TR-alpha deletion show poor feeding and growth, slowed heart rate, low basal body temperature, and reduced bone mineralization. Mice with inactivation of the TR-beta gene showed indications of inappropriately normal serum TSH levels, high serum T4 concentrations, and thyroid gland hyperplasia. Finally, knockout mice without both TR-alpha and beta genes showed thyroid hyperplasia and markedly high serum concentrations of T4, T3, and TSH – which were 11 times, 30 times, and 160 times greater than normal, respectively.
As previously mentioned, T3 binds to TR on the nucleus resulting in modulation of gene expression. All genes affected have specific DNA sequences which bind TR with high affinity. Ultimately, the human genome project provided data which allows specific DNA sequences to be identified, without these specific DNA sequences T3-dependent gene activation will be minimal or absent completely.
Within the periphery, different tissues have one of 3 deiodinases which convert the prohormone T4 to active T3. Of which three enzymes will be expressed depend on a specific pattern of development and tissue type.
It is well known that T4 and T3 have wide-reaching effects and can influence nearly every organ system within the body; specifically, three major areas include bones, heart, and metabolism regulation.
Parathyroid hormone (PTH) – PTH is the primary regulator of calcium and phosphate homeostasis in the human body. PTH gets synthesized as pre-pro-PTH which is 115 amino acids long. Within parathyroid cells, it is cleaved to pro-PTH, 90 amino acids, and finally to PTH, 84 amino acids. The 84 amino acid version of PTH is the primary stored, secreted and active form of the hormone. The short-term control of serum calcium is mediated exclusively by PTH. On a long-term basis, PTH is responsible for converting calcidiol to calcitriol, which occurs within renal tubular cells.
PTH is quickly cleared from the bloodstream by the kidney and liver. Intact PTH only has a half-life of 2-4 minutes. It is cleaved into active amino fragments (PTH 1-34) and inactive carboxyl fragments. Since PTH primarily controls calcium levels, calcium will regulate the amount of PTH released, synthesized, and degraded. In a hypocalcemic state, PTH degradation decreases and the opposite is true during hypercalcemia. Changes in serum ionized calcium concentrations as small as 0.1 mg/dL will result in increased/decreased PTH depending on the direction calcium shifts. These minute changes are sensed by extremely sensitive calcium-sensing receptors (CaSR) which occur on the surface of parathyroid cells. At baseline CaSR’s are activated via guanine nucleotide binding proteins which use a variety of secondary messengers (intracellular calcium, cAMP, or inositol phosphates) to inhibit PTH. When CaSR’s deactivate during times of hypocalcemia parathyroid cells are stimulated to release PTH. CaSR mediates the following actions of PTH: exocytosis of PTH into the bloodstream (seconds to minutes), decreases the intracellular breakdown of PTH (minutes to an hour), increase PTH gene expression (hours to days), proliferate parathyroid cells (days to weeks). While calcium is the main driver of PTH, other molecules impact PTH release as well; they include extracellular phosphate, calcitriol, and fibroblast growth factor 23 (FGF23).
The primary receptor for PTH, known as PTH1R, will bind and respond to PTH, PTH-related protein (PTHrP), and PTH1-34. The receptor is expressed heavily in bone and kidney, but may also be present in breast, heart, skin, pancreas, and vascular tissue. When PTH1R is activated multiple intracellular signaling pathways (cAMP, phospholipase C pathway, protein kinase C, and intracellular calcium) help mediate the effects of PTH. The biologic actions of PTH include: increased bone resorption (within minutes), increased GI absorption of calcium, mediated by calcitriol (24 hours or more [PTH stimulates the hydroxylation of calcidiol to calcitriol]), and decreased urine excretion of calcium (within minutes). Diving a little deeper into the actions of PTH on the bone, two primary phases mediate the increase in calcium. First, PTH mobilizes calcium from skeletal stores almost immediately. Second, as previously mentioned PTH increases bone resorption which results in the release of calcium and phosphate (these actions are not immediate). Finally, the kidney reabsorbs calcium via different mechanisms depending on the region of the nephron in which reabsorption is occurring. For example, in the proximal tubule calcium is passively reabsorbed via favorable electrical gradients, in comparison to the distal nephron where calcium is actively reabsorbed. The net effect of these simultaneous pathways is the increase of calcium, helping return the body to a homeostatic level.
Insulin – Either directly or indirectly insulin affects the function of all tissue; however, these next few paragraphs will focus in on the metabolic effects of the three organs: adipose tissue, muscle, and the liver – which is most responsible for energy storage. Insulin is a 51-amino acid peptide which is synthesized and secreted by the beta cells of the pancreas. Its action begins when it binds a cell membrane heterotetrameric receptor. The receptor has two alpha subunits which function to bind insulin, the two beta subunits which transduce the signal. Through a cascade of cell signaling insulin is a powerful regulator of metabolic action. When there is a breakdown in cell signaling, resistance or decrease in insulin, many different pathologies can occur – see pathology section for more information. There are several factors which may act to either further stimulate insulin release or inhibit. Glucose, mannose, leucine, and vagal stimulation will all increase insulin secretion. Alpha-adrenergic effects, somatostatin, and several drugs can inhibit insulin secretion.
One of the primary functions of insulin is to control glucose levels. Glucose can be attained from three sources: gluconeogenesis, oral intake, and glycogenolysis. Once glucose is inside cells one of two things will occur – it can be stored as glycogen, or it may undergo glycolysis and convert to pyruvate. Insulin modulates what happens to glucose in a few different ways, such as: stimulate glycogen synthesis, increase glucose transport into muscle and adipose, inhibit glycogenolysis and gluconeogenesis, and increase glycolysis in muscle and adipose. While most tissues can produce glucose within its cells, only the kidney and liver possess glucose-6-phosphatase which is needed to release glucose into the blood. The liver produces 80 to 90% of glucose in patients without glucose related pathology, making the liver the primary target for insulin. Through several different pathways, insulin acts upon the liver, both directly and indirectly. Directly, insulin inhibits hepatic glycogen phosphorylase, the glycogenolytic enzyme, thereby inhibiting glucose output. Indirectly, insulin decreases the flow of glucose precursors along with decreased glucagon secretion. A study of insulin infusion into dogs demonstrated the primary effects of insulin on the hepatic glucose were a result of the direct insulin pathway. However, with the infusion of very large amounts of insulin the indirect effect became more predominant.
Utilization of glucose is possible through cellular uptake which is made possible by glucose transporters, GLUT-1,2,3,4 and 5. GLUT-4 is the primary transporter in muscle and adipose; it resides within the cytoplasm until an insulin signal causes translocation to the cell membrane. When the body is in a euglycemic state, the majority of glucose uptake, which is mediated by insulin, will occur in muscle. Less than 10% of glucose is taken up by adipose tissue, which is primarily due to insulin inhibiting lipolysis. Muscle will get a majority of the glucose because when free fatty acids are not available, increased glucose uptake is required to supply muscle tissue. Insulin optimizes glycolysis in muscle by catalyzing the glycolytic pathway by increasing hexokinase and 6-phosphofructokinase activity.
As previously mentioned, in euglycemic states insulin inhibits lipolysis. After a meal, insulin will promote triglyceride storage in adipose cells. This is mediated via three primary mechanisms. First, insulin increases the clearance of chylomicrons rich in triglycerides by increasing lipoprotein lipase. However, insulin only stimulates the expression of lipoprotein lipase in adipose tissue, in muscle insulin actually inhibits lipoprotein lipase, resulting in triglyceride storage. The second mechanism is via insulin-stimulated re-esterification of fatty acids into triglycerides in adipose cells. Finally, the third mechanism is by insulin inhibiting lipolysis. The overall effect of fat metabolism by insulin is to potently reduce hepatic gluconeogenesis and hepatic glucose release by blocking the supply of fatty acids to the liver.
Ketone and insulin dynamics – Under physiologic states which result in deficient insulin levels, such as prolonged fasting or uncontrolled diabetes mellitus, fat is mobilized to meet metabolic demands. The liver is unable to handle all the fatty acids which are being shuttled its way, resulting in ketone body production. This is a result of incomplete beta-oxidation of the long-chain fatty acids which are oversupplied to the liver. Ketoacids can be employed as fuel in extrahepatic tissue, such as skeletal muscle and the heart. However, under very prolonged periods of fasting the brain will also use ketoacids for energy. Insulin acts to keep the levels of ketone bodies low; it potently drops circulating levels through three main mechanisms. First, insulin inhibits lipolysis, so the fatty acids which are needed to make ketone bodies are not available. Second, insulin will act within the liver to directly inhibit ketogenesis. Thirdly, insulin helps increase the peripheral clearance of ketone bodies.
Protein metabolism and paracrine effects – As previously mentioned insulin inhibits gluconeogenesis, this keeps amino acids readily available for protein synthesis. Insulin expedites the transportation of amino acids into the liver and skeletal muscle. In addition, insulin also escalates the amount and efficiency of ribosomes. Lastly, insulin inhibits protein breakdown; roughly 40% of proteolysis is influenced by insulin. The net result is increased protein synthesis.
Insulin has many influences on other hormones within the body. The pancreatic islet cells have alpha, beta, and delta cells. Alpha secretes glucagon, beta secrets insulin, and delta secretes somatostatin. When these hormones get secreted, they have paracrine effects on the surrounding cells. Insulin specifically will reach alpha cells first and inhibit the release of glucagon, which causes an increased effect of its metabolic actions. In hyperglycemic states, somatostatin will also be secreted, which also inhibits alpha cells from releasing glucagon to reduce glucose levels.
Insulin has other functions outside of energy metabolism which are important for the clinical setting, as abnormal responses to insulin can lead to several different pathologies. Insulin impacts steroidogenesis, fibrinolysis, vascular function, and growth.
Glucagon – glucagon is a 29 amino acid peptide which is secreted from the alpha cells of the islets of Langerhans. It acts in strong opposition of insulin, functioning to increase glucose levels within the body. Ingestion of protein, hypoglycemia, and exercise are all examples of when glucagon will be secreted to raise glucose levels. In the insulin section, there was discussion regarding insulin inhibiting glucagon secretion, but other facts will also inhibit its release, such as ingesting carbohydrates. Glucagon can raise glucose levels within the body by increasing glycogenolysis, the end product being glucose. It also promotes gluconeogenesis, which is the production of glucose by using precursor molecules like amino acids and glycerol within the liver.
The adrenal gland is located just above the kidney and is a very diverse organ in terms of hormone production. It produces aldosterone, cortisol, DHEA, norepinephrine, and epinephrine. Depending on the layer of the adrenal a different hormone will be produced. The cortex has three layers: zona glomerulosa, zona fasciculata, and zona reticularis – which secrete aldosterone, cortisol, and DHEA, respectively. The medulla of the adrenal gland is composed of chromaffin cells and is responsible for synthesizing norepinephrine and epinephrine. The molecules which stimulate, the hormones secreted and their effects will be discussed below.
Cortisol is a glucocorticoid hormone synthesized in the zona fasciculata of the adrenal gland and is stimulated by ACTH. It is an important hormone, which when found in abnormal physiologic levels can lead to several different pathologies. Cortisol primarily acts to increase glucose levels in the body, which occurs via increased gluconeogenesis, lipolysis, and proteolysis. To keep glucose levels high, cortisol also has properties which increase the resistance to insulin, which is why high levels of cortisol can lead to diabetes mellitus. Since cortisol is a glucocorticoid, it has additional properties, which are why it has use as a medication in hospitalized patients. It can increase appetite, raise blood pressure, decrease bone formation, and most importantly – decrease inflammatory and immune responses. Cortisol has a negative feedback loop which acts on the hypothalamus, anterior pituitary, and adrenal gland to inhibit the release of CRH, ACTH, and cortisol, respectively.
Aldosterone – Aldosterone is a crucial mineralocorticoid hormone in the renin-angiotensin system (RAS) – which is important for the regulation of cardiac, renal and vascular physiology. The RAS pathway begins with renin cleaving angiotensinogen into the inactive angiotensin I, which is converted by angiotensin-converting enzyme (ACE) into angiotensin II (primarily in the lungs). Angiotensin II mediates aldosterone release from the zona glomerulosa of the adrenal gland via angiotensin II type 1 receptors (AT1Rs). The RAS pathway is the primary aldosterone stimulus; however, the adrenal gland will produce small levels of angiotensin II, ACTH from the anterior pituitary, and potassium will all stimulate aldosterone release. The main action of aldosterone takes place in the kidney, where it will increase the expression of sodium channels on the epithelium within the distal tubule. This, in turn, increases sodium reabsorption, and as a result, water too, while secreting potassium. The result is an increase in extracellular fluid volume, decreased serum potassium, and increased blood pressure. Previously, primary aldosteronism was thought to be a rare cause of hypertension. However, studies over the last 15 years have shown the prevalence to be much higher. Initial workup for primary aldosteronism involves measuring renin: aldosterone ratios, helping guide what further workup is necessary for patients suspected of the disease.
Adrenal Androgens are primarily dehydroepiandrosterone (DHEA) and DHEA sulfate. The production of these androgens within the adrenal gland is a byproduct from the synthesis of cortisol. As a result, the primary stimulant of DHEA and DHEA sulfate is ACTH. These two hormones have an extremely limited if any, inherent androgenic properties. However, it is well established that the excess secretion of DHEA and DHEA sulfate are hallmarks of congenital adrenal hyperplasia (CAH). A small percentage will be converted to androstenedione, then to testosterone (and potentially estrogen) in both the adrenals and peripheral tissue. Once this conversion has occurred, physiologic effects of androgens will occur (see endocrine sex hormones for more information). Therefore, it is not DHEA and DHEA sulfate which causes virilization in young females, rather the elevated levels are converted to more potent androgens which cause the classic phenotype seen in CAH.
Normally, in both genders, DHEA and DHEA sulfate rise throughout puberty and for a couple of years post-puberty. Levels peak in the third decade before gradually declining, by the age of 80 adrenal androgens are about 25% compared to levels at the age of 25 years old. The significance of this finding (also known as adrenopause) is not known. In males, testosterone from the adrenal gland is less than 5%. However, in women, the total amount of serum testosterone derived from DHEA and DHEA sulfate is significantly higher. In the menstrual cycle, specifically the follicular phase, 65% of the testosterone production comes directly or indirectly from adrenal androgens.
Epinephrine (adrenaline) & Norepinephrine (noradrenaline) – these two hormones will be discussed together since they are both produced from the medulla of the adrenal glands and have many similarities. This discussion will begin by explaining the different effects that stimulation of alpha-1, beta-1, and beta-2 receptors. By understanding what happens when certain receptors are activated it will be easier to understand the effects of epinephrine and norepinephrine. In clinical settings, epinephrine and norepinephrine have several different uses depending on dose, and patient indication.
Epinephrine will bind and stimulate all three receptors, the predominance of the receptor affected depends on the dose administrated. At lower doses the beta receptor action predominates, resulting in increased cardiac output (CO), from the inotropic and chronotropic effects of beta-1. The stimulation of alpha-1 which would usually cause vasoconstriction is offset by vasodilation of beta-2. The result of all three receptors being stimulated is increased CO, decreased, SVR, and variable effect on the MAP. High dose epinephrine results in predominant alpha-1 stimulation. This results in increased SVR and CO. Epinephrine is released into the bloodstream under times of great stress, like “fight or flight” scenarios, or simply stress from life (school, sports, etc.). Strong emotions, including anger or fear can also stimulate secretion, it was aptly named adrenaline because when you need a surge of energy (facilitated by the above physiologic effects) epinephrine is released.
Norepinephrine has action on both alpha-1 and beta-1 receptors, with the predominant action coming from alpha-1 stimulation. As a result, there is potent vasoconstriction and a mild increase in CO. A mild chronotropic effect is noted, but due to the reflex bradycardia from increased MAP, the effect is canceled. Norepinephrine is often secreted in tandem with epinephrine because the stressors which would induce epinephrine also cause a release of norepinephrine. However, there are times when these two hormones will be secreted independently of each other. Norepinephrine and epinephrine have other functions; however, these are outside the scope of endocrine hormones and will not be discussed here.
Endocrine Sex Hormones
Endocrine sex hormones due to their intricate and overlapping properties in both genders will be explained and discussed from a gender standpoint, rather than by organ. Each of the sex hormones is expressed and active in both male and females, it is the levels and concentrations which help develop and define the external and internal function of the human body. Studies and patient cases have shown mutations in classical male hormones or classical female hormones can still lead to pathology when absent in either gender.
Female Sexual Development and Hormone Expression and Activity
Physiologist Alfred Jost formulated a simple model of normal sexual development. Chromosomal sex (XX or XY) dictates gonadal sex, which in turn determines phenotypic sex (male or female). Based on this module three interdependent yet sequential steps must occur. First, the establishment of the chromosomal sex, within the first six weeks of gestation male and female development is identical. After six weeks the gonad will develop into the appropriate tissue, testes if male or an ovary if female. The testes will begin to secrete hormones around week six; the ovary is hormonally silent. Finally, at week 12 the male phenotype will be complete, the female occurs a little later than males. The anatomic structures include both the internal urogenital tract – Müllerian or Wolffian ducts – and external genitalia. The female Müllerian ducts become the upper vagina, fallopian tubes, and uterus. The external genitalia has three common structures: genital folds, genital swellings, and genital tubercles. Depending on the hormones secreted by the gonads will determine the structure. In the male, genital folds elongate and fuse to make the shaft of the penis and urethra, the genital tubercle becomes the glans penis, and the genital swellings become the scrotum. Conversely, in females, genital folds become the labia minora, genital swellings become the labia majora, and the genital tubercle becomes the clitoris. In abnormal development when gonads are absent, phenotypic development will be female. This suggests the default development of a fetus will be female unless influenced by androgens. It is unknown if female development is dependent on hormones since gestation occurs in a female body. To date, there is no method for isolating hormones within the fetus to determine if their role is crucial for female development.
The menstrual cycle divides into two phases, follicular and luteal, which are determined by endocrine hormones which drive the cycle.
Females only have a limited number of ovulation cycles before eventually going through menopause, which is caused by the decline in the number of ovarian follicles. The definition of menopause is amenorrhea for 12 months and typically happens around age 50. The lack of ovarian follicles result in decreased estrogen – extremely elevated levels of FSH mark this condition. This is a result of the loss of the negative feedback loop because estrogen is no longer present to inhibit FSH. Estrogen is important for the development of secondary sex characteristics as well as the reproductive cycle. The action of estrogen is facilitated via estrogen receptors (ER). There are two ER molecules, ER-alpha and ER-beta. When estrogen penetrates a cell and makes it to the nucleus, it binds the ER and ultimately modulates transcriptional rates of genes responsive to estrogen. In females, if estrogen is not present and able to bind ER properly there will be a lack of sexual development, delayed epiphyseal closure, low bone density, and infertility.. Other health concerns have implications with low estrogen function, such as cardiovascular responsiveness, insulin resistance, and obesity; however, more research is needed. In females, secondary sex characteristics develop via stimulation of ERs which cause upregulation of genes, leading to changes in body habitus. For example, binding of ER-alpha in the mammary gland stimulates bud formation. Progesterone and estrogen are both required for normal breast duct formation via stimulation of ERs and Progesterone receptors (PRs). The rate of cell proliferation in lobular structures of the breast is directly proportionate to the level of PRs and ERs in the tissue. In terms of fertility, females and males both rely on estrogen and its effects to properly reproduce. Similar to males, ER-alpha or ER-alpha and ER-beta deficient mice will be infertile, while ER-beta deficient mice are sub-fertile. Additionally, mice who lack aromatase are anovulatory, thus infertile. Testosterone also plays a significant role in the development of women, particularly in muscle, overall growth, reproductive tissue, and psychological behavior. It is known that supra or sub-physiologic levels result in deviation from typical female features; however, the degree to which testosterone impacts women is not fully understood.
Male Sexual Development and Hormone Expression and Activity
As mentioned previously in the female section, from an embryological standpoint the default development will be female. Males genetically are XY – the region on the Y chromosome critical to testicular development is the SRY (sex-determining region of the Y chromosome) gene. This is the gene causing neutral gonads to develop into testes. Fetal testes secrete three hormones: anti-Müllerian hormone (AMH), testosterone, and 5-alpha-dihydrotestosterone (DHT). AMH’s primarily causes the regression of the Müllerian ducts – testosterone and DHT (androgens) are the hormones on which we will primarily focus.
As previously discussed, GnRH causes the regulation of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). GnRH’s pulsatile secretions from the hypothalamus cause a similar pulsatile appearance of LH and FSH – the half-life of LH is significantly shorter than FSH. The secretion of GnRH acts upon the gonadotrophic cells of the anterior pituitary, resulting in the release of FSH and LH.
These are the primary roles of FSH and LH. In a broad overview it can be summarized: LH acts on Leydig cells to secrete testosterone and FSH acts on Sertoli cells to promote spermatogenesis. Testosterone, like all steroid hormones, originates from cholesterol. Once testosterone is produced, it can be metabolized further via aromatization to become estradiol or reduced by 5-alpha-reductase to DHT. Cells which have androgen receptors (AR), can be bound and activated by testosterone or DHT, the latter having a much higher binding affinity. Regardless of which molecule stimulates the AR, a conformational change is induced, allowing translocation to the nucleus. Within the nucleus, a homodimer forms by combining with a second hormone-AR molecule. This creates an active molecule which can bind to androgen response elements – inducing upregulation/downregulation of transcription genes and ultimately protein synthesis. The physiologic action of testosterone is mediated via the hormone itself and its active metabolites – DHT and estradiol, resulting in the following major functions in males:
development of the male phenotype in embryological development (as discussed above),
feedback communication on the gonadotropic hypothalamic-pituitary axis,
provocation of sexual maturity at puberty and maintenance throughout adulthood,
sexual function (libido, sexual satisfaction, and erectile function),
muscle and bone mass at puberty and throughout adulthood,
maintenance of lower fat mass, initiation and maintenance of spermatogenesis,
maintenance of erythropoiesis and hematocrit levels.
The negative feedback loop of LH secretion works via two mechanisms. Estradiol inhibits GnRH by inhibiting at the level of the hypothalamus, while testosterone and DHT inhibit the pituitary gland directly. The negative feedback loop of FSH is mediated via two molecules: inhibin B (testicular peptide) and estradiol – inhibin B being the more important regulatory molecule.
Estradiol is produced normally in men when testosterone undergoes aromatization, approximately 20% of estradiol synthesis is in the testes. The remaining 80% is produced in adipose, skin, brain, and bone tissue – adipose being the most notable site of estradiol production in men. When estradiol is deficient, men may have the following problems: increased body fat delayed epiphyseal closure, and decreased bone density. Rats and mice with ER-alpha deficiency have been studied and been shown to be infertile. The testes of these rodents which lack ER-alpha have dilated seminiferous tubules containing no sperm. ER-alpha is not necessary for sperm function, but it is necessary for sperm maturation. ER-alpha, ER-alpha, and ER-beta, or aromatase-deficient mice have been shown to have abnormal mating behavior. ER-beta only deficient mice will exhibit normal mating. While it is not fully understood, it is suspected ER-alpha and estradiol are necessary for normal mating and the aggressive behaviors seen in the male genotype.
Ghrelin – Classically considered the “hunger hormone” due to its stimulation of appetite. It is a 28 amino-acid peptide synthesized predominantly in the stomach, specifically the gastric fundus where oxyntic gland P/D1 cells are found. These cells come in two types. The open type has exposure to the lumen of the stomach and is secreted directly into the stomach to intermix with gastric contents. The closed type is found close to the lamina propria and is secreted directly into the vasculature. Ghrelin is also present in the pancreas, placenta, kidney, and pituitary, but at much lower levels. Ghrelin receptors (growth hormone secretagogue receptor [GHS-R]) has two forms: GHS-R1a and GHS-R1b. GHS-R1a is found in both the central nervous system and peripheral tissue and mediates food intake and satiety. GHS-R1b has a wider distribution, but its function is unknown since it has no links to the same G protein complex that GHS-R1a is. Ghrelin levels increase during fasting, starvation, and anorexia – surges are also noted prior to meals. Ghrelin is suppressed by nutrients, carbohydrates having the greatest inhibitory effect, followed by protein and lipids. The decrease in ghrelin occurs via nonvagal signals from the stomach and intestines.
Ghrelin stimulates primarily GH secretion, and possibly GHRH itself – further stimulating GH secretion. The resultant effect is increased appetite and a positive energy balance, in addition to the effects of GH (see GH section for more information). Ghrelin acts locally in the stomach to increase gastric contraction and potentiate stomach emptying. GH is known to affect bone formation and mass, but interestingly osteoblasts express GHS-R1a suggesting a possible direct effect. Defects in GHS-R have been linked to short stature, further implicating its impact on bone formation.
Ghrelin has been demonstrated to increase the frequency of meals, yet not the size of the meals. Ghrelin also plays a regulatory role in long-term body mass. In normal BMI ranges ghrelin levels are within 550 to 650 pg/mL. Whereas obese individuals have ranges of 200 to 350 pg/mL – indicating ghrelin has an inverse relationship with BMI. Ghrelin levels are highest in fasting, anorexic, and cachectic states – where levels on average exceed 1000 pg/mL. Decreased ghrelin levels, as seen in obese subjects, has been associated with gastritis (regardless of Helicobacter pylori presence).
Leptin – Conversely, leptin is classically considered the “satiety hormone” due to its suppression of appetite. It is a 167 amino acid protein produced from the ob gene and expressed primarily in adipocytes. It mediates its actions by binding leptin receptors (LEPRs), of which six isoforms exist LEPR-a, to LEPR-f. The longest form is LEPR-b is found in many organs, but importantly it is found in the brain – specifically the hypothalamic and brainstem nuclei. Mutations in this isoform result in severe obesity.
Individuals within normal BMI ranges have shown to decrease food intake when leptin levels increase. In obese patients, the response to leptin is blunted, even with administration of exogenous leptin at supraphysiologic levels. The percentage of body fat correlates directly with leptin production and circulation. Overeating increases leptin levels by roughly 40% in just 12 hours. In comparison, fasting results in decreased leptin levels by 60 to 70% in 48 hours and can reach up to 80% in 72 hours. With regular food ingestion, leptin communicates with adipose tissue, and on the basis of body adipose percentage, adipocytes will secrete leptin accordingly. Leptin is influenced by gender since hormones influence its secretion rates. In females, estrogen increases levels of leptin, and interestingly the placenta and breast milk are sources of leptin. In males, androgens decrease the level of serum leptin. There also exists a link between nutrition and immune function mediated by leptin. In subjects with low leptin levels (as seen in prolonged starvation or cachexia) have Th1/Th2 imbalance, low CD4 counts, and decreased T-cell production. Lastly, leptin has both direct and indirect effects on bone. However, studies have both concluded a positive and negative correlation between leptin concentration and bone density. Currently, it is unclear what effect leptin has on bone and is an area of ongoing research.
Understanding how hormones interact with each other to tightly maintain the body within strict limits of homeostasis is imperative. With a firm grasp of endocrine physiology, pathology often becomes straightforward. When a hormone is either elevated or decreased it will present a certain way – due to its lack or excess of action; this allows providers to hone in their differential diagnosis, order the appropriate laboratory tests and imaging, to pinpoint the diagnosis and provide treatment. This diagnosis is not always as easy as it sounds since hormones are often intricately related and may influence other hormones, which are the primary presenting symptoms. For example, when prolactin is elevated, GnRH is inhibited, resulting in amenorrhea and infertility because of low FSH and LH levels. It may be tempting to focus only on the reproductive organs or their hormones for not functioning correctly when actuality hyperprolactinemia is the culprit. Rarely one has to consider hormone resistance syndromes when this is a discrepancy between elevated hormone levels and target organ function, i.e., receptor defects such as nephrogenic diabetes insipidus and pseudohypoparathyroidism, etc.
We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.
This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.
Click Your Answer Below
Would you like to access teaching points and more information on this topic?
Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.
Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.
Click Your Answer Below
Would you like to access teaching points and more information on this topic?
Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.
Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.
Click Your Answer Below
Would you like to access teaching points and more information on this topic?
Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.
Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.
Click Your Answer Below
Would you like to access teaching points and more information on this topic?
|Johnstone C,Hendry C,Farley A,McLafferty E, Endocrine system: part 1. Nursing standard (Royal College of Nursing (Great Britain) : 1987). 2014 May 27; [PubMed]|
|ACOG Practice Bulletin No. 107: Induction of labor. Obstetrics and gynecology. 2009 Aug; [PubMed]|
|Grotegut CA,Ngan E,Garrett ME,Miranda ML,Ashley-Koch AE,Swamy GK, The association of single-nucleotide polymorphisms in the oxytocin receptor and G protein-coupled receptor kinase 6 (GRK6) genes with oxytocin dosing requirements and labor outcomes. American journal of obstetrics and gynecology. 2017 Sep; [PubMed]|
|Sobhy SI,Mohame NA, The effect of early initiation of breast feeding on the amount of vaginal blood loss during the fourth stage of labor. The Journal of the Egyptian Public Health Association. 2004; [PubMed]|
|Dunn FL,Brennan TJ,Nelson AE,Robertson GL, The role of blood osmolality and volume in regulating vasopressin secretion in the rat. The Journal of clinical investigation. 1973 Dec; [PubMed]|
|Bie P,Secher NH,Astrup A,Warberg J, Cardiovascular and endocrine responses to head-up tilt and vasopressin infusion in humans. The American journal of physiology. 1986 Oct; [PubMed]|
|Goldsmith SR,Francis GS,Cowley AW,Cohn JN, Response of vasopressin and norepinephrine to lower body negative pressure in humans. The American journal of physiology. 1982 Dec; [PubMed]|
|Baylis PH, Osmoregulation and control of vasopressin secretion in healthy humans. The American journal of physiology. 1987 Nov; [PubMed]|
|Goldsmith SR, Vasopressin as vasopressor. The American journal of medicine. 1987 Jun; [PubMed]|
|Wetsel WC,Valença MM,Merchenthaler I,Liposits Z,López FJ,Weiner RI,Mellon PL,Negro-Vilar A, Intrinsic pulsatile secretory activity of immortalized luteinizing hormone-releasing hormone-secreting neurons. Proceedings of the National Academy of Sciences of the United States of America. 1992 May 1; [PubMed]|
|Schwanzel-Fukuda M,Bick D,Pfaff DW, Luteinizing hormone-releasing hormone (LHRH)-expressing cells do not migrate normally in an inherited hypogonadal (Kallmann) syndrome. Brain research. Molecular brain research. 1989 Dec; [PubMed]|
|Crowley WF Jr,Filicori M,Spratt DI,Santoro NF, The physiology of gonadotropin-releasing hormone (GnRH) secretion in men and women. Recent progress in hormone research. 1985; [PubMed]|
|Belchetz PE,Plant TM,Nakai Y,Keogh EJ,Knobil E, Hypophysial responses to continuous and intermittent delivery of hypopthalamic gonadotropin-releasing hormone. Science (New York, N.Y.). 1978 Nov 10; [PubMed]|
|Conn PM,Crowley WF Jr, Gonadotropin-releasing hormone and its analogues. The New England journal of medicine. 1991 Jan 10; [PubMed]|
|Pimstone B,Epstein S,Hamilton SM,LeRoith D,Hendricks S, Metabolic clearance and plasma half disappearance time of exogenous gonadotropin releasing hormone in normal subjects and in patients with liver disease and chronic renal failure. The Journal of clinical endocrinology and metabolism. 1977 Feb; [PubMed]|
|Skynner MJ,Sim JA,Herbison AE, Detection of estrogen receptor alpha and beta messenger ribonucleic acids in adult gonadotropin-releasing hormone neurons. Endocrinology. 1999 Nov; [PubMed]|
|Roy D,Angelini NL,Belsham DD, Estrogen directly respresses gonadotropin-releasing hormone (GnRH) gene expression in estrogen receptor-alpha (ERalpha)- and ERbeta-expressing GT1-7 GnRH neurons. Endocrinology. 1999 Nov; [PubMed]|
|Nieman LK,Cutler GB Jr,Oldfield EH,Loriaux DL,Chrousos GP, The ovine corticotropin-releasing hormone (CRH) stimulation test is superior to the human CRH stimulation test for the diagnosis of Cushing's disease. The Journal of clinical endocrinology and metabolism. 1989 Jul; [PubMed]|
|Garby L,Caron P,Claustrat F,Chanson P,Tabarin A,Rohmer V,Arnault G,Bonnet F,Chabre O,Christin-Maitre S,du-Boullay H,Murat A,Nakib I,Sadoul JL,Sassolas G,Claustrat B,Raverot G,Borson-Chazot F, Clinical characteristics and outcome of acromegaly induced by ectopic secretion of growth hormone-releasing hormone (GHRH): a French nationwide series of 21 cases. The Journal of clinical endocrinology and metabolism. 2012 Jun; [PubMed]|
|Lamberts SW,van der Lely AJ,de Herder WW,Hofland LJ, Octreotide. The New England journal of medicine. 1996 Jan 25; [PubMed]|
|Raulf F,Pérez J,Hoyer D,Bruns C, Differential expression of five somatostatin receptor subtypes, SSTR1-5, in the CNS and peripheral tissue. Digestion. 1994; [PubMed]|
|Broglio F,Papotti M,Muccioli G,Ghigo E, Brain-gut communication: cortistatin, somatostatin and ghrelin. Trends in endocrinology and metabolism: TEM. 2007 Aug; [PubMed]|
|Stengel A,Taché Y, Activation of somatostatin 2 receptors in the brain and the periphery induces opposite changes in circulating ghrelin levels: functional implications. Frontiers in endocrinology. 2012; [PubMed]|
|Schubert ML, Gastric secretion. Current opinion in gastroenterology. 2005 Nov; [PubMed]|
|Gonzaga MFM,de Castro LF,Naves LA,Mendonça JL,Oton de Lima B,Kessler I,Casulari LA, Prolactinomas Resistant to Treatment With Dopamine Agonists: Long-Term Follow-Up of Six Cases. Frontiers in endocrinology. 2018; [PubMed]|
|Jackson IM, Thyrotropin-releasing hormone. The New England journal of medicine. 1982 Jan 21; [PubMed]|
|Wu P,Lechan RM,Jackson IM, Identification and characterization of thyrotropin-releasing hormone precursor peptides in rat brain. Endocrinology. 1987 Jul; [PubMed]|
|Dyess EM,Segerson TP,Liposits Z,Paull WK,Kaplan MM,Wu P,Jackson IM,Lechan RM, Triiodothyronine exerts direct cell-specific regulation of thyrotropin-releasing hormone gene expression in the hypothalamic paraventricular nucleus. Endocrinology. 1988 Nov; [PubMed]|
|Magner JA, Thyroid-stimulating hormone: biosynthesis, cell biology, and bioactivity. Endocrine reviews. 1990 May; [PubMed]|
|Gómez F,Reyes FI,Faiman C, Nonpuerperal galactorrhea and hyperprolactinemia. Clinical findings, endocrine features and therapeutic responses in 56 cases. The American journal of medicine. 1977 May; [PubMed]|
|Tyson JE,Hwang P,Guyda H,Friesen HG, Studies of prolactin secretion in human pregnancy. American journal of obstetrics and gynecology. 1972 May 1; [PubMed]|
|Honbo KS,van Herle AJ,Kellett KA, Serum prolactin levels in untreated primary hypothyroidism. The American journal of medicine. 1978 May; [PubMed]|
|Snyder PJ,Jacobs LS,Utiger RD,Daughaday WH, Thyroid hormone inhibition of the prolactin response to thyrotropin-releasing hormone. The Journal of clinical investigation. 1973 Sep; [PubMed]|
|Groff TR,Shulkin BL,Utiger RD,Talbert LM, Amenorrhea-galactorrhea, hyperprolactinemia, and suprasellar pituitary enlargement as presenting features of primary hypothyroidism. Obstetrics and gynecology. 1984 Mar; [PubMed]|
|Grubb MR,Chakeres D,Malarkey WB, Patients with primary hypothyroidism presenting as prolactinomas. The American journal of medicine. 1987 Oct; [PubMed]|
|Van Herle AJ,Vassart G,Dumont JE, Control of thyroglobulin synthesis and secretion. (First of two parts). The New England journal of medicine. 1979 Aug 2; [PubMed]|
|Bianco AC,Kim BW, Deiodinases: implications of the local control of thyroid hormone action. The Journal of clinical investigation. 2006 Oct; [PubMed]|
|Bilezikian JP,Loeb JN, The influence of hyperthyroidism and hypothyroidism on alpha- and beta-adrenergic receptor systems and adrenergic responsiveness. Endocrine reviews. 1983 Fall; [PubMed]|
|Brent GA, Mechanisms of thyroid hormone action. The Journal of clinical investigation. 2012 Sep; [PubMed]|
|Mendoza A,Hollenberg AN, New insights into thyroid hormone action. Pharmacology [PubMed]|
|Brooks AJ,Waters MJ, The growth hormone receptor: mechanism of activation and clinical implications. Nature reviews. Endocrinology. 2010 Sep; [PubMed]|
|Ho Y,Liebhaber SA,Cooke NE, Activation of the human GH gene cluster: roles for targeted chromatin modification. Trends in endocrinology and metabolism: TEM. 2004 Jan-Feb; [PubMed]|
|Giustina A,Veldhuis JD, Pathophysiology of the neuroregulation of growth hormone secretion in experimental animals and the human. Endocrine reviews. 1998 Dec; [PubMed]|
|Toogood AA,Nass RM,Pezzoli SS,O'Neill PA,Thorner MO,Shalet SM, Preservation of growth hormone pulsatility despite pituitary pathology, surgery, and irradiation. The Journal of clinical endocrinology and metabolism. 1997 Jul; [PubMed]|
|Reutens AT,Veldhuis JD,Hoffman DM,Leung KC,Ho KK, A highly sensitive growth hormone (GH) enzyme-linked immunosorbent assay uncovers increased contribution of a tonic mode of GH secretion in adults with organic GH deficiency. The Journal of clinical endocrinology and metabolism. 1996 Apr; [PubMed]|
|Goldenberg N,Barkan A, Factors regulating growth hormone secretion in humans. Endocrinology and metabolism clinics of North America. 2007 Mar; [PubMed]|
|Frank SJ, Growth hormone signalling and its regulation: preventing too much of a good thing. Growth hormone [PubMed]|
|Leung KC,Waters MJ,Markus I,Baumbach WR,Ho KK, Insulin and insulin-like growth factor-I acutely inhibit surface translocation of growth hormone receptors in osteoblasts: a novel mechanism of growth hormone receptor regulation. Proceedings of the National Academy of Sciences of the United States of America. 1997 Oct 14; [PubMed]|
|Dickstein G,Shechner C,Nicholson WE,Rosner I,Shen-Orr Z,Adawi F,Lahav M, Adrenocorticotropin stimulation test: effects of basal cortisol level, time of day, and suggested new sensitive low dose test. The Journal of clinical endocrinology and metabolism. 1991 Apr; [PubMed]|
|Crowley S,Hindmarsh PC,Holownia P,Honour JW,Brook CG, The use of low doses of ACTH in the investigation of adrenal function in man. The Journal of endocrinology. 1991 Sep; [PubMed]|
|Axelrod J,Shein HM,Wurtman RJ, Stimulation of C14-melatonin synthesis from C14-tryptophan by noradrenaline in rat pineal in organ culture. Proceedings of the National Academy of Sciences of the United States of America. 1969 Feb; [PubMed]|
|Ozaki Y,Lynch HJ, Presence of melatonin in plasma and urine or pinealectomized rats. Endocrinology. 1976 Aug; [PubMed]|
|WURTMAN RJ,AXELROD J,POTTER LT, THE UPTAKE OF H3-MELATONIN IN ENDOCRINE AND NERVOUS TISSUES AND THE EFFECTS OF CONSTANT LIGHT EXPOSURE. The Journal of pharmacology and experimental therapeutics. 1964 Mar; [PubMed]|
|WURTMAN RJ,AXELROD J,PHILLIPS LS, MELATONIN SYNTHESIS IN THE PINEAL GLAND: CONTROL BY LIGHT. Science (New York, N.Y.). 1963 Nov 22; [PubMed]|
|AXELROD J,WEISSBACH H, Enzymatic O-methylation of N-acetylserotonin to melatonin. Science (New York, N.Y.). 1960 Apr 29; [PubMed]|
|Gerdin MJ,Masana MI,Rivera-Bermúdez MA,Hudson RL,Earnest DJ,Gillette MU,Dubocovich ML, Melatonin desensitizes endogenous MT2 melatonin receptors in the rat suprachiasmatic nucleus: relevance for defining the periods of sensitivity of the mammalian circadian clock to melatonin. FASEB journal : official publication of the Federation of American Societies for Experimental Biology. 2004 Nov; [PubMed]|
|Gerdin MJ,Masana MI,Dubocovich ML, Melatonin-mediated regulation of human MT(1) melatonin receptors expressed in mammalian cells. Biochemical pharmacology. 2004 Jun 1; [PubMed]|
|Lewy AJ,Wehr TA,Goodwin FK,Newsome DA,Markey SP, Light suppresses melatonin secretion in humans. Science (New York, N.Y.). 1980 Dec 12; [PubMed]|
|Lynch HJ,Jimerson DC,Ozaki Y,Post RM,Bunney WE Jr,Wurtman RJ, Entrainment of rhythmic melatonin secretion in man to a 12-hour phase shift in the light/dark cycle. Life sciences. 1978 Oct 16; [PubMed]|
|Di Cosmo C,Liao XH,Dumitrescu AM,Philp NJ,Weiss RE,Refetoff S, Mice deficient in MCT8 reveal a mechanism regulating thyroid hormone secretion. The Journal of clinical investigation. 2010 Sep; [PubMed]|
|Bassett JH,Williams GR, Critical role of the hypothalamic-pituitary-thyroid axis in bone. Bone. 2008 Sep; [PubMed]|
|Wojcicka A,Bassett JH,Williams GR, Mechanisms of action of thyroid hormones in the skeleton. Biochimica et biophysica acta. 2013 Jul; [PubMed]|
|Bartalena L, Recent achievements in studies on thyroid hormone-binding proteins. Endocrine reviews. 1990 Feb; [PubMed]|
|Engler D,Burger AG, The deiodination of the iodothyronines and of their derivatives in man. Endocrine reviews. 1984 Spring; [PubMed]|
|Spitzweg C,Heufelder AE,Morris JC, Thyroid iodine transport. Thyroid : official journal of the American Thyroid Association. 2000 Apr; [PubMed]|
|Marsili A,Zavacki AM,Harney JW,Larsen PR, Physiological role and regulation of iodothyronine deiodinases: a 2011 update. Journal of endocrinological investigation. 2011 May; [PubMed]|
|Vennström B,Mittag J,Wallis K, Severe psychomotor and metabolic damages caused by a mutant thyroid hormone receptor alpha 1 in mice: can patients with a similar mutation be found and treated? Acta paediatrica (Oslo, Norway : 1992). 2008 Dec; [PubMed]|
|Gereben B,Zavacki AM,Ribich S,Kim BW,Huang SA,Simonides WS,Zeöld A,Bianco AC, Cellular and molecular basis of deiodinase-regulated thyroid hormone signaling. Endocrine reviews. 2008 Dec; [PubMed]|
|Grais IM,Sowers JR, Thyroid and the heart. The American journal of medicine. 2014 Aug; [PubMed]|
|Mullur R,Liu YY,Brent GA, Thyroid hormone regulation of metabolism. Physiological reviews. 2014 Apr; [PubMed]|
|Mitchell CS,Savage DB,Dufour S,Schoenmakers N,Murgatroyd P,Befroy D,Halsall D,Northcott S,Raymond-Barker P,Curran S,Henning E,Keogh J,Owen P,Lazarus J,Rothman DL,Farooqi IS,Shulman GI,Chatterjee K,Petersen KF, Resistance to thyroid hormone is associated with raised energy expenditure, muscle mitochondrial uncoupling, and hyperphagia. The Journal of clinical investigation. 2010 Apr; [PubMed]|
|Brown EM, Four-parameter model of the sigmoidal relationship between parathyroid hormone release and extracellular calcium concentration in normal and abnormal parathyroid tissue. The Journal of clinical endocrinology and metabolism. 1983 Mar; [PubMed]|
|Habener JF,Kemper BW,Rich A,Potts JT Jr, Biosynthesis of parathyroid hormone. Recent progress in hormone research. 1976; [PubMed]|
|Murray TM,Rao LG,Divieti P,Bringhurst FR, Parathyroid hormone secretion and action: evidence for discrete receptors for the carboxyl-terminal region and related biological actions of carboxyl- terminal ligands. Endocrine reviews. 2005 Feb; [PubMed]|
|D'Amour P,Räkel A,Brossard JH,Rousseau L,Albert C,Cantor T, Acute regulation of circulating parathyroid hormone (PTH) molecular forms by calcium: utility of PTH fragments/PTH(1-84) ratios derived from three generations of PTH assays. The Journal of clinical endocrinology and metabolism. 2006 Jan; [PubMed]|
|Brown EM,Pollak M,Seidman CE,Seidman JG,Chou YH,Riccardi D,Hebert SC, Calcium-ion-sensing cell-surface receptors. The New England journal of medicine. 1995 Jul 27; [PubMed]|
|Naveh-Many T,Friedlaender MM,Mayer H,Silver J, Calcium regulates parathyroid hormone messenger ribonucleic acid (mRNA), but not calcitonin mRNA in vivo in the rat. Dominant role of 1,25-dihydroxyvitamin D. Endocrinology. 1989 Jul; [PubMed]|
|Naveh-Many T,Rahamimov R,Livni N,Silver J, Parathyroid cell proliferation in normal and chronic renal failure rats. The effects of calcium, phosphate, and vitamin D. The Journal of clinical investigation. 1995 Oct; [PubMed]|
|Silver J,Naveh-Many T, FGF23 and the parathyroid glands. Pediatric nephrology (Berlin, Germany). 2010 Nov; [PubMed]|
|Gardella TJ,Jüppner H, Molecular properties of the PTH/PTHrP receptor. Trends in endocrinology and metabolism: TEM. 2001 Jul; [PubMed]|
|Dobolyi A,Palkovits M,Usdin TB, The TIP39-PTH2 receptor system: unique peptidergic cell groups in the brainstem and their interactions with central regulatory mechanisms. Progress in neurobiology. 2010 Jan 11; [PubMed]|
|Pessin JE,Saltiel AR, Signaling pathways in insulin action: molecular targets of insulin resistance. The Journal of clinical investigation. 2000 Jul; [PubMed]|
|Samuel VT,Petersen KF,Shulman GI, Lipid-induced insulin resistance: unravelling the mechanism. Lancet (London, England). 2010 Jun 26; [PubMed]|
|Kido Y,Nakae J,Accili D, Clinical review 125: The insulin receptor and its cellular targets. The Journal of clinical endocrinology and metabolism. 2001 Mar; [PubMed]|
|Stumvoll M,Meyer C,Mitrakou A,Nadkarni V,Gerich JE, Renal glucose production and utilization: new aspects in humans. Diabetologia. 1997 Jul; [PubMed]|
|Edgerton DS,Lautz M,Scott M,Everett CA,Stettler KM,Neal DW,Chu CA,Cherrington AD, Insulin's direct effects on the liver dominate the control of hepatic glucose production. The Journal of clinical investigation. 2006 Feb; [PubMed]|
|Kahn BB, Lilly lecture 1995. Glucose transport: pivotal step in insulin action. Diabetes. 1996 Nov; [PubMed]|
|Strålfors P,Honnor RC, Insulin-induced dephosphorylation of hormone-sensitive lipase. Correlation with lipolysis and cAMP-dependent protein kinase activity. European journal of biochemistry. 1989 Jun 15; [PubMed]|
|Keller U,Lustenberger M,Stauffacher W, Effect of insulin on ketone body clearance studied by a ketone body [PubMed]|
|Jefferson LS, Lilly Lecture 1979: role of insulin in the regulation of protein synthesis. Diabetes. 1980 Jun; [PubMed]|
|Banskota NK,Taub R,Zellner K,King GL, Insulin, insulin-like growth factor I and platelet-derived growth factor interact additively in the induction of the protooncogene c-myc and cellular proliferation in cultured bovine aortic smooth muscle cells. Molecular endocrinology (Baltimore, Md.). 1989 Aug; [PubMed]|
|Raju B,Cryer PE, Loss of the decrement in intraislet insulin plausibly explains loss of the glucagon response to hypoglycemia in insulin-deficient diabetes: documentation of the intraislet insulin hypothesis in humans. Diabetes. 2005 Mar; [PubMed]|
|Gosmanov NR,Szoke E,Israelian Z,Smith T,Cryer PE,Gerich JE,Meyer C, Role of the decrement in intraislet insulin for the glucagon response to hypoglycemia in humans. Diabetes care. 2005 May; [PubMed]|
|Bland ML,Desclozeaux M,Ingraham HA, Tissue growth and remodeling of the embryonic and adult adrenal gland. Annals of the New York Academy of Sciences. 2003 May; [PubMed]|
|Miller WL, Molecular biology of steroid hormone synthesis. Endocrine reviews. 1988 Aug; [PubMed]|
|Smith SR,Bledsoe T,Chhetri MK, Cortisol metabolism and the pituitary-adrenal axis in adults with protein-calorie malnutrition. The Journal of clinical endocrinology and metabolism. 1975 Jan; [PubMed]|
|Mulatero P,Stowasser M,Loh KC,Fardella CE,Gordon RD,Mosso L,Gomez-Sanchez CE,Veglio F,Young WF Jr, Increased diagnosis of primary aldosteronism, including surgically correctable forms, in centers from five continents. The Journal of clinical endocrinology and metabolism. 2004 Mar; [PubMed]|
|Douma S,Petidis K,Doumas M,Papaefthimiou P,Triantafyllou A,Kartali N,Papadopoulos N,Vogiatzis K,Zamboulis C, Prevalence of primary hyperaldosteronism in resistant hypertension: a retrospective observational study. Lancet (London, England). 2008 Jun 7; [PubMed]|
|Li XC,Zhang J,Zhuo JL, The vasoprotective axes of the renin-angiotensin system: Physiological relevance and therapeutic implications in cardiovascular, hypertensive and kidney diseases. Pharmacological research. 2017 Nov; [PubMed]|
|Kakiki M,Morohashi K,Nomura M,Omura T,Horie T, Expression of aldosterone synthase cytochrome P450 (P450aldo) mRNA in rat adrenal glomerulosa cells by angiotensin II type 1 receptor. Endocrine research. 1997 Nov; [PubMed]|
|Parker LN,Lifrak ET,Odell WD, A 60,000 molecular weight human pituitary glycopeptide stimulates adrenal androgen secretion. Endocrinology. 1983 Dec; [PubMed]|
|Anderson DC, The adrenal androgen-stimulating hormone does not exist. Lancet (London, England). 1980 Aug 30; [PubMed]|
|Orentreich N,Brind JL,Rizer RL,Vogelman JH, Age changes and sex differences in serum dehydroepiandrosterone sulfate concentrations throughout adulthood. The Journal of clinical endocrinology and metabolism. 1984 Sep; [PubMed]|
|AHLQUIST RP, A study of the adrenotropic receptors. The American journal of physiology. 1948 Jun; [PubMed]|
|Müllner M,Urbanek B,Havel C,Losert H,Waechter F,Gamper G, Vasopressors for shock. The Cochrane database of systematic reviews. 2004; [PubMed]|
|Practice parameters for hemodynamic support of sepsis in adult patients in sepsis. Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. Critical care medicine. 1999 Mar; [PubMed]|
|ALLWOOD MJ,COBBOLD AF,GINSBURG J, Peripheral vascular effects of noradrenaline, isopropylnoradrenaline and dopamine. British medical bulletin. 1963 May; [PubMed]|
|De Backer D,Creteur J,Silva E,Vincent JL, Effects of dopamine, norepinephrine, and epinephrine on the splanchnic circulation in septic shock: which is best? Critical care medicine. 2003 Jun; [PubMed]|
|Moran JL,O'Fathartaigh MS,Peisach AR,Chapman MJ,Leppard P, Epinephrine as an inotropic agent in septic shock: a dose-profile analysis. Critical care medicine. 1993 Jan; [PubMed]|
|Jost A, Hormonal factors in the sex differentiation of the mammalian foetus. Philosophical transactions of the Royal Society of London. Series B, Biological sciences. 1970 Aug 6; [PubMed]|
|Arnold AP, The end of gonad-centric sex determination in mammals. Trends in genetics : TIG. 2012 Feb; [PubMed]|
|Gibson DA,Saunders PT, Estrogen dependent signaling in reproductive tissues - a role for estrogen receptors and estrogen related receptors. Molecular and cellular endocrinology. 2012 Jan 30; [PubMed]|
|MacLaughlin DT,Donahoe PK, Sex determination and differentiation. The New England journal of medicine. 2004 Jan 22; [PubMed]|
|Brennan J,Capel B, One tissue, two fates: molecular genetic events that underlie testis versus ovary development. Nature reviews. Genetics. 2004 Jul; [PubMed]|
|Filicori M,Santoro N,Merriam GR,Crowley WF Jr, Characterization of the physiological pattern of episodic gonadotropin secretion throughout the human menstrual cycle. The Journal of clinical endocrinology and metabolism. 1986 Jun; [PubMed]|
|Treloar AE,Boynton RE,Behn BG,Brown BW, Variation of the human menstrual cycle through reproductive life. International journal of fertility. 1967 Jan-Mar; [PubMed]|
|Sherman BM,West JH,Korenman SG, The menopausal transition: analysis of LH, FSH, estradiol, and progesterone concentrations during menstrual cycles of older women. The Journal of clinical endocrinology and metabolism. 1976 Apr; [PubMed]|
|Adams JM,Taylor AE,Schoenfeld DA,Crowley WF Jr,Hall JE, The midcycle gonadotropin surge in normal women occurs in the face of an unchanging gonadotropin-releasing hormone pulse frequency. The Journal of clinical endocrinology and metabolism. 1994 Sep; [PubMed]|
|Taylor AE,Whitney H,Hall JE,Martin K,Crowley WF Jr, Midcycle levels of sex steroids are sufficient to recreate the follicle-stimulating hormone but not the luteinizing hormone midcycle surge: evidence for the contribution of other ovarian factors to the surge in normal women. The Journal of clinical endocrinology and metabolism. 1995 May; [PubMed]|
|Martin KA,Welt CK,Taylor AE,Smith JA,Crowley WF Jr,Hall JE, Is GnRH reduced at the midcycle surge in the human? Evidence from a GnRH-deficient model. Neuroendocrinology. 1998 Jun; [PubMed]|
|Lubahn DB,Moyer JS,Golding TS,Couse JF,Korach KS,Smithies O, Alteration of reproductive function but not prenatal sexual development after insertional disruption of the mouse estrogen receptor gene. Proceedings of the National Academy of Sciences of the United States of America. 1993 Dec 1; [PubMed]|
|Krege JH,Hodgin JB,Couse JF,Enmark E,Warner M,Mahler JF,Sar M,Korach KS,Gustafsson JA,Smithies O, Generation and reproductive phenotypes of mice lacking estrogen receptor beta. Proceedings of the National Academy of Sciences of the United States of America. 1998 Dec 22; [PubMed]|
|Hewitt SC,Harrell JC,Korach KS, Lessons in estrogen biology from knockout and transgenic animals. Annual review of physiology. 2005; [PubMed]|
|Heldring N,Pike A,Andersson S,Matthews J,Cheng G,Hartman J,Tujague M,Ström A,Treuter E,Warner M,Gustafsson JA, Estrogen receptors: how do they signal and what are their targets. Physiological reviews. 2007 Jul; [PubMed]|
|Siiteri PK,Wilson JD, Testosterone formation and metabolism during male sexual differentiation in the human embryo. The Journal of clinical endocrinology and metabolism. 1974 Jan; [PubMed]|
|Blumenfeld Z, Investigational and experimental GnRH analogs and associated neurotransmitters. Expert opinion on investigational drugs. 2017 Jun; [PubMed]|
|Sinclair AH,Berta P,Palmer MS,Hawkins JR,Griffiths BL,Smith MJ,Foster JW,Frischauf AM,Lovell-Badge R,Goodfellow PN, A gene from the human sex-determining region encodes a protein with homology to a conserved DNA-binding motif. Nature. 1990 Jul 19; [PubMed]|
|Winters SJ,Troen P, Testosterone and estradiol are co-secreted episodically by the human testis. The Journal of clinical investigation. 1986 Oct; [PubMed]|
|Ruwanpura SM,McLachlan RI,Meachem SJ, Hormonal regulation of male germ cell development. The Journal of endocrinology. 2010 May; [PubMed]|
|Pitteloud N,Dwyer AA,DeCruz S,Lee H,Boepple PA,Crowley WF Jr,Hayes FJ, Inhibition of luteinizing hormone secretion by testosterone in men requires aromatization for its pituitary but not its hypothalamic effects: evidence from the tandem study of normal and gonadotropin-releasing hormone-deficient men. The Journal of clinical endocrinology and metabolism. 2008 Mar; [PubMed]|
|Anawalt BD,Bebb RA,Matsumoto AM,Groome NP,Illingworth PJ,McNeilly AS,Bremner WJ, Serum inhibin B levels reflect Sertoli cell function in normal men and men with testicular dysfunction. The Journal of clinical endocrinology and metabolism. 1996 Sep; [PubMed]|
|Amory JK,Bremner WJ, Regulation of testicular function in men: implications for male hormonal contraceptive development. The Journal of steroid biochemistry and molecular biology. 2003 Jun; [PubMed]|
|von Eckardstein S,Simoni M,Bergmann M,Weinbauer GF,Gassner P,Schepers AG,Nieschlag E, Serum inhibin B in combination with serum follicle-stimulating hormone (FSH) is a more sensitive marker than serum FSH alone for impaired spermatogenesis in men, but cannot predict the presence of sperm in testicular tissue samples. The Journal of clinical endocrinology and metabolism. 1999 Jul; [PubMed]|
|Finkelstein JS,Lee H,Burnett-Bowie SA,Pallais JC,Yu EW,Borges LF,Jones BF,Barry CV,Wulczyn KE,Thomas BJ,Leder BZ, Gonadal steroids and body composition, strength, and sexual function in men. The New England journal of medicine. 2013 Sep 12; [PubMed]|
|Finkelstein JS,Lee H,Leder BZ,Burnett-Bowie SA,Goldstein DW,Hahn CW,Hirsch SC,Linker A,Perros N,Servais AB,Taylor AP,Webb ML,Youngner JM,Yu EW, Gonadal steroid-dependent effects on bone turnover and bone mineral density in men. The Journal of clinical investigation. 2016 Mar 1; [PubMed]|
|Cooke PS,Nanjappa MK,Ko C,Prins GS,Hess RA, Estrogens in Male Physiology. Physiological reviews. 2017 Jul 1; [PubMed]|
|de Zegher F,Francois I,Boehmer AL,Saggese G,Müller J,Hiort O,Sultan C,Clayton P,Brauner R,Cacciari E,Ibáñez L,Van Vliet G,Tiulpakov A,Saka N,Ritzén M,Sippell WG, Androgens and fetal growth. Hormone research. 1998; [PubMed]|
|Wang Q,Li W,Liu XS,Carroll JS,Jänne OA,Keeton EK,Chinnaiyan AM,Pienta KJ,Brown M, A hierarchical network of transcription factors governs androgen receptor-dependent prostate cancer growth. Molecular cell. 2007 Aug 3; [PubMed]|
|Kojima M,Hosoda H,Date Y,Nakazato M,Matsuo H,Kangawa K, Ghrelin is a growth-hormone-releasing acylated peptide from stomach. Nature. 1999 Dec 9; [PubMed]|
|Ariyasu H,Takaya K,Tagami T,Ogawa Y,Hosoda K,Akamizu T,Suda M,Koh T,Natsui K,Toyooka S,Shirakami G,Usui T,Shimatsu A,Doi K,Hosoda H,Kojima M,Kangawa K,Nakao K, Stomach is a major source of circulating ghrelin, and feeding state determines plasma ghrelin-like immunoreactivity levels in humans. The Journal of clinical endocrinology and metabolism. 2001 Oct; [PubMed]|
|Hosoda H,Kojima M,Kangawa K, Ghrelin and the regulation of food intake and energy balance. Molecular interventions. 2002 Dec; [PubMed]|
|Müller TD,Nogueiras R,Andermann ML,Andrews ZB,Anker SD,Argente J,Batterham RL,Benoit SC,Bowers CY,Broglio F,Casanueva FF,D'Alessio D,Depoortere I,Geliebter A,Ghigo E,Cole PA,Cowley M,Cummings DE,Dagher A,Diano S,Dickson SL,Diéguez C,Granata R,Grill HJ,Grove K,Habegger KM,Heppner K,Heiman ML,Holsen L,Holst B,Inui A,Jansson JO,Kirchner H,Korbonits M,Laferrère B,LeRoux CW,Lopez M,Morin S,Nakazato M,Nass R,Perez-Tilve D,Pfluger PT,Schwartz TW,Seeley RJ,Sleeman M,Sun Y,Sussel L,Tong J,Thorner MO,van der Lely AJ,van der Ploeg LH,Zigman JM,Kojima M,Kangawa K,Smith RG,Horvath T,Tschöp MH, Ghrelin. Molecular metabolism. 2015 Jun; [PubMed]|
|Muccioli G,Baragli A,Granata R,Papotti M,Ghigo E, Heterogeneity of ghrelin/growth hormone secretagogue receptors. Toward the understanding of the molecular identity of novel ghrelin/GHS receptors. Neuroendocrinology. 2007; [PubMed]|
|Cummings DE,Foster-Schubert KE,Overduin J, Ghrelin and energy balance: focus on current controversies. Current drug targets. 2005 Mar; [PubMed]|
|Fukushima N,Hanada R,Teranishi H,Fukue Y,Tachibana T,Ishikawa H,Takeda S,Takeuchi Y,Fukumoto S,Kangawa K,Nagata K,Kojima M, Ghrelin directly regulates bone formation. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2005 May; [PubMed]|
|Pantel J,Legendre M,Cabrol S,Hilal L,Hajaji Y,Morisset S,Nivot S,Vie-Luton MP,Grouselle D,de Kerdanet M,Kadiri A,Epelbaum J,Le Bouc Y,Amselem S, Loss of constitutive activity of the growth hormone secretagogue receptor in familial short stature. The Journal of clinical investigation. 2006 Mar; [PubMed]|
|Tschöp M,Weyer C,Tataranni PA,Devanarayan V,Ravussin E,Heiman ML, Circulating ghrelin levels are decreased in human obesity. Diabetes. 2001 Apr; [PubMed]|
|Tschöp M,Wawarta R,Riepl RL,Friedrich S,Bidlingmaier M,Landgraf R,Folwaczny C, Post-prandial decrease of circulating human ghrelin levels. Journal of endocrinological investigation. 2001 Jun; [PubMed]|
|Otto B,Cuntz U,Fruehauf E,Wawarta R,Folwaczny C,Riepl RL,Heiman ML,Lehnert P,Fichter M,Tschöp M, Weight gain decreases elevated plasma ghrelin concentrations of patients with anorexia nervosa. European journal of endocrinology. 2001 Nov; [PubMed]|
|Cummings DE,Weigle DS,Frayo RS,Breen PA,Ma MK,Dellinger EP,Purnell JQ, Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. The New England journal of medicine. 2002 May 23; [PubMed]|
|Checchi S,Montanaro A,Pasqui L,Ciuoli C,Cevenini G,Sestini F,Fioravanti C,Pacini F, Serum ghrelin as a marker of atrophic body gastritis in patients with parietal cell antibodies. The Journal of clinical endocrinology and metabolism. 2007 Nov; [PubMed]|
|Procaccini C,Jirillo E,Matarese G, Leptin as an immunomodulator. Molecular aspects of medicine. 2012 Feb; [PubMed]|
|Tartaglia LA,Dembski M,Weng X,Deng N,Culpepper J,Devos R,Richards GJ,Campfield LA,Clark FT,Deeds J,Muir C,Sanker S,Moriarty A,Moore KJ,Smutko JS,Mays GG,Wool EA,Monroe CA,Tepper RI, Identification and expression cloning of a leptin receptor, OB-R. Cell. 1995 Dec 29; [PubMed]|
|Meier U,Gressner AM, Endocrine regulation of energy metabolism: review of pathobiochemical and clinical chemical aspects of leptin, ghrelin, adiponectin, and resistin. Clinical chemistry. 2004 Sep; [PubMed]|
|Sienkiewicz E,Magkos F,Aronis KN,Brinkoetter M,Chamberland JP,Chou S,Arampatzi KM,Gao C,Koniaris A,Mantzoros CS, Long-term metreleptin treatment increases bone mineral density and content at the lumbar spine of lean hypoleptinemic women. Metabolism: clinical and experimental. 2011 Sep; [PubMed]|
|Dardeno TA,Chou SH,Moon HS,Chamberland JP,Fiorenza CG,Mantzoros CS, Leptin in human physiology and therapeutics. Frontiers in neuroendocrinology. 2010 Jul; [PubMed]|
|Shetty GK,Matarese G,Magkos F,Moon HS,Liu X,Brennan AM,Mylvaganam G,Sykoutri D,Depaoli AM,Mantzoros CS, Leptin administration to overweight and obese subjects for 6 months increases free leptin concentrations but does not alter circulating hormones of the thyroid and IGF axes during weight loss induced by a mild hypocaloric diet. European journal of endocrinology. 2011 Aug; [PubMed]|
|Weigle DS,Duell PB,Connor WE,Steiner RA,Soules MR,Kuijper JL, Effect of fasting, refeeding, and dietary fat restriction on plasma leptin levels. The Journal of clinical endocrinology and metabolism. 1997 Feb; [PubMed]|
|Kelesidis T,Kelesidis I,Chou S,Mantzoros CS, Narrative review: the role of leptin in human physiology: emerging clinical applications. Annals of internal medicine. 2010 Jan 19; [PubMed]|
|Moschos S,Chan JL,Mantzoros CS, Leptin and reproduction: a review. Fertility and sterility. 2002 Mar; [PubMed]|
|Chou SH,Mantzoros C, 20 years of leptin: role of leptin in human reproductive disorders. The Journal of endocrinology. 2014 Oct; [PubMed]|
|Farooqi IS,Matarese G,Lord GM,Keogh JM,Lawrence E,Agwu C,Sanna V,Jebb SA,Perna F,Fontana S,Lechler RI,DePaoli AM,O'Rahilly S, Beneficial effects of leptin on obesity, T cell hyporesponsiveness, and neuroendocrine/metabolic dysfunction of human congenital leptin deficiency. The Journal of clinical investigation. 2002 Oct; [PubMed]|
|Thomas T,Burguera B,Melton LJ 3rd,Atkinson EJ,O'Fallon WM,Riggs BL,Khosla S, Role of serum leptin, insulin, and estrogen levels as potential mediators of the relationship between fat mass and bone mineral density in men versus women. Bone. 2001 Aug; [PubMed]|
|Ruhl CE,Everhart JE, Relationship of serum leptin concentration with bone mineral density in the United States population. Journal of bone and mineral research : the official journal of the American Society for Bone and Mineral Research. 2002 Oct; [PubMed]|
The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of NP-Advanced Physiology. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.
StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for NP-Advanced Physiology, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in NP-Advanced Physiology, you will already be prepared.
Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of NP-Advanced Physiology. When it is time for the NP-Advanced Physiology board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study NP-Advanced Physiology.