How is a CORRECT endocrinological consultation ?
The first step is a detailed history and a complete physical examination. The history includes details about the history of the disease, personal and hereditary-collateral physiological and pathological history, the history of the medication taken by the patient. The physical examination is focused on the specific manifestations of endocrinological diseases such as palpation and auscultation of the thyroid gland.
The levels of hormones in the blood vary from day to day and at different times of the day and night. For this reason, it is important that hormonal determinations be made at certain times of the day or even at certain times. For example, the diagnosis of corticospinal insufficiency (cortisol insufficient) begins with clinical suspicion, followed by the determination of blood cortisol level in the morning before 9-10 hours, while the diagnosis of Cushing’s syndrome (cortisol excess) is based on the clinical picture followed by cortisol determination salivary in the evening, before bedtime.
The conditions under which blood is collected for hormonal tests are also important. For example, when the clinical picture suggests a pheochromocytoma (adrenal gland tumor producing noradrenaline and / or adrenaline or dopamine), plasma methanephrines and normetanephrines (metabolites of adrenaline and noradrenaline) are dosed in the lying position after 30 minutes of relaxation and preferably using an intravenous catheter to reduce the risk of false positive results (plasma metanephrines increase even from pain caused by venous puncture). Aldosterone and renin, involved in blood pressure control, are measured at 8 o’clock in the morning with the patient sitting.
A number of drugs may influence hormonal analysis and as a result, hormonal testing requires, in some cases, the drug to be stopped for a variable period of time. An example is spironolactone or eplerenone which should be stopped for 4-6 weeks before testing aldosterone and renin. Some drugs or vitamins may interfere with the laboratory method used to determine the hormone. For example, biotin (vitamin H), used to stimulate hair growth, taken at doses greater than 10 mg / day, can significantly alter thyroid function (the patient would be incorrectly diagnosed with hyperthyroidism). In this situation, the biotin should be discontinued for 72 hours before carrying out the analyzes.
After establishing a biochemical diagnosis (based on blood tests , urine, saliva), the next step, depending on the pathology, is imaging. An example is Cushing’s syndrome, which is diagnosed on the basis of increased cortisol levels in saliva and / or urine or on the basis of a lack of suppression in the dexamethasone test. The next step is to obtain a cerebral MRI with pituitary protocol only after the biochemical confirmation of the diagnosis. If the pituitary examination is normal, an adrenal gland CT scan is recommended. In the case of primary hyperaldosteronism (the causes are adrenal adenoma or hyperplasia of both adrenal glands), the adrenal gland tomography computer is only made after a correct biochemical diagnosis (high serum aldosterone, low / undetectable renin values and aldosterone suppression tests are positive).
There are situations in which the biochemistry-imaging sequence is reversed. A patient makes a computerized abdomen tomography for abdominal pain and incidentally visualizes an adenoma of adrenal glands. In this case, according to the practice guides, all the hormones produced by the adrenal glands are dosed to exclude the hormonal excess, or a brain MRI performed for headaches, which incidentally shows a radiographic abnormality of the pituitary gland; In this case, depending on the appearance of the anomaly on a pituitary MRI, all or a few hormones produced by the pituitary gland are dosed.
Diabetes is a common condition with many cardiovascular complications that can significantly reduce quality of life. Screening (with fasting blood glucose, glycosylated hemoglobin or oral glucose tolerance test) is also recommended for asymptomatic people but who have risk factors: relatives with grade 1 with diabetes, cardiovascular disease, hypertension, dyslipidemia, gestational diabetes, sedentary lifestyle, etc. In the absence of these risk factors, screening for diabetes begins at the age of 45.
Another common hormonal pathology is that of the thyroid gland . The dosage of thyroid hormones and TSH is done only in people with suggestive symptoms or those who have heart failure / heart rhythm disorders. The only screening for thyroid disorders is recommended in all newborns, as delayed diagnosis can have devastating effects especially on the development of the nervous system.
Thyroid ultrasound is another overused test. Thyroid ultrasound is recommended for the description of thyroid nodules detected by physical examination or other imaging methods. Thyroid ultrasound generally has no role in diagnosing thyroid gland dysfunction (hyperthyroidism, hypothyroidism – chronic autoimmune thyroiditis). Thyroid ultrasound is not a screening test and is not done on the grounds that “I would like to see if I have something with the thyroid.” That must be defined before taking the test.
Beyond the technical details, the message for patients but also for doctors is that the diagnosis of hormonal disorders is made in a logical sequence based on scientific evidence, on practice guides so as to avoid unnecessary tests and expenses and of course the psychological discomfort caused by the possibility of a new diagnosis.