chapter 23

Hypothalamic and Pituitary Hormones

Objectives
AFTER STUDYING THIS CHAPTER, THE STUDENT WILL BE ABLE TO:

1. Describe clinical uses of selected hormones.
2. Differentiate characteristics and functions of
anterior and posterior pituitary hormones.
3. Discuss limitations of hypothalamic and pituitary
hormones as therapeutic agents.
4. State major nursing considerations in the care
of clients receiving specific hypothalamic and
pituitary hormones.

Critical Thinking Scenario

John, 11 years of age, is brought to the pediatric nurse practitioner for his annual sports physical. His mother
voices concerns about Johns short stature and questions you about the use of growth hormone. You note
that John is in the 25th percentile for height and the 50th percentile for weight.

Reflect on:
 Additional assessment questions to ask John and his mother.

 Factors that might influence their desire for increased height and the use of growth hormone to
accomplish this.
 If John uses growth hormone, outline some of the disadvantages and side effects.

OVERVIEW Corticotropin-releasing hormone or factor (CRH or

The hypothalamus and pituitary gland (Fig. 231) interact to
control most metabolic functions of the body and to maintain
homeostasis. They are anatomically connected by the hy-
pophyseal stalk. The hypothalamus controls secretions of the
pituitary gland. The pituitary gland, in turn, regulates secre-
tions or functions of other body tissues, called target tissues.
The pituitary gland is actually two glands, each with different
structures and functions. The anterior pituitary is composed of
different types of glandular cells that synthesize and secrete
different hormones. The posterior pituitary is anatomically an
extension of the hypothalamus and is composed largely of
nerve fibers. It does not manufacture any hormones itself but
stores and releases hormones synthesized in the hypothalamus.
Hypothalamic Hormones
The hypothalamus produces a releasing hormone or an inhibit-
ing hormone that corresponds to each of the major hormones of
the anterior pituitary gland.
CRF) causes release of corticotropin (also called adrenocor-
ticotropic hormone or ACTH), in response to stress and
threatening stimuli. CRH is secreted most often during sleep
and its secretion is influenced by several neurotransmitters.
Acetylcholine and serotonin stimulate secretion; gamma-
aminobutyric acid (GABA) and norepinephrine inhibit secre-
tion. The ability of CRH to stimulate corticotropin secretion
is increased by vasopressin and decreased or prevented by
somatostatin and elevated levels of glucocorticoids. CRH
can be used in the diagnosis of Cushings disease, a disorder
characterized by excess cortisol.
Growth hormone-releasing hormone (GHRH) causes
release of growth hormone in response to low blood levels
of the hormone. Found in the pancreas as well as the hypo-
thalamus, GHRH structurally resembles a group of hor-
mones that includes glucagon, secretin, vasoactive intestinal
peptide, and gastric inhibitory peptide. Secretion of hypo-
thalamic GHRH is stimulated by dopamine, norepineph-
rine, epinephrine, GABA, acetylcholine, and serotonin. The
stimulatory effect of GHRH on secretion of growth hor-
mone is blocked by somatostatin. GHRH may be used to
325
 326 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM

Hypothalamus

Hypothalamic-releasing hormones

Posterior pituitary
ADH Kidneys
Anterior pituitary

Oxytocin Uterus

Breasts

Growth ACTH TSH FSH LH Female LH Prolactin

hormone Male

Adrenal Thyroid Testis Breast

cortex Ovary

Most body Glucocorticoids, Thyroxine Estrogen Progesterone Testosterone

tissues mineralocorticoids,
and androgens
Figure 231 Hypothalamic and pituitary hormones and their target organs. The hypothalamus produces hormones
that act on the anterior pituitary or are stored in the posterior pituitary. The anterior pituitary produces hormones
that act on various body tissues and stimulate production of other hormones.

test pituitary function and to stimulate growth in children
with GHRH deficiency.
Growth hormone release-inhibiting hormone (so-
matostatin) inhibits release of growth hormone. Although
originally isolated from the hypothalamus, it is found in
many tissues. It is distributed throughout the brain and
spinal cord, where it functions as a neurotransmitter. It
is also found in the intestines and the pancreas (where it
regulates secretion of insulin and glucagon). Somatostatin
secretion is increased by several neurotransmitters, includ-
ing acetylcholine, dopamine, epinephrine, GABA, and nor-
epinephrine.
In addition to inhibiting growth hormone, somatostatin also
inhibits other functions, including secretion of corticotropin,
thyroid-stimulating hormone (TSH or thyrotropin), prolactin,
pancreatic secretions (eg, insulin, glucagon), gastrointestinal
(GI) secretions (gastrin, cholecystokinin, secretin, vasoactive
intestinal peptide), GI motility, bile flow, and mesenteric blood
flow. Hypothalamic somatostatin blocks the action of GHRH
and decreases thyrotropin-releasing hormone (TRH)-induced
release of TSH. Growth hormone stimulates secretion of so-
matostatin, and somatostatins effects on TSH may contribute
to TSH deficiency in children being treated with growth hor-
mone. A long-acting somatostatin analog, octreotide (Sando-
statin), may be used to treat acromegaly and TSH-secreting
pituitary tumors.
Thyrotropin-releasing hormone (TRH) causes release
of thyroid-stimulating hormone (TSH or thyrotropin) in re-
sponse to stress, such as exposure to cold. TRH may be used
in diagnostic tests of pituitary function and hyperthyroidism.
Gonadotropin-releasing hormone (GnRH) causes re-
lease of follicle-stimulating hormone (FSH) and luteinizing
hormone (LH). Several synthetic equivalents of GnRH are
used clinically.
Prolactin-releasing factor is active during lactation after
childbirth.
Prolactin-inhibitory factor (PIF) is active at times other
than during lactation.
Anterior Pituitary Hormones
The anterior pituitary gland produces seven hormones. Two
of these, growth hormone and prolactin, act directly on their

target tissues; the other five act indirectly by stimulating target
tissues to produce other hormones.
Corticotropin, also called ACTH, stimulates the adrenal
cortex to produce corticosteroids. Secretion is controlled by
the hypothalamus and by plasma levels of cortisol, the major
corticosteroid. When plasma levels are adequate for body
needs, the anterior pituitary does not release corticotropin
(negative feedback mechanism).
Growth hormone, also called somatotropin, stimulates
growth of body tissues. It promotes an increase in cell size
and number, including growth of muscle cells and lengthen-
ing of bone, largely by affecting metabolism of carbohydrate,
protein, fat, and bone tissue. For example, it regulates cell di-
vision and protein synthesis required for normal growth. In
children, levels of growth hormone rise rapidly during adoles-
cence, peak in the 20s, then start to decline. Deficient growth
hormone in children produces dwarfism, a condition marked
by severely decreased linear growth and, frequently, severely
delayed mental, emotional, dental, and sexual growth as well.
Deficient hormone in adults (less than expected for age) can
cause increased fat, reduced skeletal and heart muscle mass, re-
duced strength, reduced ability to exercise, and worsened cho-
lesterol levels (ie, increased low-density lipoprotein [LDL]
cholesterol and decreased high-density lipoprotein [HDL] cho-
lesterol), which increase risk factors for cardiovascular disease.
Excessive growth hormone in preadolescent children pro-
duces gigantism, resulting in heights of 8 or 9 feet if untreated.
Excessive growth hormone in adults produces acromegaly,
which distorts facial features and is associated with an in-
creased incidence of diabetes mellitus and hypertension.
Thyrotropin (also called TSH) regulates secretion of thy-
roid hormones. Thyrotropin secretion is controlled by a neg-
ative feedback mechanism in proportion to metabolic needs.
Thus, increased thyroid hormones in body fluids inhibit se-
cretion of thyrotropin by the anterior pituitary and of TRH by
the hypothalamus.
FSH, one of the gonadotropins, stimulates functions of sex
glands. It is produced by the anterior pituitary gland of both
sexes, beginning at puberty. FSH acts on the ovaries in a cycli-
cal fashion during the reproductive years, stimulating growth
of ovarian follicles. These follicles then produce estrogen,
which prepares the endometrium for implantation of a fertil-
ized ovum. FSH acts on the testes to stimulate the production
and growth of sperm (spermatogenesis), but it does not stimu-
late secretion of male sex hormones. Drug preparations of FSH
include urofollitropin (Fertinex), follitropin alfa (Gonal-F),
and follitropin beta (Follistim). These drugs are used to stimu-
late ovarian function in the treatment of infertility.
LH (also called interstitial cell-stimulating hormone) is
another gonadotropin that stimulates hormone production by
the gonads of both sexes. In women, LH is important in the
maturation and rupture of the ovarian follicle (ovulation).
After ovulation, LH acts on the cells of the collapsed sac to pro-
duce the corpus luteum, which then produces progesterone
during the last half of the menstrual cycle. When blood pro-
gesterone levels rise, a negative feedback effect is exerted on
hypothalamic and anterior pituitary secretion of gonadotropins.
CHAPTER 23 HYPOTHALAMIC AND PITUITARY HORMONES 327
Decreased pituitary secretion of LH causes the corpus luteum
to die and stop producing progesterone. Lack of progesterone
causes slough and discharge of the endometrial lining as
menstrual flow. (Of course, if the ovum has been fertilized
and attached to the endometrium, menstruation does not
occur.) In men, LH stimulates the Leydigs cells in the spaces
between the seminiferous tubules. These cells then secrete
androgens, mainly testosterone.
Prolactin plays a part in milk production by nursing
mothers. It is not usually secreted in nonpregnant women
because of the hypothalamic hormone PIF. During late
pregnancy and lactation, various stimuli, including suck-
ling, inhibit the production of PIF, and thus prolactin is syn-
thesized and released.
Melanocyte-stimulating hormone plays a role in skin
pigmentation, but its function in humans is not clearly
delineated.
Posterior Pituitary Hormones
The posterior pituitary gland stores and releases two hormones
that are synthesized by nerve cells in the hypothalamus.
Antidiuretic hormone (ADH), also called vasopressin,
functions to regulate water balance. When ADH is secreted,
it makes renal tubules more permeable to water. This allows
water in renal tubules to be reabsorbed into the plasma and so
conserves body water. In the absence of ADH, little water is
reabsorbed, and large amounts are lost in the urine.
Antidiuretic hormone is secreted when body fluids become
concentrated (high amounts of electrolytes in proportion to the
amount of water) and when blood volume is low. In the first
instance, ADH causes reabsorption of water, dilution of ex-
tracellular fluids, and restoration of normal osmotic pressure.
In the second instance, ADH raises blood volume and arterial
blood pressure toward homeostatic levels.
Oxytocin functions in childbirth and lactation. It initiates
uterine contractions at the end of gestation to induce child-
birth, and it causes milk to move from breast glands to nipples
so the infant can obtain the milk by suckling.
THERAPEUTIC LIMITATIONS
There are few therapeutic uses for hypothalamic hormones
and pituitary hormones. Most hypothalamic hormones are
used to diagnose pituitary insufficiency. Pituitary hormones
are not used extensively because most conditions in which
they are indicated are uncommon; other effective agents are
available for some uses; and deficiencies of target gland hor-
mones (eg, corticosteroids, thyroid hormones, male or female
sex hormones) are usually more effectively treated with those
hormones than with anterior pituitary hormones that stimu-
late their secretion. However, the hormones perform impor-
tant functions when used in particular circumstances, and
drug formulations of most hormones have been synthesized
for these purposes.
 328 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM
INDIVIDUAL HORMONAL AGENTS
Selected drugs are described below. Indications for use,
routes, and dosage ranges are listed in Drugs at a Glance:
Hypothalamic and Pituitary Agents.
Hypothalamic Hormones
Gonadorelin (Factrel), goserelin (Zoladex), histrelin (Sup-
prelin), leuprolide (Lupron), nafarelin (Synarel), and trip-
torelin (Trelstar) are equivalent to gonadotropin-releasing
hormone. After initial stimulation of LH and FSH secretion,
chronic administration of therapeutic doses inhibits gona-
dotropin secretion. This action results in decreased produc-
tion of testosterone and estrogen, which is reversible when
drug administration is stopped. In males, testosterone is re-
duced to castrate levels. In premenopausal females, estrogens
are reduced to postmenopausal levels. These effects occur
within 2 to 4 weeks after drug therapy is begun. In children
with central precocious puberty (CPP), gonadotropins (testos-
terone in males, estrogen in females) are reduced to prepu-
bertal levels.
The drugs cannot be given orally because they would be
destroyed by enzymes in the GI tract. Most are given by in-
jection and are available in depot preparations that can be
given once monthly or less often. Adverse effects are basi-
cally those of testosterone or estrogen deficiency. When
given for prostate cancer, the drugs may cause increased
bone pain and increased difficulty in urinating during the
first few weeks of treatment. The drugs may also cause or
aggravate depression.
Octreotide (Sandostatin) has pharmacologic actions sim-
ilar to those of somatostatin. Indications for use include
acromegaly, in which it reduces blood levels of growth hor-
mone and insulin-like growth factor-1; carcinoid tumors, in
which it inhibits diarrhea and flushing; and in vasoactive in-
testinal peptide tumors, in which it relieves diarrhea (by de-
creasing GI secretions and motility). It is also used to treat
diarrhea in acquired immunodeficiency syndrome and other
conditions. The drug is most often given subcutaneously (SC)
and may be self-administered. The long-acting formulation
(Sandostatin LAR Depot) must be given intramuscularly
(IM) in a gluteal muscle of the hip. Dosage should be reduced
for older adults.
Anterior Pituitary Hormones
Corticotropin (ACTH, Acthar), which is obtained from animal
pituitary glands, is mainly of historical interest. For therapeutic
purposes, it has been replaced by adrenal corticosteroids. It may
be used occasionally as a diagnostic test to differentiate primary
adrenal insufficiency (Addisons disease, which is associated
with atrophy of the adrenal gland) from secondary adrenal
insufficiency caused by inadequate pituitary secretion of
corticotropin. However, cosyntropin (Cortrosyn), a synthetic
formulation, is more commonly used to test for suspected
adrenal insufficiency.
Growth hormone is synthesized from bacteria by recom-
binant DNA technology. Somatropin (Humatrope) and soma-
trem (Protropin) are therapeutically equivalent to endogenous
growth hormone produced by the pituitary gland. The main
clinical use of the drugs is for children whose growth is im-
paired by a deficiency of endogenous hormone. The drugs are
ineffective when impaired growth results from other causes or
after puberty, when epiphyses of the long bones have closed.
They are also used to treat short stature in children that is
associated with chronic renal failure or Turner syndrome
(a genetic disorder that occurs in girls). In adults, the drugs
may be used to treat deficiency states (eg, those caused by
disease, surgery, or radiation of the pituitary gland) or the tis-
sue wasting associated with acquired immunodeficiency syn-
drome. In general, dosage should be individualized according
to response. Excessive administration can cause excessive
growth (gigantism).
Human chorionic gonadotropin (HCG; Chorex, others)
produces physiologic effects similar to those of the naturally
occurring LH. In males, it is used to evaluate the ability of
Leydigs cells to produce testosterone, to treat hypogonadism
due to pituitary deficiency, and to treat cryptorchidism (un-
descended testicle) in preadolescent boys. In women, HCG is
used in combination with menotropins to induce ovulation in
the treatment of infertility. Excessive doses or prolonged ad-
ministration can lead to sexual precocity, edema, and breast en-
largement caused by oversecretion of testosterone and estrogen.
Menotropins (Pergonal), a gonadotropin preparation ob-
tained from the urine of postmenopausal women, contains
both FSH and LH. It is usually combined with HCG to in-
duce ovulation in the treatment of infertility caused by lack
of pituitary gonadotropins.
Thyrotropin (Thytropar) is used as a diagnostic agent to
distinguish between primary hypothyroidism (caused by a
thyroid disorder) and secondary hypothyroidism (caused by
pituitary malfunction). If thyroid hormones in serum are
elevated after the administration of thyrotropin, then the hypo-
thyroidism is secondary to inadequate pituitary function.
Thyrotropin must be used cautiously in clients with coronary
artery disease, congestive heart failure, or adrenocortical
insufficiency. Thyrotropin alfa (Thyrogen) is a synthetic
formulation of TSH used to treat thyroid cancer.
Posterior Pituitary Hormones
Desmopressin (DDAVP, Stimate), lypressin, and vasopressin
(Pitressin) are synthetic equivalents of antidiuretic hormone
(ADH). A major clinical use is the treatment of neurogenic di-
abetes insipidus, a disorder characterized by a deficiency of
ADH and the excretion of large amounts of dilute urine. Dia-
betes insipidus may be idiopathic, hereditary, or acquired as a
result of trauma, surgery, tumor, infection, or other condi-
tions that impair the function of the hypothalamus or poste-
rior pituitary.

Drugs at a Glance: Hypothalamic and Pituitary Agents
Generic/Trade Names
Hypothalamic Hormones
Gonadorelin (Factrel)
Goserelin (Zoladex)
Leuprolide (Lupron)
Nafarelin (Synarel)
Octreotide (Sandostatin)
Anterior Pituitary Hormones
Corticotropin
(ACTH, Acthar Gel)
Cosyntropin
(Cortrosyn)
Growth hormone:
Somatrem (Protropin)
Somatropin (Genotropin,
Humatrope, Nordotropin,
Nutropin, Serostim)
Human chorionic
gonadotropin (HCG)
(Chorex, Choron, Pregnyl)
Choriogonadotropin alfa
(Ovidrel)
Menotropins (Pergonal)
Indications for Use
Diagnostic test of gonadotropic
functions of the anterior
pituitary
Endometriosis
Metastatic breast cancer
Prostate cancer
Advanced prostatic cancer
Central precocious puberty (CPP)
in children
Endometriosis
Uterine fibroid tumors
Endometriosis
Central precocious puberty in
children
Acromegaly
Carcinoid tumors
Vasoactive intestinal peptide
tumors
Diarrhea
Stimulate synthesis of hormones
by the adrenal cortex
Diagnostic test of adrenal function
Diagnostic test in suspected
adrenal insufficiency
Promote growth in children whose
growth is impaired by a defi-
ciency of endogenous growth
hormone
Cryptorchidism
Diagnostic test of testosterone
production
Induce ovulation in the treatment
of infertility
Combined with HCG to induce
ovulation in treatment of infertil-
ity caused by lack of pituitary
gonadotropins
CHAPTER 23 HYPOTHALAMIC AND PITUITARY HORMONES 329
Routes and Dosage Ranges
Adults Children
SC, IV 100 mcg
SC implant into upper abdominal
wall, 3.6 mg every 28 days or
10.8 mg every 3 months
Endometriosis, uterine fibroids, CPP, SC 50 mcg/kg/d; IM Depot-
IM depot injection, 3.75 mg Ped, weight 25 kg or less,
every mo or 11.25 every 3 mo 7.5 mg; >25 to 37.5 kg,
for 6 mo 11.25 mg; >37.5 kg, 15 mg
Prostate cancer, SC 1 mg daily; every month
IM depot 7.5 mg every mo,
22.5 mg every 3 mo, or 30 mg
every 4 mo; implant (Viadur)
one (72 mg) every 12 mo
One spray (200 mcg) in one 2 sprays (400 mcg) in each
nostril in the morning and one nostril morning and evening
spray in the other nostril in the (1600 mcg/d), until resumption
evening (400 mcg/d), starting of puberty is desired
between the second and fourth
days of the menstrual cycle
Acromegaly, SC 50100 mcg Dosage not established but
three times daily 110 mcg/kg reportedly well
Carcinoid tumors, SC 100 tolerated in young patients
600 mcg daily (average
300 mcg) in 24 divided doses
Intestinal tumors, SC 200
300 mcg daily in 2 to 4 divided
doses
Diarrhea, IV, SC 50 mcg 2 or
3 times daily initially, then
adjusted according to response
Therapeutic use, IM, SC 20 units
four times daily
Diagnostic use, IV infusion,
1025 units in 500 mL of 5%
dextrose or 0.9% sodium chlo-
ride solution, over 8 hours
Acthar Gel, IM 4080 units
q2472h
IM, IV 0.25 mg (equivalent to
25 units ACTH)
Somatrem IM, up to 0.1 mg/kg
three times per week
Somatropin IM, up to 0.06 mg/kg
three times per week
Cryptorchidism and male hypo- Preadolescent boys: Cryp-
gonadism, IM 5004000 units torchidism and hypogonadism,
23 times per week for several IM 5004000 units 23 times
weeks per week for several weeks
To induce ovulation, IM To induce ovulation, IM
500010,000 units in one 500010,000 units in one
dose, 1 d after treatment with dose, 1 d after treatment with
menotropins menotropins
IM 1 ampule (75 units FSH and
75 units LH) daily for 912 d,
followed by HCG to induce
ovulation
(continued )
 330 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM

Drugs at a Glance: Hypothalamic and Pituitary Agents (continued )

Routes and Dosage Ranges

Generic/Trade Names Indications for Use Adults Children

Thyrotropin alfa (Thyrogen)
Posterior Pituitary Hormones
Desmopressin
(DDAVP, Stimate)
Lypressin
Vasopressin (Pitressin)
Oxytocin (Pitocin)
Diagnostic test of thyroid function
Neurogenic diabetes insipidus
Hemostasis (parenteral only) in
spontaneous, trauma-induced
and perioperative bleeding
Diabetes insipidus
Diabetes insipidus
Induce labor
Control postpartum bleeding
IM 0.9 mg every 24 h for 2 doses <16 y: Dosage not established
or every 72 h for 3 doses
Diabetes insipidus, intranasally 3 mo2 y: Diabetes insipidus,
0.10.4 mL/d, usually in two intranasally 0.050.3 mL/d
divided doses in 12 doses
Hemophilia A, von Willebrands Weight >10 kg: Hemophilia A,
disease, IV 0.3 mcg/kg in von Willebrands disease, same
50 mL sterile saline, infused as adult dosage
over 1530 min Weight 10 kg: Hemophilia A,
von Willebrands disease,
IV 0.3 mcg/kg in 10 mL of
sterile saline
Intranasal spray, one or two
sprays to one or both nostrils,
34 times per day
IM, SC, intranasally on cotton IM, SC, intranasally on cotton
pledgets, 0.250.5 mL pledgets, 0.1250.5 mL
(510 units) 23 times per day (2.510 units) 34 times
per day
Induction of labor, IV 1-mL ampule
(10 units) in 1000 mL of
5% dextrose injection
(10 units/1000 mL =
10 milliunits/mL), infused at
0.22 milliunits/min initially,
then regulated according to fre-
quency and strength of uterine
contractions
Prevention or treatment of post-
partum bleeding, IV 1040 units
in 1000 mL of 5% dextrose
injection, infused at 125 mL/h
(40 milliunits/min) or
0.61.8 units (0.06 0.18 mL)
diluted in 35 mL sodium chlo-
ride injection and injected
slowly; IM 0.31 mL
(310 units)

Lypressin is used only for controlling the excessive water

loss of diabetes insipidus. Parenteral desmopressin is also
used as a hemostatic in clients with hemophilia A or mild to
moderate von Willebrands disease (type 1). The drug is ef-
fective in controlling spontaneous or trauma-induced bleed-
ing and intraoperative and postoperative bleeding when given
30 minutes before the procedure. Vasopressin is also used in
the treatment of bleeding esophageal varices because of its
vasoconstrictive effects. Desmopressin and lypressin may be
inhaled intranasally; vasopressin must be injected.
Oxytocin (Pitocin) is a synthetic drug that exerts the same
physiologic effects as the posterior pituitary hormone. Thus,
it promotes uterine contractility and is used clinically to in-
duce labor and in the postpartum period to control bleeding.
Oxytocin must be used only when clearly indicated and when
the recipient can be supervised by well-trained personnel, as
in a hospital.
Nursing Process
Assessment
Assess for disorders for which hypothalamic and pituitary
hormones are given:
For children with impaired growth, assess height and
weight (actual and compared with growth charts) and di-
agnostic x-ray reports of bone age.
For clients with diabetes insipidus, assess baseline blood
pressure, weight, ratio of fluid intake to urine output,
urine specific gravity, and laboratory reports of serum
electrolytes.
For clients with diarrhea, assess number and consistency
of stools per day as well as hydration status.

Nursing Diagnoses
Deficient Knowledge: Drug administration and effects
Altered Growth and Development
Anxiety related to multiple injections
Risk for Injury: Adverse drug effects
Planning/Goals
The client will:
Experience relief of symptoms without serious adverse
effects
Take or receive the drug accurately
Comply with procedures for monitoring and follow-up
Interventions
For children receiving growth hormone, assist the family
to set reasonable goals for increased height and weight
and to comply with accurate drug administration and
follow-up procedures (periodic x-rays to determine bone
growth and progress toward epiphyseal closure, record-
ing height and weight at least weekly).
For clients with diabetes insipidus, assist them to develop
a daily routine to monitor their response to drug therapy
(eg, weigh themselves, monitor fluid intake and urine out-
put for approximately equal amounts, or check urine spe-
cific gravity [should be at least 1.015] and replace fluids
accordingly).
Evaluation
Interview and observe for compliance with instructions
for taking the drug(s).
Observe for relief of symptoms for which pituitary hor-
mones were prescribed.
PRINCIPLES OF THERAPY
1. Hypothalamic hormones are rarely used in most clini-
cal practice settings. The drugs should be prescribed by
physicians who are knowledgeable about endocrinol-
ogy and administered according to current manufac-
turers literature.
2. Most drug therapy with pituitary hormones is given to
replace or supplement naturally occurring hormones
in situations involving inadequate function of the pitu-
Nursing Notes: Apply Your Knowledge
After surgery for a brain tumor, you note that Mr. Willis has
excessive, dilute urine output (8000 mL/24 h). The physician
diagnoses deficient antidiuretic hormone production and pre-
scribes lypressin (Diapid), a synthetic vasopressin. What assess-
ment data will indicate that this medication is effective?
CHAPTER 23 HYPOTHALAMIC AND PITUITARY HORMONES 331
itary gland (hypopituitarism). Conditions resulting from
excessive amounts of pituitary hormones (hyperpitu-
itarism) are more often treated with surgery or irradiation.
3. Diagnosis of suspected pituitary disorders should be
thorough to promote more effective treatment, including
drug therapy.
4. Even though manufacturers recommend corticotropin
for treatment of disorders that respond to glucocorti-
coids, corticotropin is less predictable and less con-
venient than glucocorticoids and has no apparent
advantages over them.
5. Dosage of any pituitary hormone must be individual-
ized because responsiveness of affected tissues varies.
6. Because the hormones are proteins, they must be
given by injection or nasal inhalation. If taken orally,
they would be destroyed by proteolytic enzymes in the
GI tract.
7. An increasing concern is inappropriate use of growth
hormone. Young athletes may use the drug for body
building and to enhance athletic performance. If so,
they are likely to use relatively high doses. In addi-
tion, the highest levels of physiologic hormone are se-
creted during adolescence. The combination of high
pharmacologic and high physiologic amounts increases
risks of health problems from excessive hormone. Also,
there is little evidence that hormone use increases mus-
cle mass or strength beyond that achieved with exercise
alone.
Middle-aged and older adults may use growth
hormone to combat the effects of aging, such as de-
creased energy, weaker muscles and joints, and wrin-
kled skin. One source of the product is apparently
anti-aging clinics. Although it is not illegal for
physicians to prescribe growth hormone for these
populations, such use is unproven in safety and ef-
fectiveness. Endocrinologists emphasize that optimal
adult levels of growth hormone are unknown and
using the drug to slow aging is unproven and poten-
tially dangerous because the long-term effects are un-
known.
Possible adverse effects, especially with high doses
or chronic use, include acromegaly, diabetes, hyper-
tension, and increased risk of serious cardiovascular
disease (eg, heart failure). There is also concern about
a possible link between growth hormone, which stim-
ulates tumor growth, and cancer. Growth hormone
stimulates the release of insulin-like growth factor-1
(IGF-1, also called somatomedin), a substance which
circulates in the blood and stimulates cell division.
Most tumor cells have receptors that recognize IGF-1,
bind it, and allow it to enter the cell, where it could trig-
ger uncontrolled cell division. This concern may be
greater for middle-aged and older adults, because ma-
lignancies are more common in these groups than in
adolescents and young adults.
332 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM
NURSING
ACTIONS Hypothalamic and Pituitary Hormones
NURSING ACTIONS
1. Administer accurately
a. Read the manufacturers instructions and drug labels care-
fully before drug preparation and administration.
2. Observe for therapeutic effects
a. With gonadorelin and related drugs, observe for ovulation
or decreased symptoms of endometriosis and absence of men-
struation.
b. With corticotropin, therapeutic effects stem largely from
increased secretion of adrenal cortex hormones, especially the
glucocorticoids, and include anti-inflammatory effects (see
Chap. 24).
c. With chorionic gonadotropin and menotropins given in
cases of female infertility, ovulation and conception are thera-
peutic effects.
d. With chorionic gonadotropin given in cryptorchidism, the
therapeutic effect is descent of the testicles from the abdomen
to the scrotum.
e. With growth hormone, observe for increased skeletal growth
and development.
f. With antidiuretics (desmopressin, lypressin, and vaso-
pressin), observe for decreased urine output, increased urine
specific gravity, decreased signs of dehydration, decreased thirst.
g. With oxytocin given to induce labor, observe for the begin-
ning or the intensifying of uterine contractions.
h. With oxytocin given to control postpartum bleeding, ob-
serve for a firm uterine fundus and decreased vaginal bleeding.
i. With octreotide given for diarrhea, observe for decreased
number and fluidity of stools.
3. Observe for adverse effects
a. With gonadorelin, observe for headache, nausea, light-
headedness, and local edema, pain and pruritus after subcuta-
neous injections.
b. With protirelin, observe for hypotension, nausea, headache,
lightheadedness, anxiety, drowsiness.
c. With corticotropin, observe for sodium and fluid retention,
edema, hypokalemia, hyperglycemia, osteoporosis, increased
susceptibility to infection, myopathy, behavioral changes.
d. With human chorionic gonadotropin given to preadolescent
boys, observe for sexual precocity, breast enlargement, and
edema.
e. With growth hormone, observe for mild edema, headache,
localized muscle pain, weakness, hyperglycemia.
f. With menotropins, observe for symptoms of ovarian hyper-
stimulation, such as abdominal discomfort, weight gain, ascites,
pleural effusion, oliguria, and hypotension.
RATIONALE/EXPLANATION
These hormone preparations are given infrequently and often re-
quire special techniques of administration.
Therapeutic effects vary widely, depending on the particular pitu-
itary hormone given and the reason for use.
Therapeutic effects depend on the reason for use. Note that differ-
ent formulations are used to stimulate ovulation and treat endo-
metriosis.
Corticotropin is usually not recommended for the numerous non-
endocrine inflammatory disorders that respond to glucocorticoids.
Administration of glucocorticoids is more convenient and effec-
tive than administration of corticotropin.
Indicated by appropriate increases in height and weight.
These effects indicate control of diabetes insipidus.
Octreotide is often used to control diarrhea associated with a
number of conditions.
Systemic reactions occur infrequently.
Although adverse effects occur in about 50% of patients, they are
usually minor and of short duration.
These adverse reactions are in general the same as those produced
by adrenal cortex hormones. Severity of adverse reactions tends to
increase with dosage and duration of corticotropin administration.
Sexual precocity results from stimulation of excessive testosterone
secretion at an early age.
Adverse effects are not common. Another adverse effect may be
development of antibodies to the drug, but this does not prevent its
growth-stimulating effects.
Adverse effects can be minimized by frequent pelvic examinations
to check for ovarian enlargement and by laboratory measurement
of estrogen levels. Multiple gestation (mostly twins) is a possibil-
ity and is related to ovarian overstimulation.
(continued )

NURSING ACTIONS
g. With desmopressin, observe for headache, nasal conges-
tion, nausea, and increase blood pressure. A more serious ad-
verse reaction is water retention and hyponatremia.
h. With lypressin, observe for headache and congestion of
nasal passages, dyspnea and coughing (if the drug is inhaled),
and water intoxication if excessive amounts of lypressin or
fluid are taken.
i. With vasopressin, observe for water intoxication; chest pain,
myocardial infarction, increased blood pressure; abdominal
cramps, nausea, and diarrhea.
j. With oxytocin, observe for excessive stimulation or con-
tractility of the uterus, uterine rupture, and cervical and per-
ineal lacerations.
k. With octreotide, observe for arrhythmias, bradycardia,
diarrhea, headache, hyperglycemia, injection site pain, and
symptoms of gallstones.
4. Observe for drug interactions
a. Drugs that increase effects of vasopressin:
General anesthetics, chlorpropamide (Diabinese)
b. Drug that decreases effects of vasopressin:
Lithium
c. Drugs that increase effects of oxytocin:
(1) Estrogens
(2) Vasoconstrictors or vasopressors (eg, ephedrine, epi-
nephrine, norepinephrine)
Nursing Notes: Apply Your Knowledge
Answer: Lypressin replaces the antidiuretic hormone that acts
to decrease urine output. If this medication is effective, you would
expect to see a decrease in urine output. The urine will appear
less dilute (may be pale yellow rather than clear) and have a
higher specific gravity. Keep accurate intake and output records
on Mr. Willis, record daily weights, and monitor specific gravity.
Review and Application Exercises
1. What hormones are secreted by the hypothalamus and
pituitary, and what are their functions?
2. What are the functions and clinical uses of ADH and
growth hormone?
CHAPTER 23 HYPOTHALAMIC AND PITUITARY HORMONES 333
RATIONALE/EXPLANATION
Adverse reactions usually occur only with high dosages and tend
to be relatively mild. Water intoxication (headache, nausea, vom-
iting, confusion, lethargy, coma, convulsions) may occur with any
antidiuretic therapy if excessive fluids are ingested.
Adverse effects are usually mild and occur infrequently with usual
doses.
With high doses, vasopressin constricts blood vessels, especially
coronary arteries, and stimulates smooth muscle of the gastro-
intestinal tract. Special caution is necessary in clients with heart
disease, asthma, or epilepsy.
Severe adverse reactions are most likely to occur when oxytocin
is given to induce labor and delivery.
These are more common effects, especially in those receiving
octreotide for acromegaly.
Potentiate vasopressin
Inhibits the renal tubular reabsorption of water normally stimu-
lated by vasopressin
With adequate estrogen levels, oxytocin increases uterine con-
tractility. When estrogen levels are low, the effect of oxytocin is
reduced.
Severe, persistent hypertension with rupture of cerebral blood ves-
sels may occur because of additive vasoconstrictor effects. This is
a potentially lethal interaction and should be avoided.
3. What are adverse effects of the hypothalamic and pituitary
hormones used in clinical practice?
SELECTED REFERENCES
Drug facts and comparisons. (Updated monthly). St. Louis: Facts and
Comparisons.
Guyton, A. C. & Hall, J. E. (2000). Textbook of medical physiology, 10th ed.
Philadelphia: W. B. Saunders.
Marshall, J. C. & Barkan, A. L. (2000). Disorders of the hypothalamus and
anterior pituitary. In H. D. Humes (Ed.), Kelleys Textbook of internal
medicine, 4th ed., pp. 26632683. Philadelphia: Lippincott Williams &
Wilkins.
Porth, C. M. (Ed.). (2002). Pathophysiology: Concepts of altered health
states, 6th ed. Philadelphia: Lippincott Williams & Wilkins.
Robinson, A. G. (2000). Disorders of posterior pituitary function. In
H. D. Humes (Ed.), Kelleys Textbook of internal medicine, 4th ed.,
pp. 26842691. Philadelphia: Lippincott Williams & Wilkins.