View Full Version : Hypothalamic–pituitary–adrenal axis - brain tumor

12-24-2012, 12:09 AM
I have a character who needs to go off the deep end. I suspect I can create the required symptoms using a benign pituitary tumor. Part of its effect will be to overstimulate adrenal hormones to produce an increased sex drive.

I'm going to give the symptoms she needs to display and hoping someone medically knowledgeable can help me craft a medical explanation for them!

1) Headache - but although due to pressure from the brain tumor it will respond to medications like Tylenol. I understand tumor headaches don't normally respond to pain medication but sometimes it can. That sometimes certain pain medication can help reduce swelling. The headaches will not be morning ones only and not when she lies down.

2) Some nausea

3) Fatigue

4) Loss of appetite

5) Mood swings

6) An increased sex drive. I know the increase of prolactin should reduce libido in women so I don't want the tumor to cause this, so non functioniing tumor as far as prolactin is concerned. However, I do want it to result in overstimulation of hormones in the adrenal gland. I understand the pituitary helps regulate adrenal hormone production.

7) Mood swings - I've read that a pituitary tumor can cause mood swings including - depression, irritability. I want her to become more aggressive, unconcerned by normal social conventions, less empathic to another person's wellbeing or feelings. This together with an increased sex drive will make her dangerous and unpredictable.

8) Cognitive dysfunction - she will think her headaches are a result of needing glasses. She's an author, her writing will become garbled, unstructured, incoherent, garbage, but she won't really notice. She will think her normal writing is rubbish.

9) She needs to deteriorate quite rapidly. (She has seen a doctor for headaches - without any other symptoms, he/she prescribes medication (like Tylenol, suggestions welcome) (which will appear to have an effect on the headache), and asks her to come back if symptoms continue or get worse. She/others will presume it's migraine related.)

But I want these other symptoms to present themselves within a week or two, rapidly getting worse with the mood swings towards the end.

I've gone for a pituitary tumor because depending on which cells are affected, the symptoms can vary considerably.

If anyone can advise on what the medical tests would then show, that would result in a decision to go for immediate brain surgery that would be so helpful. I think surgery through the nose is a possibity, but if possible I want surgery that will be a bit touch and go, cause concern as to whether she will recover normally, and require a 4 week or so recovery period.

Any advice welcome. And thank you very much.

And a merry Christmas! http://www.absolutewrite.com/forums/images/icons/icon7.gif

12-24-2012, 02:09 PM
1. Headache is usually not the first or early sign of brain tumors; symptoms caused by hormonal changes appear first.

Headache can appear and worsen rapidly in case of pituitary apoplexy (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002151/) - bleeding within a pituitary tumor. Sometimes symptoms, including headache, develop more slowly and often include vision problems and nausea (more symptoms here (http://emedicine.medscape.com/article/1198279-clinical#showall)).

Headache caused by brain tumors is due to increased intracranial pressure (pressure within the skull), which can be reduced by medicines that reduce brain swelling: steroids, such as hydrocortisone (http://emedicine.medscape.com/article/1198279-medication#showall) (but not in ACTH-releasing tumors, which stimulate steroid production in the body). In severe headache, a doctor can prescribe midazolam or opioids, such as morphine or alfentanyl (here (http://www.patient.co.uk/doctor/Rising-Intracranial-Pressure.htm)).

Before seeing a doctor, the woman would likely try Tylenol or aspirin , which could help in a mild, but probably not in severe, headache...

2. Other symptoms:

A combination of increased appetite, fatigue, irritability and mental changes can occur in thyrotropin (TSH) secreting pituitary adenomas (TSH stimulates the hormone thyroxine, so you get symptoms of hyperthyroidism). Headache can be due to large tumor size, but pituitary tumors grow slowly, so headache usually develops slowly, except in pituitary bleeding. Check combination of symptoms (http://pituitary.mgh.harvard.edu/pitsympt.htm) in various pituitary tumors.

I didn't find any type of pituitary tumor that would cause decreased appetite, increased aggressiveness and sex drive at the same time. Pituitary tumors do not likely increase sex drive; ACTH-secreting tumors, which stimulate the release of steroids from the adrenal gland, actually decrease libido (at least in men) (check Cushing syndrome (http://www.mayoclinic.com/health/cushings-syndrome/DS00470/DSECTION=symptoms))

In prolactine-secreting pituitary adenoma (prolactinoma) sex drive is decreased, but this tumor is treated with dopamine agonists and one of their side effects can be "severe hypersexuality" (http://www.ncbi.nlm.nih.gov/pubmed/21738024).

Dopamine agonists (such as ropinirole) are sometimes prescribed to treat sexual dysfunction caused by the type of antidepressants called SSRIs, such as fluoxetine (Prozac).
Quote from here (http://www.nlm.nih.gov/medlineplus/druginfo/meds/a698013.html):
"..some people who took medications such as ropinirole developed gambling problems or other intense urges or behaviors that were compulsive or unusual for them, such as increased sexual urges or behaviors..." This drug actually can actually cause other symptoms (as side effects) you've mentioned: headache, loss of appetite, nausea, aggression, increased sex drive, agitation, confusion, hallucinations (drugs.com (http://www.drugs.com/sfx/ropinirole-side-effects.html))

3. Diagnosis.

Pituitary tumor can be suspected from symptoms or changed blood levels of hormones, but before surgery a CT or MRI is required to confirm the tumor and evaluate its size. Severe and worsening headache, rapid vision loss (visual field test) and rapid worsening of other symptoms need quick surgery. CT or MRI can show bleeding in the tumor, which requires urgent surgery.

4. Treatment

There are videos on Youtube that show surgery of a pituitary adenoma through the nose. Before surgery, certain drugs to counteract the effect of increased hormone levels may be necessary.

Touch and go surgery?

12-25-2012, 12:49 AM
She could have a pituitary tumor that stimulates androgen excess (in women). Those symptoms could cause increased libido and aggression in a woman, but keep in mind, she'll probably notice hirsutism or an easier ability to gain muscle, etc., too.

Treatments for endometriosis can cause hirsutism, so you could explain where she thought that symptom came from by that.

I don't know how fast those can grow and all of that sort of thing. I'm just vaguely familiar with it as a differential diagnosis for something else, so I'm just suggesting a place for more possible areas for research :)

12-27-2012, 02:42 AM
First of all thank you to both of you for your replies! I need to go research your suggestions - work out how these affect my plot - and then come back to check my conclusions!

(Sorry for delayed reply - visiting relatives over Christmas!)

12-27-2012, 08:44 PM
A combination of increased appetite, fatigue, irritability and mental changes can occur in thyrotropin (TSH) secreting pituitary adenomas (TSH stimulates the hormone thyroxine, so you get symptoms of hyperthyroidism). Headache can be due to large tumor size, but pituitary tumors grow slowly, so headache usually develops slowly, except in pituitary bleeding.

This works best! I can increase appetite instead.

So high metabolism results in increased sex drive.

I have a head injury in plot - this could cause the tumor to bleed, and a night of passion and a stressful situation the next day could cause it to rapidly get worse resulting in a seizure.

MRI identifies tumor and bleeding plus elevated TSH levels and thus urgent surgery.

My only issue is what medication she takes for her headaches. This is a UK based story. Wouldn't aspirin worsen a bleed?

The character has been to a doctor. She's a writer, so swollen finger joints, RSI, might result in cortisone type medication if that helps. She has mentioned that she is getting headaches (but not migraine type ones) and that is her only symptom at that point, what would the doctor presribe/suggest?

I need to suggest to the reader there is a medical problem, and that the character knows that if it gets worse or continues she needs to go back to the doctor.( I want the medication to have some effect because I want another character to assume she is getting migraines which medication is helping.)

Thanks for help!