Endocrinology for GP Trainees: Your Essential Guide
Hormone harmony for harried GPs - because your patients' endocrine systems don't take coffee breaks either!
🥇 Tea-Friendly Learning 🥈 For GP Trainees Short on Time 🥉 Red Flag Focused
Last Updated: 14 March 2026
Recent NICE Updates
NICE Thyroid Disease Guideline (October 2025): Reviewed with no changes to hypothyroidism management recommendations
Executive Summary: What You'll Master Today
Because you have 47 other things to do before lunch, and that's just the morning list
What This Page Covers:
Quick Facts at a Glance:
1 in 1000
Adults with primary hyperparathyroidism
2%
UK adults with undiagnosed thyroid disease
90%
Endocrine emergencies are preventable
TSH Only
Monitor thyroxine replacement therapy
📥 Downloads & Resources
Useful downloads and web links for Endocrinology
Downloads
🧠 Brainy Bites: Essential Endocrinology Wisdom
The stuff seasoned GPs wish someone had told them sooner
TSH-Only Monitoring Rule: Once on stable thyroxine replacement, monitor TSH ONLY. No need for T4/T3. Adjust dose in 25μg steps. Target TSH 0.4-4.0 mU/L. Mnemonic: "TSH = The Single Hormone" to monitor.
Calcium Correction Magic Formula: Corrected calcium = measured calcium + 0.02 × (40 - albumin g/L). Remember: "Add 0.02 for every gram albumin is below 40". Essential for accurate interpretation.
DEXA T-Score Memory Aid: T-score: "T for Thirty-year-old" - compares to healthy 30-year-old. Normal >-1, Osteopenia -1 to -2.5, Osteoporosis ≤-2.5. Z-score: "Z for Zero difference" - compares to same age.
Addison's "4 Hypos" Rule: Remember Addisonian crisis with "4 Hypos": Hypotension, Hyponatraemia, Hypoglycaemia, Hyperkalaemia. Plus confusion and abdominal pain. Give hydrocortisone 100mg IV immediately.
Primary Hyperparathyroidism "Stones, Bones, Groans, Moans": Classic mnemonic still works: Stones (kidney), Bones (osteoporosis), Groans (GI symptoms), Moans (psychiatric). But 50% are asymptomatic - found on routine bloods.
Thyroid Storm vs Sepsis Trap: Both cause fever, tachycardia, confusion. Key difference: thyroid storm has NO focal infection source. Look for precipitant (infection, surgery, iodine). Treat both simultaneously if unsure.
1️⃣ Data Gathering & Examination Tips
Focused endocrine consultation framework for primary care
Focused Endocrine History
Key questions for endocrine consultations
Thyroid Symptoms
- Weight change, appetite, heat/cold intolerance
- Energy levels, mood, concentration
- Bowel habit, menstrual changes
- Palpitations, tremor, sweating
- Neck swelling, voice change, dysphagia
Calcium Symptoms
- Bones: bone pain, fractures, osteoporosis
- Stones: renal colic, polyuria, polydipsia
- Groans: abdominal pain, constipation, nausea
- Moans: depression, fatigue, confusion
Adrenal Symptoms
- Fatigue, weakness, weight loss (insufficiency)
- Postural dizziness, salt craving
- Weight gain, striae, bruising (Cushing)
- Hypertension, headaches, sweating (phaeochromocytoma)
Endocrine Examination
Systematic approach to examination
Thyroid Examination
- Inspection: goitre, scars, exophthalmos
- Palpation: size, consistency, nodules, lymph nodes
- Auscultation: thyroid bruit (Graves disease)
- Hands: tremor, palmar erythema, onycholysis
- Eyes: lid lag, lid retraction, proptosis
- Reflexes: delayed relaxation (hypothyroidism)
Cushing Syndrome
- Central obesity, moon face, buffalo hump
- Purple striae (>1 cm wide)
- Proximal myopathy, thin skin, bruising
- Hypertension, hyperglycaemia
Acromegaly
- Enlarged hands, feet, jaw
- Coarse facial features, frontal bossing
- Macroglossia, interdental separation
- Visual field defects (bitemporal hemianopia)
Red Flags in Consultation
Features requiring urgent action
Immediate Referral Required
- Suspected thyroid storm or myxoedema coma
- Addisonian crisis features
- Severe hypercalcaemia (>3.5 mmol/L)
- Pituitary apoplexy symptoms
- Phaeochromocytoma crisis
Thyroid Cancer Suspicion
- Hard, fixed thyroid nodule
- Rapid growth, voice change, dysphagia
- Cervical lymphadenopathy
- History of neck irradiation
2️⃣ Diagnostic Approach & Investigations
GP diagnostic framework for suspected endocrine disease
Primary Care Investigations
First-line tests and interpretation
| Test | Indication | Interpretation | Normal Range |
|---|---|---|---|
| TSH | First-line thyroid function test | High TSH = hypothyroidism, Low TSH = hyperthyroidism | 0.4-4.0 mU/L |
| Free T4 | If TSH abnormal or monitoring treatment | Confirms thyroid dysfunction severity | 9-25 pmol/L |
| Corrected Calcium | Suspected calcium disorder | High = hyperparathyroidism/malignancy, Low = hypoparathyroidism/vitamin D deficiency | 2.2-2.6 mmol/L |
| PTH | Persistent hypercalcaemia | High PTH + high calcium = primary hyperparathyroidism | 1.6-6.9 pmol/L |
| 9am Cortisol | Suspected adrenal insufficiency | <100 nmol/L = adrenal insufficiency likely, >500 nmol/L = unlikely | 200-700 nmol/L |
| DEXA Scan T-Score | Osteoporosis assessment | Normal >-1, Osteopenia -1 to -2.5, Osteoporosis ≤-2.5 | T-score >-1.0 |
| DEXA Scan Z-Score | Age-matched bone density comparison | Z-score ≤-2.0 suggests secondary osteoporosis | Z-score >-2.0 |
| Vitamin D (25-OH) | Bone health, calcium metabolism | Deficiency <25 nmol/L, Insufficiency 25-75 nmol/L | >75 nmol/L |
Thyroid Function Testing Algorithm
Step 1: Check TSH
If TSH abnormal: Check free T4 (and free T3 if hyperthyroid)
If autoimmune suspected: Check thyroid peroxidase antibodies
Subclinical disease: Repeat in 3 months to confirm persistence
Calcium Investigation Pathway
Step 1: Corrected calcium + albumin
If high: Repeat to confirm, check PTH
If PTH high/normal: Primary hyperparathyroidism likely
If PTH low: Consider malignancy, vitamin D toxicity, sarcoidosis
3️⃣ Differential Diagnosis Frameworks
Symptom-based approaches for common endocrine presentations
Hypothyroidism (TSH, free T4)
Hyperthyroidism (TSH, free T4)
Anaemia (FBC, ferritin)
Diabetes (HbA1c)
Adrenal insufficiency (9am cortisol)
Depression (clinical assessment)
Hyperthyroidism (TSH, free T4)
Diabetes (HbA1c)
Malignancy (clinical examination, investigations)
Adrenal insufficiency (9am cortisol)
Malabsorption (coeliac serology)
Primary hyperparathyroidism (PTH)
Malignancy (myeloma screen, imaging)
Vitamin D toxicity (vitamin D level)
Sarcoidosis (ACE, chest X-ray)
Thiazide diuretics (medication review)
Essential hypertension (most common)
Renal artery stenosis (renal USS Doppler)
Primary aldosteronism (renin/aldosterone ratio)
Phaeochromocytoma (24h urinary metanephrines)
Cushing syndrome (overnight dexamethasone suppression test)
4️⃣ Common Endocrine Conditions GPs Should Manage
Evidence-based management for primary care
5️⃣ Red Flags & Conditions Not to Miss
Life-threatening endocrine emergencies requiring urgent recognition
Addisonian CrisisIMMEDIATE
Features:
- Hypotension, shock
- Hyponatraemia, hyperkalaemia
- Hypoglycaemia
- Confusion, abdominal pain, vomiting
Action: Immediate hospital admission. IV hydrocortisone 100 mg stat, IV fluids, treat precipitant.
Thyroid StormIMMEDIATE
Features:
- Fever >38.5°C
- Tachycardia >140 bpm, atrial fibrillation
- Confusion, agitation, psychosis
- Precipitant: infection, surgery, iodine contrast
Action: Immediate hospital admission. Beta-blockers, antithyroid drugs, supportive care.
Myxoedema ComaIMMEDIATE
Features:
- Hypothermia <35°C
- Bradycardia, hypotension
- Reduced consciousness
- Hypoventilation, hyponatraemia
Action: Immediate hospital admission. IV levothyroxine, hydrocortisone, supportive care.
Severe HypercalcaemiaURGENT
Features:
- Corrected calcium >3.5 mmol/L
- Confusion, drowsiness
- Nausea, vomiting, dehydration
- Renal impairment
Action: Urgent hospital admission. IV fluids, bisphosphonates, treat underlying cause.
Pituitary ApoplexyIMMEDIATE
Features:
- Sudden severe headache
- Visual field defects, diplopia
- Reduced consciousness
- Hypopituitarism symptoms
Action: Immediate neurosurgical referral. MRI pituitary, hydrocortisone replacement.
Phaeochromocytoma CrisisURGENT
Features:
- Severe hypertension (>200/120 mmHg)
- Headache, sweating, palpitations
- Pallor, anxiety
- Precipitant: surgery, drugs, pregnancy
Action: Urgent hospital admission. Alpha-blockade (phenoxybenzamine), then beta-blockade.
✅ You've Got This!
A final word of encouragement before you head back to the coalface
You've Got This! ✅
Remember: You don't need to be an endocrinologist to provide excellent endocrine care. You just need to know when to worry, when to treat, and when to refer.
Most endocrine conditions present with subtle, non-specific symptoms. Your systematic approach to history-taking, targeted investigations (TSH first!), and knowledge of red flags will serve your patients well. When in doubt, NICE CKS is your friend, and endocrinologists are there to help with complex cases. The key is recognizing patterns and knowing your limits.
☕ Now go reward yourself with that well-deserved coffee