When should a patient with suspected endocrine disorders be referred to an endocrinologist?

Endocrinology Referral Criteria for Suspected Endocrine Disorders

All patients with confirmed adrenal insufficiency (primary or secondary), hypophysitis, or pheochromocytoma require immediate endocrinology referral regardless of symptom severity. 1

Mandatory Immediate Referral Situations

Adrenal Disorders

• All grades of primary adrenal insufficiency require endocrinology referral for education on steroid stress dosing, emergency injections, and medical alert systems 1
• All grades of hypophysitis (central adrenal insufficiency) require endocrinology consultation for hormone replacement management and stress dosing education 1
• Persistently elevated prolactin levels of unknown etiology warrant endocrinology evaluation to screen for pituitary tumors 1
• Men with total testosterone <150 ng/dL combined with low or low-normal LH should undergo pituitary MRI and endocrine referral regardless of prolactin levels, as non-secreting adenomas may be present 1

Thyroid Disorders

• Grade 3-4 thyrotoxicosis (severe symptoms, medically significant consequences, unable to perform activities of daily living) requires endocrine consultation for all patients 1
• Grade 2 thyrotoxicosis (moderate symptoms, able to perform ADL) warrants consideration of endocrine consultation 1
• Persistent thyrotoxicosis >6 weeks at any grade requires endocrinology referral for additional workup 1
• Physical examination findings of ophthalmopathy or thyroid bruit are diagnostic of Graves' disease and should prompt early endocrine referral 1
• Suspected Graves' disease requires endocrine consultation, as it is generally persistent and requires specialized treatment with antithyroid medications, radioactive iodine, or surgery 1

Reproductive and Gonadal Disorders

• Men with elevated baseline estradiol measurements should be referred to an endocrinologist 1
• Persistent abnormal hormone levels or severe menstrual irregularities require referral to an endocrinologist or gynecologist 2
• Women with infertility concerns need reproductive endocrinology consultation 2
• Women with signs of premature ovarian insufficiency (amenorrhea with elevated FSH in women under 40) should be referred to a specialist 2
• Persistently high prolactin levels in women with epilepsy and reproductive symptoms require endocrine evaluation 1

Adrenal Mass Evaluation

• Low threshold for multidisciplinary review (including endocrinologists) when imaging is not consistent with a benign lesion, there is evidence of hormone hypersecretion, the tumor has grown significantly during follow-up, or adrenal surgery is being considered 1

Grade-Specific Referral Timing

Grade 1 (Asymptomatic or Mild Symptoms)

• Primary adrenal insufficiency: Endocrine consultation required for all patients to initiate replacement therapy and provide education 1
• Hypophysitis: Endocrine consultation required to manage hormone replacement and avoid precipitating adrenal crisis 1
• Thyrotoxicosis: Consider endocrine consultation if persistent >6 weeks 1

Grade 2 (Moderate Symptoms, Able to Perform ADL)

• Primary adrenal insufficiency: Endocrine consultation required 1
• Hypophysitis: Endocrine consultation required 1
• Thyrotoxicosis: Consider endocrine consultation; refer to endocrinology if persistent >6 weeks 1

Grade 3-4 (Severe Symptoms, Life-Threatening)

• Primary adrenal insufficiency: Endocrine consultation required for all patients 1
• Hypophysitis: Endocrine consultation required for all patients 1
• Thyrotoxicosis: Endocrine consultation required for all patients 1

Special Clinical Scenarios Requiring Endocrine Consultation

Pre-Surgical Planning

• Endocrine consultation should be part of planning before surgery or high-stress treatments (such as cytotoxic chemotherapy) at any time during a patient's care for patients with known adrenal insufficiency 1

Reproductive Health in Men

• Men with testosterone deficiency interested in preserving fertility should have reproductive health evaluation prior to treatment, as testosterone therapy will impair spermatogenesis 1

Women with Epilepsy

• Women with epilepsy and symptoms of reproductive endocrine disorders (menstrual irregularity, infertility, weight gain, hirsutism, galactorrhea) should be investigated or referred if cycle disturbances are present 1

Common Pitfalls to Avoid

• Do not delay endocrinology referral for patients with confirmed adrenal insufficiency, as early consultation is critical for patient education on stress dosing and emergency management to prevent adrenal crisis 1
• Do not assume thyrotoxicosis will resolve without specialist input if symptoms persist beyond 6 weeks, as this may indicate Graves' disease requiring definitive treatment 1
• Do not initiate other hormone replacement before addressing adrenal insufficiency in hypophysitis patients, as this can precipitate adrenal crisis 1
• Do not overlook the need for multidisciplinary review when adrenal masses show indeterminate features or hormone hypersecretion, as this impacts surgical planning and outcomes 1