Hypopituitarism Diagnosis and Treatment

PRESENTATIONS OF HYPOPITUITARISM

This depends on the hormones which are deficient. GH deficiency causes growth disorder and abnor­mal body structure. Gonadotrophin deficiency causes infertility, men­strual and sexual dysfunction and loss of secondary sexual characteristics in men. TSH and ACTH deficiency cause growth retarda­tion, hypothyroidism, adrenal insufficiency. Mineralo­corticoid action is retained. PRL(prolactin) deficiency causes failure of lacta­tion. If Posterior pituitary is also involved there is poly­uria, polyd’Rsia due to vasopressin deficiency.

PRESENTATIONS OF HYPOPITUITARISM

HYPOPITUITARISM Diagnosis and Treatment


Lab investigations for Hypopituitarism

  • There are low levels of trophic hormones and low level of target hormones also e.g. Iow ACTH with low corti­sol, low FSH with low testosterone, estradiol, proges­terone, low level of TSH with low T31 T4, low levels of GH with low IGF (insulin like growth factors).
  • Provocative tests are done to assess pituitary reserve.
Hypopituitarism Risk Factors
  • Infections
  • Infiltrative diseases
  • Irradiation
  • Lymphocytic hypophysitis
  • Postoperative
  • Pregnancy and delivery
  • Trauma
  • Tumors
  • Vascular aneurysms

Assessment history of pituitary function,

  • Pregnancy-related hemorrhage or hypotension
  • Gonadal dysfunction
  • Empty sella
  • Craniofacial abnormalities
  • Pituitary or hypothalamic lesions
  • Inflammatory or granulomatous disease
  • Head trauma or head surgery
  • Cranial radiation

Hypopituitarism Physical Exam

  • •Pituitary failure secondary to tumors:
    • ACTH: Hypotension, anorexia, pallor, weight loss
    • Gonadotropins: Delayed puberty
    • TSH: Weight gain, hair loss, dry skin, bradycardia, hoarseness, hypotension
    • GH: Decreased muscle mass and strength, increased visceral fat, growth retardation
  • •Visual field defects
  • •Children:
    • Congenital malformations and syndromes, especially malformations of the head and genitalia
    • Growth retardation and delayed puberty

Hypopituitarism Differential Diagnosis

  • Primary hypothyroidism
  • Primary hypogonadism
  • Kallmann syndrome
  • Hypothalamic insufficiency
  • Constitutional short stature
  • Chronic liver disease
  • Addison disease, primary adrenal insufficiency

Treatment of Hypopituitarism

  • Generalized condition caused by partial or total failure of anterior pituitary gland’s hormones: adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone (TSH), luteinizing hormone (LH), follicle-stimulating hormone (FSH), growth hormone (GH), and prolactin.
  • Less commonly, the posterior pituitary gland’s hormones can be affected: AVP/ADH and oxytocin.
  • Hormone replacement therapy like glucocorti­coids, thyroid hormone, sex steroids, growth hormone, vasopressin are given.
  • Shortages of ACTH, TSH, and ADH can be life-threatening.
  • Synonym(s): Empty sella syndrome; Hypopituitarism; Pituitary cachexia; Simmonds syndrome; Panhypopituitarism; as a consequence of blood loss during pregnancy, Sheehan syndrome
  • System(s) affected: Cardiovascular; Endocrine/Metabolic; GI; Musculoskeletal; Nervous; Reproductive; Skin/Exocrine
  • Treatment of ACTH, TSH, LH, and FSH deficiencies similar to the treatment of primary hormone deficiencies of their respective target organ:
  • ACTH deficiency results in cortisol deficiency:
    • Treatment consists of administration of glucocorticoid hormones (hydrocortisone, dexamethasone, or prednisone) to mimic normal pattern of cortisol secretion; mineralocorticoid replacement is rarely necessary.
    • Dosages and administration schedule vary according to age and sex.
    • Hypoprolactinemia has no treatment.
    • LH and FSH deficiency: Treatment depends on gender and whether fertility is desired.
  • Men: Testerone replacement if fertility not desired; gonadotropins for fertility
    • Recombinant human GH (for treating short stature in children and for treating selected adult patients)
    • TSH deficiency: Goal of treatment is normal free T4 value. Treat with levothyroxine.
  • Women: Estrogen–progesterone (and possibly testosterone) replacement, or pulsatile gonadotropins for fertility
    • Infectious disease: Antibiotics as appropriate
  • Inflammatory or granulomatous disease: Specific treatment
  • Adrenal insufficiency should be excluded before thyroid hormone replacement is initiated; otherwise, thyroid hormone replacement could precipitate adrenal crisis
  • Replacement of hormones secreted by target glands