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Hypopituitarism -Quick review card

HYPOPITUITARISM  Total or partial loss of pituitary gland function caused by 
pituitary or hypothalamic disorders

Adults – Most common cause is a pituitary adenoma , pituitary surgery or radiotherapy.

 

Primary – The problem is in the gland 
due to loss , damage or dysfunction of pituitary secreting cells
 tumours causing gland destruction ischaemia causing necrosis pituitary apoplexy ( tumour ) cavernous sinus thrombosis aneurysms of the intracranial carotid artery infection , infiltration , immunological primary empty Sella syndrome iatrogenic genetic

 

Secondary – Due to diseases of the hypothalamus or pituitary stalk which interrupts the nerve or vascular connection to the pituitary gland
 tumors infiltrative traumatic brain injury hormone induced iatrogenic infectious nutritional anorexia nervosa severe systemic illness genetic

 

Presentation – insidious onset often precipitated by a stressful event 75 % or more of the gland damage -is needed before HPP symptoms can be varied and depend upon the extent and severity of hormone deficiencies , duration of the disease and the age of onset large pituitary tumors may lead to pan hypopituitarism ie deficiency of cortisol , thyroxine , sex steroids and growth hormones and loss of visual field and acuity as the supresellar extension puts pressure on the optic chiasm and nerves presenting symptoms can include headaches , amenorrhoea , galactorrhoea , visual field defects a sequential order is often noticed with GH secretion being affected first followed by gonadotrophin followed by TSH and ACTH with prolactin deficiency rarely seen ( except in Sheehan syndrome )

Growth hormone – GH
Growth 
hormone fatigue , reduced muscle mass , strength , decreased glucose , lack of drive children – short stature , faltering growth , failure to thrive

 

FSH/ LH
secondary hypogonadism delayed puberty , decreased libido , menstrual problems as oligomenorrhoea , infertility , azoospermia , testicular atrophy 
( hypogonadism in men ) . In children – failure of pubertal development

ACTH
secondary adrenal deficiency- fatigue , nausea , vomiting , weigh loss, low BP , dizziness , hypoglycaemia , pallor ,collapse during intercurrent illness

 

TSH
secondary thyroid deficiency – Features of hypothyroidism as weight gain , fatigue , cold intolerance

ADH / 
AVP- thirst , polyuria and nocturia – diabetes insipidus.

 

First line tests – Us & Es paired plasma and urine osmolarity 8 AM cortisol and ACTH ( follow abnormal cortisol with ACTH testing ) Thyroid axis T4 , TSH Men -9 AM testosterone ( fasting ) , SHBG , FSH , LH Women -Estradiol , FSH , LH , day 21 progestesterone Serum prolactin Insulin like growth factor ( IGF -1 ) Visual fields testing

MRI is the imaging of choice for pituitary masses.

REFERENCES

  1. Pituitary Disease Factfile: The pituitary foundation GP-fact-file_A5_16-10-15.pdf (pituitary.org.uk)
  2. Endocrinology in Primary Care John Marlow Oct 2013 Endocrinology in Primary Care (hee.nhs.uk)
  3. Hypopituitarism ARUP Consult Hypopituitarism | Choose the Right Test (arupconsult.com)
  4. Hypopituitarism BMJ Best Practice Hypopituitarism – History and exam | BMJ Best Practice
  5. Kim, Seong Yeon. “Diagnosis and Treatment of Hypopituitarism.” Endocrinology and metabolism (Seoul, Korea) vol. 30,4 (2015): 443-55. doi:10.3803/EnM.2015.30.4.443 Diagnosis and Treatment of Hypopituitarism (nih.gov)
  6. The Lancet Hypopituitarism Fast Facts
    Claire E Higham, Gudmundur Johannsson, Stephen M Shalet
    Published online: March 31, 2016 Hypopituitarism (thelancet.com)

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