Hypopituitarism

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See also: Prolactinoma written for patients

Hypopituitarism is the inability of the pituitary gland to provide sufficient hormones, due to an inability of the pituitary gland to produce hormones or due to an insufficient supply of hypothalamic-releasing hormones.

Symptoms depend on the degree of hormone depletion and the rapidity of onset. Hypopituitarism is usually a mixture of several hormonal deficiencies but rarely involves all the pituitary hormones. Hypopituitarism is usually chronic and lifelong, unless successful surgery or medical treatment of the underlying disorder can restore pituitary function.[1]

Taken from the results of one study:[1]

  • The incidence of hypopituitarism is estimated to be 4·2 per 100,000 per year.
  • The prevalence of hypopituitarism is estimated to be 45·5 per 100,000.

The most common cause of hypopituitarism is anterior pituitary tumours. The causes of hypopituitarism include:

  • Pituitary tumours: for example, adenomas.
  • Non-pituitary tumours: craniopharyngiomas, meningiomas, gliomas, chordomas, ependymomas, metastases.
  • Infiltrative processes: sarcoidosis, histiocytosis X, haemochromatosis.
  • Infections: cerebral abscess, meningitis, encephalitis, tuberculosis, syphilis.
  • Ischaemia and infarction: subarachnoid haemorrhage, ischaemic stroke, Sheehan's syndrome (postpartum haemorrhage with anterior pituitary infarction), pituitary apoplexy (caused by an acute infarction of a pituitary adenoma).[2]
  • Empty sella syndrome: radiological diagnosis of absence of normal pituitary within the sella turcica. Usually benign and asymptomatic but may develop headaches and hypopituitarism.
  • Iatrogenic: irradiation,[3] neurosurgery, withholding previous chronic glucocorticoid replacement.
  • Head injury (may have occurred up to several years before).[4]
  • Congenital: Kallmann's syndrome (congenital hypogonadotropic hypogonadism with midline defects such as anosmia).[5]
  • Autoimmune: lymphocytic hypophysitis.[6]
  • Pituitary hypoplasia or aplasia.
  • Genetic causes - eg, PIT1, PROP1 gene mutations, septo-optic dysplasia.
  • Idiopathic causes.
  • Presentation varies from asymptomatic to acute pituitary failure with acute collapse and coma, depending on the aetiology, rapidity of onset, and predominant hormones involved.
  • Initially, a patient with any hormone deficiency may be asymptomatic.
  • May present with endocrine dysfunction:
    • Adrenocorticotrophic hormone (ACTH) deficiency:
      • See also the separate article on Adrenal Insufficiency and Addison's Disease.
      • Chronic: fatigue, pallor, anorexia, weight loss.
      • Acute: weakness, dizziness, nausea, vomiting, circulatory collapse, fever, shock.
      • Children: delayed puberty, failure to thrive.
      • Hypoglycaemia, hypotension, anaemia, lymphocytosis, eosinophilia, hyponatraemia.
    • Thyroid-stimulating hormone (TSH) deficiency:
      • See also the separate article on Hypothyroidism.
      • Tiredness, cold intolerance, constipation, hair loss, dry skin, hoarseness, cognitive slowing.
      • Weight gain, bradycardia, hypotension.
      • Children: delayed development, growth restriction and intellectual impairment.
    • Gonadotrophin deficiency:
      • Women: oligomenorrhoea, loss of libido, dyspareunia, infertility, osteoporosis.
      • Men: loss of libido, impaired sexual function, mood impairment, loss of facial, scrotal, and body hair; decreased muscle mass, osteoporosis, anaemia.
      • Children: delayed puberty.
    • Growth hormone deficiency:
      • See also the separate article on Short Stature.
      • Decreased muscle mass and strength, visceral obesity, fatigue, decreased quality of life, impairment of attention and memory.
      • Dyslipidaemia, premature atherosclerosis.
      • Children: growth restriction.
    • Antidiuretic hormone deficiency:
      • Polyuria, polydipsia.
      • Decreased urine osmolality, hypernatraemia.
    • May also present with features attributable to the underlying cause:
      • Space-occupying lesion: headaches or visual field deficits.
      • Large lesions involving the hypothalamus: polydipsia and inappropriate secretion of antidiuretic hormone.
  • Usually occurs in a patient known to have hypopituitarism and often develops gradually but may occur suddenly due to pituitary apoplexy.[7]
  • May be triggered by infection, trauma, surgery, hypothermia or pituitary haemorrhage.
  • Clinical features include hormone deficiencies, meningism, visual field defects, ophthalmoplegia, reduced consciousness, hypotension, hypothermia and hypoglycaemia.
  • Treatment is required urgently in the form of intravenous hydrocortisone. Thyroid replacement (T3) should only be started once hydrocortisone therapy has been given. Pituitary apoplexy requires urgent surgery.

See also the separate article on Pituitary Function Tests.

  • Blood glucose, renal function and electrolytes (disturbances of renal function, glucose and electrolytes are common).
  • Hormonal assays:
    • TFTs, prolactin, gonadotrophins, testosterone, cortisol.
    • Measurement of gonadotrophins, TSH, growth hormone, glucose and cortisol following triple stimulation with gonadotrophin-releasing hormone (GnRH), thyrotropin-releasing hormone (TRH) and insulin-induced hypoglycaemia.
  • Cranial MRI scan should be performed to exclude tumours and other lesions of the sellar and parasellar region after hypopituitarism has been confirmed.[1]

Hypopituitarism is sometimes associated with diabetes mellitus, dyslipidaemia, cardiovascular disease and osteoporosis.[1]

  • After pituitary surgery, glucocorticoid replacement should be given to avoid undetected hypoadrenalism until deficits of ACTH and other pituitary hormones are excluded about four weeks after surgery.
  • Following traumatic brain injury or subarachnoid haemorrhage, there is a high risk of hypopituitarism but symptoms are usually masked by the sequelae of brain injury. Endocrine assessment should be routinely performed, especially following moderate or severe head injury.
  • Acute resuscitation, including intravenous fluids, may be required (see the separate article on Acute Pituitary Failure).
  • If hypopituitarism has been caused by a tumour, pituitary function may be restored after successful surgical or medical removal of the lesion.
  • Medical care consists of hormone replacement as appropriate and treatment of the underlying cause.
  • Glucocorticoids are required if the ACTH-adrenal axis is impaired, especially in acute presentations. Increased doses of glucocorticoids are required following any form of emotional or physical stress (eg, during an infection) to prevent acute decompensation.
  • Secondary hypothyroidism: thyroid hormone replacement.
  • Gonadotrophin deficiency: testosterone replacement; oestrogens, with or without progesterone, for women (combined oral contraceptive pill for premenopausal women).
  • Growth hormone replacement.
  • Management of Diabetes Insipidus.
  • Surgical:
    • In pituitary apoplexy, prompt surgical decompression may be life-saving.
    • Removal of macroadenomas that do not respond to medical therapy.
  • Morbidity is variable depending on the degree of hormone deficiency and the underlying cause.
  • Susceptibility to infection is increased.
  • Although an increased mortality rate in hypopituitary patients is well documented, the actual cause of the increased mortality is not clear.[9]
  • If adequately replaced, prognosis in hypopituitarism is good. Prognosis is therefore usually dependent on the underlying cause.
  • Good obstetric care has reduced the incidence of postpartum hypopituitarism.
  • Radiation therapy that minimises exposure to the pituitary reduces incidence and time of onset of hypopituitarism.
  • Improved neurosurgical techniques reduce the likelihood of subsequent hypopituitarism.

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Further reading & references

  1. Schneider HJ, Aimaretti G, Kreitschmann, et al; Hypopituitarism. Lancet. 2007 Apr 28 369(9571):1461
  2. Semple PL, Webb MK, de Villiers JC, et al; Pituitary apoplexy. Neurosurgery. 2005 56(1):65-72
  3. Darzy KH, Shalet SM; Hypopituitarism following Radiotherapy Revisited. Endocr Dev. 2009 15:1-24. Epub 2009 Mar 3.
  4. Popovic V, Aimaretti G, Casanueva FF, et al; Hypopituitarism following traumatic brain injury. Growth Horm IGF Res. 2005 Jun 15(3):177-84. Epub 2005 Mar 21.
  5. Hypogonadotropic hypogonadism 2 with or without anosmia, HH2; Online Mendelian Inheritance in Man (OMIM)
  6. Cauley K, Dalal A, Olson B, et al; Lymphocytic hypophysitis. Conn Med. 2005 Mar 69(3):143-6.
  7. Nawar RN, AbdelMannan D, Selman WR, et al; Pituitary tumor apoplexy: a review. J Intensive Care Med. 2008 Mar-Apr 23(2):75-90. doi: 10.1177/0885066607312992.
  8. Prabhakar VK, Shalet SM; Aetiology, diagnosis, and management of hypopituitarism in adult life. Postgrad Med J. 2006 Apr 82(966):259-66.
  9. Stochholm K, Christiansen J, Laursen T, et al; Mortality and reduced growth hormone secretion. Horm Res. 2007 68 Suppl 5:173-6. doi: 10.1159/000110618. Epub 2007 Dec 10.
Author:
Dr Colin Tidy
Peer Reviewer:
Dr Adrian Bonsall
Document ID:
2302 (v22)
Last Checked:
12 March 2014
Next Review:
11 March 2019

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