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Hypopituitarism

Definition Anterior Pituitary Hormones Deficiency

Hypopituitarism Panhypopit uitarism Gonadotrophin Deficiency (FSH, LH)
Diminished hormonal secretion of 1 Partial/ Total Failure of all 8 of Males Females
or more of 8 hormones produced by Pituitary Gland Vital Hormones
Pituitary Gland

Epidemiology
Relatively Rare
45/100,000 people had been diagnosed
4 new cases per year
Major Percentage (61%)
Tumours of the Pituitary Gland

Etiology
1° 2°
Directly affecting Pituitary Gland Deficiencies of Releasing Hormones
produced by Hypothalamus
(Idiopathic, Infe ction, Trauma, Tumour)
GH Deficiency
Type Causes
Neoplastic Pituitary Adenomas compressing normal tissue (commonly)
Brain tumours outside gland (rare)
• Craniopharyngioma, Meningioma, Chordoma,
Ependymoma, Glioma
Cancer Metastasis
Inflammation Infections of Brain (Brain Abscess, Meningitis, Encephalitis)
Infiltration Infections of Gland
Infection Infiltrated by Abnormal cell (Neurosarcoidosis, Histiocytosis)
Autoimmune, Lymph ocytic Hypophysitis
(Immu ne system directly attack pituitary)
Physical Traumatic Brain Injury
Subarachnoid Haemorrhage
Neurosurgery
Ionizing Radiation (Therapy for previous brain tumour)
Congenital Complications during Delivery TSH Deficiency
Insuffi cient development of Gland
Transcription factor Defects
(Pit-1, PROP1, HESX1, LHX3, LH X4)
Vascular Pituitary Apoplexy (Haemorrhage, Infarction of Pituitary)
Sheehan’s Syndrome
(Infarction of Pituitary after blood loss during childbirth)

Clinical Features
In most cases, 3 or More Hormones are deficient
Pattern of Hormonal Events in Hypopituitarism
↓ Gonadotrophin (FSH, LH)
Hypogonadism
↓
↓ GH Level ACTH Deficiency
Short Stature, Delayed Growth, Delayed Puberty
↓
↓ TSH Level
Hypothyroidism
↓
↓ ACTH Level
Adrenal Insufficiency

Hypopituitarism Hypopituitarism
Prolactin Deficiency
Pallor
Skin Wrinkling
Absence of Facial Hair

Posterior Pituitary Hormones Deficiency

ADH Deficiency
Leads to Syndrome of Diabetes Insipidus
• Inability to concentrate urine
• Polyuria
• Extreme Thirst, Polydipsia (due to dehydration)
• Hypernatraemia (↑ Na in Blood)
Oxytocin Deficiency
Few symptoms (only required at time of Childbirth, Breastfeeding)
↓ Milk Secretion
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Investigations Management
Hormone Level Test
ACTH Deficiency
• Short ACTH Stimulation Test
• Insulin Tolerance Test
LH/ FSH Deficiency
• Male – Major random serum testosterone, LH, FSH
• Female
o Pre Menopause (ask Menses Cycle)
o Post Menopause (Serum LH, FSH)
TSH Deficiency
• Random serum Thyroxi ne
• False +ve – Presence of Inactive TSH Isoform in 2° Hypothyroidism
GH Deficiency
• Measure only at Peak Hormone Level (eg. Morning, After Exercise) Presence of Macroadenoma
• Insulin Tolerance Test Removal of Tumour by Surgical or Radiation
Insulin Tolerance Test Removal of > 75% of Pituitary Gland may lead to Hypopituitarism
Principle
• Put patient under Hypoglycaemic state
• Detect Increment of GH, ACTH
• In GH, ACTH Deficiency – Level will Not Increase
Contraindication
• Ischaemic Heart Disease
• Severe Hypopituitarism
Normal Findings
• Cortisol > 550 nmol/L
• GH – 20 mU/L
Radiograph
MRI, CT Scan, X-Ray
Detect
• Enlargement of Pituitary
• Abnormal areas of Enhancement
• Deviation of Pituitary Stalk
• Evidence of Locally Aggressive Tumour
Visual Field Test
Computer Perimetry, Goldmann Perimetry
Tumour present may compress Optic Chiasm
Impair Vision
Findings - ↓ Visual Fields