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Hypopituitarism

Last updated: November 13, 2020

Summary

Hypopituitarism refers to the inadequate production of one or more anterior pituitary hormones as a result of damage to the pituitary gland and/or hypothalamus. These hormones include growth hormone (GH), prolactin, thyroid stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), follicle stimulating hormone (FSH), and luteinizing hormone (LH). In some cases, the posterior pituitary hormones (e.g., ADH) may also be affected, which is known as panhypopituitarism. The most common cause of hypopituitarism is compression of the pituitary gland by a non-secretory pituitary macroadenoma. Other common causes include postpartum pituitary necrosis (Sheehan syndrome), traumatic brain injury, hypophysectomy, and/or irradiation of the pituitary gland. Clinical manifestations vary significantly and depend on the specific hormone deficiency, the age of disease onset, the rate at which hypopituitarism develops, and the underlying cause of hypopituitarism: Growth hormone deficiency during childhood presents with growth retardation, while prolactin deficiency manifests as lactation failure among women. Deficiencies of other anterior pituitary hormones, on the other hand, manifest with clinical features of hypogonadotropic hypogonadism, secondary hypothyroidism, and/or secondary adrenal insufficiency. Severe pituitary damage can also result in central diabetes insipidus as a result of ADH deficiency. Diagnosis of hypopituitarism involves measuring specific hormone levels (depending on the underlying hormone deficiency) and cranial imaging (in order to identify damage to the pituitary gland and/or hypothalamus). Treatment of hypopituitarism consists of hormone replacement therapy and treatment of the underlying disorder (e.g., transsphenoidal resection of pituitary adenomas).

Etiology

References:[1][2][3][4][5][6][7]

Pathophysiology

References:[8][9][10]

Clinical features

Symptoms are variable and depend on the specific hormone deficiency, the age of disease onset, the rate at which hypopituitarism develops, and the underlying cause of hypopituitarism.

Pituitary apoplexy, which results in acute hypocortisolism and hypothyroidism, can manifest with severe headache, sudden hypotension, and hypovolemic shock!

References:[9]

Diagnostics

Since the pattern of hormone deficiency may vary, each hormone deficiency must be tested individually.

References:[9][11][12]

Treatment

Management consists of treating the underlying cause (e.g., transsphenoidal resection in cases of pituitary macroadenomas) and hormone replacement therapy.

Patients with TSH deficiency should not be treated with levothyroxine until ACTH deficiency has been ruled out and/or treated because levothyroxine increases the clearance of cortisol and may precipitate an adrenal crisis!

Immediate treatment with glucocorticoids, without waiting for diagnostic confirmation, is required when acute ACTH deficiency is suspected (e.g., following pituitary apoplexy) to prevent an adrenal crisis!

In addition to hormone replacement therapy, the underlying cause of hypopituitarism should be treated, e.g., via transsphenoidal resection in the case of pituitary macroadenomas!

References:[5][13]

References

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  2. Fischer C. Master the Boards USMLE Step 2 CK. Kaplan Publishing ; 2015
  3. Snyder PJ. Causes of hypopituitarism. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/causes-of-hypopituitarism?source=see_link.Last updated: October 21, 2015. Accessed: February 9, 2017.
  4. Shivaprasad C. Sheehan's syndrome: Newer advances. Indian J Endocrinol Metab. 2011; 15 (Suppl 3): p.S203-207. doi: 10.4103/2230-8210.84869 . | Open in Read by QxMD
  5. Corenblum B. Hypopituitarism (Panhypopituitarism). In: Khardori R, Hypopituitarism (Panhypopituitarism). New York, NY: WebMD. http://emedicine.medscape.com/article/122287-overview#a5. Updated: July 11, 2016. Accessed: February 9, 2017.
  6. Vaphiades MS. Pituitary Apoplexy. In: Roy H, Pituitary Apoplexy. New York, NY: WebMD. http://emedicine.medscape.com/article/1198279-clinical#b5. Updated: May 23, 2015. Accessed: February 9, 2017.
  7. Le T, Bhushan V, Skelley N. First Aid for the USMLE Step 2 CK. McGraw-Hill Education ; 2012
  8. Snyder PJ. Clinical manifestations of hypopituitarism. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-manifestations-of-hypopituitarism.Last updated: March 8, 2016. Accessed: February 9, 2017.
  9. Snyder PJ. Diagnostic testing for hypopituitarism. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/diagnostic-testing-for-hypopituitarism.Last updated: July 18, 2016. Accessed: February 9, 2017.
  10. Master-Hunter T, Heiman DL. Amenorrhea: Evaluation and Treatment. Am Fam Physician. 2006; 73 (8): p.1374-1382.
  11. Snyder PJ. Treatment of hypopituitarism. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/treatment-of-hypopituitarism.Last updated: November 3, 2015. Accessed: February 9, 2017.
  12. Kasper DL, Fauci AS, Hauser SL, Longo DL, Lameson JL, Loscalzo J. Harrison's Principles of Internal Medicine. McGraw-Hill Education ; 2015
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