Hypopituitarism

Dr Madhukar Mittal

Medical Endocrinology

Master Gland

• Pituitary– Anterior– Posterior

Hormones

• Anterior Pituitary Hypothalamus– Prolactin Dopamine– GH

GHRH, Somatostatin– FSH GnRH– LH GnRH– TSH TRH– ACTH CRH

Hormones

• Posterior Pituitary– Oxytocin– Vasopressin (ADH)

Portal System

• Hypothalamic pituitary

Feedback Loop

Anterior Pituitary Hormone Expression

• Lactotrope– PRL Breast, other Milk

• Somatotrope– GH Liver, other IGF-1

• Thyrotrope– TSH Thyroid T4

• Gonadotrope– FSH, LH Ovary, Testis Sex steroid

• Corticotrope– POMC ACTH Adrenal

Cortisol

Causes of Hypopituitarism

• Developmental• Traumatic• Neoplastic• Inflammatory/Infiltrative• Vascular• Infections

Causes

Developmental

• Transcription factor defect

• Aplasia/dysplasia• Congenital CNS mass• Primary empty sella• Hypothalamic disorders

(Prader-Willi, Laurence-Moon-Biedl, Kallmann, Septo-optic dysplasia)

Causes

Traumatic

• Surgical resection• Radiation damage• Head injuries

Neoplastic

• Pituitary adenoma• Germinoma,

Ependymoma, Glioma• Rathke’s cyst• Craniopharyngioma• Hypothalamic hamartoma• Metastases (B, L, C)• Lymphoma, Leukemia

Inflammatory/Infiltrative

• Lymphocytic hypophysitis• Hemochromatosis• Sarcoidosis• Histiocytosis X

Vascular

• Pituitary Apoplexy• Postpartum necrosis• Sickle cell disease• Arteritis

Infections

• Fungal (histoplasmosis)• Parasitic (Toxoplasmosis)• Tuberculosis

Clinical

• Hormonal deficiency

• Local mass effect

• Metabolic effect

Manifestations of Hormonal deficiency

• PRL• TSH• GH• LH/FSH• ACTH

• ADH• Oxytocin??

Local mass effect

• Pituitary• Optic chiasm

– Loss of red perception– Bitemporal hemianopia– Scotoma– Blindness

• Cavernous sinus– Cranial nerve III, IV, VI, V1, V2– Ophthalmoplegia, Facial numbness

Local mass effect

• Brain– Headache, Hydrocephalus– Dementia, Psychosis

• Frontal Lobe– Personality disorder– Anosmia

• Hypothalamus– Temperature dysregulation– Appetite & Thirst disorders– Diabetes insipidus– Obesity, Sleep disorders– Autonomic dysfunction

Evaluation

• GH– Clonidine– GHRH test– Insulin tolerance test– L-Arginine– L-Dopa test

• Prolactin– Serum levels– TRH test

• ACTH– CRH test– Insulin tolerance test

• TSH– Basal TSH– TRH test

• LH/FSH– Basal LH, FSH– Testosterone– Estrogen

– GnRH test

Imaging

• MRI

Other Tests

• Fundus, Perimetry• Na, K• Osmolarity Urine/serum• Water deprivation test

Treatment

ACTH deficiency

• Hydrocortisone• Prednisolone

TSH deficiency

• Levothyroxine

FSH/LH deficiency

• Males– Testosterone (Inj/Oral/Patch/Gel)

• Females– Estrogen (Tab/Patch)– Progesterone– For fertility : hCG, hMG

GH deficiency

• GH (Somatotropin) s.c.– Children– Adults

Vasopressin

• Desmopressin– s.c./Intranasal/Oral

Tumors

• Trans-sphenoidal Surgery

Other Treatment

• Radiotherapy• Medical

Thank You