Diagnosis
Hypopituitarism
A biochemical deficiency of one or more of the hormones of the anterior or posterior pituitary gland.
Also known as: Sheehans syndrome
Etiology
Cause [sf9][nmd][q32][iso]
Pituitary tumors:
Nonfunctioning adenoma
Prolactinoma
Gonadotropinoma
TSH-secreting tumor
Non-pituitary tumors:
Craniopharyngioma (suprasellar tumor)
Meningeoma
Chordoma
Ependymoma
Non-tumoral causes:
Idiopathic/congenital hypopituitarism
Empty sella syndrome
Sheehans syndrome: Postpartum hemorrhage, hypovolemia/shock, thrombosis
Pituitary hemorrhage
Lymphocytic hypophysitis
Arachnoid cyst
Rathke´s cleft cyst
Cranial radiotherapy of CNS-tumor
Head injury
Pathophysiology: [sf9][q32][h5n]
The pituitary gland is the master regulator of the endocrine system, controlling adrenal, thyroid, and gonadal function, water balance, lactation, and the GH/IGF-I axis.
Gonadotropin deficiency --> Hypogonadism (94%)
TSH deficiency --> Hypothyroidism (81%)
GH deficiency --> Pituitary dwarfism (81%)
ACTH deficiency --> Hypoadrenalism (65%)
ADH deficiency --> Diabetes insipidus
Psychiatric manifestations
Visual field defects --> bitemporal hemianopsia
Epidemiology
Incidence per 100.000 [iso]
Symptoms & findings
Symptoms
Agalactorrhea, Alopecia, Amenorrhea, Bilateral hemianopsia, Bradycardia, Cold intolerance, Coma, Confusion, Constipation, Decreased consciousness, Decreased libido, Depression, Dyspnea, Epicanthal folds, Failure to thrive, Fatigue, Fever, Flat nasal bridge, Headache, Hyperpigmentation, Hypotension, Infertility, Lethargy, Loss of appetite, Menorrhagia, Mental retardation, Myxedema, Nausea, Pallor, Palpebral fissures, Polydipsia, Polyuria, Tachycardia, Vomiting, Weakness, Weight gain, Weight loss
Clinical findings
Decreased Cortisol, Decreased T3, Decreased T4, Hyperkalemia, Hyponatremia
Anamneses
None listed.
Localized findings
Approach
Blood test: [q32][v13][h5n]
Hypothalamic-pituitary-adrenal axis: Cortisol, ACTH, Cosyntropin test
Hypothalamic-pituitary-thyroid axis: fT4, fT3, TSH, Anti-peroxidase antibodies
Hypothalamic-pituitary-gonadal axis: FSH, LH, Estradiol, Testosterone
Hypothalamic-pituitary-somatotropic axis: IGF-1
Hypothalamic-pituitary-prolactin axis: Prolactin
Vasopressin Stimulation Test
Insulin tolerance test: for assessing deficiencies of both GH and ACTH levels
ACTH stimulation test
MR caput
Treatment
Pituitary hormone replacement therapy: [q32][nmd]
Growth hormone replacement:
GH 0.2-0.4 mg (based on age/gender), increment 0.1mg every 2-4 weeks
Sex steroid and gonadotropin replacement
Testosterone: oral, depot injection, pellets, patches and gels
Side effects: prostate hypertrophy/cancer, gynecomastia, polycythemia, liver dysfunction/jaundice/tumor
Estrogen replacement for women with uterus
Human chorionic gonadotropin 2000IU twice weekly for induction of fertility
FSH 75IU 3 times per week
Adrenocorticosteroid replacement:
Cortisol: Hydrocortisone 15-25mg 2-3 times per day
Dehydroepiandosterone 25-50mg per day
Thyroxine replacement: Levothyroxine 100ug per day
Differential diagnoses
Adrenal insufficiency, Hyponatremia, Hypothyroidism, Hypovolemia, Pituitary adenoma, Shock
References
[1] Kurian J, Philip R, Jacob C, Abdul Kadar CS, Charamelsankaran K, Sharma RN. Adult hypopituitarism: A single centre experience. Indian J Endocrinol Metab. 2017 Oct;21(Suppl 2):S4–S79.
[2] Sherlock M, Ayuk J, Tomlinson JW, Toogood AA, Aragon-Alonso A, Sheppard MC, Bates AS, Stewart PM. Mortality in patients with pituitary disease. Endocr Rev. 2010 Jun;31(3):301-42.
[3] Toogood AA, Stewart PM. Hypopituitarism: clinical features, diagnosis, and management. Endocrinol Metab Clin North Am. 2008 Mar;37(1):235-61, x.
[4] Regal M, Páramo C, Sierra SM, Garcia-Mayor RV. Prevalence and incidence of hypopituitarism in an adult Caucasian population in northwestern Spain. Clin Endocrinol (Oxf). 2001 Dec;55(6):735-40.
[5] Gounden V, Anastasopoulou C, Jialal I. Hypopituitarism. [Updated 2023 Sep 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470414/
[6] https://emedicine.medscape.com/article/122287