Hypopituitarism Dr Madhukar Mittal Medical Endocrinology

Master Gland Pituitary –Anterior –Posterior

Hormones Anterior PituitaryHypothalamus –ProlactinDopamine –GHGHRH, Somatostatin –FSHGnRH –LHGnRH –TSHTRH –ACTHCRH

Hormones Posterior Pituitary –Oxytocin –Vasopressin (ADH)

Portal System Hypothalamic pituitary

Feedback Loop

Anterior Pituitary Hormone Expression Lactotrope – PRLBreast, otherMilk Somatotrope – GHLiver, otherIGF-1 Thyrotrope – TSHThyroidT4 Gonadotrope – FSH, LHOvary, TestisSex steroid Corticotrope –POMCACTHAdrenalCortisol

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

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