1. Hypopituitarism Dr Madhukar Mittal Medical Endocrinology

2. Master Gland Pituitary –Anterior –Posterior

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

4. Hormones Posterior Pituitary –Oxytocin –Vasopressin (ADH)

6. Portal System Hypothalamic pituitary

7. Feedback Loop

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

9. Causes of Hypopituitarism Developmental Traumatic Neoplastic Inflammatory/Infiltrative Vascular Infections

10. Causes Developmental Transcription factor defect Aplasia/dysplasia Congenital CNS mass Primary empty sella Hypothalamic disorders (Prader-Willi, Laurence- Moon-Biedl, Kallmann, Septo-optic dysplasia)

11. 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

12. Inflammatory/Infiltrative Lymphocytic hypophysitis Hemochromatosis Sarcoidosis Histiocytosis X Vascular Pituitary Apoplexy Postpartum necrosis Sickle cell disease Arteritis

13. Infections Fungal (histoplasmosis) Parasitic (Toxoplasmosis) Tuberculosis

14. Clinical Hormonal deficiency Local mass effect Metabolic effect

15. Manifestations of Hormonal deficiency PRL TSH GH LH/FSH ACTH ADH Oxytocin??

16. 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

18. 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

19. Evaluation GH –Clonidine –GHRH test –Insulin tolerance test –L-Arginine –L-Dopa test

20. Prolactin –Serum levels –TRH test

21. ACTH –CRH test –Insulin tolerance test

22. TSH –Basal TSH –TRH test

23. LH/FSH –Basal LH, FSH –Testosterone –Estrogen –GnRH test

24. Imaging MRI

25. Other Tests Fundus, Perimetry Na, K Osmolarity Urine/serum Water deprivation test

26. Treatment

27. ACTH deficiency Hydrocortisone Prednisolone

28. TSH deficiency Levothyroxine

29. FSH/LH deficiency Males –Testosterone (Inj/Oral/Patch/Gel) Females –Estrogen (Tab/Patch) –Progesterone –For fertility : hCG, hMG

30. GH deficiency GH (Somatotropin) s.c. –Children –Adults

31. Vasopressin Desmopressin –s.c./Intranasal/Oral

32. Tumors Trans-sphenoidal Surgery

34. Other Treatment Radiotherapy Medical

35. Thank You