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A Healthcare Provider’s Guide to Pituitary Disorders
Pituitary disease is most often caused by benign adenomas which are classified as either functioning (overproducing one or more hormones) or non-functioning. These uncommon lesions occur with an incidence of 35 cases per million per year. Pituitary disorders can also be caused by a variety of other etiologies including infiltrative, immunologic, ischemic, hypothalamic and metastatic disease as well as trauma.
Signs & Symptoms
In addition to the relatively low frequency of pituitary disorders, patients suffering with pituitary diseases can initially present with diverse symptoms to any medical specialty.
For physicians, the non-specific symptomatology of pituitary disease is a major barrier to even a preliminary diagnosis. To assist in this, a partial list of common signs and symptoms of pituitary hormone deficiency and excess are listed below. Within the context of the indicated symptoms, the following three questions can also help the clinician identify a potential pituitary disease.
- Are there signs or symptoms of deficiencies in pituitary hormones? Hormonal deficiencies can occur in isolation or in combinations.
- Are there signs or symptoms of excess in pituitary hormones? Hormonal overproduction can also occur in isolation or in combinations and can occur in the background of other hormonal deficiencies.
- Are there signs or symptoms of a space-occupying pituitary lesion? Clinical manifestations include headaches, visual problems (especially peripheral vision loss) and occasionally seizures or cranial nerve deficits.
Some examples of Medical Specialties to which Pituitary Disease patients may present
- Obstetrics and Gynecology: galactorrhea, menstrual irregularities, infertility, hirsutism
- Urology: impotence, hypogonadism
- Neurology: headache, proximal muscle weakness, carpal tunnel syndrome
- Ophthalmology: blurred vision, visual field loss, diplopia
- Dermatology: dry, oily, diaphoretic skin
- Orthopedics: joint pain, joint/bone abnormalities
- Family Practice/Internal medicine: all of the above, polyuria, fatigue, depression, hair loss
Partial List of Signs and Symptoms of Pituitary Hormone Disregulation
|ACH||Adrenal Insufficiency||abdominal discomfort, joint aches, orthostasis|
|TSH||Hypothyroidism||constipation, cold intolerance, proximal muscle weakness, dry skin, memory loss, hair loss|
|LH/FSH||Hypogonadism||sexual dysfunction, hot flashes, menstrual irregularity|
|GH||Adult growth hormone deficiency||lack of vigor, decreased exercise tolerance, feelings of social isolation|
|ADH||Diabetes insipidus||polydipsia, polyuria, nocturia|
||galactorrhea, sexual dysfunction
||moon face, truncal obesity, purple stria, hirsutism, hypertension, diabetes mellitus, proximal muscle weakness
enlarged hands/feet/jaw, carpal tunnel syndrome, oily skin, joint pain
While a preliminary diagnosis of pituitary disease can be challenging, the initial basic work-up for pituitary disease is straightforward and can be easily initiated if pituitary disease is suspected. Head MR imaging should be performed if either the laboratory evaluation indicates the presence of pituitary disease or if a space-occupying lesion is suspected. The correct interpretation of the laboratory evaluation can sometimes be difficult due to the nuances of pituitary disease; assistance in this process is offered through the OHSU consultation service. The OHSU NW Pituitary Center offers endocrine testing or they can be consulted independently to assist referring physicians in performing dynamic endocrine testing.
The Basic Pituitary Disease/Pituitary Tumor Work-up
Hormones to check:
- 8:00 a.m. serum cortisol and ACTH (or cortrosyn stimulation test)
- TSH and Free T4
- LH and FSH
- Testosterone (men)
- IGF-1 (Insulin-like Growth Factor-1)
- 24 hour Urine Free Cortisol (for Cushing’s)
Imaging (if indicated)
- Head MR imaging (with and without gadolinium)
If the work-up indicates the presence of a pituitary tumor or disease, many clinicians will seek the help of pituitary disease experts to help treat and manage the patient. Treatment typically includes a combination of medicines and surgery and may involve irradiation. However, the majority of non-prolactin secreting tumors require surgery. Pituitary disease patients should be evaluated pre- and post-operatively by an endocrinologist comfortable in managing neuroendocrine diseases.
The most common surgical approach for the resection of pituitary tumors is through the sphenoid sinus (transsphenoidal). Surgical outcome studies have repeatedly shown that surgeons highly experienced in this procedure obtain the highest cure rates with the lowest rates of recurrence, post-operative complications and pituitary dysfunction.