Hypopituitarism Dr Madhukar Mittal Medical Endocrinology Master Gland

Hypopituitarism Dr Madhukar Mittal Medical Endocrinology

Master Gland • Pituitary – Anterior – Posterior

Hormones • Anterior Pituitary – – – Prolactin GH FSH LH TSH ACTH Hypothalamus Dopamine GHRH, Somatostatin Gn. RH TRH CRH

Hormones • Posterior Pituitary – Oxytocin – Vasopressin (ADH)

Portal System • Hypothalamic pituitary

Feedback Loop

Anterior Pituitary Hormone Expression • Lactotrope – PRL Breast, other Milk GH Liver, other IGF-1 TSH Thyroid T 4 • Somatotrope – • Thyrotrope – • Gonadotrope – FSH, LH Ovary, Testis Sex steroid ACTH Cortisol • Corticotrope – POMC Adrenal

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 Neoplastic • Surgical resection • Radiation damage • Head injuries • Pituitary adenoma • Germinoma, Ependymoma, Glioma • Rathke’s cyst • Craniopharyngioma • Hypothalamic hamartoma • Metastases (B, L, C) • Lymphoma, Leukemia

Inflammatory/Infiltrative Vascular • • Lymphocytic hypophysitis Hemochromatosis Sarcoidosis Histiocytosis X 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, V 1, V 2 – 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 – Gn. RH 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 : h. CG, h. MG

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

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

Tumors • Trans-sphenoidal Surgery

Other Treatment • Radiotherapy • Medical

Thank You