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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
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
Other Tests Fundus, Perimetry Na, K Osmolarity Urine/serum Water deprivation test
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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ANT. PITUITARY : ( UNDER INFLUENCE OF HYPTHALAMUS RELEASING HORMONES ALL RELEASING HORMONES ARE STIMULATORY EXCEPT DOPMAMINE INHIBITS PROLACTIN SOMATOSTAIN.
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