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Hypopituitarism

In This Article

Introduction

Hypopituitarism entails reduced secretion of anterior pituitary hormones.
 
Which hormones go first?
Anterior pituitary hormones are affected in the following order:

  • GH >> muscle and bone
  • FSH >> ovary
  • LH >> testes
  • Polactin >> breast
  • TSH >> thyroid
  • ACTH >> kidney and adrenal gland

N.B.
Rather than prolactin deficiency, hyperprolactinaemia occurs relatively early because of loss of tonic inhibitory control by dopamine.
 
Which hormones go when?

  • Deficiency of hypothalamic-releasing hormones or pituitary hormones may be either selective or multiple.
  • Multiple deficiencies usually result from tumour growth or other destructive lesions.
  • Panhypopituitarism is deficiency of all anterior hormones, usually caused by irradiation, surgery, or pituitary tumour.
  • Vasopressin and oxytocin secretion will only be affected if the hypothalamus is involved by either hypothalamic tumour or by extension of a pituitary lesion.

 

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Aetiology

The commonest cause of hypopituitarism is a pituitary or hypothalamic tumour, or treatment of a tumour by surgical removal or radiotherapy.
 
Causes are at 3 levels:
1.     Hypothalamus: Kallman’s syndrome, tumour, inflammation, infection (meningitis, TB), ischaemia.
2.     Pituitary stalk: trauma, surgery, mass lesion (craniopharyngioma), meningioma, carotid artery aneurysm.
3.     Pituitary: tumour, irradiation, inflammation, autoimmunity, infiltration (haemochromatosis, amyloid, metastases), ischaemia (pituitary apoplexy, DIC – snake bite common cause in India, Sheehan’s syndrome – pituitary necrosis after postpartum haemorrhage).
 

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Autoimmune Hypophysitis

  • Inflamed pituitary
  • Mimics pituitary adenoma
  • May be triggered by pregnancy or immunotherapy blocking CTLA-4.
  • No pituitary autoantigen is yet used diagnostically.

 
Classification of different causes:
 

Neoplastic Primary tumour of pituitary or hypothalamus
Secondary deposits, especially breast
Lymphoma
Infective Basal meningitis, e.g. tuberculsosis
Encephalitis
Syphilis
Vascular Pituitary apoplexy
Sheehan’s syndrome
Carotid artery aneurysms
Trauma Skull fracture
Surgery
Infiltrations Sarcoidosis
Haemochromatosis
Immunological Pituitary antibodies
Congenital Kalmann’s syndrome
Functional Anorexia
Starvation
Emotional deprivation
Others Radiation damage
Chemotherapy
Empty sella syndrome

 
 

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Some Specific Syndromes

  • Kallmann’s Syndrome: congenital deficiency of gonadotrophin-releasing hormone (GnRH).
  • Sheehan’s Syndrome: pituitary infarction following severe postpartum haemorrhage. Rare in developed countries.
  • Pituitary Apoplexy: rapid enlargement of pituitary tumour due to infarction or haemorrhage. There is severe haemorrhage and sudden severe visual loss, sometimes followed by acute, life-threatening hypopituitarism.
  • Empty Sella Syndrome: Radiologically the sella turcica (the bony structure that surrounds the pituitary) appears devoid of pituitary tissue. In some cases, the pituitary is actually placed eccentrically and function is usually normal. In others, there is pituitary atrophy (after injury, surgery or radiotherapy) and associated hypopituitarism.
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Clinical Features

These depend on the extent of hypothalamic-pituitary differences. They result from either hormone deficiency or mass effect from a tumour.
 

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