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For further information, see CMDT Part 26-01: Anterior Hypopituitarism

Key Features

Essentials of Diagnosis

  • Adrenocorticotropic hormone (ACTH) deficiency: reduced adrenal secretion of cortisol and epinephrine; aldosterone secretion remains intact

  • Growth hormone (GH) deficiency: in children, causes short stature; in adults, causes asthenia, obesity, and increased cardiovascular risk

  • Prolactin deficiency: postpartum lactation failure

  • Thyroid-stimulating hormone (TSH) deficiency: causes secondary hypothyroidism

  • Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) deficiency: cause hypogonadism and infertility in men and women

General Considerations

  • Caused by hypothalamic or pituitary dysfunction, including the following:

    • Mass lesions

      • Pituitary neuroendocrine tumors

      • Craniopharyngioma

      • Plasmacytoma

      • Germ cell tumors

      • Glioma

      • Lymphomas

      • Cysts (Rathke cleft, dermoid, epidermoid, arachnoid)

      • Meningioma

      • Hemangiopericytoma

    • Vascular lesions

      • Pituitary tumor apoplexy

      • Acute Sheehan syndrome

      • Cavernous sinus aneurysm

      • Subarachnoid hemorrhage

    • Inflammatory/infiltrative lesions

      • Granulomatosis with polyangiitis

      • Xanthomatosis

      • Giant cell granuloma

      • Langerhans cell histiocytosis

      • Sarcoidosis

      • Syphilis

      • Hypophysitis

      • Tuberculosis

    • Infectious lesions can be bacterial, fungal, or parasitic

    • Pituitary metastases

      • Often present with visual loss or ophthalmoplegia, ACTH deficiency, TSH deficiency (65%), or diabetes insipidus (26%); about 88% of patients also have gonadotropin deficiency

      • 45% due to breast cancer

      • 21% due to lung cancer

    • Lymphocytic hypophysitis is an autoimmune disorder affecting the pituitary gland

    • Pituitary stalk thickening in adults is caused most frequently by

      • Autoimmune hypophysitis

      • Metastases

      • Neurosarcoidosis

      • Congenital ectopic posterior pituitary

  • May have single or multiple hormonal deficiencies of the anterior and posterior pituitary

  • Hypopituitarism without mass lesions may be due to

    • Cranial radiation

    • Surgery

    • Encephalitis

    • Hemochromatosis

    • Autoimmune (including ipilimumab therapy)

    • Stroke

    • Post-CABG

    • Long-term intrathecal opioid infusion

    • X-linked congenital adrenal hypoplasia

    • Moderate to severe traumatic brain injury (Glasgow coma scale ≤ 13/15)

    • Idiopathic

  • About 25–30% of survivors of moderate to severe traumatic brain injury have at least one pituitary hormone deficiency

  • About 55% of survivors of aneurysmal subarachnoid hemorrhage have at least one pituitary hormone deficiency

  • Some degree of hypopituitarism, most commonly GH deficiency and hypogonadotropic hypogonadism, occurs in one-third of patients who have had an ischemic stroke

  • Kallmann syndrome is the most common cause of congenital isolated gonadotropin deficiency

Clinical Findings

Symptoms and Signs

  • Hypopituitarism caused by a mass lesion or hypophysitis

    • Headaches or visual field defects

    • Fatigue

    • Dizziness and hypotension

    • Confusion, cognitive dysfunction

    • Sexual dysfunction

    • Polydipsia

    • Cold intolerance

  • GH deficiency

    • Hypoglycemia in infancy and short stature in childhood

    • In adulthood, mild to moderate central obesity, increased systolic blood pressure, increased low-density lipoprotein (LDL) cholesterol, and reduced cardiac output

    • Reduced muscle mass, reduced physical and mental energy, impaired concentration and memory, and depression

    • Osteopenia and an increased risk of fractures in chronic deficiency

  • Gonadotropin deficiency

    • Also known as hypogonadotropic hypogonadism

    • Caused by insufficiencies in luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which cause hypogonadism and infertility

  • Congenital gonadotropin deficiency

  • Kallmann syndrome

    • Hypogonadism and anosmia or hyposmia

    • Renal anomalies (28%)

    • Midline craniofacial defects (50%): ...

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