Hypopituitarism history and symptoms

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Elsaiey, MBBCH [2], Iqra Qamar M.D.[3]

Overview

A positive history of head trauma, adenoma, a lesion such as a sellar lesion, or any symptom related to pituitary hormonal deficiency is suggestive of hypopituitarism. Patients of hypopituitarism may be asymptomatic or show symptoms which can be nonspecific or specific for the deficient hormone. Patients with acute onset of hypopituitarism can present with a headache, nausea, vomiting, visual impairment, fatigue, cold intolerance, hypotension, and dizziness. Patients with chronic hypopituitarism can present with pallor, weight loss, and anorexia.

History

Past medical history

A positive history of head trauma, adenoma, a lesion such as a sellar lesion, or any symptom related to pituitary hormonal deficiency is suggestive of hypopituitarism.
The Growth Hormone Research Society recommends the consideration of diagnosis of growth hormone (GH) deficiency only in those patients who have a positive history of any pituitary disease or damage secondary to trauma, surgery, radiation, tumor, and previous history of growth hormone therapy because some factors such as obesity and age can affect the results of dynamic tests and may lead to inappropriate diagnosis^[1]^[2]

Symptoms

Clinical presentation in hypopituitarism depends upon following factors:

(a) The onset

Acute: Sudden onset of symptoms as seen in pituitary apoplexy.
Chronic: Slow onset, may take years to manifest such as radiation damage.

(b) The severity of hormonal deficiency

Complete hormonal deficiency: May present even in normal circumstances.
Partial hormonal deficiency: May present only in times of stress.

(c) The number of deficient hormones

One hormone or some hormones are deficient.
All of the pituitary hormones (panhypopituitarism).

Patients of hypopituitarism may be asymptomatic or show symptoms which can be nonspecific or specific for the deficient hormone such as an adrenal crisis or profound hypothyroidism. Patients can also present with symptoms suggestive of a mass lesion. Metastasis usually involves posterior pituitary initially thus presenting as diabetes insipidus. Patients with a sellar mass may present with a headache, diplopia, or visual loss.

Non-specific symptoms

Patients of hypopituitarism may present with the following symptoms:

Acute hypopituitarism (several hours to a few days)	Chronic hypopituitarism (week to months/years)
Headache Nausea and vomiting Visual impairment fatigue Cold intolerance Hypotension Dizziness	Pallor Weight loss Anorexia

Symptoms of deficient hormones

In hypopituitarism, either one of the pituitary gland hormones may be deficient or all hormones may be deficient (depending upon the extent of pituitary gland involvement- complete or partial). The following table enlists the symptoms associated with each hormonal deficiency:^[3]

Pituitary gland	Hormone	Symptoms of deficiency
Anterior pituitary	Adrenocorticotrophic Hormone (ACTH)	The most critical hormonal deficiency associated with hypopituitarism.^[4]^[5] Nausea and vomiting Fatigue Abdominal pain Weight loss Chest pain Confusion (hypoglycemia)
	Growth Hormone (GH)	Short stature (in children) Fatigue Decreased tolerance of exercise Decreased social functioning Increased cardiovascular risk Decrease muscle mass Decrease bone mineral density which may lead to osteoporosis^[6]
	Gonadotropin hormones: Luteinizing Hormone (LH) Follicle Stimulating Hormone (FSH)	In men: Loss of libido Erectile dysfunction Decreased volume of ejaculate Hot flashes Decrease bone mass Reduced energy and vitality Infertility In women:^[7] Amenorrhea Oligomenorrhea Dyspareunia Decreased libido Hot flashes Vaginal dryness Infertility
	Thyroid Stimulating Hormone (TSH)	Constipation Cold intolerance Weight gain Dry skin Hoarseness Edema Depression Menorrhagia Arthralgia Psychomotor retardation
	Prolactin	Postpartum lactation failure
Posterior pituitary	Oxytocin	Muscle aches Decreased milk ejection during lactation Sleep disturbance Anxiety
Posterior pituitary	Anti Diuretic Hormone (ADH)	Polyuria Polydipsia Nocturia

References

↑ “Consensus guidelines for the diagnosis and treatment of adults with growth hormone deficiency: summary statement of the Growth Hormone Research Society Workshop on Adult Growth Hormone Deficiency”. J. Clin. Endocrinol. Metab. 83 (2): 379–81. 1998. doi:10.1210/jcem.83.2.4611. PMID 9467545.
↑ Prabhakar VK, Shalet SM (2006). “Aetiology, diagnosis, and management of hypopituitarism in adult life”. Postgrad Med J. 82 (966): 259–66. doi:10.1136/pgmj.2005.039768. PMC 2585697. PMID 16597813.
↑ Fleseriu, Maria; Hashim, Ibrahim A.; Karavitaki, Niki; Melmed, Shlomo; Murad, M. Hassan; Salvatori, Roberto; Samuels, Mary H. (2016). “Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline”. The Journal of Clinical Endocrinology & Metabolism. 101 (11): 3888–3921. doi:10.1210/jc.2016-2118. ISSN 0021-972X.
↑ Burke, C.W. (1985). “Adrenocortical insufficiency”. Clinics in Endocrinology and Metabolism. 14 (4): 947–976. doi:10.1016/S0300-595X(85)80084-0. ISSN 0300-595X.
↑ Bancos I, Hahner S, Tomlinson J, Arlt W (2015). “Diagnosis and management of adrenal insufficiency”. Lancet Diabetes Endocrinol. 3 (3): 216–26. doi:10.1016/S2213-8587(14)70142-1. PMID 25098712.
↑ Murray RD, Columb B, Adams JE, Shalet SM (2004). “Low bone mass is an infrequent feature of the adult growth hormone deficiency syndrome in middle-age adults and the elderly”. J Clin Endocrinol Metab. 89 (3): 1124–30. doi:10.1210/jc.2003-030685. PMID 15001597.
↑ Miller KK, Biller BM, Hier J, Arena E, Klibanski A (2002). “Androgens and bone density in women with hypopituitarism”. J Clin Endocrinol Metab. 87 (6): 2770–6. doi:10.1210/jcem.87.6.8557. PMID 12050248.

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[pmid9467545-1] “Consensus guidelines for the diagnosis and treatment of adults with growth hormone deficiency: summary statement of the Growth Hormone Research Society Workshop on Adult Growth Hormone Deficiency”. J. Clin. Endocrinol. Metab. 83 (2): 379–81. 1998. doi:10.1210/jcem.83.2.4611. PMID 9467545.

[pmid16597813-2] Prabhakar VK, Shalet SM (2006). “Aetiology, diagnosis, and management of hypopituitarism in adult life”. Postgrad Med J. 82 (966): 259–66. doi:10.1136/pgmj.2005.039768. PMC 2585697. PMID 16597813.

[FleseriuHashim2016-3] Fleseriu, Maria; Hashim, Ibrahim A.; Karavitaki, Niki; Melmed, Shlomo; Murad, M. Hassan; Salvatori, Roberto; Samuels, Mary H. (2016). “Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline”. The Journal of Clinical Endocrinology & Metabolism. 101 (11): 3888–3921. doi:10.1210/jc.2016-2118. ISSN 0021-972X.

[Burke1985-4] Burke, C.W. (1985). “Adrenocortical insufficiency”. Clinics in Endocrinology and Metabolism. 14 (4): 947–976. doi:10.1016/S0300-595X(85)80084-0. ISSN 0300-595X.

[pmid25098712-5] Bancos I, Hahner S, Tomlinson J, Arlt W (2015). “Diagnosis and management of adrenal insufficiency”. Lancet Diabetes Endocrinol. 3 (3): 216–26. doi:10.1016/S2213-8587(14)70142-1. PMID 25098712.

[pmid15001597-6] Murray RD, Columb B, Adams JE, Shalet SM (2004). “Low bone mass is an infrequent feature of the adult growth hormone deficiency syndrome in middle-age adults and the elderly”. J Clin Endocrinol Metab. 89 (3): 1124–30. doi:10.1210/jc.2003-030685. PMID 15001597.

[pmid12050248-7] Miller KK, Biller BM, Hier J, Arena E, Klibanski A (2002). “Androgens and bone density in women with hypopituitarism”. J Clin Endocrinol Metab. 87 (6): 2770–6. doi:10.1210/jcem.87.6.8557. PMID 12050248.

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