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Pituitary Disease in Adults MJA PracticeMJA Essentials Practice Essentials EndocrinologyEndocrinology 9: Pituitary disease in adults David M Hurley and Ken K Y Ho Heightened awareness is needed to detect the sometimes subtle symptoms and signs of pituitary disease DESPITE SIGNIFICANT ADVANCES in the biochemical eval- ABSTRACT uation of pituitary function, diagnosis of pituitary disorders is often delayed by lack of awareness of these conditions and The Medical Journal of Australia ISSN: 0025-729X 19 ■ Pituitary adenomas are found in 10%–25% of unselected the subtlety of their symptoms and signs. In this article we April 2004 180 8 419-425 autopsy series and are evident in about 10% of focus on practical clinical aspects and areas in which there ©The Medical Journal of Australia 2004 www.mja.com.au asymptomatic individuals by magnetic resonance have MJAbeen Practice significant Essentials recent —Enbdocrinology developments. Adrenal disor- imaging. ders related to pituitary disease are also considered. Recent ■ developments include the wider availability of high quality Diagnosis of pituitary disorders is often delayed by lack magnetic resonance imaging, recognition of “incidentalo- of awareness and the subtlety of symptoms and signs. mas” and the important role of growth hormone in adults, ■ Hypopituitarism is suspected when peripheral hormone development of new therapies for acromegaly and prolac- concentrations are low without an elevation in the tinoma, and improved diagnostic methods for Cushing’s corresponding pituitary tropic hormone(s). syndrome. ■ Severe adult-onset growth-hormone deficiency results in reduced muscle mass, increased fat mass and diminished quality of life, which are reversed by growth Epidemiology hormone replacement therapy. While pituitary disorders are considered uncommon, pitui- ■ While trans-sphenoidal surgery remains first-line tary adenomas are found in 10%–25% of unselected treatment for acromegaly, drug treatment has an autopsy series,1 and magnetic resonance imaging reveals important role in controlling residual growth-hormone pituitary lesions in about 10% of normal individuals.2 The excess and, in some circumstances, as first-line reasons for this discrepancy are not clear. With the advent of treatment. high-resolution cranial imaging, unsuspected and often clinically significant pituitary lesions are commonly discov- ■ Dopamine-agonist therapy (cabergoline or bromocriptine) ered during investigation of unrelated conditions. is the treatment of choice for micro- and macroprolactinomas. ■ In patients with suggestive clinical features, elevated Presentation and investigation 24-hour urine free cortisol level is usually sufficient to Pituitary disease may present with one or more of the diagnose endogenous Cushing’s syndrome; careful following: additional investigation is needed to determine whether ■ deficiency of one or more pituitary hormones; the cause is Cushing’s disease (pituitary adenoma ■ hormone excess (especially of prolactin, growth hormone secreting adrenocorticotropic hormone [ACTH]), ectopic and adrenocorticotropic hormone [ACTH]); ACTH secretion or adrenal disease. ■ mass effects of an expanding lesion (eg, headache, bitem- MJA 2004; 180: 419–425 poral hemianopia); or ■ an unexpected finding of computed tomography or mag- netic resonance imaging (“incidentaloma”). Assessment of pituitary function Box 1 lists the hormones that should be measured initially to detect pituitary hypo- or hyperfunction. Series Editors: Donald J Chisholm and Jeffrey D Zajac Department of Endocrinology and Diabetes, Royal Perth Pituitary imaging Hospital, Perth, WA. David M Hurley, PhD, FRACP, Endocrinologist and Director, Division of Magnetic resonance imaging (MRI) is the method of choice Medical Specialties. for imaging the pituitary gland. Superb resolution allows Pituitary Research Unit, Garvan Institute of Medical small lesions to be visualised and clearly defines the relation- Research, Sydney, NSW. ship of larger lesions to the optic chiasm and adjacent Ken K Y Ho, MD, FRACP, Head, and Professor and Chairman, structures. Department of Endocrinology, St Vincent’s Hospital, Sydney, NSW. Reprints will not be available from the authors. Correspondence: Dr David Visual field assessment M Hurley, Department of Endocrinology and Diabetes, Royal Perth Hospital, Wellington Street Campus, Box X2213, GPO, Perth, WA 6847. Suprasellar extension of a pituitary adenoma or other mass [email protected] lesion may elevate and compress the optic chiasm, causing MJA Vol 180 19 April 2004 419 Endocrinology MJA Practice Essentials bitemporal hemianopia. Asymmetrical involvement of the cortisol response to insulin-induced hypoglycaemia (insulin chiasm and optic nerves and tracts may produce different tolerance test) or to tetracosactrin (Synacthen [Novartis]) patterns of visual impairment. Clinical assessment of visual should be tested. The insulin tolerance test is also used to fields is difficult. All patients with suprasellar extension of a confirm growth-hormone deficiency (see below). A low- pituitary mass should undergo computerised (eg, Hum- dose short Synacthen test is emerging as an alternative for phrey) assessment of visual fields. diagnosing secondary hypoadrenalism but does not evaluate growth-hormone status. Hypopituitarism Management Hypopituitarism is suspected when concentrations of hor- mone from peripheral target glands are low without an Hypoadrenalism: Impaired ACTH secretion requires glu- elevation in levels of the corresponding pituitary tropic cocorticoid but not mineralocorticoid replacement. Options hormones. Serum levels of thyroid-stimulating hormone, include cortisone acetate (12.5–25 mg morning, 12.5 mg ACTH and gonadotropins are often “normal” in patients night), hydrocortisone (10–20 mg morning, 10 mg night) or with hypopituitarism. In older men, a subnormal plasma prednisolone (2.5–5 mg morning, 2.5 mg night). Plasma testosterone level with “normal” levels of luteinising hor- cortisol levels are not helpful in monitoring therapy. Doses mone (LH) and follicle-stimulating hormone (FSH) is often should be at least doubled during acute illness, and adminis- attributed to “male menopause” or “andropause”; these tered without delay by intramuscular or intravenous injec- patients must be properly assessed to exclude significant tion in patients who are vomiting. Patient education is of pituitary abnormalities. Subnormal early-morning levels of paramount importance, and the possession of a card or plasma cortisol with low or “normal” plasma ACTH level bracelet displaying steroid dependency is essential. confirms secondary hypoadrenalism. In other patients, the Hypothyroidism: Thyroxine doses are similar to those for primary hypothyroidism (ie, 50–150 µg daily). Plasma TSH measurement is not helpful for adjusting the thyroxine dose 1: Baseline endocrine evaluation of pituitary in hypopituitarism. function* Hypogonadism: Options for oestrogen replacement in Serum levels of the following hormones should be measured in a µ morning blood sample:† women include transdermal oestradiol patches (50–100 g daily), subcutaneous oestradiol implants or oral therapy (eg, ■ Prolactin oestradiol 1–2 mg/day or equivalent). Hepatic metabolic ■ Luteinising hormone, follicle-stimulating hormone and testosterone or oestradiol effects are lower with transdermal and subcutanous delivery ■ Thyroid-stimulating hormone and thyroxine than with oral therapy. Oral oestrogens also attenuate the effects of growth hormone. The dose of oestrogen in the oral ■ Adrenocorticotropic hormone and cortisol contraceptive pill exceeds replacement requirements. In ■ Insulin-like growth factor-1 women who have not undergone hysterectomy, pro- * As serum levels of tropic hormones are often “normal” in patients with gestogens are co-administered in a cyclical or continuous hypopituitarism, it is essential that levels of target-gland hormones are also regimen (eg, medroxyprogesterone acetate, 2.5–5 mg daily). measured (ie, thyroxine, cortisol and testosterone or oestradiol). The need for oestrogen therapy in older women should be † Cortisol and testosterone levels are highest in the morning. reviewed in the light of recent studies showing a small but significant risk of adverse events. In men, options for testosterone replacement include 2: Symptoms and signs in acromegaly intramuscular testosterone esters every 2–3 weeks, subcuta- Excess acral growth neous testosterone implants every 3–5 months (three or four Facial features enlargement 200 mg pellets) or testosterone patches daily. Soft tissue swelling Gonadotropin therapy is needed to induce ovulation or Excessive sweating spermatogenesis. Headache Peripheral neuropathy Diabetes insipidus: Biochemically confirmed diabetes Decreased energy insipidus is treated with intranasal desmopressin, a long- Paresthesia acting analogue of antidiuretic hormone (vasopressin), usu- Osteoarthritis ally taken before bed. Some patients require a second dose Erectile impairment about 12 hours later. An oral preparation that was recently Daytime somnolence Carpal tunnel syndrome added to the Pharmaceutical Benefits Scheme has low and Muscular weakness variable bioavailability which limits its usefulness. More Depression detailed discussion of the management of diabetes insipidus Decreased libido is beyond the scope of this article. Hypertrichosis Dyspnoea Galactorrhoea Growth-hormone deficiency in adults 0255075 100 Prevalence (%) The recognition that growth hormone should be replaced in adults with growth-hormone deficiency
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