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Hypopituitarism

Hypopituitarism. Adenohypophysial deficit Anterior pituitary insufficiency. Clinical features. Gradual, insidious onset Initial loss of GH and gonadotrophin secretion followed by deficiences of TSH, then ACTH, and finally PRL

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Hypopituitarism

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  1. Hypopituitarism Adenohypophysial deficit Anterior pituitary insufficiency

  2. Clinical features • Gradual, insidious onset • Initial loss of GH and gonadotrophin secretion followed by deficiences of TSH, then ACTH, and finally PRL GH: decreased growth (childhood-onset GHD), adult-onset GHD: increased mortality due to cardiovascular diasease, decreased LBM, increased visceral BF, salt and water depletion, decreased BMD, reduced cardiac output, decreased exercise capacity, dry skin, decreased sweating, depression of mood, impaired social function, low self-esteem, LH/FSH:amenorrhea, decreased libido, impotence, decreased body hair

  3. Clinical features (2) TSH:cold intolerance, dry skin, mental dullness, bradycardia, constipation, hoarseness, anaemia, rarely myxoedema ACTH:weakness, nausea, vomiting, anorexia, weight loss, fever, postural hypotension, hypoglycemia, depigmentation, diminished tanning, decreased body hair, hyponatremia PRL: failure of postpartum lactation P/E:abnormal findings may be subtle PATIENTS WITH HYPOPITUITARISM ARE NOT CACHECTIC ! (They are usually slightly overweight) fine, pale, and smooth skin with fine wrinkling on the face deficient or absent body and pubic hair, atrophy of genitalia decreased muscle strenght, postural hypotension, bradycardia, delayed deep tendon reflexes

  4. Causes • More then 75% of the gland must be destroyed before clinical manifestations are evident • „Nine I’s”: invasive, infarction, infiltrative, injury, immunologic, iatrogenic, infectious, idiopathic, isolated. • Invasive: adenomas, craniopharyngioma, other primary CNS tumors, metastatic lesions • Infarction: Simmonds /1914/:pituitary necrosis in a woman with severe puerperal sepsis Sheehan’s syndrome /1937/: pituitary ischaemic infarction due to postpartum hemorrhage and vascular collapse  failure to lactate, to resume normal menstrual periods

  5. Causes (2) Pituitary apoplexy = spontaneous hemorrhagic infarction of a pituitary tumor: a fulminant clinical syndrome: severe headache, visual impairment, ophtalmoplegias, meningismus, altered level of consciousness. Sometimes related to DM, radiotherapy, open heart surgery. Corticosteroids, transsphenoidal decompression of the intrasellar contents may be lifesaving. Silent pituitary apoplexy: may cure the hipersecretory pituitary adenoma without impairing the secretion of other anterior pituitary hormones. • Infiltrative: sarcoidosis, hemochromatosis, histiocytosis X • Injury: severe head trauma  anterior pituitary insufficiency and/or DI

  6. Causes (3) • Immunologic: lymphocytic hypophysitis  anterior hypopituitarism; most often in women during pregnancy or in the postpartum period; may result in isolated hormone deficiences (ACTH, PRL); NMR; glucocorticoids, self-limiting disease • Iatrogenic: surgery, radiotherapy • Infectious: TBC, syphilis, mycotic infections • Idiopathic: either isolated or multiple deficiences • Isolated (monotropic): - congenital monotropic GH deficiency (sporadic, familial), - monotropic ACTH deficiency (rare; most acquired cases due to lympocytic hypophysitis), - isolated gonadotropin deficiency (not uncommon, Kallman’s syndrome – X-linked dominant, defect in LHRH secretion associated with hyposmia/anosmia, sometimes color blindness and nerve deafness

  7. Causes (4) Other causes of isolated hypogonadotropic hypogonadism: weight loss, emotional or physical stress, intensive athletic training, anorexia nervosa, marked obesity, sickle cell anemia, other chronic ilnesses, eg. poorly controlled DM and malnutrition, autoimmune hypophysitis

  8. Diagnosis • Assessment of target gland function: fT3, fT4, cortisol, T, E2, GH, IGF-1, ACTH stimulation test • Evaluation of PRL • Differentiation of primary and secondary hypofunction • Stimulation tests: TRH (TSH, PRL), LHRH (LH, FSH), GHRH, arginine (GH), CRH? (ACTH)

  9. Treatment • ACTH: glucocorticoid supplementation; hydrocortisone 20-30 mg orally in 2-3 divided doses (minimum effective dosage); increased dosage during periods of stress (illness, surgery, trauma); mineralocorticoid therapy (fludrocortisone) usually not required • TSH:levothyroxine sodium orally (50-150 g).Caution: First hydrocortisone, then thyroxine! • GH: still under investigation, expensive!

  10. Treatment (2) • Gonadotropins: • Estrogens and progesterone (HRT) • Ovulation induction: clomiphene citrate, pulsatile LHRH infusion pumps, chorionic gonadotropins (LH), human menopausal gonadotropins (FSH) • Androgens in women • Androgens in men: testosterone enanthate 200 mg every 2 weeks i.m., transdermal preparations • Spermatogenesis: chorionic gonadotropins (LH), human menopausal gonadotropins (FSH), pulsatile LHRH infusion pumps.

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