Hypopituitarism Dr Madhukar Mittal Medical Endocrinology.
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Transcript of Hypopituitarism Dr Madhukar Mittal Medical Endocrinology.
Hypopituitarism
Dr Madhukar Mittal
Medical Endocrinology
Master Gland
• Pituitary– Anterior– Posterior
Hormones
• Anterior Pituitary Hypothalamus– Prolactin Dopamine– GH
GHRH, Somatostatin– FSH GnRH– LH GnRH– TSH TRH– ACTH CRH
Hormones
• Posterior Pituitary– Oxytocin– Vasopressin (ADH)
Portal System
• Hypothalamic pituitary
Feedback Loop
Anterior Pituitary Hormone Expression
• Lactotrope– PRL Breast, other Milk
• Somatotrope– GH Liver, other IGF-1
• Thyrotrope– TSH Thyroid T4
• Gonadotrope– FSH, LH Ovary, Testis Sex steroid
• Corticotrope– POMC ACTH Adrenal
Cortisol
Causes of Hypopituitarism
• Developmental• Traumatic• Neoplastic• Inflammatory/Infiltrative• Vascular• Infections
Causes
Developmental
• Transcription factor defect
• Aplasia/dysplasia• Congenital CNS mass• Primary empty sella• Hypothalamic disorders
(Prader-Willi, Laurence-Moon-Biedl, Kallmann, Septo-optic dysplasia)
Causes
Traumatic
• Surgical resection• Radiation damage• Head injuries
Neoplastic
• Pituitary adenoma• Germinoma,
Ependymoma, Glioma• Rathke’s cyst• Craniopharyngioma• Hypothalamic hamartoma• Metastases (B, L, C)• Lymphoma, Leukemia
Inflammatory/Infiltrative
• Lymphocytic hypophysitis• Hemochromatosis• Sarcoidosis• Histiocytosis X
Vascular
• Pituitary Apoplexy• Postpartum necrosis• Sickle cell disease• Arteritis
Infections
• Fungal (histoplasmosis)• Parasitic (Toxoplasmosis)• Tuberculosis
Clinical
• Hormonal deficiency
• Local mass effect
• Metabolic effect
Manifestations of Hormonal deficiency
• PRL• TSH• GH• LH/FSH• ACTH
• ADH• Oxytocin??
Local mass effect
• Pituitary• Optic chiasm
– Loss of red perception– Bitemporal hemianopia– Scotoma– Blindness
• Cavernous sinus– Cranial nerve III, IV, VI, V1, V2– Ophthalmoplegia, Facial numbness
Local mass effect
• Brain– Headache, Hydrocephalus– Dementia, Psychosis
• Frontal Lobe– Personality disorder– Anosmia
• Hypothalamus– Temperature dysregulation– Appetite & Thirst disorders– Diabetes insipidus– Obesity, Sleep disorders– Autonomic dysfunction
Evaluation
• GH– Clonidine– GHRH test– Insulin tolerance test– L-Arginine– L-Dopa test
• Prolactin– Serum levels– TRH test
• ACTH– CRH test– Insulin tolerance test
• TSH– Basal TSH– TRH test
• LH/FSH– Basal LH, FSH– Testosterone– Estrogen
– GnRH test
Imaging
• MRI
Other Tests
• Fundus, Perimetry• Na, K• Osmolarity Urine/serum• Water deprivation test
Treatment
ACTH deficiency
• Hydrocortisone• Prednisolone
TSH deficiency
• Levothyroxine
FSH/LH deficiency
• Males– Testosterone (Inj/Oral/Patch/Gel)
• Females– Estrogen (Tab/Patch)– Progesterone– For fertility : hCG, hMG
GH deficiency
• GH (Somatotropin) s.c.– Children– Adults
Vasopressin
• Desmopressin– s.c./Intranasal/Oral
Tumors
• Trans-sphenoidal Surgery
Other Treatment
• Radiotherapy• Medical
Thank You