Pituitary Disorders: Diagnosis and Management

Watch now to find out. How much can genetic testing really help? What's new in AML research? How can your genetic profile influence treatment decisions? Register now for our upcoming webinar to learn the answers from AML experts. Published on February 9, This is one more reason to pay attention to your body. Lewis Blevins shares information on the diagnosis and treatment of pituitary disorders.

The program begins with a discussion of the problems that occur when the pituitary gland malfunctions and why it malfunctions. Pituitary tumors usually cause these issues and, luckily, only a very small percentage of these tumors are cancer. Blevins talks in depth about the diagnosis, misdiagnosis, evaluation and treatment of pituitary disorders. Blevins concludes the program by sharing how patients can benefit from doing research.

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INTRODUCTION

The pituitary gland is known as the master gland, and if it malfunctions it can cause big problems in your body. The symptoms of pituitary disorders can vary greatly, one more reason to pay attention to your body. Coming up you'll hear from a renowned expert as he shares information on the diagnosis and treatment of pituitary disorders.

Today we're talking about something maybe you hadn't thought about, and that is pituitary disorders. We're going to understand this really pea sized gland at the base of your brain and how it really is a master gland, and it can cause plenty of problems if it's malfunctioning. We're going to understand what are those problems, how do you get an accurate diagnosis and what are the treatments. Macroprolactinomas are less common and seen more in men. With the availability of medical treatment for hyperprolactinemia and amenorrhea, pregnancy in these women is quite common. Dopamine agonists DA rapidly restore fertility in infertile women with hyperprolactinemia and amenorrhea Estrogen derived from placenta stimulates prolactin secretion and causes hypertrophy of lactotrophs.

Dopamine binds to receptors on lactotroph cells in the anterior pituitary and downregulates adenyl cyclase resulting in inhibition of PRL secretion. All DA cross placenta.

Pituitary Disorders: Symptoms, Diagnosis and Treatment | Pituitary Tumor | Patient Power

It is recommended to use barrier contraception until the first cycles have occurred and to stop the drug once pregnancy is confirmed. Data on safety of cabergoline is accumulating. Recent data of pregnant women is available. The incidence of abortions, stillbirths, ectopic pregnancy, hydatidiform moles, low birth weight babies and neonatal malformations are comparable to that of general population.

The incidence of congenital malformation in patients taking cabergoline is reported around 2. Microadenomas follow a being course and tumor regrowth occurs in about 1. Patients are followed monthly for symptoms of tumor expansion like headache and visual disturbances and every trimester for visual field testing. In case of symptoms and appearance of visual field defects, a non-contrast MRI is to be performed after the first trimester. If tumor expansion is documented, DA can be restarted and an eye is kept on visual symptoms and field of vision.

Women who had previously responded to DA and had received it for a sufficient time before pregnancy are good indicators of response during pregnancy. Enlargement of macroprolactinoma is a significant issue and is quite common especially in women who did not have surgery or radiation before conception. First is to stop DA after confirmation of pregnancy and monitor closely during pregnancy. Monitoring includes looking for appearance of headache and visual symptoms every month, visual field examination every two months and non-contrast MRI after the first trimester.

If there is increase in tumor size, DA is to be restarted. The second option is to continue DA throughout pregnancy and monitor as in macroadenoma. This option is preferred if tumor is outside the sellar boundaries. If MRI after first trimester reveals further enlargement of the mass despite continuation of DA, either delivery if the term is nearer or trans-sphenoid surgery TSS if term is not close are the choices, keeping in mind that there is increased risk of abortions with TSS.

It is suggested that in situations where facility for doing periodic MRI is not available, monthly monitoring of PRL levels and timely institution of bromocriptine is an option. Pregnancy rarely occurs in untreated Cushing's syndrome CS because hypercortisolism exerts profound effect on reproductive axis preventing normal follicular development and ovulation. Striae, hypertension and gestational diabetes are the most common signs of CS in pregnant women; however, these occur in normal pregnancy also.

Furthermore, proximal muscle weakness, spontaneous bruising and wide purple striae favor diagnosis of CS. In addition, increase in urinary hydroxycorticosteroid excretion may be because of CS and not because of pregnancy. Plasma ACTH levels may be high normal in pregnant women with pituitary-dependent Cushing's disease, and detectable levels do not rule out adrenal etiology. Adrenal CT should be avoided and ultrasound can be used for evaluation of adrenals but is less helpful.

Treatment of CS during pregnancy must be individualized.

During first trimester, the first line of treatment is medical with surgical resection to follow. Among drugs, either metyrapone or ketoconazole can be used though both have side effects, but metyrapone is preferred. Data from India regarding CS and pregnancy is limited to single case reports. Pregnancy was complicated by pregnancy-induced hypertension, glucose intolerance, prematurity and IUGR.

Pregnancy is rare in acromegaly, because expanding tumor mass decreases gonadotroph and or GnRH reserve and secretion. Simultaneous occurrence of hyperprolactinemia also impairs fertility. The enlargement of pituitary mass occurs less frequently and is mostly limited to macroadenomas. In a recent study, only 3 out of 27 cases of acromegaly had increase in size of pituitary mass whereas 22 remained stable during pregnancy. Two important features of pituitary GH differentiate it from placental variant, pituitary GH is highly pulsatile and responds to TRH stimulation.

On investigations was found to have biochemical evidence of GH excess, and MRI revealed a pituitary macroadenoma. She was operated in 22 nd week of pregnancy and delivered a normal baby. She was later on treated with gamma knife after delivery. Lymphocytic hypophysitis LH also called autoimmune hypophysitis is the most common among inflammations affecting pituitary gland. LH is six times more common in women and shows a striking association with pregnancy;[ 69 ] patients present in last month of pregnancy or immediately after delivery; although, it can occur in men as well as in children.

LH may be associated with other autoimmune disorders especially Hashimoto's thyroiditis. The cause of this paradox is not completely understood but there are some explanations. First pituitary enlarges during pregnancy, which may lead to release of pituitary antibodies. The cause of this paradox is possibly related to increased exposure of pituitary to systemic blood and consequently more accessibility to immune system. LH should be suspected if following three features are present: Once diagnosis of LH is convincingly supported, pituitary hormone deficiencies should be replaced.

Since LH is an autoimmune disease, treatment with steroids is advocated, which often resolves sellar mass and improves endocrine dysfunction. Surgery should be opted if patient has visual impairment. Transsphenoidal surgery may require to confirm diagnosis and to relieve symptoms of compression. There are a few reported cases of lymphocytic hypophysitis from India. In most of the cases, diagnosis has been established in surgical specimen biopsies. Common differentiating features between Sheehan's syndrome and lymphocytic hypophysitis. Differentiating features on MR imaging between lymphocytic hypophysitis and pituitary adenoma.

SS means deficiency of anterior pituitary hormone resulting from infarction and necrosis of the physiologically enlarged pituitary gland of pregnancy, usually preceded by postpartum hemorrhage PPH. Till the disease was known as Simmond's disease and was believed to be due to thrombosis or bacterial emboli in hypophyseal arteries. Sheehan later discovered that Simmond's disease was due to necrosis of anterior pituitary following PPH. Role of autoimmunity in the development of hypopituitarism has been suggested. It is believed that tissue necrosis could release sequestered antigens, triggering pituitary autoimmunity and delayed hypopituitarism.

Variable patterns of pituitary hormone deficiency have been observed in patients with SS. Disease presents with lactation failure, failure of resumption of menstrual cycles, symptoms of hypothyroidism and hypoadrenal state. Sparing or recovery of gonadotroph function and consequent pregnancy has been reported in some cases.

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One of the first presentations of SS is failure of lactation; however, SS can be associated with hyperprolactinemia also. Clinical features in these patients include severe hypothyroidism, fine wrinkling around mouth suggestive of GH deficiency, hypotension and hypopigmentation suggestive of ACTH deficiency and loss of secondary sex characters suggestive of gonadotroph deficiency [ Figure 1 ].

Anemia and other cytopenias are common in these patients. Diagnosis of SS is simple in an area where it is common. Clinical hypopituitarism associated with low or inappropriately normal basal pituitary hormones in the context of previous pregnancy, without any pituitary mass lesion on imaging makes a diagnosis of disorder likely.

Imaging studies preferably MRI reveal a small pituitary with partial or complete empty sella [ Figure 1 ].

The diagnostic criteria for Sheehan's syndrome have recently been proposed. Treatment of SS consists of replacement of deficient hormones. Glucocorticoids are replaced without the need for fludrocortisones and are to be started before replacing thyroxine; hypogonadism increases the risk of osteoporosis and causes decrease in secondary sex characters, so replacement is needed especially in premenopausal women. GH replacement has recently been shown to improve quality of life in these patients.

National Center for Biotechnology Information , U. Indian J Endocrinol Metab. Laway and Shahnaz A. Author information Copyright and License information Disclaimer. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC.

Abstract Pregnancy is associated with normal physiological changes in endocrine system that assists fetal survival as well as preparation of labor.

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Cushing's disease, growth hormone, lymphocytic hypophysitis, pituitary disorders, placenta, pregnancy, prolactinoma, Sheehan's syndrome. Table 1 Hormone changes during pregnancy. Open in a separate window. Thyroid axis During pregnancy, a number of physiological changes occur in the size of the thyroid gland and level of thyroid hormones. Growth hormone axis During pregnancy there is decrease in the number of somatotroph cells. Pituitary adrenal axis In pregnancy, maternal hypothalamic-pituitary axis is activated, which leads to an increase in plasma adrenocorticotropic hormone ACTH , cortisol both free and total and urinary free cortisol.

Dopamine agonists during pregnancy Dopamine binds to receptors on lactotroph cells in the anterior pituitary and downregulates adenyl cyclase resulting in inhibition of PRL secretion. Effect of pregnancy on prolactinoma and its management Microprolactinoma Microadenomas follow a being course and tumor regrowth occurs in about 1. Macroprolactinoma Enlargement of macroprolactinoma is a significant issue and is quite common especially in women who did not have surgery or radiation before conception.

Table 3 Differentiating features on MR imaging between lymphocytic hypophysitis and pituitary adenoma. Footnotes Source of Support: Nil Conflict of Interest: Pituitary gland growth during normal pregnancy: An in vivo study using magnetic resonance imaging. Pituitary dimensions and volume measurements in pregnancy and post-partum MR assessment.

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Size and shape of the pituitary gland during pregnancy and postpartum measurement with MR imaging. The hormone applications of steroid hormone radioimmunoassay to clinical obstetrics. Pattern of increase in circulating prolactin levels during human gestation. Am J Obstet Gynecol. Direct arterial vascularization of estrogen-induced prolactin-secreting anterior pituitary tumors. Progesterone incuces acute release of prolactin in estrogen primed ovariectomized women.

Diagnosis and Treatment of Hypopituitarism

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