Hypopituitarism (Panhypopituitarism) Treatment & Management

  • Author: Bernard Corenblum, MD, FRCPC; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
 
Updated: Jul 11, 2016
 

Approach Considerations

Missed or delayed diagnosis of hypopituitarism could potentially lead to permanent disability or death. Medical care consists of hormone replacement as appropriate and treatment of the underlying cause. Glucocorticoids are required if the ACTH-adrenal axis is impaired. This is particularly important in sudden collapse due to pituitary apoplexy or acute obstetric hemorrhage with pituitary insufficiency. In such circumstances, do not delay initiation of a possibly life-saving treatment pending a definitive diagnosis. Treat secondary hypothyroidism with thyroid hormone replacement.

Treat gonadotropin deficiency with sex-appropriate hormones. In men, testosterone replacement is used and substituted with HCG injections if the patient desires fertility. In women, estrogen replacement is used with or without progesterone as appropriate.

GH is replaced in children as appropriate. GH is not routinely replaced in adults unless the patient is symptomatic of GH deficiency, after all other pituitary hormones have been replaced. Then, a 6-month trial of replacement GH therapy may be considered.

Surgical care depends on the underlying cause and clinical state. In pituitary apoplexy, prompt surgical decompression may be life saving if head imaging reveals clinically significant tumor mass effect. Microadenomas do not need surgical treatment, unless GH or ACTH hypersecretion is present. Prolactinomas, small and large, generally respond to medical therapy with tumor shrinkage and alleviation of mass symptoms. Debulk macroadenomas with mass symptoms that that do not respond to medical therapy or are not expected to respond to medical therapy. Some asymptomatic nonsecreting macroadenomas may have an option of close clinical/radiological observation. If radiotherapy is used, long-term new-onset hypopituitarism may occur and must be monitored. The most common cause of nonsecreting pituitary adenomas are variants of gonadotropin-secreting tumors, and perhaps a third may demonstrate some decrease in mass with treatment with the potent dopamine agonist cabergoline.[14]

A study by Lee et al found that in patients with nonfunctioning pituitary adenomas, gross-total resection and/or adjuvant radiotherapy appear to prevent tumor recurrence or regrowth. The study involved 289 patients, 193 of whom had gross-total resection, 53 of whom had near-total resection, and 43 of whom had subtotal resection.[15]

In very ill hospitalized patients or in patients undergoing major procedures, stress-dose steroids are required and are quickly tapered to a maintenance schedule after the procedure. Minor procedures or illnesses may not necessitate a change in steroid dose or may require a simple doubling of the usual daily dose until the illness resolves. Other hormone replacements are continued at their usual maintenance doses as appropriate.

No special diet is necessary in patients with hypopituitarism unless dictated by an underlying disease process. Also, no activity restrictions are necessary unless dictated by an underlying disease process. Include an endocrinologist, a neurosurgeon, and a radiologist in consultations, as appropriate.

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Prevention

Good obstetric care has reduced the incidence of postpartum hypopituitarism. Radiation therapy that minimizes exposure of the pituitary reduces the time of onset of hypopituitarism. Experienced neurosurgeons employing high-resolution microscopic hypophyseal surgery may reduce the likelihood of subsequent hypopituitarism.

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Long-Term Monitoring

Provide long-term follow-up care for complications of underreplacement or overreplacement. Stressful situations warrant an adjustment in therapy. Unlike adults, children require GH replacement.

Follow-up care also involves adjusting hormone replacement to physiologic maintenance levels using the lowest dose. Monitor the patient to avoid overreplacement. The incidence of new neoplasms is increased in young people treated with growth hormone who had previous tumor treatment.[16]  This does not appear to be the case in adult patients. Excessive glucocorticoid or thyroid doses, or inadequate sex steroid doses, have been associated with decreased bone mineral density.

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Contributor Information and Disclosures
Author

Bernard Corenblum, MD, FRCPC Professor of Medicine, Director, Endocrine-Metabolic Testing and Treatment Unit, Ovulation Induction Program, Department of Internal Medicine, Division of Endocrinology, University of Calgary Faculty of Medicine, Canada

Disclosure: Nothing to disclose.

Coauthor(s)

James R Mulinda, MD, FACP Consulting Staff, Department of Endocrinology, Endocrinology Associates, Inc

James R Mulinda, MD, FACP is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Acknowledgements

David S Schade, MD Chief, Division of Endocrinology and Metabolism, Professor, Department of Internal Medicine, University of New Mexico School of Medicine and Health Sciences Center

David S Schade, MD is a member of the following medical societies: American College of Physicians, American Diabetes Association, American Federation for Medical Research, Endocrine Society, New Mexico Medical Society, New York Academy of Sciences, and Society for Experimental Biology and Medicine

Disclosure: Nothing to disclose.

Don S Schalch, MD Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and Endocrine Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Kim SY. Diagnosis and Treatment of Hypopituitarism. Endocrinol Metab (Seoul). 2015 Dec. 30(4):443-55. [Medline]. [Full Text].

  2. Schneider HJ, Schneider M, Saller B, et al. Prevalence of anterior pituitary insufficiency 3 and 12 months after traumatic brain injury. Eur J Endocrinol. 2006 Feb. 154(2):259-65. [Medline].

  3. Kokshoorn NE, Smit JW, Nieuwlaat WA, et al. Low prevalence of hypopituitarism after traumatic brain injury: a multicenter study. Eur J Endocrinol. 2011 Aug. 165(2):225-31. [Medline].

  4. Appelman-Dijkstra NM, Kokshoorn NE, Dekkers OM, et al. Pituitary dysfunction in adult patients after cranial radiotherapy: systematic review and meta-analysis. J Clin Endocrinol Metab. 2011 Aug. 96(8):2330-40. [Medline]. [Full Text].

  5. Fernandez A, Brada M, Zabuliene L, Karavitaki N, Wass JA. Radiation-induced hypopituitarism. Endocr Relat Cancer. 2009 Sep. 16(3):733-72. [Medline].

  6. Fatemi N, Dusick JR, Mattozo C, et al. Pituitary hormonal loss and recovery after transsphenoidal adenoma removal. Neurosurgery. 2008 Oct. 63(4):709-18; discussion 718-9. [Medline].

  7. Regal M, Paramo C, Sierra SM, Garcia-Mayor RV. Prevalence and incidence of hypopituitarism in an adult Caucasian population in northwestern Spain. Clin Endocrinol (Oxf). 2001 Dec. 55(6):735-40. [Medline].

  8. Clayton RN. Mortality, cardiovascular events and risk factors in hypopituitarism. Growth Horm IGF Res. 1998 Feb. 8 Suppl A:69-76. [Medline].

  9. O'Reilly MW, Reulen RC, Gupta S, et al. ACTH and gonadotropin deficiency predict mortality in patients treated for nonfunctioning pituitary adenoma (NFPA): long-term follow-up of 519 patients in two large European centres. Clin Endocrinol (Oxf). 2016 Jun 21. [Medline].

  10. Bulow B, Hagmar L, Eskilsson J, Erfurth EM. Hypopituitary females have a high incidence of cardiovascular morbidity and an increased prevalence of cardiovascular risk factors. J Clin Endocrinol Metab. 2000 Feb. 85(2):574-84. [Medline].

  11. Nakamoto J. Laboratory diagnosis of multiple pituitary hormone deficiencies: issues with testing of the growth and thyroid axes. Pediatr Endocrinol Rev. 2009 Jan. 6 Suppl 2:291-7. [Medline].

  12. Li G, Shao P, Sun X, Wang Q, Zhang L. Magnetic resonance imaging and pituitary function in children with panhypopituitarism. Horm Res Paediatr. 2010. 73(3):205-9. [Medline].

  13. Child CJ, Zimmermann AG, Woodmansee WW, et al. Assessment of primary cancers in GH-treated adult hypopituitary patients: an analysis from the Hypopituitary Control and Complications Study. Eur J Endocrinol. 2011 Aug. 165(2):217-223. [Medline]. [Full Text].

  14. Dutta P, Bhansali A, Singh P, et al. Congenital hypopituitarism: clinico-radiological correlation. J Pediatr Endocrinol Metab. 2009 Oct. 22(10):921-8. [Medline].

  15. Lee MH, Lee JH, Seol HJ, et al. Clinical Concerns about Recurrence of Non-Functioning Pituitary Adenoma. Brain Tumor Res Treat. 2016 Apr. 4(1):1-7. [Medline]. [Full Text].

  16. Harsch IA, Schuller A, Hahn EG, Hensen J. Cortisone replacement therapy in endocrine disorders - quality of self-care. J Eval Clin Pract. 2010 Jun. 16(3):492-8. [Medline].

  17. de Graaff LC, De Bellis A, Bellastella A, et al. Antipituitary antibodies in dutch patients with idiopathic hypopituitarism. Horm Res. 2009 Jan. 71(1):22-7. [Medline].

  18. Welsh J. Managing hypopituitarism in emergency departments. Emerg Nurse. 2015 Oct 9. 23 (6):32-7. [Medline].

  19. Silva PP, Bhatnagar S, Herman SD, Zafonte R, Klibanski A, Miller KK, et al. Predictors of Hypopituitarism in Patients with Traumatic Brain Injury. J Neurotrauma. 2015 Sep 29. [Medline].

  20. Klose M, Feldt-Rasmussen U. Hypopituitarism in Traumatic Brain Injury-A Critical Note. J Clin Med. 2015 Jul 14. 4 (7):1480-97. [Medline].

  21. Crespo I, Santos A, Webb SM. Quality of life in patients with hypopituitarism. Curr Opin Endocrinol Diabetes Obes. 2015 Aug. 22 (4):306-12. [Medline].

 
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