eMedicine Specialties > Emergency Medicine > Endocrine & Metabolic

Hypopituitarism: Follow-up

Author: Lisa Diane Mills, MD, Assistant Professor of Emergency Medicine, Director, Section of Emergency Medicine Ultrasound, Louisiana State University at New Orleans
Contributor Information and Disclosures

Updated: Aug 14, 2008

Follow-up

Further Inpatient Care

  • Acutely decompensated hypopituitarism requires admission.
  • Once diagnosed, hypopituitarism due to pituitary adenomas may be entirely reversible by means of tumor resection or by shrinking it with pharmacologic therapy or radiation.
  • Pituitary surgery is an option, depending on the size of the tumor, the degree of destruction of adjacent tissue, and the ability of the neurosurgeon to remove the tumor without disturbing the normal pituitary tissue. If the tumor can be removed selectively, hormone secretion may return to normal.
  • Recovery of baseline pituitary function is unlikely if hypothalamic or pituitary tissue has been destroyed by radiation, surgery (total hypophysectomy), or hemorrhage. Life-long hormone replacement will be required.
  • Hormone replacement is the treatment option. Initiation of this treatment is outside the purview of emergency medicine, but an overview is provided below.   
  • Thyroxine deficiency is resolved easily with once-a-day replacement. Administer levothyroxine (Synthroid) at an initial dose of 25 mcg, then increase as needed to a maintenance dose.
    • Hypothyroidism can mask a hypocortisol state.
    • Upon initiating thyroid replacement, a patient's cortisol level drops acutely, creating an adrenocortical crisis.
    • Prior to replacement of thyroid hormone, patients should be treated empirically with glucocorticoids if adrenal insufficiency is potentially present.
  • Maintenance treatment of adrenal insufficiency consists of 10-20 mg of hydrocortisone daily, often with a dose of 10 mg every morning and 5 mg every evening.  
    • A similar treatment comprises 5 mg of prednisone each morning and 2.5 mg each evening.
    • In acute adrenal insufficiency, a bolus of hydrocortisone 100-250 mg IV, followed by hydrocortisone 100 mg IV every 8 hours, would sustain a patient through physiologic stress (eg, infection, injury).
  • Treat FSH and LH deficiency in premenopausal women with oral contraceptive pills containing estrogen and progesterone.  
    • The pills provide a cyclical release of hormone and stimulate normal endometrial growth and shedding.
    • In males, testosterone can be given orally as a testosterone enanthate patch 200-300 mg every 2-3 weeks or as a depot injection 300 mg IM every 3 weeks.
  • Recombinant GH has had tremendous significance for children. Growth hormone replacement in adults can be initiated at a recommended dose of 300 mcg/day or lower and titrated according to IGF-1 levels and tolerance to side effects.
  • Prolactin deficiency rarely is present and is only of significance in lactating, postpartum women. However, no replacement is currently available for prolactin deficiency.
  • Treat ADH deficiency with vasopressin in doses of 5-10 units given IM or SC every 6 hours. Desmopressin (DDAVP), a synthetic form of vasopressin, can be given intranasally and can last up to 12-24 hours.

Further Outpatient Care

  • Patients with hypopituitarism who are seen in the ED for nonendocrinologic reasons should be reminded to increase their baseline steroids in response to the stress. They should follow up with their primary doctor or endocrinologist as previously directed by the physician.
  • Outpatient evaluation of patients for hypopituitarism in a well-appearing patient can be orchestrated by the primary doctor in consultation with appropriate specialists.

Inpatient & Outpatient Medications

Deterrence/Prevention

  • Prevention of hypopituitarism is a complex sociomedical process outside the purview of the clinical practice of emergency medicine.
  • Prevention of acute decompensation can be accomplished by reminding patients to increase the hydrocortisone dose in response to stress.

Complications

  • Visual deficit
  • Adrenal crisis
  • Long-term hormone replacement therapy
  • Susceptibility to infection and other stressors due to limited ability of the endocrine system to respond appropriately

Prognosis

  • Stable patients who are diagnosed with hypopituitarism have a favorable prognosis with replacement hormone therapy.
  • Patients with acute decompensation are in critical condition with a high mortality rate.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Patients with acutely decompensated hypopituitarism require early administration of stress doses of glucocorticoids. Failure to administer glucocorticoids is not practicing to the standard of care.
  • The initial presentation of hypopituitarism is a difficult diagnosis in the acutely decompensated or the stable patient. The emergency physician should keep these diagnoses in mind but can not be expected to make this diagnosis in the ED.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Jerome FX Naradzay, MD, and Stuart A Brilliant, MD, to the development and writing of this article.



More on Hypopituitarism

Overview: Hypopituitarism
Differential Diagnoses & Workup: Hypopituitarism
Treatment & Medication: Hypopituitarism
Follow-up: Hypopituitarism
References
[ CLOSE WINDOW ]

References

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

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

  3. Abboud CF. Hypopituitarism. In: Conn RB, ed. Current Diagnosis. 8th ed. 1991:811-19.

  4. Abboud CF. Anterior pituitary failure. In: The Pituitary. 2nd ed. 2002:349-404.

  5. Arafah BM, Nasrallah MP. Pituitary tumors: pathophysiology, clinical manifestations and management. Endocr Relat Cancer. Dec 2001;8(4):287-305. [Medline].

  6. Baldelli R, Bellone S, Corneli G, et al. Traumatic brain injury-induced hypopituitarism in adolescence. Pituitary. 2005;8(3-4):255-7. [Medline].

  7. Benvenga S. Brain injury and hypopituitarism: the historical background. Pituitary. 2005;8(3-4):193-5. [Medline].

  8. Blondell RD. Hypopituitarism. Am Fam Physician. Jun 1991;43(6):2029-36. [Medline].

  9. Chang YC, Tsai JC, Tseng FY. Neuropsychiatric disturbances and hypopituitarism after traumatic brain injury in an elderly man. J Formos Med Assoc. Feb 2006;105(2):172-6. [Medline].

  10. Darzy KH, Shalet SM. Hypopituitarism as a consequence of brain tumours and radiotherapy. Pituitary. 2005;8(3-4):203-11. [Medline].

  11. Giordano G, Aimaretti G, Ghigo E. Variations of pituitary function over time after brain injuries: the lesson from a prospective study. Pituitary. 2005;8(3-4):227-31. [Medline].

  12. Guyton AC, Hall JE. The pituitary hormones and their control by the hypothalamus. In: Textbook of Medical Physiology. 11th ed. 2005:846-856.

  13. Insel JR, Dhanjal N. Pituitary infarction resulting from intranasal cocaine abuse. Endocr Pract. Nov-Dec 2004;10(6):478-82. [Medline].

  14. Kreitschmann-Andermahr I. Subarachnoid hemorrhage as a cause of hypopituitarism. Pituitary. 2005;8(3-4):219-25. [Medline].

  15. Landman RE, Wardlaw SL, McConnell RJ, et al. Pituitary lymphoma presenting as fever of unknown origin. J Clin Endocrinol Metab. Apr 2001;86(4):1470-6. [Medline].

  16. Lanes R. Metabolic abnormalities in growth hormone deficiency. Pediatr Endocrinol Rev. Dec 2004;2(2):209-15. [Medline].

  17. Lin SH, Hung YH, Lin YF. Severe hyponatremia as the presenting feature of clinically non-functional pituitary adenoma with hypopituitarism. Clin Nephrol. Jan 2002;57(1):85-8. [Medline].

  18. Masel BE. Traumatic brain injury induced hypopituitarism: the need and hope of rehabilitation. Pituitary. 2005;8(3-4):263-6. [Medline].

  19. McArthur RG, Morgan K, Phillips JA 3rd, et al. The natural history of familial hypopituitarism. Am J Med Genet. Nov 1985;22(3):553-66. [Medline].

  20. Minniti G, Esposito V, Piccirilli M, et al. Diagnosis and management of pituitary tumours in the elderly: a review based on personal experience and evidence of literature. Eur J Endocrinol. Dec 2005;153(6):723-35. [Medline].

  21. Moll GW, Bock HG. Two tumors detected by thyroid assessment in two children. Endocr Pract. Nov-Dec 2001;7(6):467-73. [Medline].

  22. Ozkan Y, Colak R. Sheehan syndrome: clinical and laboratory evaluation of 20 cases. Neuro Endocrinol Lett. Jun 2005;26(3):257-60. [Medline].

  23. Pivnick EK, Burstein S, Wilroy RS. Hallermann-Streiff syndrome with hypopituitarism contributing to growth failure. Am J Med Genet. Dec 15 1991;41(4):503-7. [Medline].

  24. Popovic V. GH deficiency as the most common pituitary defect after TBI: clinical implications. Pituitary. 2005;8(3-4):239-43. [Medline].

  25. Reynaud R, Chadli-Chaieb M, Vallette-Kasic S, et al. A familial form of congenital hypopituitarism due to a PROP1 mutation in a large kindred: phenotypic and in vitro functional studies. J Clin Endocrinol Metab. Nov 2004;89(11):5779-86. [Medline].

  26. Schneider HJ, Aimaretti G, Kreitschmann-Andermahr I, et al. Hypopituitarism. Lancet. Apr 28 2007;369(9571):1461-70. [Medline].

  27. Sert M, Tetiker T, Kirim S, et al. Clinical report of 28 patients with Sheehan's syndrome. Endocr J. Jun 2003;50(3):297-301. [Medline].

  28. Somali MH, Anastasiou AL, Goulis DG, et al. Pituitary abscess presenting with cranial nerve paresis. Case report and review of literature. J Endocrinol Invest. Jan 2001;24(1):45-50. [Medline].

  29. Tanriverdi F, Senyurek H, Unluhizarci K, et al. High risk of hypopituitarism after traumatic brain injury: a prospective investigation of anterior pituitary function in the acute phase and 12 months after trauma. J Clin Endocrinol Metab. Jun 2006;91(6):2105-11. [Medline].

  30. Tindall GT, Barrow DL. Pituitary deficiency states. In: Disorders of the Pituitary. Vol 1. 1986:451-72.

  31. van Aken MO, Lamberts SW. Diagnosis and treatment of hypopituitarism: an update. Pituitary. 2005;8(3-4):183-91. [Medline].

  32. Vance ML. Hypopituitarism. N Engl J Med. Jun 9 1994;330(23):1651-62. [Medline].

  33. Wass JAH, Besser GM, DeGroot LJ. Tests of Pituitary Function. Endocrinology. 1989;1:491-7.

  34. Williams HR, Oliver NS, Murphy F, et al. The role of the biochemistry department in the diagnosis of pituitary apoplexy. Ann Clin Biochem. Mar 2004;41:162-5. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

hypopituitarism, pituitary apoplexy, Sheehan's syndrome, Sheehan syndrome, pituitary hormone deficiencies, thyrotropin, thyroid-stimulating hormone, TSH, gonadotropins, follicle-stimulating hormone, FSH, luteinizing hormone, LH, growth hormone, GH, corticotropin, adrenocorticotropic hormone, ACTH, prolactin hormone, PRL, traumatic brain injury, TBI, cocaine snorting, subarachnoid hemorrhage, postpartum hypotension, pituitary insufficiency

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Lisa Diane Mills, MD, Assistant Professor of Emergency Medicine, Director, Section of Emergency Medicine Ultrasound, Louisiana State University at New Orleans
Lisa Diane Mills, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Southern Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Howard A Bessen, MD, Professor of Medicine, Department of Emergency Medicine, UCLA School of Medicine; Program Director, Harbor-UCLA Medical Center
Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.