History

Types of pituitary microadenomas

Nonsecreting incidentalomas usually have no associated symptoms. They are ordinarily found in people who have radiologic studies for other reasons (eg, headaches). Unlike macroadenomas, incidentalomas are too small to cause pressure-related symptoms such as headache, diplopia, or visual-field loss. Moreover, they are not associated with hypopituitarism.^{[1, 2]}

Prolactinomas may be asymptomatic if prolactin levels are only slightly elevated. In women, hyperprolactinemia may cause galactorrhea, oligomenorrhea/amenorrhea, decreased libido, or infertility. In men, hypogonadism, erectile dysfunction, and decreased libido may ensue. Galactorrhea is uncommon in men.

Corticotropin-secreting adenomas cause Cushing disease.

Growth hormone–secreting adenomas cause acromegaly.

Thyroid-stimulating hormone (TSH)–secreting adenomas are a very rare cause of hyperthyroidism, and the patient has a nonsuppressed serum TSH level. This biochemical pattern needs to be differentiated from thyroid hormone resistance.

Gonadotropin-secreting adenomas have been reported. The frequency is rare. Women may present with amenorrhea and a mismatch between estrogen and gonadotropin levels (eg, elevated gonadotropin levels despite normal or elevated levels estrogen levels without suppression of gonadotropins).^[12]They may be misdiagnosed as having ovarian failure.

Physical

Any physical abnormalities are caused by excessive hormone secretion (eg, galactorrhea due to hyperprolactinemia, acromegaly due to excessive growth hormone, corticotropin-mediated Cushing disease). Most microadenomas found incidentally on CT scan or MRI are clinically inactive and neurologically silent.

Patients with prolactin-secreting adenomas may present with galactorrhea/menstrual disorders. Other causes of galactorrhea need to be excluded, such as hypothyroidism, chest wall lesions, and medications.

Growth hormone–secreting adenomas cause acromegaly, with coarsening of facial features and increased width of the hands and feet. Progressive bony proliferation of the mandible both lengthens and thickens it, resulting in separation of the lower teeth and an underbite. Skin thickness is increased compared with age- and sex-matched controls (>2 mm in reproductive-aged women, >3 mm in men).The clinical changes may be subtle or even not noticeable at the time of presentation.

Corticotropin-secreting adenomas cause Cushing disease, characterized by weight gain, primarily in the facial, nuchal, truncal, and girdle areas (ie, centripetal or "buffalo" obesity). Protein breakdown leads to thin, friable skin (2 mm in reproductive-aged women, < 3 mm in men) that bruises easily; this breakdown may form wide striae that are often purple. The protein breakdown often causes muscle weakness (proximal muscles more than distal muscles), wasting, and osteopenia with fragility fractures. Women often develop hirsutism. In children, growth is arrested. Depression/anxiety is common.

Causes

As with adenomas elsewhere, the likely cause of pituitary microadenomas is a local mutation leading to autonomous growth and/or secretion. A variety of tumor suppressor genes and oncogenes have been described in sporadic pituitary tumorigenesis.^{[13, 4]}

Differential Diagnoses

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Media Gallery

MRI showing a nonenhancing area in the pituitary consistent with a microadenoma, in a patient with hyperprolactinemia.

of 1

Author

Andre E Manov, MD, MSHM, FACP, CPE Professor, Department of Medicine, University of Nevada School of Medicine; Professor, Department of Internal Medicine, TCU Burnett School of Medicine; Professor, Department of Internal Medicine, Touro University of Nevada; Program Director, Transitional Residency Program, Core Faculty, Internal Medicine Residency Program, Director, Medicine Clinic, Sunrise Health GME, MountainView Hospital

Andre E Manov, MD, MSHM, FACP, CPE is a member of the following medical societies: American College of Physicians, American Diabetes Association, British Diabetic Association, Diabetes UK

Disclosure: Nothing to disclose.

Coauthor(s)

Sarah N Polis Resident Physician, Department of Internal Medicine, Mountain View Hospital, Sunrise Health GME Consortium

Disclosure: Nothing to disclose.

Kartika Shetty, MD, FACP Program Director, Internal Medicine Residency Program, Sunrise GME; Facility Medical Director, TEAMHealth, Mountain View Hospital

Kartika Shetty, MD, FACP is a member of the following medical societies: American College of Physicians, Association of Program Directors in Internal Medicine, Medical Council of India

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

George T Griffing, MD Professor Emeritus of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for Physician Leadership, American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society, International Society for Clinical Densitometry, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

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.

Acknowledgements

David M Klachko, MD, MEd Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Missouri-Columbia School of Medicine

David M Klachko, MD, MEd is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Federation for Medical Research, Missouri State Medical Association, Sigma Xi, and The Endocrine Society

Disclosure: Nothing to disclose.