Diagnosis and treatment of hypopituitarism: an update

Continuous Glucose Monitoring: A Possible Aid for Detecting Hypoglycemic Events during Insulin Tolerance Tests

The combined pituitary function test evaluates the anterior pituitary gland, while the insulin tolerance test evaluates growth hormone deficiencies. However, successful stimulation requires achieving an appropriate level of hypoglycemia. Close medical supervision for glucose monitoring is required during hypoglycemia induction and the test is often very tedious. In addition, a capillary blood sugar test (BST) and serum glucose levels may differ greatly. An alternative approach may be utilizing a continuous glucose-monitoring (CGM) system. We provide three cases in which CGM was successfully used alongside a standard BST and serum glucose levels during the combined pituitary function test to better detect and induce hypoglycemia. Three participants who were diagnosed with multiple pituitary hormone deficiencies during childhood were re-evaluated in adulthood; a Dexcom G6 CGM was used. The CGM sensor glucose and BST levels were simultaneously assessed for glycemic changes and when adequate hypoglycemia was reached during the combined pituitary function test. The CGM sensor glucose, BST, and serum glucose levels showed similar glucose trends in all three patients. A Bland-Altman analysis revealed that the CGM underestimated the BST values by approximately 9.68 mg/dL, and a Wilcoxon signed-rank test showed that the CGM and BST measurements significantly differed during the stimulation test (p = 0.003). Nevertheless, in all three cases, the CGM sensor mimicked the glycemic variability changes in the BST reading and assisted in monitoring appropriate hypoglycemia nadir. Thus, CGM can be used as a safe aid for clinicians to use during insulin tolerance tests where critical hypoglycemia is induced.

Functioning Endocrine Outcome after Endoscopic Endonasal Transsellar Approach for Pituitary Neuroendocrine Tumors

BACKGROUND

The endoscopic endonasal approach (EEA) is a well-established technique for the treatment of pituitary neuroendocrine tumor Preservation of normal gland tissue is crucial to retain effective neuroendocrine pituitary function. The aim of this paper is to analyze pituitary endocrine secretion after EEA for pituitary neuroendocrine tumor to identify potential predictors of functioning gland recovery.

METHODS

Patients who underwent an exclusive EEA for pituitary neuroendocrine tumors between October 2014 and November 2019 were reviewed. Patients were divided into groups according to postoperative pituitary function (Group 1, unchanged; group 2, recovering; group 3, worsening).

RESULTS

Among the 45 patients enrolled, 15 presented a silent tumor and showed no hormonal impairment, and 30 patients presented pituitary dysfunction. A total of 19 patients (42.2%) were included in group 1, 12 (26.7%) patients showed pituitary function recovery after surgery (group 2), and 14 patients (31.1%) exhibited the onset of new pituitary deficiency postoperatively (group 3). Younger patients and those with functioning tumor were more likely to have complete pituitary hormonal recovery (p = 0.0297 and p = 0.007, respectively). No predictors of functional gland worsening were identified.

CONCLUSION

EEA for pituitary neuroendocrine tumor is a reliable and safe technique regarding postoperative hormonal function. Preserving pituitary function after tumor resection should be a primary goal in a minimally invasive approach.

High Prevalence of Nonalcoholic Fatty Liver Disease Among Adolescents and Young Adults With Hypopituitarism due to Growth Hormone Deficiency

OBJECTIVE

To investigate the prevalence of nonalcoholic fatty liver disease (NAFLD) in adolescents and young adults with hypopituitarism and to examine the associations of growth hormone (GH) deficiency with the occurrence of NAFLD.

METHODS

A cross-sectional study for the determination of NAFLD prevalence included 76 patients with childhood-onset hypopituitarism and 74 controls matched by age and body mass index (BMI). We investigated the prevalence of NAFLD in adolescent and young adult patients with hypopituitarism as well as the age- and BMI-matched controls. Among patients with hypopituitarism, anthropometric, clinical, and biochemical assessments using transient elastography and magnetic resonance imaging were performed. Logistic regression was used to identify the factors associated with NAFLD.

RESULTS

The adolescents and young adults with hypopituitarism exhibited higher prevalence of NAFLD than the age- and BMI-matched controls. Among patients with hypopituitarism, obesity and obesity-related metabolic derangements were significantly associated with liver steatosis and fibrosis, whereas lower insulin-like growth factor (IGF)-I standard deviation score (SDS) and IGF-I/IGF-binding protein 3 molar ratios were associated with steatosis. In regression analyses adjusted for BMI SDS, steatosis was found to be associated with a lower IGF-I SDS and IGF-I/IGF-binding protein 3 molar ratios, whereas liver fibrosis was found to be associated with a lower IGF-I SDS.

CONCLUSION

Our results suggest that GH deficiency contributes to the occurrence of NAFLD, along with obesity and obesity-related metabolic changes. Because NAFLD occurs early in patients with hypopituitarism, the surveillance, weight control, and timely replacement of deficit hormones, including GH, are essential.

Recurrent Hypoglycemia in Diabetic Patient With Hypopituitarism: The Houssay Phenomenon

The association of treatment of diabetes mellitus and hypoglycemia is well described in the literature. However, the association of recurrent hypoglycemia in diabetic patients with hypopituitarism has been rarely described. This phenomenon, called Houssay phenomenon, usually occurs in individuals with a long diabetes evolution. It is caused by the failure of counter-regulatory hormones produced by the anterior pituitary gland to correct hypoglycemia. We describe this phenomenon in an elderly female known with type 2 diabetes mellitus taking insulin and oral diabetes medications. Workup showed partially empty sella on pituitary imaging. Hormonal assessment showed very low morning cortisol, low adrenocorticotropin hormone (ACTH) and zero response to synacthen. Loss of these counter-regulatory hormones leads to hypoglycemia (Houssay phenomenon). Hypopituitarism has several causes, including pituitary adenoma and traumatic brain injury as common causes among the others. In our reported case, we correlate our patient’s condition to Houssay phenomenon, for the implication of refractory hypoglycemic episodes and cortisol deficiency, all of which are the consequences of hypopituitarism. Clinicians should be aware of the link between diabetes and hypopituitarism to avoid deleterious consequences of hypoglycemia.

UNDERSTANDING PROLACTIN REGULATION AND DETERMINING THE EFFICACY OF CABERGOLINE AND DOMPERIDONE TO MITIGATE PROLACTIN-ASSOCIATED OVARIAN CYCLE PROBLEMS IN ZOO AFRICAN ELEPHANTS (LOXODONTA AFRICANA )

Perturbations in serum prolactin secretion, both over- and underproduction, are observed in zoo African elephants (Loxodonta africana) that exhibit abnormal ovarian cycles. Similar prolactin problems are associated with infertility in other species. Pituitary prolactin is held under constant inhibition by a hypothalamic-derived neurotransmitter, dopamine; thus, regulation by exogenous treatment with agonists or antagonists may be capable of reinitiating normal ovarian cycles. This study tested the efficacy of oral administration of cabergoline (agonist) and domperidone (antagonist) as possible treatments for hyperprolactinemia or chronic low prolactin, respectively. Hyperprolactinemic (overall mean prolactin, >30 ng/ml), acyclic elephants were administered oral cabergoline (2 mg, n = 4) or placebo (dextrose capsule, n = 4) twice weekly. Overall mean prolactin concentration decreased in treated females compared with controls (32.22 ± 14.75 vs 77.53 ± 0.96 ng/ml; P = 0.01). Interestingly, overall mean progestagen concentrations also increased slightly (P < 0.05) in treated females (0.15 ± 0.01 ng/ml) compared with controls (0.07 ± 0.01 ng/ml), but no reinitation of normal cyclic patterns was observed. Chronic low prolactin (overall mean prolactin, <10 ng/ml), acyclic females were orally administered domperidone (2 g/day, n = 4) or placebo (dextrose capsule, n = 4) for 4 wk, followed by 8 wk of no treatment (four cycles) to simulate the prolactin pattern observed in normal cycling elephants. Overall mean prolactin concentrations increased (P = 0.005) during domperidone treatment (21.77 ± 3.69 ng/ml) compared with controls (5.77 ± 0.46 ng/ml), but progestagen concentrations were unaltered. Prolactin regulation by dopamine was confirmed by expected responses to dopamine agonist and antagonist treatment. Although prolactin concentrations were successfully reduced by cabergoline, and domperidone initiated the expected cyclic prolactin pattern, neither treatment induced normal ovarian activity.

Hormone-related diseases and prostate cancer: An English national record linkage study

Insulin-like growth factor-I (IGF-I) and testosterone may be related to prostate cancer risk. Acromegaly is associated with clinically high IGF-I concentrations. Klinefelter's syndrome, testicular hypofunction and hypopituitarism are associated with clinically low testosterone concentrations. We aimed to investigate whether diagnosis with these conditions was associated with subsequent prostate cancer diagnosis and mortality. We used linked English national Hospital Episode Statistics and mortality data from 1999 to 2017 to construct and follow-up cohorts of men aged ≥35 years diagnosed with (i) acromegaly (n = 2,495) and (ii) hypogonadal-associated diseases (n = 18,763): Klinefelter's syndrome (n = 1,992), testicular hypofunction (n = 8,086) and hypopituitarism (n = 10,331). We estimated adjusted hazard ratios (HRs) and confidence intervals (CIs) for prostate cancer diagnosis and death using Cox regression in comparison with an unexposed reference cohort of 4.3 million men, who were admitted to hospital for a range of minor surgeries and conditions (n observed cases = 130,000, n prostate cancer deaths = 30,000). For men diagnosed with acromegaly, HR for prostate cancer diagnosis was 1.33 (95% CI 1.09-1.63; p = 0.005; n observed cases = 96), HR for prostate cancer death was 1.44 (95% CI 0.92-2.26; p = 0.11; n deaths = 19). Diagnosis with Klinefelter's syndrome was associated with a lower prostate cancer risk (HR = 0.58, 95% CI 0.37-0.91; p = 0.02; n observed cases = 19) and hypopituitarism was associated with a reduction in prostate cancer death (HR = 0.53, 95% CI 0.35-0.79; p = 0.002; n deaths = 23). These results support the hypothesised roles of IGF-I and testosterone in prostate cancer development and/or progression. These findings are important because they provide insight into prostate cancer aetiology.

Long-term endocrine effects and trends in body mass index changes in patients with childhood-onset brain tumors

As survival rates have improved owing to advances in management strategies for pediatric brain tumors, long-term complications such as endocrine dysfunction, have emerged as a major issue. This study investigated the long-term endocrine effects of childhood-onset brain tumors in a large number of patients. This study included 151 patients with brain tumors diagnosed between January 1995 and December 2016. The following data were retrospectively reviewed: tumor location, tumor histology, endocrine abnormalities, hypothalamic involvement on brain imaging, treatment modalities, and trends in body mass index. The mean age at diagnosis of patients with sellar/suprasellar (SE/SUP-SE) tumors and supra/infratentorial (ST/IT) tumors was 9.9 ± 4.5 and 6.5 ± 4.2 years, respectively. In patient with prepubertal age at diagnosis, height standard deviation score was lower in patients with SE/SUP-SE tumors at diagnosis (P = 0.031), which was lower in patients with ST/IT tumors at the final visit (P < 0.001). The prevalence of combined pituitary hormone deficiencies was higher among patients with SE/SUP-SE tumors than in those with ST/IT tumors (81.7 vs. 36.1%, P < 0.001). Among 98 non-obese patients with SE/SUP-SE tumors, 36.7% developed obesity. The prevalence of combined pituitary hormone deficiencies and obesity was higher in patients with SE/SUP-SE tumors than in those with tumors in other locations; growth impairment was more severe in patients with ST/IT tumors.

The Missing Link: A Case of Absent Pituitary Infundibulum and Ectopic Neurohypophysis in a Pediatric Patient with Heterotaxy Syndrome

We report a case of absent pituitary infundibulum and ectopic neurohypophysis in a 4-year-old patient presenting clinically with hypopituitarism as well as heterotaxy syndrome complicated by global developmental delay and growth retardation. The clinical and laboratory workup of our patient suggested underlying hypopituitarism related to either congenital or acquired pathology, necessitating MRI to distinguish between them. We explain the various structural causes of hypopituitarism and detail how to predict the MRI findings and treatment, based on a fundamental understanding of the anatomy and pathophysiology of the hypothalamic pituitary axis and distinguishing anterior versus posterior pituitary hormone derangements. We also discuss two important theories widely acknowledged in the literature to explain congenital hypopituitarism: 1. Head trauma typically during birth resulting in a stretch injury to the infundibulum. 2. Congenital fetal maldevelopment of midline structures.

Hypopituitarism in the elderly: a narrative review on clinical management of hypothalamic-pituitary-gonadal, hypothalamic-pituitary-thyroid and hypothalamic-pituitary-adrenal axes dysfunction

Hypopituitarism is an uncommon and under-investigated endocrine disorder in old age since signs and symptoms are unspecific and, at least in part, can be attributed to the physiological effects of aging and related co-morbidities. Clinical presentation is often insidious being characterized by non-specific manifestations, such as weight gain, fatigue, low muscle strength, bradipsychism, hypotension or intolerance to cold. In these circumstances, hypopituitarism is a rarely life-threatening condition, but evolution may be more dramatic as a result of pituitary apoplexy, or when a serious condition of adrenal insufficiency suddenly occurs. Clinical presentation depends on the effects that each pituitary deficit can cause, and on their mutual relationship, but also, inevitably, it depends on the severity and duration of the deficit itself, as well as on the general condition of the patient. Indeed, indications and methods of hormone replacement therapy must include the need to normalize the endocrine profile without contributing to the worsening of intercurrent diseases, such as those of glucose and bone metabolism, and the cardiovascular system, or to the increasing cancer risk. Hormonal requirements of elderly patients are reduced compared to young adults, but a prompt diagnosis and appropriate treatment of pituitary deficiencies are strongly recommended, also in this age range.

Takotsubo Syndrome: A Pathway through the Pituitary Disease

Takotsubo cardiomyopathy (TTC) is characterized by reversible left ventricular apical and/or midventricular hypokinesia with unknown etiology. The clinical presentation is similar to acute myocardial infarction in the absence of significant obstructive coronary artery disease. Various predisposing factors have been related to TTC, such as acute neurological illnesses, endocrine diseases, pain, and emotional stress. We present the first description of an association between TTC cardiomyopathy and panhypopituitarism. This case reinforces the connection between the hormonal and cardiovascular systems. Furthermore, it supports the importance of a comprehensive and integrated medical history in the approach of a patient with cardiac disease, towards clinical decision-making.

Management of electrolyte and fluid disorders after brain surgery for pituitary/suprasellar tumours

Disturbances in salt and water balances are relatively common in children after brain surgeries for suprasellar and pituitary tumours, presenting diagnostic and therapeutic challenges. Although hypernatraemia associated with central diabetes insipidus is commonly encountered, it is hyponatraemia (HN) that poses more of a diagnostic dilemma. The main differential diagnoses causing HN are the syndrome of inappropriate antidiuretic hormone secretion, marked by inappropriate retention of water, and cerebral salt wasting, characterized by polyuria and natriuresis. Diagnosis and management can be even more difficult when these conditions precede or coexist with each other. These diagnostic and therapeutic dilemmas are discussed in detail in this review.

Diagnosis and Treatment of Hypopituitarism

Hypopituitarism is a chronic endocrine illness that caused by varied etiologies. Clinical manifestations of hypopituitarism are variable, often insidious in onset and dependent on the degree and severity of hormone deficiency. However, it is associated with increased mortality and morbidity. Therefore, early diagnosis and prompt treatment is necessary. Hypopituitarism can be easily diagnosed by measuring basal pituitary and target hormone levels except growth hormone (GH) and adrenocorticotropic hormone (ACTH) deficiency. Dynamic stimulation tests are indicated in equivocal basal hormone levels and GH/ACTH deficiency. Knowledge of the use and limitations of these stimulation tests is mandatory for proper interpretation. It is necessary for physicians to inform their patients that they may require lifetime treatment. Hormone replacement therapy should be individualized according to the specific needs of each patient, taking into account possible interactions. Long-term endocrinological follow-up of hypopituitary patients is important to monitor hormonal replacement regimes and avoid under- or overtreatment.

Pituitary cell differentiation from stem cells and other cells: toward restorative therapy for hypopituitarism?

The pituitary gland, key regulator of our endocrine system, produces multiple hormones that steer essential physiological processes. Hence, deficient pituitary function (hypopituitarism) leads to severe disorders. Hypopituitarism can be caused by defective embryonic development, or by damage through tumor growth/resection and traumatic brain injury. Lifelong hormone replacement is needed but associated with significant side effects. It would be more desirable to restore pituitary tissue and function. Recently, we showed that the adult (mouse) pituitary holds regenerative capacity in which local stem cells are involved. Repair of deficient pituitary may therefore be achieved by activating these resident stem cells. Alternatively, pituitary dysfunction may be mended by cell (replacement) therapy. The hormonal cells to be transplanted could be obtained by (trans-)differentiating various kinds of stem cells or other cells. Here, we summarize the studies on pituitary cell regeneration and on (trans-)differentiation toward hormonal cells, and speculate on restorative therapies for pituitary deficiency.

Hormones and the bone marrow: panhypopituitarism and pancytopenia in a man with a pituitary adenoma

In rare cases, pancytopenia results from hormonal deficiencies that arise in the setting of panhypopituitarism. Here we describe the unusual case of a 60-year-old man who presented with progressive fatigue and polyuria, and whose laboratory workup revealed a deficiency of the five hormones associated with the action of the anterior pituitary (thyroid hormone, testosterone, cortisol, prolactin, and insulin-like growth factor-1). Imaging of the pituitary demonstrated a cystic mass consistent with a pituitary adenoma replacing much of the normal pituitary tissue. His symptoms and hematologic abnormalities rapidly resolved with prednisone and levothyroxine supplementation. While the majority of reported cases of panhypopituitarism with bone marrow suppression are the result of peripartum sepsis or hemorrhage leading to pituitary gland necrosis (Sheehan's syndrome), it is also important to consider the diagnosis of hypopituitarism in patients with hypothyroidism, low cortisol levels, and pancytopenia. The causal relationship between pancytopenia and panhypopituitarism is not well understood, though it does reinforce the important influence of these endocrine hormones on the health of the bone marrow.

Measurement of height velocity is an useful marker for monitoring pituitary function in patients who had traumatic brain injury

To assess the incidence of abnormal neuroendocrine function post-traumatic brain injuriy (TBI) in a large group of paediatric patients and its correlations with clinical parameters (Glasgow coma scale-GCS, Glasgow outcome scale-GOS, TC marshall scale, height velocity). We evaluated 70 patients [58 M, 12 F; age at the time of TBI (mean ± SEM) 8.12 ± 4.23 years] previously hospitalized for TBI at the "Regina Margherita" Hospital, in Turin and "Maggiore della Carità Hospital" in Novara, Italy, between 1998 and 2008. All patients included underwent: auxological, clinical, hormonal and biochemical assessments at recall (after at least 1 year from TBI to T0); auxological visit after 6 months (T6) and hormonal assessments at 12 months (T12) in patients with height velocity (HV) below the 25th centile. At T0, 4 cases of hypothalamus-pituitary dysfunction had been diagnosed; At T6 20/70 patients had an HV <25th centile, but no one had HV < the 3rd centile limit. At T12, among the 20 patients with HV <25th centile, in 13 patients the HV was below the 25th centile and GHRH + Arginine test has been performed. Four subjects demonstrated an impaired GH peak and were classified as GH deficiency (GHD). Of these 4 subjects, 3 subjects showed isolated GHD, while one patient showed multiple hypopituitarism presenting also secondary hypocortisolism and hypothyroidism. The GCS at admission and GOS do not correlate with the onset of hypopituitarism. A simple measurement of the height velocity at least 1 year after the TBI, is enough to recognize patients with a pituitary impairment related to GH deficiency. We suggest to follow-up paediatric population who had TBI with auxological evaluations every 6 months, limiting hormonal evaluation in patients with a reduction of height velocity below the 25th centile limit.

Health-related quality of life and psychiatric symptoms improve effectively within a short time in patients surgically treated for pituitary tumors--a longitudinal study of 106 patients

BACKGROUND

Reduced health-related quality of life (HRQoL) is a common complaint in patients suffering from pituitary tumors. Although successful tumor treatment has been reported to lead to an improvement in perceived HRQoL, the temporal gradient at which these improvements occur has not been fully addressed.

METHODS

Using three validated health-related questionnaires (SF-36, SCL-90-R, QLS-H), we assessed HRQoL in 106 adult patients harboring pituitary tumors (mean age 48.0 ± 16.0 years) before as well as 3 and 12 months after initiation of treatment. The AcroQoL questionnaire was additionally applied in acromegalic patients.

RESULTS

There was a significant improvement in all but one scale (role-physical) of the SF-36 questionnaire and all but two scales (interpersonal sensitivity, paranoid ideation) of the SCL-90-R, the QLS-H score and the AcroQoL subscales within 3 months after surgical treatment. The trend to amelioration continued at the 12 month re-assessment, but did not reach statistical significance. Linear regression analyses revealed that younger age and male gender favor a more distinct improvement of HRQoL after treatment.

CONCLUSIONS

HRQoL is considerably reduced before treatment for pituitary disease. Improvement is an early postoperative phenomenon and occurs within 3 months after treatment. Men and younger patients are more likely to improve within this time span.

An unusual suspect causing behavioural problems and pituitary failure in a child

A 9-year-old boy presented with feeding and behavioural problems and was diagnosed with Autistic Spectrum Disorder and Attention Deficit Hyperactivity Disorder. By age 11 he was becoming increasingly disinhibited and was refusing almost all oral food intake. Believing the cause to be psychogenic, he was placed in an inpatient eating disorder facility. After 3 days of continuous vomiting and minimal intake, he was admitted back to hospital for further investigations. A hypovolaemic hypernatraemia prompted an MRI brain scan, revealing several tumour masses with suprasellar and pituitary involvement. Histological investigation revealed primary, non-malignant germ-cell tumours. The tumours were treated with craniopharyngeal radiotherapy and permanent pituitary hormone replacement.

Low prevalence of hypopituitarism after traumatic brain injury: a multicenter study

OBJECTIVE

Hypopituitarism after traumatic brain injury (TBI) is considered to be a prevalent condition. However, prevalence rates differ considerably among reported studies, due to differences in definitions, endocrine assessments of hypopituitarism, and confounding factors, such as timing of evaluation and the severity of the trauma. Aim To evaluate the prevalence of hypopituitarism in a large cohort of TBI patients after long-term follow-up using a standardized endocrine evaluation. Study design Cross-sectional study.

PATIENTS AND METHODS

We included 112 patients with TBI, hospitalized for at least 3 days and duration of follow-up >1 year after TBI from five (neurosurgical) referral centers. Evaluation of pituitary function included fasting morning hormone measurements and insulin tolerance test (n=90) or, when contraindicated, ACTH stimulation and/or CRH stimulation tests and a GH releasing hormone-arginine test (n=22). Clinical evaluation included quality of life questionnaires.

RESULTS

We studied 112 patients (75 males), with median age 48 years and mean body mass index (BMI) 26.7±4.8 kg/m(2). Mean duration of hospitalization was 11 (3-105), and 33% of the patients had a severe trauma (Glasgow Coma Scale <9) after TBI. The mean duration of follow-up was 4 (1-12) years. Hypopituitarism was diagnosed in 5.4% (6/112) of patients: severe GH deficiency (n=3), hypogonadism (n=1), adrenal insufficiency (n=2). Patients diagnosed with pituitary insufficiency had significantly higher BMI (P=0.002).

CONCLUSION

In this study, the prevalence of hypopituitarism during long-term follow-up after TBI was low. Prospective studies are urgently needed to find reliable predictive tools for the identification of patients with a significant pre-test likelihood for hypopituitarism after TBI.

Should anterior pituitary function be tested during follow-up of all patients presenting at the emergency department because of traumatic brain injury?

CONTEXT

A wide range (15-56%) of prevalences of anterior pituitary insufficiency are reported in patients after traumatic brain injury (TBI). However, different study populations, study designs, and diagnostic procedures were used. No data are available on emergency-department-based cohorts of TBI patients.

OBJECTIVE

To assess the prevalence of pituitary dysfunction in an emergency-department-based cohort of TBI patients using strict endocrinological diagnostic criteria.

METHODS

Of all the patients presenting in the emergency department with TBI over a 2-year period, 516 matched the inclusion criteria. One hundred and seven patients (77 with mild TBI and 30 with moderate/severe TBI) agreed to participate. They were screened for anterior pituitary insufficiency by GHRH-arginine testing, evaluation of fasting morning hormone levels (cortisol, TSH, free thyroxine, FSH, LH, and 17beta-estradiol or testosterone), and menstrual history 3-30 months after TBI. Abnormal screening results were defined as low peak GH to GHRH-arginine, or low levels of any of the end-organ hormones with low or normal pituitary hormone levels. Patients with abnormal screening results were extensively evaluated, including additional hormone provocation tests (insulin tolerance test, ACTH stimulation test, and repeated GHRH-arginine test) and assessment of free testosterone levels.

RESULTS

Screening results were abnormal in 15 of 107 patients. In a subsequent extensive endocrine evaluation, anterior pituitary dysfunction was diagnosed in only one patient (partial hypocortisolism).

CONCLUSION

By applying strict diagnostic criteria to an emergency-department-based cohort of TBI patients, it was shown that anterior pituitary dysfunction is rare (<1%). Routine pituitary screening in unselected patients after TBI is unlikely to be cost-effective.

Perioperative cortisol can predict hypothalamus-pituitary-adrenal status in clinically non-functioning pituitary adenomas

BACKGROUND

Peri-operative steroids are administered routinely to patients with pituitary adenoma undergoing transsphenoidal adenomectomy (TSA).

AIM

To evaluate hypothalamic-pituitary-adrenal (HPA) axis before and after programmed endoscopic TSA (E-TSA) in patients with clinically non-functioning pituitary macroadenoma (NFPA).

DESIGN

Open prospective.

SETTING

Tertiary referral hospitals.

PATIENTS

Seventy-two consecutive patients (20-87 yr, 37 males).

INTERVENTIONS

Adrenal steroid replacement therapy (ASRT) was given only in patients with hypocortisolism [08:00 h cortisol (F) <8 microg/dl].

MAIN OUTCOME MEASUREMENTS

After ETSA, achieving wide (>90%) selective resection of the adenoma in all, F and clinical picture were checked at day 2. The low-dose (1 microg) ACTH test (LDACTH) was performed at 6 weeks and repeated at 12 months.

RESULTS

Hypocortisolism was present pre-operatively in 14 patients (19.4%), persisted post-operatively in all but one, and was detected de novo at the post-operative day 2 control in 6 (10.3%). In all but one the post-operative day 2 basal F and peak F during LDACTH test were concordant. No patient whose F was > 8 microg/dl was treated with ASRT or developed symptoms of adrenal failure during the follow-up (1-11 yr, median 5).

CONCLUSIONS

HPA function is usually preserved in NFPA and is infrequently impaired after complete tumor removal by E-TSA. The 08:00 h. plasma cortisol evaluation before and 2 days after surgery, using as cut-off the value of 8 microg/dl, allows full evaluation of HPA status. Peri-operative steroid treatment should be given only in patients with hypocortisolism.

[The influence of estrogen and progestogen replacement on growth hormone activity in women with hypopituitarism]

Treatment of hypogonadotropic hypogonadism in adult women with hypopituitarism can include a wide range of estrogen and progestogen treatment alternatives and oral administration is the route of least cost and greatest patient comfort. The oral estrogen route has a major impact on the growth hormone-insulin-like growth factor I (GH/IGF-1) axis. Oral estrogen therapy, when given concurrently with GH to patients with hypopituitarism, antagonizes the biological effects of GH treatment and aggravates the abnormalities of body composition and the metabolism in general. It is presumed that oral estrogen suppresses the secretion/production of IGF-1 by a hepatic first-pass mechanism, resulting in increased GH secretion by means of suppressing the IGF-1 negative feedback that is present in healthy women. This is clinically manifested in reduced lean body mass, increased fat mass, an atherogenic lipid profile and damage to psychological well-being. Some studies have indicated that progestogens with androgenic actions reverse the effect of reduced serum IGF-1 levels that is induced by the oral estrogens. Neutral progestogens do not exert this effect, however the stronger the androgenic potentialis, the more the effect of reduced IGF-1 will be reversed. This bibliographical review will deal with the clinical aspects of estrogen and progestogen replacement in women with hypopituitarism, their interactions with other hormone deficiencies and the impact of estrogen treatment on the metabolic actions of GH.

Effects of traumatic brain injury and subarachnoid hemorrhage on anterior pituitary function

Traumatic brain injuries and subarachnoid hemorrhage are frequent events in Spain. Both are well recognized causes of anterior hypopituitarism, the prevalence ranging from 20 to 80% according to recent series. Consensus is lacking on how to assess pituitary function after the injury, although periodic assessment is clearly needed because hypopituitarism may appear at any time in the first year after the event. Hormone replacement when necessary helps recovery and reduces morbidity and mortality.

Evolving hypopituitarism as a consequence of traumatic brain injury (TBI) in childhood - call for attention

Hypopituitarism is a common complication of TBI in long-term survivors, more frequent than previously realized. It may be partial or complete, sometimes very subtle without visible lesions in hypothalamo-pituitary region and is diagnosed only by biochemical means. Neuroendocrine abnormalities caused by TBI may have significant implications for the recovery and rehabilitation of these patients. The subjects at risk are those who have suffered moderate to severe trauma, although mild intensity trauma may precede hypopituitarism also. Particular attention should be paid to this problem in children and adolescents. We describe a patient with hypopituitarism thought to be idiopathic due to mild head trauma which caused diabetes insipidus in childhood, gradual failure of pituitary hormones during the period of growth and development, and metabolic (dyslipidemia), physical (obesity), and cognitive impairments in the adult period.

Hypopituitarism

Incidence and prevalence of hypopituitarism are estimated to be 4.2 per 100,000 per year and 45.5 per 100,000, respectively. Although the clinical symptoms of this disorder are usually unspecific, it can cause life-threatening events and lead to increased mortality. Current research has refined the diagnosis of hypopituitarism. Identification of growth hormone and corticotropin deficiency generally requires a stimulation test, whereas other deficiencies can be detected by basal hormones in combination with clinical judgment. Newly developed formulations of replacement hormones are convenient and physiological. Work has shown that many patients with brain damage--such as traumatic brain injury or aneurysmal subarachnoid haemorrhage--are at high risk of (sometimes unrecognised) hypopituitarism. Thus, a much increased true prevalence of this disorder needs to be assumed. As a result, hypopituitarism is not a rare disease and should be recognised by the general practitioner.

Anterior pituitary hormone replacement therapy--a clinical review

This clinical review summarizes current approaches to diagnosis and treatment of anterior pituitary hormone deficiency. The diagnostic value of endocrine function tests and replacement strategies for hydrocortisone, thyroxine, sex steroids, and growth hormone replacement are reviewed. Female androgen deficiency syndrome and the current role of DHEA and testosterone replacement in women are also discussed.

Hypopituitarism

Hypopituitarism is the partial or complete insufficiency of anterior pituitary hormone secretion and may result from pituitary or hypothalamic disease. The reported incidence (12-42 new cases per million per year) and prevalence (300-455 per million) is probably underestimated if its occurrence after brain injuries (30-70% of cases) is considered. Clinical manifestations depend on the extent of hormone deficiency and may be non specific, such as fatigue, hypotension, cold intolerance, or more indicative such as growth retardation or impotence and infertility in GH and gonadotropin deficiency, respectively.A number of inflammatory, granulomatous or neoplastic diseases as well as traumatic or radiation injuries involving the hypothalamic-pituitary region can lead to hypopituitarism. Several genetic defects are possible causes of syndromic and non syndromic isolated/multiple pituitary hormone deficiencies. Unexplained gonadal dysfunctions, developmental craniofacial abnormalities, newly discovered empty sella and previous pregnancy-associated hemorrhage or blood pressure changes may be associated with defective anterior pituitary function.The diagnosis of hypopituitarism relies on the measurement of basal and stimulated secretion of anterior pituitary hormones and of the hormones secreted by pituitary target glands. MR imaging of the hypothalamo-pituitary region may provide essential information. Genetic testing, when indicated, may be diagnostic.Secondary hypothyroidism is a rare disease. The biochemical diagnosis is suggested by low serum FT4 levels and inappropriately normal or low basal TSH levels that do not rise normally after TRH. L-thyroxine is the treatment of choice. Before starting replacement therapy, concomitant corticotropin deficiency should be excluded in order to avoid acute adrenal insufficiency. Prolactin deficiency is also very rare and generally occurs after global failure of pituitary function. Prolactin deficiency prevents lactation. Hypogonadotropic hypogonadism in males is characterized by low testosterone with low or normal LH and FSH serum concentrations and impaired spermatogenesis. Hyperprolactinemia as well as low sex hormone binding globulin concentrations enter the differential diagnosis. Irregular menses and amenorrhea with low serum estradiol concentration (<100 pmol/l) and normal or low gonadotropin concentrations are the typical features of hypogonadotropic hypogonadism in females. In post menopausal women, failure to detect high serum gonadotropin values is highly suggestive of the diagnosis. In males, replacement therapy with oral or injectable testosterone results in wide fluctuations of serum hormone levels. More recently developed transdermal testosterone preparations allow stable physiological serum testosterone levels. Pulsatile GnRH administration can be used to stimulate spermatogenesis in men and ovulation in women with GnRH deficiency and normal gonadotropin secretion. Gonadotropin administration is indicated in cases of gonadotropin deficiency or GnRH resistance but is also an option, in alternative to pulsatile GnRH, for patients with defective GnRH secretion.