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Questions and Answers
Which of the following laboratory evaluations is essential for assessing growth hormone levels?
What condition is characterized by hypersecretion of one or more anterior pituitary hormones?
What is the gold standard imaging technique for evaluating pituitary masses?
Which symptom is NOT typically associated with TSH secreting pituitary adenomas?
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In terms of pituitary mass size determination, which classification describes a mass that is less than 1 cm?
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What is the recommended follow-up MRI duration for a microadenoma if no growth is noted after the initial 12 months?
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Which condition directly results from hypoperfusion of the anterior pituitary gland during childbirth?
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What is a major factor that increases the risk of ischemic injury to the pituitary gland during pregnancy?
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What is the typical incidence of Sheehan's Syndrome globally with regards to live births?
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In the case of incidental pituitary adenoma, when should biochemical testing be performed?
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Which of the following is a consequence of a null cell pituitary adenoma?
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What percentage of patients with Sheehan's Syndrome experience loss of all pituitary hormones?
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What is the main physiological mechanism leading to empty sella syndrome?
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What is a common symptom of hypopituitarism?
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Which condition is characterized by the development of a small pituitary within a sella of normal size, sometimes described on MRI as 'empty sella'?
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What is a potential cause of Empty Sella Syndrome?
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Which condition results from acute hemorrhage into the pituitary gland and can cause rapid onset of hormone deficiency?
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What is the recommended management for patients with Sheehan syndrome?
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What is the least effective treatment for GH and ACTH secreting tumors compared to prolactinomas?
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What imaging findings suggest a craniopharyngioma?
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Which treatment method is preferred for invasive prolactinomas?
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What is NOT one of the primary goals in the treatment of pituitary adenomas?
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Which parameter is indicative of a prolactinoma diagnosis?
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What condition must be evaluated when an incidental pituitary mass is discovered?
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What is the desired surgical approach for pituitary tumors when resection is required?
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What is a common complication associated with unmonitored growth of a pituitary adenoma?
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What is the primary function of the Luteinizing Hormone (LH) produced by the anterior pituitary gland?
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Which of the following conditions is primarily characterized by hypersecretion of growth hormone?
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Which characteristic is most associated with a pituitary adenoma?
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What is the primary consequence of the mass effect caused by pituitary tumors?
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In patients with a prolactinoma, which symptom is most likely experienced by males?
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Which posterior pituitary hormone is crucial for childbirth?
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What is a common neurological manifestation of a pituitary adenoma due to its mass effect?
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What percentage of intracranial tumors are pituitary tumors?
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Which of the following conditions is NOT a result of pituitary hypersecretion?
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What is the most common mass found in the pituitary gland?
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Which laboratory test is vital for assessing adrenal function when considering pituitary mass evaluation?
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What distinguishes a macroadenoma from a microadenoma on imaging?
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Which symptom would most likely suggest the presence of a pituitary mass effect?
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What role does MRI play in the evaluation of pituitary masses?
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What condition might be indicated by unexplained osteopenia in a patient undergoing pituitary evaluation?
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What is a key characteristic of Pituitary Apoplexy?
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Which of the following describes a long-term consequence of Sheehan Syndrome?
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In patients with hypopituitarism, which symptom is specifically associated with prolactin deficiency?
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What is the primary aim of evaluating patients diagnosed with Empty Sella Syndrome?
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Which statement accurately reflects the long-term management of patients with Sheehan Syndrome?
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What is the recommended MRI follow-up time frame for a macroadenoma if there is no initial growth noted?
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What percentage of patients with Sheehan's Syndrome experience selective loss of pituitary hormones?
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Which factor contributes to the susceptibility of the anterior pituitary gland to ischemic injury during pregnancy?
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What condition may occur as a result of herniation of arachnoid tissue into the sella turcica?
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In which situation is biochemical testing primarily recommended for patients with incidental pituitary adenoma?
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Which statement describes a significant pathophysiological event in Sheehan's Syndrome?
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What is a likely outcome of a null cell pituitary adenoma in relation to surrounding tissues?
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What factor has improved the global incidence of Sheehan's Syndrome over the past 50 years?
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What is the primary non-surgical treatment for prolactinomas that reduces hormone levels?
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Which treatment is preferred for large invasive GH and ACTH secreting tumors?
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What is a common radiographic finding associated with craniopharyngiomas on imaging?
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In the management of incidental pituitary adenomas, what is one of the critical questions that must be investigated?
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What is the desired surgical approach for resection of pituitary tumors that extend significantly outside the sella turcica?
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What hormone level is indicative of a prolactinoma diagnosis?
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What is one of the primary goals in the treatment of pituitary adenomas?
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Which treatment option is commonly used to decrease tumor size in pituitary adenomas?
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What type of tumor accounts for the majority of pituitary masses?
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What is a primary clinical feature of acromegaly caused by GH secreting adenomas?
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Which of the following is a consequence of pituitary hypersecretion?
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Which of the following is true regarding Sheehan syndrome?
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Which posterior pituitary hormone is primarily responsible for water balance?
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Which condition can lead to both oligo/amenorrhea and galactorrhea in women?
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Which symptom is commonly associated with mass effect from pituitary tumors?
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What percentage of the population is estimated to have a clinically silent pituitary adenoma?
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What is the typical treatment approach for prolactinomas?
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Which condition results from compromised blood flow leading to rapid onset of hormone deficiency?
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Which laboratory test is crucial for assessing adrenal function in the context of a suspected pituitary mass?
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What imaging findings on an MRI with gadolinium would support the diagnosis of a macroadenoma?
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Which condition is most likely indicated by unexplained osteopenia in a patient undergoing evaluation for pituitary issues?
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What are the clinical features associated with ACTH-secreting tumors?
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Which symptom is typically associated with TSH-secreting pituitary adenomas?
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What is the primary goal when treating pituitary adenomas that are secreting excessive hormones?
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What type of pituitary adenoma treatment would be preferable for large invasive tumors?
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What imaging characteristic is typically associated with craniopharyngioma?
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Which treatment is not effective for managing growth hormone-secreting tumors?
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In incidental findings of a pituitary adenoma, what must be assessed?
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What approach is typically preferred for resecting pituitary tumors?
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What hormonal change is observed following successful treatment of a prolactinoma?
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Why may radiation therapy be indicated in the management of pituitary adenomas?
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What long-term change may occur in patients with Sheehan Syndrome regarding their pituitary gland appearance on MRI?
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Which of the following best describes the evaluation process for identifying hormone deficiencies after delivery in patients at risk of Sheehan Syndrome?
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What is the primary consequence of pituitary apoplexy?
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Which factor is NOT typically considered a cause of Empty Sella Syndrome?
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What treatment option is NOT available for patients with Sheehan Syndrome?
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What condition is characterized by the absence of functional anterior pituitary hormone secretion due to ischemic injury?
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Which hormone is secreted by the posterior pituitary gland and plays a crucial role in lactation?
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Which of the following pituitary tumors is the most common type found in the population?
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Which of the following symptoms is commonly associated with mass effect from a pituitary adenoma?
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Which anterior pituitary hormone is primarily involved in regulating the adrenal cortex?
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What is the typical manifestation of hypersecretion of growth hormone in adults?
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In the context of pituitary masses, what does the term 'incidentaloma' refer to?
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Which pituitary disorder is most associated with excessive cortisol release?
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Which of the following conditions primarily results in hormone deficiencies rather than hypersecretion?
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What imaging technique is most useful for evaluating pituitary masses?
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What is the long-term follow-up recommendation for a microadenoma if no growth is observed at the 6-12 month follow-up?
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Which condition is primarily caused by maternal hemorrhage leading to hypoperfusion during childbirth?
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What percentage of patients with Sheehan's Syndrome typically experience selective loss of pituitary hormones?
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In the context of Sheehan Syndrome, why is the pituitary gland particularly vulnerable to ischemic injury during pregnancy?
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What is the main consequence of a null cell pituitary adenoma?
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What triggers the necrosis of the pituitary gland in Sheehan Syndrome?
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What is the expected outcome in patients with Empty Sella Syndrome?
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Which of the following factors contributes to the development of selective hormone loss in Sheehan Syndrome?
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Study Notes
Pituitary Function
- The anterior pituitary gland produces LH, FSH, prolactin, TSH, ACTH, and GH.
- The posterior pituitary gland produces oxytocin, which is important for childbirth and lactation, and ADH, which maintains water balance.
Pituitary Tumors
- 10% of all intracranial tumors are pituitary tumors.
- Most pituitary tumors are benign.
Pituitary Adenoma
- Pituitary adenomas are the most common pituitary mass and are benign tumors.
- They make up 16% of the population.
- They can cause pituitary hypersecretion or hyposecretion of hormones.
- 15% of all intracranial neoplasms are pituitary adenomas.
- Prevalence is 80 per 100,000.
- Up to 1/4th of pituitary glands contain a microadenoma at autopsy.
Prolactinoma
- A basal prolactin level of > 200 ng/mL is diagnostic of prolactinoma.
- Prolactinomas are treated with dopamine agonists, which decrease prolactin levels and can reduce tumor size.
Pituitary Adenoma Treatment
- The three primary goals of treatment of pituitary adenomas are reducing hormone hypersecretion, decreasing tumor size, and correcting hormone deficiencies.
- Treatment is chosen based on symptoms of hormonal excess or insufficiency.
- MRI with and without gadolinium is the modality of choice for diagnosis.
- Microadenomas are < 1 cm, and macroadenomas are ≥ 1 cm.
- Surgery, often transsphenoidal, is the preferred treatment.
- Radiation therapy may decrease the size of tumors and hormone production.
Hypopituitarism
- Causes of hypopituitarism include null cell pituitary adenoma, Sheehan syndrome, empty sella syndrome, and pituitary apoplexy.
- Hypopituitarism can be a slow onset condition.
Sheehan Syndrome
- Sheehan Syndrome is infarction of the anterior pituitary gland during childbirth.
- It is caused by maternal hemorrhage and hypotension, resulting in hypoperfusion and subsequent pituitary infarction.
- Incidence has decreased due to improved obstetric care and postpartum care.
- The loss of all pituitary hormones may occur in 56% of cases.
- GH deficiency is the most common hormone deficiency.
- The treatment involves lifelong hormonal replacement.
Empty Sella Syndrome
- Enlarged sella turcica in the absence of a pituitary tumor.
- May be caused by increased CSF entering the sella, secondary to tumor, previous surgery, radiation, or infarction, or congenital.
- Long-term consequence of Sheehan Syndrome.
Pituitary Apoplexy
- A sudden hemorrhage into the pituitary gland.
Pituitary Function
- Anterior Pituitary Gland produces Luteinizing Hormone (LH), Follicle-Stimulating Hormone (FSH), Prolactin, Thyroid Stimulating Hormone (TSH), Adrenocorticotropic Hormone (ACTH), and Growth Hormone (GH).
- Posterior Pituitary Gland produces Oxytocin, which is important in childbirth and lactation; and ADH, which is important for maintaining water balance.
Pituitary Tumors
- 10% of all intracranial tumors are pituitary tumors.
- Most pituitary tumors are benign.
- Tumor growth in the sella and suprasellar regions can cause neurological damage.
Pituitary Adenoma
- Most common pituitary mass.
- Benign tumor of the anterior pituitary, which can cause hypersecretion or hyposecretion.
- Prevalence is 80/100,000.
Pituitary Mass/Adenoma: Clinical Features
- Asymptomatic cases are common and may be discovered as an incidental finding on MRI/CT scans.
- Neurological Manifestations (Mass Effect): Headache, visual disturbance, mental status changes, CN abnormalities, vomiting, papilledema, pituitary apoplexy.
Pituitary Adenoma: Hypersecretion of Hormones
- Prolactinoma: Hypogonadism (oligo/amenorrhea, galactorrhea, infertility, decreased libido in both sexes), post-menopausal females & males may only experience symptoms related to the mass effect of the tumor.
- GH secreting: Acromegaly and gigantism.
- ACTH secreting: Adrenal hyperplasia, leading to Cushingoid features (weight gain, hirsutism, amenorrhea, decreased libido, unexplained osteopenia).
- TSH secreting: Goiter, palpitations, tremor.
- Lymphocytic hypophysitis: Mass effect and adrenal insufficiency.
When to Evaluate for Pituitary Mass
- Consider evaluation for pituitary mass when there is hypersecretion of one or more anterior pituitary hormones, hypopituitarism, vision changes, or headache.
Pituitary Mass Laboratory Evaluation
- Labs should be chosen based on the symptoms of hormonal excess or insufficiency.
- Labs should include: IGF-1, Prolactin, TSH & Free T4, AM Cortisol, ACTH, LH & FSH, and testosterone/estradiol as appropriate.
- Consider: CBC & UA, ESR & CRP, Serum Na, alpha-fetoprotein and HCG, auto-antibodies, and surgical biopsy.
Pituitary Mass Imaging
- MRI (T1-weighted with & without gadolinium): Gold standard, allows visualization of the pituitary gland and surrounding tissue, determines tumor size, differentiates adenoma vs. hyperplasia, mass vs. inflammation vs. abscess, and hemorrhage vs. aneurysm.
- Skull Radiograph: May show enlargement or distortion of the sella if tumors are > 10 mm, suprasellar calcification suggests craniopharyngioma.
- CT: May show some macroadenomas.
Pituitary Adenoma Treatment
- Three goals: Reduce hormone hypersecretion, decrease tumor size, and correct hormone deficiencies.
Prolactinoma Treatment
- Diagnosis: Basal prolactin level of > 200 ng/mL and brain MRI.
- Medical Treatment: Dopamine agonists (bromocriptine & cabergoline) decrease prolactin levels and can reduce tumor size.
GH & ACTH Secreting Tumor Treatment
- Medical management is less effective than for prolactinomas.
- Surgery is preferred for these tumors.
Pituitary Adenoma: General Treatment
- Requires an accurate diagnosis of the lesion type.
- Transsphenoidal resection is the preferred surgical approach.
- Transfrontal resection may be necessary for tumors with optic chiasm compression or those extending outside the sella turcica.
- Radiation Therapy: May be used alone or in conjunction with surgery to decrease tumor size and hormone production.
Management of Incidental Pituitary Adenoma
- If no mass effect on MRI, and the tumor is not secreting excess hormone, repeat MRI in 6 months for macroadenoma and 12 months for microadenoma.
- If no growth at 6-12 month follow-up, repeat MRI every 1-2 years for 3 years, then intermittently.
- Biochemical testing is not recommended unless the tumor enlarges or the patient develops symptoms.
Hypopituitarism
- Possible causes: Null cell pituitary adenoma, Sheehan Syndrome, Empty Sella Syndrome, Pituitary Apoplexy, Surgery, radiation, inflammatory reactions, DIC, sickle cell, and necrosis from increased ICP.
Sheehan’s Syndrome
- Infarction of the anterior pituitary gland during childbirth, resulting in pituitary gland necrosis and hypopituitarism.
- Global incidence is 1/100,000 live births.
Sheehan Syndrome: Pathophysiology
- Pregnancy causes the pituitary gland to increase in size and the number of prolactin-secreting cells, but the blood supply does not increase, making it vulnerable to ischemic injury.
- Hypotension during childbirth can lead to hypoperfusion and pituitary infarction.
Sheehan Syndrome: Clinical Features
- Patients may experience loss of all pituitary hormones (56%) or selective loss (44%), with GH deficiency being most common.
- Patients will not lactate due to prolactin deficiency.
- Other hormone deficiencies can be evaluated 6 weeks after delivery.
- Long-term symptoms may develop slowly, and mild hypopituitarism can go undetected for years.
- Eventually, a small pituitary may develop within a sella of normal size, appearing as an "empty sella" on MRI.
Sheehan Syndrome: Treatment
- Lifelong hormonal replacement.
- No treatment available to induce lactation.
Empty Sella Syndrome
- Diagnosed when the normal pituitary gland is not seen or is excessively small on MRI and does not cause symptoms, although can cause pituitary hormone deficiency.
- Causes: Increased CSF entering and enlarging the sella turcica, secondary to a tumor, previous pituitary surgery, radiation, infarction, congenital, or long-term consequence of Sheehan Syndrome.
Pituitary Apoplexy
- Acute hemorrhage into the pituitary gland, usually at the site of a preexisting adenoma.
- Can cause acute pituitary hormone deficiency or mass effect.
- Symptoms: Severe headache, visual loss, diplopia, hypopituitarism.
Pituitary Function
- Pituitary Gland: Located at the base of the brain, it is a crucial endocrine organ.
- Anterior Pituitary: Secretes luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), and growth hormone (GH).
- Posterior Pituitary: Secretes oxytocin, which plays a role in childbirth and lactation, and antidiuretic hormone (ADH), which is essential for maintaining water balance.
Pituitary Tumors
- Pituitary tumors account for 10% of all intracranial tumors.
- Most are benign.
- Tumor growth within the sella and suprasellar regions can lead to serious neurological damage.
Pituitary Adenoma
- Benign tumor of the anterior pituitary.
- Most common pituitary mass.
- Can cause both hypersecretion and hyposecretion of pituitary hormones.
- Prevalence: 80/100,000.
- At autopsy, up to 25% of pituitary glands have unsuspected microadenomas.
Pituitary Mass/Adenoma: Clinical Features
- Asymptomatic: Incidental finding on MRI or CT.
- Neurological Manifestations (Mass effect): Headaches, visual disturbances (optic chiasm compression), mental status changes (bitemporal hemianopsia), cranial nerve abnormalities, vomiting, papilledema, pituitary apoplexy.
Pituitary Adenoma: Hypersecretion of Hormones
- Prolactinoma: Hypogonadism (oligo\amenorrhea, galactorrhea, infertility, decreased libido in both sexes).
- Growth Hormone (GH) secreting: Acromegaly, gigantism.
- ACTH secreting: Adrenal hyperplasia (Cushingoid features; weight gain, hirsutism, amenorrhea, decreased libido, unexplained osteopenia).
- TSH secreting: Goiter, palpitations, tremor.
- Lymphocytic Hypophysitis: Mass effect and adrenal insufficiency.
Pituitary Mass: When to Evaluate
- Consider evaluation for a pituitary mass when hypersecretion of 1 or more anterior pituitary hormones, hypopituitarism, vision changes, headache (mass effect) or a complex hormonal excess and/or deficiencies present.
Pituitary Mass: Laboratory Evaluation
- Choose labs based on suspected hormonal excess or insufficiency:
- IGF-1
- Prolactin
- TSH & Free T4
- AM Cortisol (8 am)
- ACTH
- LH & FSH, estradiol (females) & testosterone (males)
- Consider:
- CBC & UA
- ESR & CRP
- Serum Na
- Alpha-fetoprotein & HCG (suspected germ-cell tumor)
- Autoantibodies
- Surgical biopsy
Pituitary Mass: Imaging
- MRI with T1 weighted images with and without gadolinium is the gold standard.
- Determines size:
- < 1 cm = Microadenoma
- ≥ 1 cm = Macroadenoma.
- Differentiates: Adenoma vs. hyperplasia, mass vs. inflammation vs abscess, hemorrhage vs aneurysm.
- Skull radiograph may show enlargement or distortion of the sella if tumors > 10 mm in diameter.
- Suprasellar calcification suggests a craniopharyngioma.
- CT may show some macroadenomas.
Pituitary Adenoma Treatment
- Three primary goals:
- Reducing hormone hypersecretion and its clinical manifestations.
- Decreasing tumor size to improve symptoms of mass effect.
- Correcting hormone deficiencies.
Prolactinoma: Diagnosis & Treatment
- Diagnosis: Basal prolactin level of > 200 ng/mL, brain MRI.
- Medical Treatment:
- Dopamine agonists (bromocriptine & cabergoline) decrease prolactin levels and can reduce tumor size.
- Can stop galactorrhea and return menses to normal.
GH & ACTH Secreting Tumors
- Medical management of GH and ACTH secreting tumors is less effective than prolactinomas.
- Surgery is preferred for these tumors.
Pituitary Adenoma: Overall Treatment
- Requires accurate diagnosis of lesion type.
- Most are benign and slow-growing.
- If resection is required:
- Transsphenoidal is the preferred approach.
- Transfrontal resection may be necessary for tumors with optic chiasm compression or those that extend far outside the sella turcica.
- Radiation therapy alone or in conjunction with surgery may decrease tumor size and hormone production.
Management of Incidental Pituitary Adenoma
- If there is no mass effect on MRI and the tumor is not secreting excess hormone, repeat MRI in 6 months for macroadenoma and 12 months for microadenoma to assess for further growth.
- If no growth is noted at the 6-12 month follow up, repeat MRI every 1-2 years for 3 years total (then intermittently).
- Biochemical testing is not recommended unless the tumor enlarges, or the patient develops symptoms.
Hypopituitarism
- Causes:
- Null cell pituitary adenoma: Growth of a non-secreting tumor can cause destruction of the adjacent normal gland.
- Sheehan Syndrome: Infarction of the anterior pituitary during childbirth resulting in pituitary gland necrosis and hypopituitarism.
- Empty sella Syndrome: Condition due to an incompetent diaphragm sella that allows herniation of arachnoid into the sella turcica.
- Pituitary Apoplexy: Acute hemorrhage into the pituitary gland (often at site of preexisting adenoma).
- Other: Surgery, radiation, inflammatory reactions, Disseminated Intravascular Coagulation (DIC), sickle cell, necrosis from increased Intracranial Pressure (ICP).
Sheehan's Syndrome
- Infarction of the anterior pituitary gland during childbirth due to maternal hemorrhage and hypotension resulting in hypoperfusion.
- Incidence: Improved in the past 50 years due to better delivery and postpartum care.
- Globally about 1/100,000 live births.
- Rare in industrialized nations due to better care.
Sheehan's Syndrome Pathophysiology
- Pregnancy causes the pituitary gland to increase in size and the number of prolactin-secreting cells.
- Despite the increase in size of the anterior pituitary, the blood supply does not increase, making it vulnerable to ischemic injury.
- If hypotension occurs and blood flow is compromised (obstetrical hemorrhage), it can result in pituitary infarction and hypopituitarism (necrosis can occur).
Sheehan's Syndrome: Hormone Deficiencies
- Loss of all pituitary hormones: 56%.
- Selective loss of pituitary hormones: 44%.
- GH deficiency is most common and affects the peripheral region of the pituitary gland.
Sheehan's Syndrome: Clinical Features
- Hypopituitarism: Severe development of lethargy, anorexia, weight loss.
- Patients will not lactate due to prolactin deficiency.
- Emergent testing and treatment for secondary cortisol deficiency is required.
- Other hormone deficiencies can be evaluated 6 weeks after delivery.
- Long-term symptoms may develop slowly over months to years, mild hypopituitarism can go unrecognized.
- Eventual development of a small pituitary within a sella of normal size, sometimes appearing as an "empty sella" on MRI.
Sheehan's Syndrome: Treatment
- Lifelong hormonal replacement.
- No treatment available to induce lactation.
Empty Sella Syndrome
- Diagnosed when the normal pituitary gland is not seen or is excessively small on MRI.
- Radiologic finding, not a distinct clinical condition.
- Causes:
- Increased CSF entering and enlarging sella.
- Secondary to tumor.
- Previous pituitary surgery, radiation, or infarction.
- Congenital.
- Can be a long-term consequence of Sheehan's Syndrome.
- Evaluation: To determine if there is a cause, or if the patient has signs/symptoms of pituitary hormone deficiency.
- Repeat imaging is usually not necessary.
Pituitary Apoplexy
- Acute hemorrhage into the pituitary gland (often at site of preexisting adenoma).
- Can cause acute pituitary hormone deficiency or mass effect from rapid expansion of the sellar contents.
- Symptoms: Severe headache, visual loss, diplopia, hypopituitarism.
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Description
This quiz covers the essential functions of the pituitary gland, including the hormones it produces and their roles in the body. It also delves into common disorders such as pituitary tumors and adenomas, with a specific focus on prolactinomas and their treatment. Test your knowledge on this vital aspect of endocrinology.
