History

Fact Explanation
Features of space occupying lesion [1] Pituitary adenoma causing hypopituitarism act as space occupying lesions giving rise to symptoms such as headache worse in morning, visual disturbances including uni/ bitemporal hemianopia, personality changes, temporal lobe epilepsy [1][2][3]
Galactorrhea [1][2][3] Abnormal secretion of breast milk occurs due to pituitary tumor secreting prolactin or due to pressure on pituitary gland/ stalk resulting in lack of inhibitory hormone of prolactin [1][3]
Features of acromegaly () [1] Macroadenoma secreting growth hormone (GH) results in excess GH causing symptoms of acromegaly such as prognathism, spade like hands and feet. There would be associated deficiency of other pituitary hormones due to compression of normal tissues thus mixed picture of various hormone excess and deficiency can occur [1]
Features of GH (growth hormone) deficiency. [1][2] Features such as Reduced muscle mass, strength and energy occur. Typically GH is the first hormone to decrease preceding panhypopituitarism. [1][4]
Features of ACTH deficiency [1] Patients with severe fatigue, drowsiness symptoms should be investigated bearing hypopituitarism in mind. Other symptoms such as anorexia, nausea, vomiting, abdominal pain, weight loss, sudden collapse, loss of axillary and pubic hair may also be present. Mild ACTH deficiency may only be unmasked during intercurrent illness. Sudden collapse may occur due to hypoglycaemia or circulatory failure[1][4]
Features of gonodotrophins deficiency [1] Such as reduced muscle mass, energy, erectile dysfunction in men; oligo/amenorrhea, dyspareunia, breast atrophy in women; loss of libido, infertility in both [1][3]
Features of hypothyroidism [1] Hypothyroidism occur secondary to thyroid stimulating hormone (TSH) deficiency resulting in symptoms of weight gain, cold intolerence, apathy, dry skin and constipation [1] [1]
Symptoms of diabetes insipidus [1] Symptoms such as polyuria, polydipsia, nocturia due to anti diuretic hormone (ADH) deficiency, maybe due to hypothalamic or stalk disorder. [1]
Postpartum lactation failure [1][6] Prolactin deficiency usually due to Sheehan syndrome (usually after postpartum haemorrhage leading to ischemic pituitary necrosis) also maybe due to lymphocytic hypophysitis or pituitary apoplexy [1][6][7]
Pituitary apoplexy [4][5] Pituitary apoplexy is a medical emergency with symptoms of sudden, severe headache, vomiting, visual loss, cranial-nerve (III, IV, VI) palsy and depressed sensorium occuring due to infarction or haemorrhage into an undiagnosed tumor. High degree of suspicion of cancer (lymphoma ) should be kept in mind while investigating such patients. [1][4][5]
History of head injury [1] Patients usually present within an year of the history of head injury with symptoms of hyptopituitarism [1]
History of postpartum haemorrhage [7] This is associated with ischemic necrosis of the pituitary gland resulting in Sheehan's syndrome [7]
History of radiotherapy [1] Cranial or total body radiation are known to result in hypopituitarism [1]
Features of haemochromatosis [1] Such as pigmented palmer creases, gums. Hypopituitarism is a known complication of haemochromatosis [1]
Hyposmia /anosmia [1] Associated with Kallman syndrome. [1]
History of infections [1] Infections such as TB, syphilis and mycoses are known to affect pituitary gland resulting in hypopituitarism [1]
Family history of features of hypopituitarism [1][8] Combined pituitary hormone deficiency has been described by various genetic mutations including some form which is inherited as X linked recessive familial disorder. [8]
References
  1. PRABHAKAR VK, SHALET SM. Aetiology, diagnosis, and management of hypopituitarism in adult life. Postgrad Med J [online] 2006 Apr, 82(966):259-266 [viewed 04 September 2014] Available from: doi:10.1136/pgmj.2005.039768
  2. CAUGHEY JE, JAMES A, MACLEOD EK. Hypopituitarism with Pituitary Tumours Br Med J [online] 1952 Jun 7, 1(4770):1216-1219 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2023562
  3. GONDIM, Jackson; SCHOPS, Michele and FERREIRA, Erica. Hypopituitarism and amenorrhea- galactorrhea syndrome caused by thrombosis of both internal carotid artery and giant intrasellar aneurysm: case report. Arq. Neuro-Psiquiatr. [online]. 2004, vol.62, n.1 [viewed 04 September 2014] pp. 158-161 . Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2004000100029&lng=en&nrm=iso&tlng=en
  4. BRAR KS, GARG MK, SURYANARAYANA KM. Adult hypopituitarism: Are we missing or is it clinical lethargy? Indian J Endocrinol Metab [online] 2011, 15(3):170-174 [viewed 09 September 2014] Available from: doi:10.4103/2230-8210.83400
  5. FOO SH, SOBAH SA. Burkitt's lymphoma presenting with hypopituitarism: a case report and review of literature Endocrinol Diabetes Metab Case Rep [online] 2014:140029 [viewed 09 September 2014] Available from: doi:10.1530/EDM-14-0029
  6. SHERIFF FG, HOWLETT WP, KILONZO KG. Post-partum pituitary insufficiency and livedo reticularis presenting a diagnostic challenge in a resource limited setting in Tanzania: a case report, clinical discussion and brief review of existing literature BMC Endocr Disord [online] :4 [viewed 09 September 2014] Available from: doi:10.1186/1472-6823-12-4
  7. SHIVAPRASAD C. Sheehan's syndrome: Newer advances Indian J Endocrinol Metab [online] 2011 Sep, 15(Suppl3):S203-S207 [viewed 09 September 2014] Available from: doi:10.4103/2230-8210.84869
  8. WANG CHUN LIN, LIANG LI, SHEN ZHENG, ZOU CHAO CHUN, FU JUN FEN, DONG GUAN PING. X-linked recessive combined pituitary hormone deficiency is mapped to Xp22.3–Xp11 in a Chinese family. Genomics [online] 2011 December, 98(6):440-444 [viewed 13 September 2014] Available from: doi:10.1016/j.ygeno.2011.09.002

Examination

Fact Explanation
Sparse body hair [2][3] Facial, axillary, chest and pubic hair maybe sparse and pubic hair maybe of female pattern in men due to hypogonadism [4]
Visual field defect [1][2] Such as bitemporal hemianopia occur due to compression of the optic chiasma by the tumor [1]
Features of hypothyroidism [2] Features of hypothyroidism such as dry skin, loss of lateral eye brow, coarse hair, increased body weight, slow deep tendon reflexes due to thyroid stimulating hormone (TSH) deficiency [1]
Cranial nerve palsies [4][5] Cranial nerve III, IV and VI lesion causes drooping of eyelids, double vision on lateral vision are associated with large tumors especially the involvement of cranial nerve [4][5]
Hyperpigmentation Hyperpigmentation is mainly noticed in the skin, palmer creases and gum in haemochromatosis [1]
Large hands and feet [2] Due to increased GH, caused by a GH secreting adenoma which compresses the normal gland and cause hypopituitarism otherwise.
Galactorrhea [1] Milk maybe expressed from the breast due to underlying prolactinoma [1]
Features of gonadotrophin deficiency [1][2] Such as soft testis, reduced muscle mass, small prostate. [1]
Features of shock [4] Low blood pressure, tachycardia, cold clammy skin and hypotension are seen in pituitary apoplexy [4]
References
  1. PRABHAKAR VK, SHALET SM. Aetiology, diagnosis, and management of hypopituitarism in adult life. Postgrad Med J [online] 2006 Apr, 82(966):259-266 [viewed 04 September 2014] Available from: doi:10.1136/pgmj.2005.039768
  2. CAUGHEY JE, JAMES A, MACLEOD EK. Hypopituitarism with Pituitary Tumours Br Med J [online] 1952 Jun 7, 1(4770):1216-1219 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2023562
  3. GONDIM, Jackson; SCHOPS, Michele and FERREIRA, Erica. Hypopituitarism and amenorrhea- galactorrhea syndrome caused by thrombosis of both internal carotid artery and giant intrasellar aneurysm: case report. Arq. Neuro-Psiquiatr. [online]. 2004, vol.62, n.1 [viewed 04 September 2014] pp. 158-161 . Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2004000100029&lng=en&nrm=iso&tlng=en
  4. BRAR KS, GARG MK, SURYANARAYANA KM. Adult hypopituitarism: Are we missing or is it clinical lethargy? Indian J Endocrinol Metab [online] 2011, 15(3):170-174 [viewed 09 September 2014] Available from: doi:10.4103/2230-8210.83400
  5. FOO SH, SOBAH SA. Burkitt's lymphoma presenting with hypopituitarism: a case report and review of literature Endocrinol Diabetes Metab Case Rep [online] 2014:140029 [viewed 09 September 2014] Available from: doi:10.1530/EDM-14-0029

Differential Diagnoses

Fact Explanation
Pituitary adenoma [1] Macroadenomas (>1cm usually non functional tumors) cause compression of surrounding normal pituitary tissue or increase the intrasellar pressure by disruption of vascular portal system causing necrosis of the gland resulting in hyposecretion of the hormones [1] Microadenomas (<1cm) secreting prolactin may result in hypogonadism due to its inhibitory effect on FSH (Follicle-stimulating hormone) and LH (Luteinizing hormone).[1]
Peripituitary tumors (Craniopharyngioma, meningioma, chordoma, optic nerve glioma, germinomas) [1][3] Tumors in the tissue surrounding pituitary gland may result in disruption of it resulting in hyposecretion of its hormones. [1]
Metastatic tumor affecting the pituitary gland [1] Breast, lungs, colon, prostate are examples of cancers can spread to pituitary gland [1]
Growth hormone (GH) gene GH‐116 or GH releasing hormone receptor gene GHRH‐R17 mutations [1] Results in isolated GH deficiency [1]
TPit gene mutation. [1] Present with isolated Adrenocorticotropic hormone deficiency. [1]
Gonadotrophin releasing hormone receptor (GnRH‐R) gene defect [1] Results in isolated hypogonadotrophic hypogonadism, unlike Kallman's syndrome not associated with anosmia/ hyposmia. [1]
Kallman's syndrome (KAL gene defect ) [1] X‐linked; causes isolated hypogonadotrophic hypogonadism and anosmia/ hyposmia. [1]
PIT 1 gene mutation [1] GH, Prolactin (PRL), Thyroid stimulating hormone (TSH) deficiency occur [1]
PROP 1 gene mutation [1] GH, PRL, TSH, FSH, LH deficiencies with or without partial ACTH deficiency occur [1]
After head injury [1][4] This occurs within an year of occurence of head injury, usually causes GH, FSH and LH deficiencies [1]
Infarction or haemorrhage into tumourous or non tumourous pituitary gland [1] This is known as pituitary apoplexy and patient present with acute headache and meningism. [1]
Sheehan's syndrome [1][4][6] This occurs in postpartum period causing necrosis of the pituitary gland due to ischemia of the gland; this occurs usually following postpartum haemorrhage. [1][4][6]
Surgery of the pituitary gland for pituitary adenoma [1] This depends on size of initial adenoma and state of invasion and also depends on operating surgeon's skills. [1]
Cranial radiotherapy (intended for cranial tumors, prophylactically for acute lymphoblastic leukaemia, total body irradiotion) [1][4] The outcome depends on total dose and fraction of radiation received, duration of treatment and time since last radiation. Gamma knife surgery for pituitary adenoma has been reported to less disrupt pituitary functions than conventional radiotherapy. [1]
Infections affecting the pituitary gland [1] TB, syphilis and mycoses are known to affect pituitary gland [1][4]
Conditions that infiltrate the pituitary gland [1] Sarcoidosis, histiocytosis X, primary haemochromatosis, lymphoma are also known to cause hypopituitarism by infiltration of the pituitary gland. [1][4][5][7]
Autoimmune (lymphocytic hypophysitis) [1][4] This condition results in isolated or combined deficiencies of ACTH, TSH, FSH, LH, GH and rarely Anti diuretic hormone (ADH) deficiency. [1]
Vascular causes [1] Subarachnoidal haemorrhage and carotid artery aneurysm are known causes of hypopituitarism [1][2][4]
References
  1. PRABHAKAR VK, SHALET SM. Aetiology, diagnosis, and management of hypopituitarism in adult life. Postgrad Med J [online] 2006 Apr, 82(966):259-266 [viewed 04 September 2014] Available from: doi:10.1136/pgmj.2005.039768
  2. GONDIM, Jackson; SCHOPS, Michele and FERREIRA, Erica. Hypopituitarism and amenorrhea- galactorrhea syndrome caused by thrombosis of both internal carotid artery and giant intrasellar aneurysm: case report. Arq. Neuro-Psiquiatr. [online]. 2004, vol.62, n.1 [viewed 04 September 2014] pp. 158-161 . Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2004000100029&lng=en&nrm=iso&tlng=en
  3. CAUGHEY JE, JAMES A, MACLEOD EK. Hypopituitarism with Pituitary Tumours Br Med J [online] 1952 Jun 7, 1(4770):1216-1219 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2023562
  4. BRAR KS, GARG MK, SURYANARAYANA KM. Adult hypopituitarism: Are we missing or is it clinical lethargy? Indian J Endocrinol Metab [online] 2011, 15(3):170-174 [viewed 09 September 2014] Available from: doi:10.4103/2230-8210.83400
  5. FOO SH, SOBAH SA. Burkitt's lymphoma presenting with hypopituitarism: a case report and review of literature Endocrinol Diabetes Metab Case Rep [online] 2014:140029 [viewed 09 September 2014] Available from: doi:10.1530/EDM-14-0029
  6. SHIVAPRASAD C. Sheehan's syndrome: Newer advances Indian J Endocrinol Metab [online] 2011 Sep, 15(Suppl3):S203-S207 [viewed 09 September 2014] Available from: doi:10.4103/2230-8210.84869
  7. OGAWA Y, TOMINAGA T, IKEDA H. Neurosarcoidosis manifesting as tremor of the extremities and severe hypopituitarism: case report. Neurol Med Chir (Tokyo) [online] 2008 Jul, 48(7):314-7 [viewed 13 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18654052

Investigations - for Diagnosis

Fact Explanation
Serum ferritin [1] Elevated in haemochromatosis [1]
Human chorionic gonadotrophin (HCG) levels [1] Elevate in germ cell tumors [1]
Serum and CSF angiotensin converting enzyme (ACE) [1] Elevated in sarcoidosis [1]
Insulin tolerance test (ITT) is used to assess peak GH and ACTH levels [1] This is considered as a gold standard test. Contraindicated in patients with ischemic heart disease, arrhythmia, unexplained blackouts and epilepsy. Patient should be carefully monitored during the test. After overnight fast IV insulin of 0.05–0.15 units/kg is given to the patient and blood is drawn at 0, 30, 60, 90, 120 minutes intervals to assess blood glucose, GH and ACTH levels; at hypoglycemia < 2.2 mmol/l, GH level of 5 μg/l and cortisol level of 500 nmol/l is considered normal; peak GH levels less than 3 μg/l (9 mU/l) is considered as severe GH deficiency. [1][4]
Combined growth hormone releasing hormone (GHRH) and arginine test [1] This test is used along with ITT to confirm GH deficiency or used where ITT is contraindicated. [1]
Combined GHRH and hexarelin tests [1] Hexareline ideally increase GH levels; this test is used in young and middle aged patients with age specific cut offs. [1]
Glucagon stimulation test (GST) [1] This can be used to determine both GH and ACTH deficiencies. [1]
IGF1 levels [1] IGF is secreted in response to GH and will be low in GH deficiency, an age specific cut offs should be used for interpretation. Other factors such as hypothyroidism, malnutrition, liver disease and diabetes mellitus also cause low IGF levels, thus interfere with interpretation, if present. [1]
Free and total thyroxine, TSH levels [1][4] Low serum thyroxine levels with normal or low TSH points towards TSH deficiency [1]
FSH, LH, oestradiol in women and testosterone in men [1][4] In men low testosterone with low or normal gonadotrophins and in premenopausal women low oestradiol with no elevation in gonadotrohpins or in postmenopausal women lack of the normal elevation of gonadotrophin indicates gonadotrophin deficiency [1]
Urine volume and osmolality [1] Increased volume (>40ml/kg/day) and low urine osmolality of <300 mOsmol/kg indicates possible diabetes insipidus due to ADH deficiency. [1]
Water deprivation test [1] Water is not given to the patient for 8 hours and basal and hourly plasma and urine osmolalities and urine volume is recorded along with body weight which is measured 2 hourly. After 8 hrs IM desmopressin 2 μg is injected and urine and plasma osmolality is remeasured. Urine initially of low osmolality (<300 mOsmol/kg) becomes concentrated (>750 mOsmol/kg) afeter desmopressin injection shows ADH deficiency [1]
Hypertonic saline infusion test [1] This is used where results of water deprivation tests are borderline to confirm ADH deficiency [1]
Basal (9 am) cortisol level [1][4] Level less than 100 nmol/l is considered very low. [1]
Short synacthen test [1] Considered the first line test to assess ACTH levels. IM synacthen 250 μg is injected and if 30 minute cortisol level is >550 nmol its considered normal.
Skull X ray [2] Demonstration of large sella turcica with eroded clinoid process indicate pituitary tumor [2]
MRI (magnetic resonance image) of the hypothalamo‐pituitary region with IV gadolinium or a contrast CT head [1][3] This aids to visualise the tumor [1]
Goldmann perimetry [1] Visual field defect such as bitemporal hemianopia may occur due to compression of the optic chiasma by the tumor [1]
References
  1. PRABHAKAR VK, SHALET SM. Aetiology, diagnosis, and management of hypopituitarism in adult life. Postgrad Med J [online] 2006 Apr, 82(966):259-266 [viewed 04 September 2014] Available from: doi:10.1136/pgmj.2005.039768
  2. CAUGHEY JE, JAMES A, MACLEOD EK. Hypopituitarism with Pituitary Tumours Br Med J [online] 1952 Jun 7, 1(4770):1216-1219 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2023562
  3. GONDIM, Jackson; SCHOPS, Michele and FERREIRA, Erica. Hypopituitarism and amenorrhea- galactorrhea syndrome caused by thrombosis of both internal carotid artery and giant intrasellar aneurysm: case report. Arq. Neuro-Psiquiatr. [online]. 2004, vol.62, n.1 [viewed 04 September 2014] pp. 158-161 . Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2004000100029&lng=en&nrm=iso&tlng=en
  4. BRAR KS, GARG MK, SURYANARAYANA KM. Adult hypopituitarism: Are we missing or is it clinical lethargy? Indian J Endocrinol Metab [online] 2011, 15(3):170-174 [viewed 09 September 2014] Available from: doi:10.4103/2230-8210.83400

Investigations - Fitness for Management

Fact Explanation
ECG [1] A baseline ECG is obtained prior to an insulin tolerence test, any abnormality in ECG is considered as contraindication for the test [1]
Investigations for pre-operative fitness assessment [2] Chest x-ray, full blood count, renal function tests, blood gases and lung function are the basic investigations done pre operatively. They should be done according to patient's symptoms and according to the particular ASA (American society of anesthesiologists) category the individual patient falls in.
References
  1. PRABHAKAR VK, SHALET SM. Aetiology, diagnosis, and management of hypopituitarism in adult life. Postgrad Med J [online] 2006 Apr, 82(966):259-266 [viewed 04 September 2014] Available from: doi:10.1136/pgmj.2005.039768
  2. Preoperative Tests: The Use of Routine Preoperative Tests for Elective Surgery. NICE Clinical Guidelines, No. 3. [online] London: National Collaborating Centre for Acute Care (UK); 2003 Jun [Viewed on 30/04/2014] Available from: http://www.ncbi.nlm.nih.gov/books/NBK48482/

Investigations - Followup

Fact Explanation
Basic investigations for patients on GH replacement [1] Body weight, Blood pressure, IGF1 levels, fasting glucose, HbA1c, lipid profile, waist‐hip ratio, bone densitometry 2 yrly for those who initially had low bone mineral density are done to monitor the treatment response. [1][2]
24 hr urine cortisol level. [1] Done in patients who are on glucocorticoid replacement therapy.This is used to detect over replacement of glucocorticoid which could cause harmful side effects [1]
Serum cortisol levels. [1] This is done for those who are on glucocorticoid replacement therapy to determine subclinical, over or under treatment. An eight hour or modified 3 point curve can be used [1]
Serum free thyroxine [1] This is used to titrate the thyroxine dose and to assess treatment response along with clinical improvement. [1]
Basic investigations for patients on testosterone replacement [1] Haemoglobin levels, packed cell volume, lipid profile, and prostate specific antigen levels are done [1]
Serum sodium levels [1] Done in patients taking desmopressin whenever the dose is changed. Desmopressin in overdose can cause hyponatremia thus patient should be monitored. [1]
Hormone panel [1] Mandatory to be done after surgery to determine possible post surgical hypopituitarism. [1]
References
  1. PRABHAKAR VK, SHALET SM. Aetiology, diagnosis, and management of hypopituitarism in adult life. Postgrad Med J [online] 2006 Apr, 82(966):259-266 [viewed 04 September 2014] Available from: doi:10.1136/pgmj.2005.039768
  2. BRAR KS, GARG MK, SURYANARAYANA KM. Adult hypopituitarism: Are we missing or is it clinical lethargy? Indian J Endocrinol Metab [online] 2011, 15(3):170-174 [viewed 09 September 2014] Available from: doi:10.4103/2230-8210.83400

Management - General Measures

Fact Explanation
Patient education [1] This is vital. Patient should be educated regarding the disease and the treatment. Asking patient to double the treatment dose if on glucocorticoid treatment at time of intercurrent illness is essential as it is life saving. [1][2]
Medical alert bracelet [1] This should be worn at all times by patients on glucocorticoid treatment as increased dose would be life saving at times of emergencies [1][2]
Pre treatment counselling. [1] Patient should be counselled regarding possible post operative/ radiotherapy hypopituitarism [1]
References
  1. PRABHAKAR VK, SHALET SM. Aetiology, diagnosis, and management of hypopituitarism in adult life. Postgrad Med J [online] 2006 Apr, 82(966):259-266 [viewed 04 September 2014] Available from: doi:10.1136/pgmj.2005.039768
  2. CAUGHEY JE, JAMES A, MACLEOD EK. Hypopituitarism with Pituitary Tumours Br Med J [online] 1952 Jun 7, 1(4770):1216-1219 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2023562

Management - Specific Treatments

Fact Explanation
Treatment of pituitary adenoma. [1] Medical/ surgical therapy and/or radiotherapy is used. The specific modality chosen depends on type of the adenoma, a prolactin secreting macroadenoma responds well to a dopamine agonist whereas a non functioning pituitary adenoma is treated by its surgical removal followed by radiotherapy. [1]
Hormone Replacement Therapy Hormone replacement therapy is used to maintain normal hormonal balance of the body. The deficient hormone or the hormone secreted by end organ is given to the patient. [1]
Treatment of GH deficiency [1] GH is given as 0.27-0.7 mg SC every evening To replace the daily requirement . Adult GH replacement is controversial and policies differ from one country to the other. IGF concentrations are monitored and the dose is titrated accordingly. [1][3]
Treatment of ACTH deficiency [1] Hydrocortisone 10 mg on waking up, 5 mg at noon, 5 mg early evening is given. This mimics the ACTH function, the end organ hormone is replaced rather than ACTH itself; glucocorticoid replacement is essential for life while over treatment can cause side effects such as central obesity and low bone mineral density. [1][2]
Treatment of hypothyroidism. [1][3] Thyroxine 75-150 μg/ day is used to mimic normal function of TSH. A lower dose of 25 μg/ day is used in patients with cardiac disease and in elderly. Patient should be investigated for ACTH deficiency and if present should be treated prior to starting thyroxine. [1][3]
Treatment for men with gonadotrophin deficiency [1] IM, transdermal, oral, implant, buccal testosterone preparations are available. Any one of these forms can be used. A trial dose is used in women when they have symptoms such as low libido and low sense of wellbeing even after oestrogen replacement when no other explanation can be found to these symptoms. [1]
Treatment for women with gonadotrophin deficiency [1] Oestrogen replacement is achieved by oral or transdermal preparations, some of these may also contains progesterone which is used in patients with intact uterus. [1]
Fertility treatment for men and women with gonadotrophin deficiency [1] If pituitary failure is secondary to hypothalamic failure pulsatile GnRH can be given but in men with primary pituitary failure the testosterone replacement is stopped 4 weeks prior and then treated with IM or SC HCG to acheive spermatogenesis, in women treatment with LH activity is necessary to achieve fertility. [1][3]
Treatment of ADH deficiency. [1] Desmopressin oral or nasal is used [1]
References
  1. PRABHAKAR VK, SHALET SM. Aetiology, diagnosis, and management of hypopituitarism in adult life. Postgrad Med J [online] 2006 Apr, 82(966):259-266 [viewed 04 September 2014] Available from: doi:10.1136/pgmj.2005.039768
  2. CAUGHEY JE, JAMES A, MACLEOD EK. Hypopituitarism with Pituitary Tumours Br Med J [online] 1952 Jun 7, 1(4770):1216-1219 [viewed 04 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2023562
  3. BRAR KS, GARG MK, SURYANARAYANA KM. Adult hypopituitarism: Are we missing or is it clinical lethargy? Indian J Endocrinol Metab [online] 2011, 15(3):170-174 [viewed 09 September 2014] Available from: doi:10.4103/2230-8210.83400