Clinical presentation of hypopituitarism depends on the severity of the disease. It can be asymptomatic or mild to severe as in the case of a hypopituitary coma or an acute pituitary failure. In most patients the hypopituitarism presents itself as an endocrine dysfunction such as:

Adrenocorticotrophic deficiency

Acute symptoms include weakness, nausea, dizziness, vomiting, fever, circulatory collapse and shock. Chronic symptoms are fatigue, anorexia, weight loss and pallor. In children delayed puberty, failure to thrive, hypotension, anemia, hypoglycemia, lymphocytosis, eosinophilia and hyponatremia may occur.

Thyroid stimulating hormone deficiency

Various symptoms include weight gain, hypotension, bradycardia, cold intolerance, constipation, hair loss, cognitive slowing hoarseness and dry skin.

Growth hormone deficiency

Deficiency of growth hormone may result in a short stature, reduced muscle mass and strength, fatigue, visceral obesity, dyslipidemia, atherosclerosis, impaired memory and attention and a decreased quality of life. In children severe growth restriction has been documented.

Antidiuretic hormone deficiency

The symptoms of decreased antidiuretic hormone secretion include, a reduced urine osmolality, polydipsia, polyuria and hypernatremia.

• Fatigue

  KEYWORDS: Fatigue; Hormones; Pituitary [ncbi.nlm.nih.gov]

  Signs and symptoms of secondary hypothyroidism include fatigue, weakness, weight gain, thickened subcutaneous tissues, constipation, cold intolerance, altered mental status, impaired memory, and anemia. [emedicine.com]

  In adults, the deficiency is linked to fatiguability, increased body fat, low muscle mass and a higher risk for the development of cardiovascular disease. [news-medical.net]

  Symptoms and Signs of Pituitary Hormone Deficiency Pituitary Hormone Target Organs Effect of Deficiency ACTH Adrenal glands: cortisol and DHEA Fatigue, low sodium in blood, weight loss, skin pallor TSH Thyroid gland: thyroid hormone Fatigue, weight gain [pituitarysociety.org]

• Weight Gain

  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. [ncbi.nlm.nih.gov]

  gain increased sensitivity to cold constipation dry skin pale appearance low blood pressure and dizziness on standing (postural hypotension) headaches vision disturbance Diabetes Insipidus Each of the symptoms described above occur in response to the [pituitary.org.uk]

  Symptoms and Signs of Pituitary Hormone Deficiency Pituitary Hormone Target Organs Effect of Deficiency ACTH Adrenal glands: cortisol and DHEA Fatigue, low sodium in blood, weight loss, skin pallor TSH Thyroid gland: thyroid hormone Fatigue, weight gain [pituitarysociety.org]

  Symptoms and signs of central hypothyroidism might include weakness, fatigue, decreased energy, increased need for sleep, cold intolerance, and weight gain. [pituitaryworldnews.com]

• Pallor

  Symptoms and Signs of Pituitary Hormone Deficiency Pituitary Hormone Target Organs Effect of Deficiency ACTH Adrenal glands: cortisol and DHEA Fatigue, low sodium in blood, weight loss, skin pallor TSH Thyroid gland: thyroid hormone Fatigue, weight gain [pituitarysociety.org]

  A deficiency can lead to symptoms such as: Fatigue Low blood pressure Low serum sodium levels Low hemoglobin levels leading to pallor Low blood glucose In such patients, any crisis situation which puts increased stress on the body such as serious infections [news-medical.net]

  Chronic symptoms are fatigue, anorexia, weight loss and pallor. In children delayed puberty, failure to thrive, hypotension, anemia, hypoglycemia, lymphocytosis, eosinophilia and hyponatremia may occur. [symptoma.com]

  Observe eyelids, nails beds and skin pallor which indicate anemia. Ensure safety prequitions for patients with impaired visual field. Wet the eye with sterile water to provide comfort to the eye. [nursingexercise.com]

• Hypothermia

  TSH – central hypothyroidism, which can present in extreme state with myxedema coma à altered mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and CHF/cardiogenic shock ! 3. [errolozdalga.com]

  May be triggered by infection, trauma, surgery, hypothermia or pituitary haemorrhage. [patient.info]

  A severe deficiency in TSH also has the potential to cause hypothermia, coma and death in rare cases. Children with abnormally low TSH levels are mentally and physically backward. [news-medical.net]

  Some of the clinical features of hypopituitary coma include meningism, hormonal deficiencies, hypotension, ophthalmoplegia, reduced consciousness, visual field defects, hypoglycemia and hypothermia. [symptoma.com]

• Nausea

  RESULTS: Nausea and vomiting were the most common complaints, accounting for 69.57% of the gastrointestinal symptoms in Group G. Hyponatremia was the most common electrolyte disorder, occurring in 72.86% (n = 18) of patients in Group G. [ncbi.nlm.nih.gov]

  EMERGENCY Nausea, vomiting, extreme weakness, dehydration, and fever suggest adrenal insufficiency that may require emergency medical care. [healthcommunities.com]

  Low ACTH may cause nausea or vomiting, cold, clammy skin, fast heart beat, dizziness, confusion, dehydration. Low TSH may cause tiredness, dry skin, constipation, weight gain, slow hear rate, slow growth. [cincinnatichildrens.org]

• Geophagia

  Prasad's syndrome is characterized by geophagia, growth retardation, hypogonadism, and zinc deficiency. We report a 15-year-old boy whose medical history and clinical and laboratory findings were fully compatible with Prasad's syndrome. [ncbi.nlm.nih.gov]

• Arthralgia

  Within days, he developed severe fatigue, myalgias and arthralgias. Initial testing demonstrated central hypogonadism, followed by a low normal insulin-like growth factor-1 and an abnormal L-dopamine growth hormone stimulation test result. [ncbi.nlm.nih.gov]

  Signs and symptoms of ACTH deficiency may be profound and potentially fatal; they include myalgias, arthralgias, fatigue, headache, weight loss, anorexia, nausea, vomiting, abdominal pain, altered mentation or altered consciousness, dry wrinkled skin, [emedicine.com]

  Lean Tanned Tired Tearful Weakness Anorexia Dizzy Giants Flu-like myalgias/arthralgias Depression / psychosis / low self-esteem N&V, abdominal pain, diarrhoea / constipation No skin pigmentation as low ACTH – usually adrenal insufficiency e.g. with [almostadoctor.co.uk]

  Side effects may include soft tissue swelling and edema, arthralgias, myalgias, headache, and carpal tunnel syndrome. [endocrinologyadvisor.com]

• Vaginal Dryness

  Symptoms can include: In children, lack of growth In women, lack of menstrual periods and vaginal dryness In men, shrinking testicles and erectile dysfunction Confusion, weight gain, and constipation Weakness, low blood sugar, and feeling stressed Not [msdmanuals.com]

  Premenopausal women present with altered menstrual function, ranging from regular anovulatory periods to amenorrhea, as well as hot flashes, decreased libido, breast atrophy, vaginal dryness, and dyspareunia. [emedicine.com]

  dryness, absence of milk production in new mothers (Sheehan’s syndrome) In men: loss of libido and potency, reduced muscular strength, shrinking and softening of the testes, decreased secondary hair growth Hypopituitarism Diagnosis Patient history and [healthcommunities.com]

  In women, the symptoms may include: delayed menstrual periods reduction in libido vaginal dryness subfertility and infertility Affected women are also more likely to develop osteoporosis and weak bone structures prone to fractures later in life. [news-medical.net]

• Headache

  Headache or specific symptoms/signs of hypopituitarism appeared within 1 year of delivery. Five patients had headache, and 8 had difficulty breastfeeding or amenorrhea. [ncbi.nlm.nih.gov]

  Patients may also experience headaches, irregular periods (in women), impotence (in men) and peripheral vision loss. [emoryhealthcare.org]

  Postmenopausal women usually present with headache or visual abnormalities due to other hormonal deficiencies or mass lesions. In children, FSH and LH deficiency can cause eunuchoidism and lack of sexual development. [emedicine.com]

• Focal Neurological Deficit

  Infants and children present with seizures and stroke-like episodes with focal neurologic deficits. [ncbi.nlm.nih.gov]

Diagnosis of hypopituitarism is made based on various imaging and laboratory tests. Some of them are, MRI, CT Scan, levels of various hormones such as free thyroxin (FT4), thyroid-stimulating hormone (TSH), prolactin, luteinizing hormone (LH), testosterone and estradiol for men and women respectively in the blood.

Moreover the cortisol levels are assessed using provocative testing of the adrenal-pituitary axis. In some individuals the insulin tolerance tests may be required for a better assessment of the adrenocorticotropic hormone (ACTH), growth hormone (GH) and prolactin levels [9].

Treatment of hypothyroidism is based on replacing the deficient hormones. Glucocorticoids must be administered in case of ACTH deficiency, in the case of an emergency such as a pituitary apoplexy or an obstetric pituitary hemorrhage. Gonadotropin deficiency is corrected by replacing the sex appropriate hormones, such as testosterone in men and estrogen replacement in women with or without progesterone replacement.

Growth hormone is not replaced often in adults unless symptom of GH deficiency arises [10]. Growth hormones are replaced in children whenever appropriate. Secondary hypothyroidism can be treated efficiently by thyroid replacement. In hospitalized patients on corticosteroids, the dose can be simply doubled up in case of a surgery.

Prognosis is mostly good, if the hormones are replaced sufficiently [7]. Though there is an increased morbidity among hypopituitarism patients, the reason for morbidity is not yet clearly understood [8].

Complications

The complications associated with hypopituitarism depend on the severity of the deficiency. Infection may be a major cause for complications. Some of the complications of hypopituitarism include amenorrhea, hypothyroidism, hypotension, infertility, osteoporosis, failure to develop during puberty and short stature.

Hypopituitarism can usually develop into hypopituitary coma due to pituitary apoplexy. Some of the clinical features of hypopituitary coma include meningism, hormonal deficiencies, hypotension, ophthalmoplegia, reduced consciousness, visual field defects, hypoglycemia and hypothermia.

Hypopituitarism can be caused by several factors as given below.

• Trauma of the head
• Brain surgery [1]
• Brain tumor [2]
• Radiation therapy [3]
• Stroke
• Inflammation or an infection of the brain tissues
• Tumor of the pituitary gland or the hypothalamus 
• Subarachnoid hemorrhage [4]

Apart from this hypopituitarism can also be caused by rare immune or metabolic diseases such as hemochromatosis, histiocytosis X, lymphocytic hypophysitis, sarcoidosis and a very rare condition following a pregnancy called the Sheehan`s syndrome.

Hypopituitarism is listed under the rare diseases by the National institute of health (NIH), as less than 200,000 people are affected by this in the United States. It has been estimated that 4.2 cases per 100,000 people are being reported every year, internationally [5].

According to a study conducted by Regal et al, it has been estimated that there is a prevalence of 45.5 cases for every 100,000 of the adult population [6].

The pituitary gland produces the trophic stimulus to the target glands. Hence when the trophic stimulus is impaired, the hormone production from the target gland is impaired resulting in the secondary failure of the target glands.

In normal cases, the secretion of the tropic stimulus is based on the subphysiological hormonal levels, by a feedback mechanism. But in case of hypopituitarism the levels of the trophic hormones are suboptimal or absent, resulting in reduced production of the target gland hormones.

Hypopituitarism can never be prevented, though it can be treated efficiently if detected early. Trauma to the pituitary gland can be minimized if hypophyseal surgery is carried out under high resolution microscopes. Obstetric pituitarism can be minimized by proper postpartum care. Minimum exposure of the pituitary gland during radiation therapy is mandatory to prevent hypopituitarism due to radiation exposure.

Hypopituitarism is a condition, where there is a decrease in hormones secreted by the pituitary gland. The pituitary gland is a small gland located below the brain. It secretes a number of important hormones such as the growth hormone, thyroid stimulating hormone, follicle stimulating hormone, luteinizing hormone, prolactin and adrenocorticotropic hormone.

These hormones play a major role in growth and development of the body and regulating the blood pressure and metabolism. Insufficient secretion of any of these hormones, can result in a dysfunction of that particular area, and is manifested by specific symptoms. Treatment includes the replacement of the deficient hormones by hormone replacement therapy.

Definition

Pituitary is a small pea-sized gland situated at the base of the brain. It is connected to the hypothalamus of the brain by a small stalk. The pituitary gland secretes a number of hormones such as the adrenocorticotropic hormone (ACTH), growth hormone (GH), prolactin, antidiuretic hormone and thyroid-stimulating hormone (TSH). 

Cause

Hypopituitarism occurs when there is a deficient secretion of one or many of these hormones. Some of the causes for hypopituitarism include, a tumor of the pituitary gland, radiation therapy involving the pituitary gland, trauma of the pituitary due to road accidents, autoimmune disorders affecting the pituitary, surgery involving the pituitary gland, severe infections such as meningitis that can affect the pituitary and many such. 

Symptoms

Hypopituitarism is marked by various symptoms like fatigue, undue tiredness, blackouts, loose stools, low blood pressure and such as a result of deficient ACTH. Deficiency of growth hormone may result in stunted growth, weakness and tiredness in adults. Low sex hormones can result in less sex drive in women and loss of libido in men, impotence, and irregular or absent menstrual periods. Less thyroid hormone can result in dry skin and tiredness. Lack of antidiuretic hormone can result in increased thirst and copious urine output.

Diagnosis

Hypopituitarism is usually diagnosed using blood tests to detect the hormone levels, visual field checks for ruling out tumors of the pituitary gland, MRIs and CT scans. 

Treatment

Treatment of hypopituitarism is done mainly by hormone replacement therapy.

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