Hypopituitarism

Apart from headache due to stretching of the diaphragma sellae

and visual abnormalities, clinical presentation depends on the

deficiency of the specific anterior pituitary hormones involved.

Individual or multiple hormones may be involved, so questioning

in relation to deficiencies of the thyroid, adrenocortical and

reproductive hormones is needed.

Family history

Enquire about family history since pituitary disease can occur as

part of inherited multiple endocrine neoplasia or familial pituitary

syndromes.

The physical examination

Acromegaly

Examination sequence

• Look at the face for coarsening of features, thick, greasy

skin, prominent supraorbital ridges, enlargement of the

nose, prognathism (protrusion of the mandible) and

separation of the lower teeth (Fig. 10.9A,B).

• Examine the hands and feet for soft-tissue enlargement

and tight-fitting rings or shoes, carpal tunnel syndrome

and arthropathy (Fig. 10.9C,D).

• Assess the visual fields (p. 162).

• Check the blood pressure and perform urinalysis.

Hypertension and diabetes mellitus are common

associations.

THE PITUITARY

Fig. 10.8 Pituitary macroadenoma. The tumour extends into the

suprasellar cistern and is compressing the optic chiasm. Courtesy of

Dr Dilip Patel.

Anatomy and physiology

The pituitary gland is enclosed in the sella turcica at the base of

the skull beneath the hypothalamus. It is bridged over by a fold of

dura mater (diaphragma sellae) with the sphenoidal sinus below

and the optic chiasm above. Lateral to the pituitary fossa are the

cavernous sinuses, containing cranial nerves III, IV and VI and the

internal carotid arteries. The gland comprises anterior and posterior

lobes. The anterior lobe secretes adrenocorticotrophic hormone

(ACTH), prolactin, growth hormone (GH), thyroid-stimulating

hormone (TSH) and gonadotrophins (luteinising hormone (LH)

and follicle-stimulating hormone (FSH)). The posterior lobe is

an extension of the hypothalamus, and secretes vasopressin

(antidiuretic hormone) and oxytocin.

The history

Common presenting symptoms

Pituitary tumours are common and are found incidentally in around

10% of patients undergoing head computed tomography (CT) or

magnetic resonance imaging (MRI). Hypopituitarism can result

from a space-occupying lesion or from a destructive or infiltrative

process such as trauma, radiotherapy, sarcoidosis, tuberculosis

or metastatic disease. Pituitary infarction or haemorrhage can

result in acute hypopituitarism (referred to as pituitary apoplexy)

and is a medical emergency; it is often associated with headache,

vomiting, visual impairment and altered consciousness.

Non-functioning pituitary adenomas may be asymptomatic

or may present with local effects, such as compression of the

optic chiasm causing visual loss (typically bitemporal upper

quadrantanopia or hemianopia; Fig. 10.8 and see Fig. 8.5)

The history • 201

10

• absent axillary hair (Fig. 10.10B)

• reduced/absent secondary sexual hair and testicular

atrophy (caused by gonadotrophin deficiency)

• visual field defects (most often bitemporal hemianopia),

optic atrophy or cranial nerve defects (III, IV and VI),

caused by a tumour compressing the optic chiasm, optic

nerve or cavernous sinus.

Hypopituitarism

Examination sequence

Look for:

• extreme skin pallor (a combination of mild anaemia and

melanocyte-stimulating hormone deficiency; Fig. 10.10A)

A

B

C

D

Fig. 10.9 Acromegaly. A Typical facies. B Prognathism and separation of the lower teeth. C Large, fleshy hands. D Widening of the feet.

THE ADRENALS

Anatomy and physiology

The adrenals are small, pyramidal organs lying immediately

above the kidneys on their posteromedial surface. The adrenal

medulla is part of the sympathetic nervous system and

secretes catecholamines. The adrenal cortex secretes cortisol

(a glucocorticoid), mineralocorticoids and androgens.

The history

Common presenting symptoms

Cushing’s syndrome is caused by excess exogenous or

endogenous glucocorticoid exposure. Most c