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  2. INTRODUCTION • Deficient production of anterior pituitary hormones leads to features of hypopituitarism. • It is a clinical syndrome of deficiency in pituitary hormone production and secretion. • Panhypopituitarism refers to involvement of all pituitary hormones; however, it is rare. • It may result from disorders involving the pituitary gland, hypothalamus or surrounding structures.
  3. CLINICAL FEATURES • Mass lesions- - Space occupying lesions result in headache, visual disturbances and rarely, personality changes, temporal lobe epilepsy, and CSF rhinorrhoea. -Actively secreting tumors can produce a complex picture of combined hormonal excess and deficiency • Growth hormone -Reduced energy and vitality -Reduced muscle mass and strength -Increased central adiposity -Decreased sweating and impaired thermogenesis -Reduced bone mineral density (BMD)
  4. CLINICAL FEATURES • Adrenocorticotrophic hormone -Fatigue, weakness, anorexia, weight loss, nausea, vomiting, abdominal pain, hypoglycaemia, circulatory collapse; loss of axillary/pubic hair in women • Gonadotrophins -Men: erectile dysfunction, reduced muscle mass, erythropoiesis, reduced energy and vitality -Women: oligomenorrhoea/amenorrhoea, dyspareunia, breast atrophy -Both: loss of libido, flushes, infertility, regression of sexual characteristics, reduced BMD.
  5. CLINICAL FEATURES • Thyroid stimulating hormone -Fatigue, apathy, cold intolerance, constipation, weight gain, dry skin, psychomotor retardation. • Antidiuretic hormone -Polyuria, polydipsia, nocturia. • Prolactin -Lactational failure •Excessive mortality rates due to cardiovascular disease
  6. PITUITARY APOPLEXY • Hemorrhagic infarction of a pituitary adenoma/tumor • Considered a neurosurgical emergency • Presentation: -Hypoglycemia -Hypotension and shock -CNS hemorrhage -Severe headache -Visual changes -Opthalmoplegia
  7. PITUITARY APOPLEXY • Risk factors: -Diabetes -Radiation treatment -Warfarin use • Symptoms may occur immediately or may develop over 1-2 days • Diagnose with CT/MRI • Treatment: -Surgical - Trans-sphenoid decompression -Medical therapy - if symptoms are mild Corticosteroids
  8. KALLMANN SYNDROME • Kallmann syndrome is a genetic disorder that prevents a person from starting or fully completing puberty. • It results from defective hypothlamic gonadotropin-releasing hormone synthesis. • Symptoms include absent or delayed puberty,infertility,inability to smell. • Hormone replacement therapy is the major form of treatment with the aim to replace the missing testosterone or oestrogen and progesterone.
  9. PRADER-WILLI SYNDROME • Prader-willi syndrome is a genetic disorder due to loss of function of specific genes. • This is a contiguous gene syndrome that results from deletion of the paternal copies of the imprinted SNRPN gene, the NECDIN gene, and possibly other genes on chromosome15q. • Prader-Willi syndrome is associated with hypogonadotropic hypogonadism. • In newborns symptoms include weak muscles,poor feeding and slow development,Beginning in childhood person becomes constantly hungry which often leads to obesity and type 2 diabetes mellitus.
  10. SHEEHAN'S SYNDROME • Ischemic pituitary necrosis after substantial blood loss during childbirth • No correlation between severity of hemorrhage and symptoms • Recognised days to weeks post-partum - Secondary hypothyroidism - Lactational Failure - Secondary Adrenal insufficiency - Lethargy, anorexia, weight loss - Typically long interval between obstetric event and diagnosis
  11. EMPTY SELLA SYNDROME • Usually have normal pituitary function - Implying that the surrounding rim of pituitary tissue is fully functional • Hypopituitarism may develop insidiously when >90% tissue is compressed. • Primary empty sella may develop as a consequence of congenital weakness of the diaphragm • Pituitary masses may undergo clinically silent infarction with secondary development of a partial or totally empty sella by cerebrospinal fluid (CSF) filling the dural herniation. • Rarely, functional pituitary adenomas may arise within the rim of pituitary tissue, and these are not always visible on MRI
  12. DIAGNOSIS • Thorough clinical examination including visual field charting is essential • Simultaneous measurements of basal anterior pituitary and target organ hormone levels • Dynamic/provocative tests are necessary to assess GH secretory reserve and ACTH-adrenal axis
  14. TREATMENT • Hormone replacement therapy • It should mimic physiological hormone production • Those with glucocorticoid replacement require dose adjustments during stressful events like acute illness, pregnancy, surgery, dental procedures, trauma, and acute hospitalization
  15. TSH DEFICIENCY • Thyroxine is the treatment of choice. • ACTH deficiency should be treated if present before initiating thyroxine replacement. • TSH monitoring is unhelpful • Long term over treatment may result in AF & reduction in bone mineral density
  16. GONADOTROPHIN DEFICIENCY MEN •Testosterone replacement has beneficial effects on body composition, sexual function, mood, behavior & BMD. •Treatment is contraindicated in patients with prostate cancer and male breast cancer WOMEN • Oestrogen replacement alleviates symptoms of deficiency and is bone protective. • It is often given with cyclical/continuous progesterone.
  17. GH DEFICIENCY • Human GH 0.2-0.3 mg s.c. is given daily,titrating the dose every 4-6 weeks • Side effects include headache, arthralgia,myalgia, fluid retention. • Absolute contraindications are active malignancy, benign intracranial hypertension and proliferative diabetic retinopathy
  18. VASOPRESSIN DEFICIENCY • In mild Diabetes Insipidus, (urine output <41/day), adequate oral fluid intake is sufficient • In severe forms desmopressin is the treatment of choice • Hyponatremia is a common side effect ACTH DEFICIENCY • Hydrocortisone is the preferred agent • 2 to 3-fold increase in glucocorticoid dose is needed temporarily during intercurrent illness, surgery, etc.
  19. Hormone Replacement Therapy For Adult Hypopituitarism
  20. References : • Davidson’s Principles and Practice of Medicine • Harrison's Principles of Internal Medicine