The pituitary gland is a small, bean-shaped gland situated at the base of your brain, somewhat behind your nose and between your ears. Despite its small size, the gland influences nearly every part of your body. The hormones it produces help regulate important functions, such as growth, blood pressure and reproduction.

1. Clinical Endocrinology
Lecture: Pituitary Gland
By
Dr. Liban A. Adem

2. Diseases of the Pituitary and Hypothalamus
Contents:
1. Hypo/hyperpituitarism
2. Prolactinoma
3. Acromegaly
4. Cushing’s Disease
5. Non-functioning Pituitary Adenoma
6. Craniopharyngioma
7. Kallmann Syndrome (Hypogonadotropic Hypogonadism)
8. Hypophysitis
9. Diabetes Insipidus
10. Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH, SIAD) and
the Clinical Management of Hyponatremia

3. Topic Outline:
• Introduction to Pituitary Gland
• Anatomy: Gross and Microscopical of Pituitary Gland
• Hypothalamic Pituitary Axis
• Hormone secreted from Pituitary Gland
• Diseases Found in pituitary Gland
• Causative of the disease
• Clinical Manifestation
• Investigation of the disease
• Management of the disease

4. Introduction to Pituitary Gland
• The pituitary gland is found at the base of the brain, inferior
to the hypothalamus.
• It releases hormones into the blood in response to signals from
the hypothalamus known as ‘stimulating hormones’.
• Hormones from the pituitary gland regulate the function of
peripheral endocrine tissues throughout the body.

5. Anatomy of Pituitary Gland
Pituitary Gland :(Hypophysis Cerebri)
 Small oval endocrine gland , ½ gm
in weight, measuring 12 mm in
transverse diameter and 8 mm in
anteroposterior diameter.
 It lies in the hypophyseal
(pituitary) fossa under cover of the
diaphragma sellae and consists of
2 lobes (large anterior lobe and
small posterior lobe).

6. Anatomical Relations:
1. Superior : Diaphragma sellae , Optic
chiasma and infundibulum connecting the
pituitary gland to hypothalamus.
2. Below: Body of sphenoid & Sphenoidal air
sinuses.
3. Posterior : Dorsum sellae and brain stem.
4.Anterior : Tuberculum sellae is the anterior
wall of the pituitary fossa.
5.On each side: Cavernous sinus containing
internal carotid artery and abducent nerve.

8. Blood supply Of Pituitary
1. Inferior hypophyseal artery: Arises from
internal carotid artery inside the cavernous
sinus and supplies the posterior lobe.
2. Superior hypophyseal artery: arise from
internal carotid artery after leaving the
cavernous sinus, they supply the
infandibulum.
3. Hypothalamo-hypophyseal portal system of
veins supplies the anterior lobe and carries the
hormone-releasing factors from the
hypothalamus down to the anterior lobe.
4. Large hypophyseal veins drain the gland into
the cavernous sinus.

10. Normal Microscopical of Pituitary Gland
When looking under microscopic in
normal Pituitary Gland (Histological)
It is divided into:
a) Anterior lobe
(adenohypophysis): dark &
cellular.
b) Posterior lobe(neurohypophysis):
pale & fibrous

11. Anterior lobe (Adenohypophysis)
• It lies anterior to the
hypophyseal cleft.
• It is subdivided into 3 parts:
1- Pars distalis.
2- Pars tuberalis.
3- Pars intermedia.

12. 1- Pars distalis
• It is composed of :
A. Irregular cords of polygonal
cells,
B. Surrounded by fenestrated
blood capillaries,
C. Supported by a network of
reticular fibers.

13. 1- Pars distalis
It consists of 2 types of cells:
1- Chromophobes (52%):
 Have weak affinity to stains.
 They are cells smaller than the chromophils
 Have a non granular pale cytoplasm ( few organelles).
• Function: They do not secrete hormones. They are reserve cells or
degranulated chromophils.
2- Chromophils (48%):
 Have great affinity to stains.
 They have granular darkly stained cytoplasm
 They are classified according to their granules into two types:
• Acidophils: which have great affinity to acidic stains.
• Basophils: which have great affinity to basic stains.

14. Chromophils Chromophobes
1- Percentage 48% 52%
2- size Larger Smaller
3- Cytoplasm Granular, dark Non granular, pale
4- Function Secretion of hormones A- act as a reserve.
B- degranulated chromophils.

15. a- Acidophils (37%)
• They secrete hormones of protein
in nature.
• They are periodic acid Schiff (PAS)
negative.
• They are smaller than the
basophils but contain larger
secretory granules.
• EM: protein secreting cells.
• Acidophils are of two types:
1- Somatotrophs: secret growth
hormone.
2- Mammotrophs: secret prolactin.

16. Mammotrophs
• The secretory granules in these cells
are small, but in pregnant and
lactating females they become large
and numerous & are called
pregnancy cells or Erdheim cells.
• When suckling is terminated,
lysosomes eliminate the excess
secretory granules, a process known
as crinophagy.

17. b- Basophils (11%)
• They secrete hormones of glycoprotein in nature.
• They are PAS +ve (except the corticotrophs which secrete a
polypeptide hormone ( so, it is PAS –ve).
• They are larger than the acidophils, but contain smaller secretory
granules.
– EM: protein secreting cells.
• Basophils are of three types:
1- Thyrotrophs: secrete thyroid stimulating hormone (TSH).
2- Gonadotrophs: They secrete two hormones:
 Follicle stimulating hormone (FSH).
 Luteinizing hormone (LH)
3- Corticotrophs: secrete adrenocorticotrophic hormone (ACTH)

18. Acidophils Basophils
1- Percentage 37% 11%
2- Nature of hormones Protein Glycoprotein
3- PAS Negative Positive
4- size Smaller Larger
5- Granules Larger Smaller
6- Secretion Somatotrophs (growth h.)
Mammotrophs (prolactin)
Thyrotrophs (TSH)
Gonadotrophs .
(FSH& LH)
Corticotrophs (ACTH)

19. 2- The pars tuberalis
• It is a superior extension
that surrounds the
infundibulum.
• It is highly vascular.
• It is formed of
chromophobe-like cells.
• Function: non specific.

20. 3- The pars intermedia
• It lies between the pars
distalis and pars nervosa.
• In humans, it is a
rudimentary region. It is
made up of cords of faint
basophilic cells with few
secretory granules.
• Function: non specific.

21. II- Posterior lobe (neurohypophysis)
• It lies posterior to the hypophyseal cleft.
• It consists of 3 parts:
1- The median eminence: a funnel shaped
downward extension of the hypothalamus.
2- The infundibulum: which together with
the pars tuberalis constitute the
infundibular stalk.
3- The pars nervosa: which is connected to
the base of the brain by the infundibulum
and the median eminence

22. Pars Nervosa
• It consists of:
1- Unmyelinated axons of neurosecretory cells:
 Their cell bodies present in the supraoptic&
paraventricular nuclei of the hypothalamus.
 Their axons form the hypothalamo-hypophyseal
tract carrying the neurosecretion from the
hypothalamic nuclei to the pars nervosa.
2- Herring bodies:
 acidophilic homogenous bodies.
 Represent accumulation of neurosecretory
granules at the dilated terminal ends of axons.
3- Pituicytes: modified glial cells for support
nutrition& isolation.
4- Rich fenestrated blood capillaries.

23. Neurosecretion
1-Oxytocin:
– Uterus
– Mammary glands
2- Vasopressin (ADH) (ADH)(ADH):
– ↑ water reabsorption from collecting ducts →
concentrated urine

24. Hypothalamic Pituitary Axis
 Endocrine Function responds to feedback control
 Hypothalamus, Pituitary stalk and Pituitary Gland
 create an anatomical and functional integrated (Neuroendocrine
System)
• Neuron groups in hypothalamus secrete a number of factors that stimulate
Anterior Pituitary secretion of hypothalamic factors, in turn, are
antagonized by hormones secreted by peripheral target organs, thereby
completing a feedback loop.
• In addition, specific hypothalamic inhibitory hormones have been identified
– e.g. Dopamine inhibits pituitary secretion of prolactin.
 Hypothalamus regulates secretion of hormones from adenohypophysis
(anterior pituitary gland) by releasing
 Stimulating factors (corticotropin-releasing hormone, CRH; Growth
hormone-releasing hormone, GHRH; gonadotropin-releasing
hormone, GnRH; thyrotropin-releasing hormone, TRH, and.

25. Cont..
• Inhibitory factors (growth hormone inhibitory hormone, GHIH or
Somatostatin; Prolactin inhibitory factor, PIF or Dopamine these in
turn modulate release of six hormones from anterior pituitary;
Anterior Pituitary:
1. Growth Hormone (GH): Regulated by GHRH
2. Prolactin (PRL): Inhibited by dopamine from hypothalamus,
stimulated by thyrotropin-releasing hormone (TRH)
3. Adrenocorticotrophic hormone (ACTH): Regulated by corticotropin-
releasing hormone(CRH)
4. Thyroid-stimulating hormone (TSH): Regulated by TRH
5. Follicle –Stimulating Hormone (FSH): Regulated by Gonadotrophin-
releasing Hormone (GnRH)
6. Luteinizing hormone (LH): regulated by GnRH
– FLAT PiG: FSH, LH, ACTH, TSH, PRL, GH

26. Posterior Lope
 Posterior pituitary gland contains pituicytes a
modified glial cells ,with no secretary function, axon
terminal and unmyelinated nerve fibers containing
ADH and Oxytocin
 Both are Synthesized in neurons of hypothalamus and transported
along axons to neurohypophysis. Stored and released from there.
1. ADH Promotes water reabsorption from distal renal tubules
2. Oxytocin stimulates contraction of pregnant uterus at term and also of cells
around lactiferous ducts in breast

29. Hyper/Hypopituitarism

30. Definition
• The pituitary gland also called the hyophysis, is a small gland that lies in the
sella turica, a bony cavity at the base of the brain, the arachnoid membrane
(diaphragm sellae) separates it from and prevents cerebrospinal fluid from
entering the sella turcica.
• Optic chiasm is 5-10 mm above this diaphragm.
• The pituitary gland is connected to the hypothalamus by the pituitary
(hypophyseal) stalk.
• Pituitary stalk (also known as the infundibular stalk or the infundibulum) is the
connection between the hypothalamus and the pituitary gland. Compression of
the pituitary stalk by suprasellar tumor causes a decrease in all anterior
pituitary hormones except prolactin which increases leading to prolactinemia.

31. • Physiologically, the pituitary gland is divisible into two distinct portions:
- Anterior pituitary: also known as adenohypophysis originates from the Rathke’s
pouch,
• which is an embryonic invagination of the pharyngeal epithelium.
- Posterior pituitary: also known as the neurohypophysis originates from a
neural tissue outgrowth from the hypothalamus.
• Anatomically, there is an intermediate lobe of pituitary which synthesizes
and secretes melanocyte stimulating hormone (MSH).
• Six important peptide hormones plus several less important ones are
secreted by the anterior pituitary, and two important peptide hormones are
secreted by the posterior pituitary. The hormones of the anterior pituitary
play major roles in the control of metabolic functions throughout the body.

32. Hypopituitarism
• Hypopituitarism is a rare condition charactered by the complete
or partial absence of one, or more, or all of the hormones in the
anterior lobe of pituitary gland that is sometimes
associated with the absence of hormones of the
posterior lobe as well.
• The clinical presentation is variable and depends on the
underlying lesion and the pattern of resulting hormone deficiency.
• The most common cause is a pituitary macroadenoma but other
causes are listed in next Slide.

34. • Structural
– Primary pituitary tumour
– Adenoma*
– Carcinoma (exceptionally rare)
– Craniopharyngioma*
– Meningioma*
– Secondary tumour (including leukaemia and
lymphoma)
– Chordoma
– Germinoma (pinealoma)
– Arachnoid cyst
– Rathke’s cleft cyst
– Haemorrhage (apoplexy)
• Inflammatory/infiltrative
– Sarcoidosis
– Infections, e.g. pituitary abscess, tuberculosis,
syphilis, encephalitis
– Lymphocytic hypophysitis
– Haemochromatosis
– Langerhans cell histiocytosis
• Congenital deficiencies
– GnRH (Kallmann’s syndrome)*
– GHRH
– TRH
– CRH
• Functional
• Chronic systemic illness
• Anorexia nervosa
• Excessive exercise
• Other
• Head injury*
• (Para)sellar surgery*
• (Para)sellar radiotherapy*
• Post-partum necrosis(Sheehan’s
syndrome)
• Opiate analgesia
• The most common causes of pituitary hormone
deficiency.
• (CRH = corticotrophin-releasing hormone; GHRH =
growth hormone-releasing
• hormone; GnRH = gonadotrophin-releasing hormone;
TRH = thyrotrophin releasing hormone.

35. Local complications
• Headache
• Visual field defect
• Disconnection
hyperprolactinaemia
• Diplopia (cavernous sinus
involvement)
• Acute
infarction/expansion
(pituitary apoplexy)
Hormone excess
Hyperprolactinaemia
• Galactorrhoea
• Amenorrhoea
• Hypogonadism
Acromegaly
• Headache
• Sweating
• Change in shoe
and ring size
Cushing’s disease
• Weight gain
• Bruising
• Myopathy
• Hypertension
• Striae
• Depression
Hypopituitarism
Growth hormone
• Lethargy
Gonadotrophins
• Lethargy
•Loss of libido
• Hair loss
• Amenorrhoea
ACTH
• Lethargy
• Postural hypotension
• Pallor
• Hair loss
TSH
• Lethargy
Vasopressin
(usually post-surgical)
• Thirst and polyuria
Common symptoms and signs to consider in a
patient with suspected pituitary disease.

36. Anterior Pituitary Disorder
Hypo-functioning Pituitary

37. Hypopituitarism in adults (Simmonds's Disease)
Its decline of pituitary function with the resultant decrease of
gonadal adrenocortical and thyroid functions.
• Etiology:
1. Sheehan’s Syndrome(infraction of anterior PG)
• Pituitary infection following post-partum haemorrhage, due
to pituitary gland increase in size or doubles in size during
pregnancy without increasing of blood supply, so it may
become liable to ischemic injuries.
2. Pituitary Tumors, Pi- irradiation or hypophysectomy
3. Tuberculoma, Sarcoidosis, haemochromatosis

38. Anterior Pituitary Hypofunction
Courses:
1. Neoplasm:
– Pituitary tumors
– Metastases
– Meningioma
– Craniophyaryngioma
2. Inflammatory:
– TB basal meningitis
– Encephalitis
3. Vascular:
– Post-partum Necrosis (Sheehan
Syndrome)
4. Inflitrative:
– Hemochromatosis
– Sarcoidosis
Courses:
5. Physical Injury:
• Surgery
• Irradiation and
• Empty sella Syndrome
6. Immunological:
• Pituitary antibodies
7. Congenital:
• Kilmann's Syndrome
8. Functional:
• Anoxia nervosa
• Starvation and
• Emotional deprivation

39. Clinical Classification
• Local mass effect
• Hormonal deficiency
• Metabolic effect

40. Local mass effect
• Pituitary
• Optic chiasm
– Loss of red perception
– Bitemporal hemianopia
– Scotoma
– Blindness
• Cavernous sinus
– Cranial nerve III, IV, VI, V1, V2
– Ophthalmoplegia, Facial numbness

42. Local mass effect
• Brain
– Headache, Hydrocephalus
– Dementia, Psychosis
• Frontal Lobe
– Personality disorder
– Anosmia
• Hypothalamus
– Temperature dysregulation
– Appetite & Thirst disorders
– Diabetes insipidus
– Obesity, Sleep disorders
– Autonomic dysfunction

43. Manifestations of Hormonal deficiency
• PRL
• TSH
• GH
• LH/FSH
• ACTH
• ADH Antidiuretic hormone
• Oxytocin??

44. Hormone Features of deficiency
GH Children: growth retardation
Adults: ↓muscle bulk
Tendency to hypoglycaemia.
Failure of lactation
Children: delayed puberty
Female: oligomenorrhoea, infertility,atrophy of breast &
genitalia, los of libido
Male:Impotence,azoospermia,testicular atrophy, loss of
libido
Both Sexes: Loss of libido, loss of body hair, weight loss,
hypotension, hypoglycemia, decreased pigmentation,
hyponatremia, nausea, vomiting
Prolactin
Gonadotrophins
ACTH
TSH Weight gain, cold intolerance, hair loss, constipation, dry skin,
hoarseness,bradycardia, fatigue
Thirst, polyuria
Vasopressin

45. Clinical Manifestations
• GH is the first to be compromised followed by deficiencies
Gonadotropin, TSH, and ACTH.
1. GH Deficiency in adulty causes wrinkling around the eyes and
mouse with decreased strength and exercise capacity.
2. Gonadal Dysfunction; Loss of Libido, Amenorrhea, Impotence.
3. Thyroid Dysfunction; apathy, bradycardia and so on
4. Adrenal Dysfunction; hypoglycemia, hypotension, tiredness.
5. Neurological; with pituitary tumors.

46. Clinical of acute onset pituitary
• Acute onset is rare:
– And coused by hemorrhage or infarction in a
pituitary adenoma.
• E.g. Pituitary Apoplexy;
– Signs and symptoms are : Severe headache
with life-threatening hypopituitarism and visual
loss.
• Its treated by trans-sphenoidal decompression of
the pituitary gland.
• (RARELY, pituitary apoplexy produces
(Autohypophysectomy) with cure of acromegaly,
Cushing disease or hyperprolactinemia. Both
anticoagulants and radiotherapy predispose to
hemorrhagic infarction
Causes of coma in patients
with Hypopituitarism:
1. Hypoglycemia due to GH
and Cortisol Deficiency
2. Hypothermia due to
hypothyroidism
3. Water intoxication as
cortisol and thyroxine are
essential for water
excretion (plasma Na and
K are Low)

47. Investigations
• GH
– Clonidine
– GHRH test
– Insulin tolerance test
– L-Arginine
– L-Dopa test
• Prolactin
– Serum levels
– TRH test
• ACTH
– CRH test
– Insulin tolerance test
• TSH
• Basal TSH
• TRH test
• LH/FSH
• Basal LH, FSH
• Testosterone
• Estrogen
• GnRH test

48. Imaging & Others Tests
• MRI
• Fundus, Perimetry
• Na, K
• Osmolarity Urine/serum
• Water deprivation test

49. Investigations Cont.
1. Panhypopituitarism must be differentiated from primary
polyglandular deficiency states affecting Thyroid, adrenal and
gonads e.g. Schmidt’s Syndrome.
How to Differentiate
• If the is Decreased Hormone
Plus Increased of trophic
pituitary hormones.
• e.g. Cortisol, Thyroid
(ACTH,TSH)= Defect in the
gland itself
• E.g. Thyroid, adrenal or
gonadal primary hypofunction
• If there is decreased in
tropic pituitary hormones,
this means hypothalamic or
pituitary defect.

50. Cont.
2. To differentiate whether the defect is pituitary or hypothalamus, we
can use “Hypothalamic releasing hormone tests’’
3. GH levels my be undetectable under basal conditions so, we use
stimulating test.
– E.g. Insulin stimulation test (Insulin Hypoglycemia Release of GH)
– Infusion of GH (Arginine) releasing hormone may be used if the
insulin test is uncertain.
– Note: Stimulation test is unessential if there are decrease of
three or more of the other pituitary hormones (TSH, ACTH, LH,
FSH)
4. CT, MRI for pituitary gland.

51. Differential Diagnosis of Panhypotuitarism in adult
1. A) Primary hypothyroidism
B)Primary adrenal hypofunction
1. Anorexia Nervosa: (Functional Hypopituitarism)
 Young Female: Anorexia with loss body weight,
amenorrhea (Axillary &pubic are normal) to be
differentiated from panhypopituitarism

52. • ACTH deficiency
– Hydrocortisone
– Prednisolone
• TSH deficiency
– Levothyroxine
• FSH/LH deficiency
– Males
• Testosterone
(Inj/Oral/Patch/Gel)
– Females
• Estrogen (Tab/Patch)
• Progesterone
• For fertility : hCG, hMG
• GH deficiency
• GH (Somatotropin) s.c.
• Children
• Adults
• Vasopressin
• Desmopressin
• s.c./Intranasal/Oral
• Tumors
• Trans-sphenoidal Surgery

53. Other Treatment
• Radiotherapy
• Medical

54. Treatment of Panhypopituitarism in adult
• Drugs:
1. Hydrocortisone 20mg am, 10mg pm or
Prednisalone 5mg am, 2.5mg pm.
2. Cyclical estrogen / progesterone for Women and
Testosterones for Men
3. Thyroxine 100-150

55. Diseases caused by Hypopituitarism
Pituitary dwarfism:

56. Definition
• Abnormally short height in childhood due to the lack of
growth hormone.
• Often referred to as growth hormone deficiency
• People with pituitary dwarfism lack growth hormone that is
produced in the pituitary gland, located at the base of the
brain.

57. Etiology (causes)
• GHRH (growth hormone releasing hormone deficiency) deficiency.
• GH deficiency.
• Deficient local secretion of IGF-1 by chondrocytes.
• GH insensitivity: mutation of GH receptor gene leading to defective
growth hormone receptors which will lead to decrease in linear growth
and is called Laron dwarfism. It is characterized by high serum levels of
growth hormone in the presence of low IGF-1 levels.

58. • Reduction in GH secretion in infancy or early childhood
• It occurs because of the following reasons:
a. Tumor of chromophobes, which compresses and destroys the normal
cells secreting GH
b. Deficiency of GH-releasing hormone secreted by hypothalamus
c. Atrophy or degeneration of acidophilic cells in the anterior pituitary
• Pan-hypopituitarism
– I. Reduction in the secretion of all the hormones of anterior pituitary
gland.
– II. This type of dwarfism is associated with other symptoms due to the
deficiency of other anterior pituitary hormones
• Chromosomal abnormalities

59. Treatments
• Growth hormone
injections given at
home several times a
week or daily
• Most common side
effects include fluid
retention and muscle
and joint aches

60. Hyperprolactinaemia
or
Galactorrhoea
Lecture: Clinical Approach

61. Definition of the Disease
• The hormone prolactin (lactotroph hormone) is produced in the
anterior pituitary gland.
• Hyperprolactinemia means the overproduction of prolactin.
• Prolactin is a major hormone regulating breast milk production, but it
has several other activities, as well.
• In contrast with other anterior pituitary hormones that are stimulated by
releasing hormones from the hypothalamus; prolactin is under a tonic
suppression by dopamine produced by hypothalamic cells.

62. Cont..
• Prolactinoma is mostly a benign tumor (>98%); however, some
rare malignant cases are also known.
• A pituitary adenoma smaller than 1 cm in diameter is called
microadenoma (microprolactinoma), whereas over 1 cm, it is
termed macroadenoma (macroprolactinoma).
• Prolactin is the only pituitary hormone whose serum level may
refer to the tumor size.
• Prolactinoma is the only pituitary tumor whose treatment is
primarily medical.

63. Cont…
• Prolactin inhibits the secretion of hypothalamic gonadotropin-releasing hormone
(GnRH) and also that of pituitary gonadotropins (luteinizing hormone (LH), follicle-
stimulating hormone (FSH)), and therefore prolactin overproduction can result in low
sex steroid levels in both sexes (secondary/ hypogonadotropic hypogonadism).
• It must be noted that hyperprolactinemia can have many different causes apart from
prolactinoma. These are presented in next Slides.
• One of the most important causes for hyperprolactinemia in clinical practice is
related to drugs having dopamine antagonistic properties.
• The major hormonal effects of hyperprolactinemia are related to the decreased
levels of some sex hormones and to galactorrhea (milk production in non-lactating
women or very rarely in men). Moreover,
• Pituitary macroadenomas can have mass effects/ compression symptoms due to the
large size of the tumor.

64. Causes of high plasma prolactin levels.
Hypothalamic disease:
1. Tumours compressing the hypothalamus
2. Infiltrative disease (sarcoidosis)
3. Large pituitary tumours causing stalk
compression
Metabolic:
1. Hypothyroidism
2. Chronic renal disease
Idiopathic hyperprolactemia
Physiological:
1. Pregnancy
2. Nipple stimulation
3. Sexual intercourse
4. Stress (simple venepuncture may cause PRL
elevation)
Pituitary tumours:
1. Prolactinoma
2. Non-functioning tumours (elevation of prolactin
is usually modest due to stalk compression and
lack of inhibition of prolactin secretion)
Drugs:
1. Large list including:
2. Anti-emetics
3. Antidepressants and antipsychotics
4. Opiates
5. Anti-HIV treatment

66. In Females :
 Galactorrhea (Non-puerperal lactation)
• Unilateral or bilateral
• Free floating or expressive
• Continuous or intermittent
• Ovulatory dysfunction
• Oligo-ovulation
• LPD
• Anovulation
• Menstrual troubles
• Oligomenorrhea
• Hypomenorrhea
• Amenorrhea
• Osteoporosis
• Nervous manifestations ( headache )
• Visual field defects ( Bitemporal
Hemianopia )
• Hirsutism
In Male:
1. Impotence
2. Oligospermia
3. Gynecomastia
4. Headache
5. Osteoporosis
6. Visual field defects

67. Clinical symptoms of
hyperprolactinemia in
premenopausal females:
• Menstrual irregularity: oligo-
/amenorrhea – most
common symptom
• Infertility
• Galactorrhea – 25–40% of all
cases
• Low bone mineral density
Compression symptoms/mass
effects with macroadenomas:
In postmenopausal women, these are often the
first symptoms, since estrogen levels are already
low:
• Headache.
• Impaired vision (visual loss – typically
bitemporal hemianopsia, dual vision).
• Signs of hypopituitarism (secondary
hypothyroidism, secondary adrenal
insufficiency).
• In severe cases tumors can infiltrate the
cavernous sinus leading to cerebral nerve
palsies, or even increased intracranial
pressure can occur.

68. Investigation
• Pregnancy should first be excluded before further investigations are performed in women of
child-bearing potential. The upper limit of normal for many assays of serum prolactin is
approximately 500 mIU/L (24 ng/mL).
• In non-pregnant and non-lactating patients, monomeric prolactin concentrations of 500–1000
mIU/L (24–47 ng/mL) are likely to be induced by stress or drugs, and a repeat measurement is
indicated.
• Levels between 1000 and 5000 mIU/L (47–236 ng/mL) are likely to be due to either drugs, a
microprolactinoma or ‘disconnection’ hyperprolactinaemia.
• Levels above 5000 mIU/L (236 ng/mL) are highly suggestive of a macroprolactinoma.
– Patients with prolactin excess should have tests of gonadal function , and T4 and TSH
should be measured to exclude primary hypothyroidism causing TRH-induced prolactin
excess.
• Unless the prolactin falls after withdrawal of relevant drug therapy, a serum prolactin
consistently above the reference range is an indication for MRI or CT scan of the
hypothalamus and pituitary. Patients with a macroadenoma also need tests for
hypopituitarism

69. Management
• Remember that there are four main known
causes of hyperprolactinemia and treatment is
based on that conditions.
• Pregnancy
• Drug use
• Hypothyroidism
• Pituitary tumors

70. Medical Treatment Goals
• Suppressing prolactin secretion and its
clinical and biochemicalconsequences,
• Reducing the size of the
prolactinoma, and
• Preventing its progression or
recurrence.

71. Dopamine agonists
• Are the preferred treatment for most
patients with hyperprolactinemic disorders.
• These agents are extremely effective in:
1. Lowering serum prolactin levels,
2. Eliminating galactorrhea,
3. Restoring gonadal function, and
4. Decreasing tumor size.

73. Radiotherapy
• Stereotactic radiosurgery (SRS) has
become more popular because MRI allows more
accurate resolution and dose planning.
• Radiotherapy should be considered in
patients with macroadenomas who are
resistant to or intolerant of medical therapy
and in whom surgery has failed.