In station 5 you may be asked to assess a patient with headache, bumping into things etc.
History (3 minutes):
- Timing questions: when did symptoms start, did they come on suddenly/gradually, are they getting worse, intermittent (eg. times of stress)/constant symptoms
- Headache
- Change in vision- bumping into things, double vision, blurring
- Gonadotropin deficiency: reduced sex drive, no/irregular periods, difficulty conceiving, hot flushes, reduced breast size, reduced body hair
- GH deficiency: weight gain
- TSH deficiency: feeling cold, dry skin, hair loss, tired, constipated, puffy face, weight gain
- ACTH deficiency (secondary adrenal insufficiency): dizzy on standing, tired, weak, off food, weight loss, nausea, vomiting, abdo pain NB: no hyperpigmentation and no salt wasting compared with primary adrenal insufficiency
- PMH (pituitary surgery, radiation, cancer, head injury), Fx, Dx, Sx
Examine (3 minutes):
- Weight, reduced body hair, pale
- Neuro exam including cranial nerves (bitemporal visual field defect)
- Fundoscopy
- Systemic examination
ICE and Explanation (2 minutes)
VIVA
Hypopituitarism:
Deficiency of one/several/all of the anterior pituitary hormones
The secretion of gonadotropins and growth hormone is more likely to be affected than ACTH and thyroid-stimulating hormone (TSH).
Causes of hypopituitarism:
- Pituitary tumour: often non-functioning macroadenoma but can be adenoma secreting prolactin/GH/ACTH/TSH with compression of remaining tissues
- Iatrogenic (pituitary surgery/radiation therapy to pituitary or hypothalamus for CNS/nasopharyngeal malignancies)
- Compression/infiltration due to meningioma/craniopharyngioma/metastasis/sarcoid/tuberculoma/haemochromatosis/abscess
- Pituitary apoplexy (acute infarction of a pituitary adenoma)
- Head injury and stroke and meningitis
- Infarction of pituitary (Sheehan Syndrome)
- Empty sella syndrome
Investigations:
FBC, U+E (low Na), Glucose (low)
9am cortisol (low), TFTs (TSH can be low/normal/high, low T4), LH (low), FSH (low), morning testosterone (low), oestradiol (low), IGF-1 (low), prolactin (low or raised)
CT/MRI head/pituitary
Management:
Hormone replacement (hydrocortisone, levothyroxine, sex hormones, growth hormone)
Surgery: transphenoidal surgery if mass effect
Written by Dr Sarah Kennedy
Resources used to write this document include those listed in the references section of this webpage and also:
https://patient.info/doctor/hypopituitarism-pro