Pituitary Disorders

The Endocrine System

Consists of several glands

located in various parts of the
body

Pituitary gland

The Master Gland

Primary function is to
control other glands.
Produces many hormones.
Secretion is controlled by
the hypothalamus

Hypothalamus and Pituitary

The hypothalamus-pituitary unit :
the most dominant portion of the entire
endocrine system
regulates the function of the thyroid,
adrenal and reproductive glands
also controls lactation, milk secretion and
water metabolism

Anatomy

Hypothalamus-functions

Hypothalamus- integrative center for endocrine and autonomic

nervous system
Control of some endocrine glands by neural and hormonal
pathways
Two major groups of hormones secreted: inhibiting and releasing

Hypothalamus and anterior pituitary

Midsagital view
illustrates parvicellular
neurosecretory cells
secrete releasing factors
into capillaries which are
then transported to the
anterior pituitary gland
to regulate the secretion
of pituitary hormones

Hypothalamus and posterior pituitary

Midsagital view illustrates

that magnocellular neurons
nuclei secrete oxytocin and
vasopressin directly into
capillaries in the posterior
lobe

Hypothalamic releasing hormones

Hypothalamic releasing
hormone
Corticotropin releasing
hormone (CRH)
Thyrotropin releasing
hormone (TRH)
Growth hormone releasing
hormone (GHRH)
Somatostatin
Gonadotropin releasing
hormone (GnRH)
Prolactin releasing hormone
(PRH)
Prolactin inhibiting hormone
(dopamine)

Effect on pituitary
Stimulates ACTH
secretion
Stimulates TSH and
Prolactin secretion
Stimulates GH secretion
Inhibits GH (and other
hormone) secretion
Stimulates LH and FSH
secretion
Stimulates PRL secretion
Inhibits PRL secretion

Pituitary Gland

Anterior pituitary cells and hormones

Cell type

Pituitary
population

Product

Target

Corticotroph

15-20%

ACTH
Adrenal gland
-lipotropin Adipocytes
Melanocytes

Thyrotroph
Gonadotroph
Somatotroph
Lactotroph

3-5%
10-15%
40-50%
10-15%

TSH
LH, FSH
GH
PRL

Thyroid gland
Gonads
All tissues, liver
Breasts
gonads

ANTERIOR PITUITARY
(Adenohypophysis)
ACTH

ANTERIOR
PITUITARY(adenohypophysis)
- TSH
Stimulates the thyroid
gland
metabolic rate
- GH (Growth Hormone)
stimulates growth of
bone/tissue
glucose usage
consumption of fats as
an energy source

Anterior pituitary

Posterior Pituitary
Oxytocin
stimulates gravid uterus
causes let down of milk from the breast
ADH (vasopressin)
causes the kidney to retain water.

Pituitary Tumors

PITUITARY TUMORS

10% OF ALL BRAIN TUMORS

Tumors usually cause hyper release of
hormones

Etiology of Pituitary Tumor

Non-Functioning Pituitary Adenomas
Endocrine active pituitary adenomas
Prolactinoma
Somatotropinoma
Corticotropinoma
Thyrotropinoma
Other mixed endocrine active adenomas
Malignant pituitary tumors: Functional and non-functional pituitary
carcinoma
Metastases in the pituitary (breast, lung, stomach, kidney)

Abnormal Pituitary Function

Associated with Pituitary
Tumors
Hypopituitarism
Hypersecretion of Pituitary Hormones

Hypopituitarism
Pituitary adenomas most common cause
Sequence of function loss from mass
effect:
Growth hormone GH deficiency
Gonadotropins
hypogonadism
ACTH
hypoadrenalism
TSH
hypothyroidism

Hypopituitarism

Hypopituitarism

Hypersecretion of Pituitary
Hormones
- Hyperprolactinemia
- Acromegaly
- Cushings Disease

Hypersecretion of Pituitary
Hormones

Hypersecretion of Pituitary
Hormones

Acromegaly

http://www.endotext.com/neuroendo/neuroendo5e/neuroendoframe5e.htm

Cushings Disease

Williams Textbook of Endocrinology. 8th Ed. Foster, DW, Wilson, JD (Eds), WB Saunders, Philadelphia, 1996

Cushings Syndrome vs. Cushings

Disease
Cushings syndrome is a
syndrome due to excess cortisol
from pituitary, adrenal or other
sources (exogenous
glucocorticoids, ectopic ACTH,
etc.)
Cushings disease
hypercortisolism due to excess
pituitary secretion of ACTH (about

Hypercorticolism
terti
er

secund
er

prime
r

Cushings Syndrome
Moon facies
Facial plethora
Supraclavicular
fat pads
Buffalo hump
Truncal obesity
Weight gain
Purple striae

Proximal muscle
weakness
Easy bruising
Hirsutism
Hypertension
Osteopenia
Diabetes
mellitus/IGT
Impaired immune
function/poor
wound
healing

Central Obesity in Cushings

Disease

Williams Textbook of Endocrinology. 8th Ed. Foster, DW, Wilson, JD (Eds), WB Saunders, Philadelphia, 1996

Progressive Obesity of Cushings

Disease

Age 6

Age 7

Age 8

Williams Textbook of Endocrinology. 8th Ed. Foster, DW, Wilson, JD (Eds), WB Saunders, Philadelphia, 1996

Age 9

Age

Buffalo Hump in Cushings

Disease

Orth, D. UpToDate

Striae in Cushings Disease

Orth, D. UpToDate

SIGNS & SYMPTOMS: Cushings

Evaluation of Pituitary Mass

Clinical Evaluation
Hormonal Evaluation
Radiologic Evaluation

Clinical Evaluation

examined for clinical signs suspicious for

pituitary hyperfunction or hypofunction

Hormonal Evaluation
Basal hormone measurement and
dynamic stimulation testing.
Screening basal hormone
measurements :

Prolactin
TSH, FT4
ACTH, AM cortisol, midnight salivary cortisol
LH, FSH, estradiol or testosterone
Insulin-like growth factor-1 (IGF-1)

Mulinda, J. Pituitary Macroadenomas, 9/19/05. http://www.emedicine.com/med/topic1379.htm

Hormonal Evaluation
Dynamic stimulation/suppression testing :
may be useful in select cases to further
evaluate pituitary reserve and/or for
pituitary hyperfunction

Dexamethasone suppression testing

Oral glucose GH suppression test
GHRH
CRH stimulation
TRH stimulation
GnRH stimulation
Insulin-induced hypoglycemia

Mulinda, J. Pituitary Macroadenomas, 9/19/05. http://www.emedicine.com/med/topic1379.htm

Dexametason test
Low dose : 2 mg
High dose : 8 mg

Glucosa GH suppression test

75 g
Glucosa

GHRH

TRH Stimulating
N

N/

CRH Stimulating

Inf Petrosal Sinus Sampling

GnRH stimulation

Radiologic Evaluation
MRI
Preferred imaging study for the pituitary
Better visualization of soft tissues and vascular
structures than CT
Structures such as fatty marrow and orbital fat
show up as bright images.
high-intensity signals of structures with high
water content, such as cerebrospinal fluid and
cystic lesions

Mulinda, J. Pituitary Macroadenomas, 9/19/05. http://www.emedicine.com/med/topic1379.htm

Radiologic Evaluation
CT-scan

Better at visualizing bony structures and calcifications

within soft tissues
Better at determining diagnosis of tumors with
calcification, such as germinomas, craniopharyngiomas,
and meningiomas
May be useful when MRI is contraindicated, such as in
patients with pacemakers or metallic implants in the
brain or eyes
Disadvantages include:
less optimal soft tissue imaging compared to MRI
use of intravenous contrast media
exposure to radiation

Diagnosis
Usually delayed non specific nature of
symptoms
MRI imaging modality of choice
Tests can reveal whether adenoma is
hypo- or hyperfunctional

DIAGNOSIS -- deficiency

DIAGNOSIS - excess

Dexametason test

TREATMENT

DIABETES INSIPIDUS
Diabetes insipidus is a disorder of the
posterior lobe of the pituitary gland
characterized by a deficiency of antidiuretic
hormone (ADH), or vasopressin. Great
thirst (polydipsia) and large volumes of
dilute urine characterize the disorder.

A) Central diabetes insipidus

Head trauma or surgery
Pituitary or hypothalamic
tumor
Intracerebral occlusion or
infection

B) Nephrogenic diabetes insipidus

Systemic diseases involving
the kidney
Multiple myeloma
sickle cell anemia
Polycystic kidney disease
Pyelonephritis
Medications such as lithium

T
Y
P
E

Pathophysiology
Central DI :
Loss of vasopressinproducing cells,
Causing deficiency in
antidiuretic hormone
(ADH) synthesis or
release;
Deficiency in ADH,
resulting in an inability
to conserve water,
leading to extreme
polyuria and polydipsia

Pathophysiology
Nefrogenic DI
Depression of
aldosterone release
or inability of the
nephrons to respond
to ADH,
causing extreme
polyuria and
polydipsia

Signs and symptoms

Polyuria with urine output of 5 to 15 L daily
Polydipsia, especially a desire for cold
fluids
Marked dehydration, as evidenced by dry
mucous membranes, dry skin, and weight
loss
Anorexia and epigastric fullness
Nocturia and related fatigue from
interrupted sleep

Diagnostic test results

High serum osmolality, usually above 300
mOsm/kg of water
Low urine osmolarity, usually 50 to 200
mOsm/kg of water;
low urine-specifi c gravity of less than 1.005
Increased creatinine and blood urea nitrogen
(BUN) levels resulting from dehydration
Positive response to water deprivation test:
Urine output decreases and specific gravity
increases

Water deprivation test

Goals of management
The objectives of therapy are
(1)to replace ADH (which is usually a
long-term therapeutic program),
(2) to ensure adequate fluid
replacement, and
(3) to identify and correct the
underlying cause

Treatments
Replacement vasopressin therapy
with intranasal or I.V. DDAVP
(desmopressin acetate)
Correction of dehydration and
electrolyte imbalances

Treatment
A thiazide diuretic to deplete sodium
and increase renal water
reabsorption
Restriction of salt and protein intake