Pituitary Disorders

The Endocrine System

• Consists of several glands

located in various parts of the
Pituitary gland
body

“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
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 Effect on pituitary

Corticotropin releasing hormone Stimulates ACTH secretion

(CRH)
Thyrotropin releasing hormone Stimulates TSH and Prolactin
(TRH) secretion
Growth hormone releasing Stimulates GH secretion
hormone (GHRH)
Somatostatin Inhibits GH (and other hormone)
secretion
Gonadotropin releasing hormone Stimulates LH and FSH secretion
(GnRH)
Prolactin releasing hormone (PRH) Stimulates PRL secretion

Prolactin inhibiting hormone Inhibits PRL secretion

(dopamine)
 Pituitary Gland

Posterior • oxytocin
Pituitary • ADH

• Thyroid-stimulating hormone (TSH)

• Growth hormone (GH)
Anterior • Adrenocorticotropin (ACTH)
Pituitary • Follicle-stimulating hormone (FSH)
• Prolactin
• Luteinizing hormone (LH)
 Anterior pituitary cells and hormones

Cell type Pituitary Product Target

population
Corticotroph 15-20% ACTH Adrenal gland
b-lipotropin Adipocytes
Melanocytes
Thyrotroph 3-5% TSH Thyroid gland
Gonadotroph 10-15% LH, FSH Gonads
Somatotroph 40-50% GH All tissues, liver
Lactotroph 10-15% PRL 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

• promotes mammary gland growth

Prolactin and milk secretion

• stimulates growth of ovarian

FSH follicles & spermatogenesis in males

• regulates growth of gonads &

LH reproductive activities
 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

• decreased muscle strength

• decreased exercise tolerance
GH deficiency • diminished libido
• increased body fat

• oligo/amenorrhea
• diminished libido
Gonadotropin • Infertility
deficiency • dypareunia
• impotence
• osteopenia
 Hypopituitarism
• malaise
• fatigue
ACTH • anorexia
deficiency • hypoglycemia
• mineralocorticoid secretion is preserved

• malaise
• leg cramps
• fatigue
TSH deficiency • dry skin,
• cold intolerance
• clinically similar to primary hypothroidism
Hypersecretion of Pituitary Hormones

- Hyperprolactinemia
- Acromegaly
- Cushing’s Disease
 Hypersecretion of Pituitary Hormones
• oligo/amenorrhea
• galactorrhea
• infertility
Prolactinoma • osteopenia
• decreased libido
• headaches
• visual field defects

• ventricular hypertrophy/diastolic
dysfunction
• sleep apnea
Acromegaly • peripheral neuropathy
• muscular atrophy
• often insidious and may be missed
 Hypersecretion of Pituitary Hormones

• central obesity
• supraclavicular fat pads,
Cushing’s • proximal myopathy, wide
• purplish striae (> 1cm)
Disease • skin atrophy
• spotaneous ecchymoses,
• hypokalemia

• heat intolerance
• weight loss
TSH secreting • weakness, tremor
• sinus tachycardia
adenoma • atrial fibrillation
• heart failure
• clinically similar to primary hyperthyroidism
 Acromegaly

http://www.endotext.com/neuroendo/neuroendo5e/neuroendoframe5e.htm
 Cushing’s Disease

William’s Textbook of Endocrinology. 8th Ed. Foster, DW, Wilson, JD (Eds), WB Saunders, Philadelphia, 1996
Cushing’s Syndrome vs. Cushing’s Disease

• Cushing’s syndrome is a syndrome due to

excess cortisol from pituitary, adrenal or
other sources (exogenous glucocorticoids,
ectopic ACTH, etc.)

• Cushing’s disease
hypercortisolism due to excess pituitary
secretion of ACTH (about 70% of cases of
endogenous Cushing’s syndrome)
 Cushing’s Syndrome

• Moon facies • Proximal muscle

• Facial plethora weakness
• Supraclavicular fat • Easy bruising
pads • Hirsutism
• Hypertension
• Buffalo hump • Osteopenia
• Truncal obesity • Diabetes mellitus/IGT
• Weight gain • Impaired immune
• Purple striae function/poor wound
healing
 Central Obesity in Cushing’s Disease

William’s Textbook of Endocrinology. 8th Ed. Foster, DW, Wilson, JD (Eds), WB Saunders, Philadelphia, 1996
 Progressive Obesity of Cushing’s Disease

Age 6 Age 7 Age 8 Age 9 Age 11

William’s Textbook of Endocrinology. 8th Ed. Foster, DW, Wilson, JD (Eds), WB Saunders, Philadelphia, 1996
 Buffalo Hump in Cushing’s Disease

Orth, D. UpToDate
 Striae in Cushing’s Disease

Orth, D. UpToDate
SIGNS & SYMPTOMS: Cushing’s
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

 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
• insulin tolerance test, GH-RH/arginine test,
GH IGF-1 levels

• sexual history
• menstrual history
Gonadotropins • FSH/LH/estradiol/Prolactin/testosterone
levels

• AM cortisol, cosyntropin test

ACTH • insulin tolerance test

• T4
TSH • TSH levels
 DIAGNOSIS - excess
• prolactin level, drug history, clinical setting (e.g.
Prolactinoma pregnancy, breast stimulation, stress, hypoglycemia

• IGF-1 level
Acromegaly • oral glucose tolerance test

Cushing’s • 24 hr urine cortisol

disease • overnight dexamethasone suppression test

TSH • free T4, T3, TSH levels

overproduction
 TREATMENT
surgical
resection
dopamine • prolactinoma
agonist therapy
• agromegaly
Octreotide • TSH producing adenomas

Deficiency • require replacement of the indicated

states hormone