Panhypopituitarism

Question 1

Symptoms / clinical features of panhypopituitarism? (5)

Answer 1

Symptoms of each hormone deficiencies.

Try and identify which hormone is affected.

ACTH: adrenal insufficiency - fatigue, hypoglycaemia, postural dizziness/falls

TSH: slowness - fatigue, slow thinking, constipation, bradycardia, anaemia

LH/FSH - Male (infertility, loss of libido and energy), Female (amenorrhea, infertility, vaginal atrophy, hot flushes - i.e. symptoms of menopause)

GH: decrease in BMD/#, increased CV risk

Prolactin: inability to lactate during breastfeeding.

Question 2

What are the causes/risk factors for Panhypopituitarism? (5)

Answer 2

Basically: mass (Adenoma, carcinoma, mets), surgery/trauma, RTx, stroke and infiltration.

Pituitary

• Adenoma, carcinoma, mets
• Surgery and RTx
• Infiltrative: sarcoid, haemochromatosis, lymphocytic hypophysitis
• infarction/haemorrhage (e.g. Sheehan’s)

Hypothalamic

• Benign tumours (craniopharyngioma)
• Malignant tumours or mets
• Stroke/bleed.
• Cranial irradiation (e.g. SCLC)
• Infiltrative as above

Question 3

Investigations to review for panhypopituitarism?

Answer 3

T: Pituitary hormones level, Provocative testing (e.g. SynACTHen), MRI brain

Exclude other causes for symptoms: anaemia, hypoglycaemia, infection, depression

Screen for complications: postural BP, investigate for CV risk factors (GH deficiency - inc CV risk - lipid BGL, profiles, HBA1C, ECG), BMD (OP with hypothyroid, GH def)

Question 4

Pharmacological management of Panhypopituitarism? (5)

Answer 4

All: Hydrocortisone, Thyroxine

Males: testosterone (PO, IM, transdermal)

Females: oestrogen/progesterone (PO, transdermal, implantable)

Pulsatile GnRH agonist for fertility

Question 5

What are complications associated with testosterone therapy? (3)

Answer 5

OSA

VTE

CV risks

Question 6

What is your approach to managing this patient’s panhypopituitarism?

Answer 6

Goals: minimise symptoms, effect of end-organ insufficiency, prevent complications

Confirm dx: review pituitary panel, gland hormone levels, MRIB, any results of provocative testing

A: screen & treat depression, anaemia, infection

Screen for complications: postural BP (if not done), ECG (GH), lipid profiles/glucose/HBA1C, DEXA

T: Non-pharm

• Educate: with goal of improving their understanding and foster self-efficacy - complications, falls, infection, CV, bone health risk
• Sick day plan: stress-dosing steroids
• Lifestyle to moderate CV risk factors: balanced-high-fibre-low-fat diet, mod-exercise, weight loss, smoking/alcohol
• Maintain optimal Ca/Vit D
• Infection prophylaxis - vaccinate
• Safety: falls prevention, OT/PT
• Discuss options for family planning if young (GnRH agonist to increase fertility)

T: Pharm

• Manage HTN, DM, dyslipidaemia
• OP management
• Hydrocortisone + Thyroxine for all
• Testosterone for men, estrogen/progesterone for female
• No GH