Hypopituitarism

  • Diagnosis
  • Algorithms
  • Background
  • Lab Tests
  • References
  • Related Content

Indications for Testing

  • Anterior pituitary – symptoms compatible with multiple pituitary hormone deficiencies
    • Fatigue, depression, and other endocrine dysfunction
  • Posterior pituitary – symptoms of central diabetes insipidus
    • Polydipsia, polyuria, and nocturia
    • Children – fever, weight loss, irritability, delayed growth

Laboratory Testing

  • Anterior pituitary testing
  • Posterior pituitary testing
    • Urine osmolality (UO) and/or serum/plasma osmolality (SO) and serum/plasma sodium (Na)
      • UO<SO and high Na – central diabetes insipidus
      • UO<250 mOsm/Kg and low Na – primary polydipsia
      • UO<SO and normal Na – perform water deprivation test in hospital and order SO
        • SO>290 mOsm/kg, Na>140 mmol/L, and weight loss nearing 3% – diabetes insipidus
            • Order ADH/AVH plasma
              • Low ADH/AVH – central diabetes insipidus
              • High ADH/AVH– nephrogenic diabetes insipidus
            • Alternatively, administer vasopressin, and order UO 1-2 hours post administration
              • >50% increased UO – central diabetes insipidus
              • <50% increased UO – nephrogenic diabetes insipidus

Histology

  • Immunohistochemistry if pituitary adenoma is present – consider prolactin, growth hormone, ACTH, or TSH

Imaging Studies

  • MRI usually required to identify sellar and parasellar masses

Central Diabetes Insipidus (Posterior Pituitary) Testing Algorithm

Hypopituitarism (Anterior Pituitary) Testing Algorithm

The pituitary gland, often referred to as the master gland, controls the function of multiple endocrine glands. Hypopituitarism is defined as either partial or complete deficiency of anterior or posterior pituitary hormone secretion.

Epidemiology

  • Incidence  – 4-5/100,000
  • Age – incidence increases with age

Etiology

Pathophysiology

  • Anterior pituitary produces 6 major hormones
  • Posterior pituitary produces
    •  Oxytocin
    • Antidiuretic hormone/arginine vasopressin hormone (ADH/AVH)
  • Any insult to gland or vascular supply may cause hormone deficiency (hypopituitarism)
    • Loss of any of these hormones will produce symptoms based on the hormones lost

Clinical Presentation

  • Varied – dependent on the region of pituitary gland involved and age of patient
  • Nonspecific
    • Headache
    • Visual disturbances
    • Weakness
  • Anterior pituitary
    • Gonadotropic hormones (FSH, LH, PRL)
    • GH
      • Adults – fatigue, decreased muscle mass and strength, reduced bone marrow density
      • Children – short stature, failure to thrive
      • Infants – seizures, hypoglycemia
    • ACTH
      • Adults – fatigue, nausea, vomiting
      • Children/infants – acute adrenal crises with shock
    • TSH
      • Adults – weight gain, coarse hair, fatigue
      • Children/infants – failure to thrive
  • Posterior pituitary (hypothalamic)
    • Central diabetes insipidus
      • Adults – polydipsia, polyuria, nocturia
      • Children – vomiting, diarrhea, dry skin, weight loss, irritability
      • Infants – fever, unusually wet diapers (polyuria), delayed growth, irritability

Treatment

  • Hormone replacement based on deficiencies

Indications for Laboratory Testing

Tests generally appear in the order most useful for common clinical situations.
Click on number for test-specific information in the ARUP Laboratory Test Directory

Cortisol, Serum 0070030
Method: Quantitative Chemiluminescent Immunoassay

Adrenocorticotropic Hormone 0070010
Method: Quantitative Chemiluminescent Immunoassay

11-Deoxycortisol Quantitative by HPLC-MS/MS, Serum or Plasma 0092331
Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry

Thyroid Stimulating Hormone with reflex to Free Thyroxine 2006108
Method: Quantitative Electrochemiluminescent Immunoassay

Luteinizing Hormone and Follicle Stimulating Hormone 0070193
Method: Quantitative Electrochemiluminescent Immunoassay

Testosterone, Free and Total (Includes Sex Hormone Binding Globulin), Adult Male 0070109
Method: Quantitative Electrochemiluminescent Immunoassay
The concentration of free testosterone is derived from a mathematical expression based on the constant for the binding of testosterone to sex hormone binding globulin. 

Estradiol, Adult Premenopausal Female, Serum or Plasma 0070045
Method: Quantitative Chemiluminescent Immunoassay

Estrogens, Fractionated by Tandem Mass Spectrometry 0093248
Method: Quantitative High Performance Liquid Chromatography-Tandem Mass Spectrometry

Prolactin 0070115
Method: Quantitative Chemiluminescent Immunoassay

IGF-1 (Insulin-Like Growth Factor 1) 0070125
Method: Quantitative Chemiluminescent Immunoassay

IGF Binding Protein-3 0070060
Method: Quantitative Chemiluminescent Immunoassay

Growth Hormone 0070080
Method: Quantitative Chemiluminescent Immunoassay

Osmolality, Urine 0020228
Method: Freezing Point

Osmolality, Serum or Plasma 0020046
Method: Freezing Point

Sodium, Plasma or Serum 0020001
Method: Quantitative Ion-Selective Electrode

Arginine Vasopressin Hormone 0070027
Method: Quantitative Radioimmunoassay

ACTH by Immunohistochemistry 2003427
Method: Immunohistochemistry

Growth Hormone by Immunohistochemistry 2003929
Method: Immunohistochemistry

Prolactin by Immunohistochemistry 2004109
Method: Immunohistochemistry

Additional Tests Available

Thyroid Stimulating Hormone 0070145
Method: Quantitative Chemiluminescent Immunoassay

Thyroxine, Free (Free T4) 0070138
Method: Quantitative Electrochemiluminescent Immunoassay

Testosterone Free, Adult Male 0070111
Method: Quantitative Electrochemiluminescent Immunoassay
Total Testosterone and SHBG are measured and free testosterone is estimated from these measurements.

Follicle Stimulating Hormone, Serum 0070055
Method: Quantitative Electrochemiluminescent Immunoassay

Luteinizing Hormone, Serum 0070093
Method: Quantitative Electrochemiluminescent Immunoassay

Adrenocorticotropic Hormone Stimulation, 0 Minutes 0070031
Method: Quantitative Chemiluminescent Immunoassay

Guidelines

Ghigo E, Masel B, Aimaretti G, Léon-Carrión J, Casanueva F, Dominguez-Morales M, Elovic E, Perrone K, Stalla G, Thompson C, Urban R. Consensus guidelines on screening for hypopituitarism following traumatic brain injury. Brain Inj. 2005; 19(9): 711-24. PubMed

General References

Darzy K, Shalet S. Hypopituitarism following radiotherapy. Pituitary. 2009; 12(1): 40-50. PubMed

Kargi A, Merriam G. Diagnosis and treatment of growth hormone deficiency in adults. Nat Rev Endocrinol. 2013; 9(6): 335-45. PubMed

Kelberman D, Dattani M. Hypopituitarism oddities: congenital causes. Horm Res. 2007; 68 Suppl 5: 138-44. PubMed

Nakamoto J. Laboratory diagnosis of multiple pituitary hormone deficiencies: issues with testing of the growth and thyroid axes. Pediatr Endocrinol Rev. 2009; 6 Suppl 2: 291-7. PubMed

Prabhakar V, Shalet S. Aetiology, diagnosis, and management of hypopituitarism in adult life. Postgrad Med J. 2006; 82(966): 259-66. PubMed

Schneider H, Aimaretti G, Kreitschmann-Andermahr I, Stalla G, Ghigo E. Hypopituitarism. Lancet. 2007; 369(9571): 1461-70. PubMed

Toogood A, Stewart P. Hypopituitarism: clinical features, diagnosis, and management. Endocrinol Metab Clin North Am. 2008; 37(1): 235-61, x. PubMed

References from the ARUP Institute for Clinical and Experimental Pathology®

Gronowski A, Fantz C, Parvin C, Sokoll L, Wiley C, Wener M, Grenache D. Use of serum FSH to identify perimenopausal women with pituitary hCG. Clin Chem. 2008; 54(4): 652-6. PubMed

Thienpont L, Van Uytfanghe K, Blincko S, Ramsay C, Xie H, Doss R, Keevil B, Owen L, Rockwood A, Kushnir M, Chun K, Chandler D, Field H, Sluss P. State-of-the-art of serum testosterone measurement by isotope dilution-liquid chromatography-tandem mass spectrometry. Clin Chem. 2008; 54(8): 1290-7. PubMed

Medical Reviewers

Last Update: January 2016