Clinical presentation of hypopituitarism depends on the severity of the disease. It can be asymptomatic or mild to severe as in the case of a hypopituitary coma or an acute pituitary failure. In most patients the hypopituitarism presents itself as an endocrine dysfunction such as:

Adrenocorticotrophic deficiency

Acute symptoms include weakness, nausea, dizziness, vomiting, fever, circulatory collapse and shock. Chronic symptoms are fatigue, anorexia, weight loss and pallor. In children delayed puberty, failure to thrive, hypotension, anemia, hypoglycemia, lymphocytosis, eosinophilia and hyponatremia may occur.

Thyroid stimulating hormone deficiency

Various symptoms include weight gain, hypotension, bradycardia, cold intolerance, constipation, hair loss, cognitive slowing hoarseness and dry skin.

Growth hormone deficiency

Deficiency of growth hormone may result in a short stature, reduced muscle mass and strength, fatigue, visceral obesity, dyslipidemia, atherosclerosis, impaired memory and attention and a decreased quality of life. In children severe growth restriction has been documented.

Antidiuretic hormone deficiency

The symptoms of decreased antidiuretic hormone secretion include, a reduced urine osmolality, polydipsia, polyuria and hypernatremia.

• Fatigue

  In adults, the deficiency is linked to fatiguability, increased body fat, low muscle mass and a higher risk for the development of cardiovascular disease. [news-medical.net]

  Symptoms of ACTH and cortisol deficiency With gradual onset of deficiency over days or weeks, symptoms may include: Weight loss Fatigue Weakness Depression Apathy Nausea Vomiting Loss of appetite Abdominal pain As ACTH deficiency becomes more severe or [pacificneuroscienceinstitute.org]

  Symptoms and signs of central hypothyroidism might include weakness, fatigue, decreased energy, increased need for sleep, cold intolerance, and weight gain. [pituitaryworldnews.org]

  KEYWORDS: Fatigue; Hormones; Pituitary [ncbi.nlm.nih.gov]

• Weight Gain

  Symptoms and signs of central hypothyroidism might include weakness, fatigue, decreased energy, increased need for sleep, cold intolerance, and weight gain. [pituitaryworldnews.org]

  Clinical presentation is often insidious being characterized by non-specific manifestations, such as weight gain, fatigue, low muscle strength, bradipsychism, hypotension or intolerance to cold. [ncbi.nlm.nih.gov]

  Symptoms and Signs of Pituitary Hormone Deficiency Pituitary Hormone Target Organs Effect of Deficiency ACTH Adrenal glands: cortisol and DHEA Fatigue, low sodium in blood, weight loss, skin pallor TSH Thyroid gland: thyroid hormone Fatigue, weight gain [pituitarysociety.org]

  GH deficiency During childhood: dwarfism (see short stature) During adulthood: usually asymptomatic; subtle findings include weight gain, weakness, and depression Prolactin deficiency Females: lactation failure following delivery Males: asymptomatic FSH [amboss.com]

• Cold Intolerance

  Symptoms of Thyroid stimulating hormone deficiency Symptoms tend to be unspecific and may include: Decreased energy level Increased need to sleep Cold intolerance Dry skin Constipation Muscle aches Mood swings and memory loss Treatment of Thyroid stimulating [pacificneuroscienceinstitute.org]

  Symptoms and signs of central hypothyroidism might include weakness, fatigue, decreased energy, increased need for sleep, cold intolerance, and weight gain. [pituitaryworldnews.org]

  Signs and symptoms of secondary hypothyroidism include fatigue, weakness, weight gain, thickened subcutaneous tissues, constipation, cold intolerance, altered mental status, impaired memory, and anemia. [emedicine.com]

  Tiredness, cold intolerance, constipation, hair loss, dry skin, hoarseness, cognitive slowing. Weight gain, bradycardia, hypotension. Children: delayed development, growth restriction and intellectual impairment. [patient.info]

  Signs and symptoms of hypothyroidism can include weight gain, fatigue, dry skin, constipation, cold intolerance and hair loss. [pituitary.mgh.harvard.edu]

• Pallor

  Symptoms and Signs of Pituitary Hormone Deficiency Pituitary Hormone Target Organs Effect of Deficiency ACTH Adrenal glands: cortisol and DHEA Fatigue, low sodium in blood, weight loss, skin pallor TSH Thyroid gland: thyroid hormone Fatigue, weight gain [pituitarysociety.org]

  Observe eyelids, nails beds and skin pallor which indicate anemia. Ensure safety prequitions for patients with impaired visual field. Wet the eye with sterile water to provide comfort to the eye. [nursingexercise.com]

  A deficiency can lead to symptoms such as: Fatigue Low blood pressure Low serum sodium levels Low hemoglobin levels leading to pallor Low blood glucose In such patients, any crisis situation which puts increased stress on the body such as serious infections [news-medical.net]

  Chronic: fatigue, pallor, anorexia, weight loss. Acute: weakness, dizziness, nausea, vomiting, circulatory collapse, fever, shock. Children: delayed puberty, failure to thrive. [patient.info]

• Hypothermia

  May be triggered by infection, trauma, surgery, hypothermia or pituitary haemorrhage. [patient.info]

  A severe deficiency in TSH also has the potential to cause hypothermia, coma and death in rare cases. Children with abnormally low TSH levels are mentally and physically backward. [news-medical.net]

  TSH – central hypothyroidism, which can present in extreme state with myxedema coma à altered mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, and CHF/cardiogenic shock ! 3. [errolozdalga.com]

  Some of the clinical features of hypopituitary coma include meningism, hormonal deficiencies, hypotension, ophthalmoplegia, reduced consciousness, visual field defects, hypoglycemia and hypothermia. [symptoma.com]

• Constipation

  […] hoarseness Sensitivity to cold or difficulty staying warm Slow heartbeat; intolerance to cold Slowed or impaired thinking Abdominal discomfort Facial puffiness Extreme thirst combined with excessive urination (due to diabetes insipidus), dehydration, and constipation [healthcommunities.com]

  TSH deficiency causing thyroid hormone deficiency: Symptoms include fatigue, weakness, difficulty losing weight, generalized body puffiness, feeling cold, constipation, difficulty with memory and an inability to concentrate. [pituitarysociety.org]

  Symptoms of Thyroid stimulating hormone deficiency Symptoms tend to be unspecific and may include: Decreased energy level Increased need to sleep Cold intolerance Dry skin Constipation Muscle aches Mood swings and memory loss Treatment of Thyroid stimulating [pacificneuroscienceinstitute.org]

  We started treatment with oral levothyroxine (25μg/day) for central hypothyroidism, which improved the constipation and psychomotor development. [elsevier.es]

• Nausea

  Abstract A 50-year-old woman presented with a headache and nausea. A sellar and suprasellar mass was detected on MRI; the tumor was heterogeneously enhanced with gadolinium, and the pituitary stalk was slightly thickened. [ncbi.nlm.nih.gov]

  EMERGENCY Nausea, vomiting, extreme weakness, dehydration, and fever suggest adrenal insufficiency that may require emergency medical care. [healthcommunities.com]

  Symptoms of ACTH and cortisol deficiency With gradual onset of deficiency over days or weeks, symptoms may include: Weight loss Fatigue Weakness Depression Apathy Nausea Vomiting Loss of appetite Abdominal pain As ACTH deficiency becomes more severe or [pacificneuroscienceinstitute.org]

• Polydipsia

  BACKGROUND: A 42-year-old woman presented to the neuroendocrine unit of a hospital with recent-onset polydipsia, polyuria and oligomenorrhea. She had no visual symptoms, head injury or history of malignancy. [ncbi.nlm.nih.gov]

  Large lesions involving the hypothalamus: polydipsia and inappropriate secretion of antidiuretic hormone. [patient.info]

  Diagnosis Indications for Testing Anterior pituitary – symptoms compatible with multiple pituitary hormone deficiencies Fatigue, depression, and other endocrine disorders Posterior pituitary – symptoms of central diabetes insipidus Polydipsia, polyuria [arupconsult.com]

• Failure to Thrive

  […] of pubertal development Infants – cryptorchidism, microphallus 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 [arupconsult.com]

  Acute deficiency may present as: Nausea Vomiting Dizziness circulatory collapse Children may manifest failure to thrive and poor growth. [news-medical.net]

  Children: delayed puberty, failure to thrive. Hypoglycaemia, hypotension, anaemia, lymphocytosis, eosinophilia, hyponatraemia. Thyroid-stimulating hormone (TSH) deficiency: See also the separate Hypothyroidism article. [patient.info]

  In children delayed puberty, failure to thrive, hypotension, anemia, hypoglycemia, lymphocytosis, eosinophilia and hyponatremia may occur. [symptoma.com]

• Abdominal Pain

  Symptoms of ACTH and cortisol deficiency With gradual onset of deficiency over days or weeks, symptoms may include: Weight loss Fatigue Weakness Depression Apathy Nausea Vomiting Loss of appetite Abdominal pain As ACTH deficiency becomes more severe or [pacificneuroscienceinstitute.org]

  Overall symptoms may include fatigue, sensitivity to cold, weakness, decreased appetite, weight loss and abdominal pain. Low blood pressure, headache and visual disturbances are other associated symptoms. [medical-dictionary.thefreedictionary.com]

  Signs and symptoms of ACTH deficiency may be profound and potentially fatal; they include myalgias, arthralgias, fatigue, headache, weight loss, anorexia, nausea, vomiting, abdominal pain, altered mentation or altered consciousness, dry wrinkled skin, [emedicine.com]

  Other symptoms and signs include weakness, headache, abdominal pain, low blood pressure, vision problems, facial swelling, hoarseness, joint stiffness, and loss of pubic or armpit hair. Causes of hypopituitarism Hypopituitarism has many causes. [medicinenet.com]

  ACTH deficiency causing cortisol deficiency: Symptoms include weakness, fatigue, weight loss, abdominal pain, low blood pressure and low serum sodium levels. [pituitarysociety.org]

• Hypotension

  Patients with adrenal crisis and hypotension require immediate treatment. In patients with coronary artery disease, thyroxine can worsen the patient’s cardiac condition. [clinicaladvisor.com]

  In children delayed puberty, failure to thrive, hypotension, anemia, hypoglycemia, lymphocytosis, eosinophilia and hyponatremia may occur. [symptoma.com]

  Acute loss of adrenal function is a medical emergency and may lead to hypotension and death if not treated. [emedicine.com]

  Hypoglycaemia, hypotension, anaemia, lymphocytosis, eosinophilia, hyponatraemia. Thyroid-stimulating hormone (TSH) deficiency: See also the separate Hypothyroidism article. [patient.info]

  Unexplained hypoglycemia (100%) and hypotension (66.7%) were the most common findings at presentation. [ncbi.nlm.nih.gov]

• Diplopia

  Four months later, he presented with a sudden onset of diplopia, syncope, headache, general malaise and loss of appetite. Magnetic resonance imaging of the brain revealed a tumorous process of the sellar region. [ncbi.nlm.nih.gov]

  […] hypoglycemia (see adrenal insufficiency) Central diabetes insipidus: : polyuria, polydipsia Intrasellar/parasellar masses (e.g., pituitary macroadenomas, craniopharyngiomas) can present with headache, visual field defects (bitemporal hemianopsia), and/or diplopia [amboss.com]

  Case presentation, management and outcome A 39-year-old Malay woman presented at our institution in July 2013 with a 1-week history of painful diplopia associated with drooping of right upper eyelid preceded by a 2-week history of intermittent pre-syncopal [edmcasereports.com]

• Thin Skin

  They include abnormal body composition with increased adiposity, thin skin, osteopenia, hyperlipidemia, insulin resistance and diminished quality of life (10, 11). [scielo.org.ar]

• Arthralgia

  Within days, he developed severe fatigue, myalgias and arthralgias. Initial testing demonstrated central hypogonadism, followed by a low normal insulin-like growth factor-1 and an abnormal L-dopamine growth hormone stimulation test result. [ncbi.nlm.nih.gov]

  Signs and symptoms of ACTH deficiency may be profound and potentially fatal; they include myalgias, arthralgias, fatigue, headache, weight loss, anorexia, nausea, vomiting, abdominal pain, altered mentation or altered consciousness, dry wrinkled skin, [emedicine.com]

  Lean Tanned Tired Tearful Weakness Anorexia Dizzy Giants Flu-like myalgias/arthralgias Depression / psychosis / low self-esteem N&V, abdominal pain, diarrhoea / constipation No skin pigmentation as low ACTH – usually adrenal insufficiency e.g. with [almostadoctor.co.uk]

  Side effects may include soft tissue swelling and edema, arthralgias, myalgias, headache, and carpal tunnel syndrome. [endocrinologyadvisor.com]

• Loss of Libido

  Gonadotrophin deficiency: Women: oligomenorrhoea, loss of libido, dyspareunia, infertility, osteoporosis. [patient.info]

  […] of axillary and pubic hair In women: cessation of menstruation (amenorrhea), breast atrophy, vaginal dryness, absence of milk production in new mothers (Sheehan’s syndrome) In men: loss of libido and potency, reduced muscular strength, shrinking and [healthcommunities.com]

  In man, sex hormone deficiency might lead to weakness, decreased strength, gain in fat mass, easy fatigability, loss of muscle mass, depression, emotional lability, hot flashes and flushes, diminished or loss of libido, erectile dysfunction including [pituitaryworldnews.org]

  LH and FSH deficiency in Men : LH and FSH deficiency may cause loss of libido (interest in sexual activity), difficulty in achieving and sustaining an erection and infertility due to a low sperm count, and osteoporosis, which can result in a tendency [pituitarysociety.org]

• Breast Atrophy

  atrophy, vaginal dryness, absence of milk production in new mothers (Sheehan’s syndrome) In men: loss of libido and potency, reduced muscular strength, shrinking and softening of the testes, decreased secondary hair growth Hypopituitarism Diagnosis Patient [healthcommunities.com]

  Premenopausal women present with altered menstrual function, ranging from regular anovulatory periods to amenorrhea, as well as hot flashes, decreased libido, breast atrophy, vaginal dryness, and dyspareunia. [emedicine.com]

  Deficiency of LH and FSH (Hypogonadotropic Hypogonadism) Women develop ovarian suppression with irregular periods or absence of periods (amenorrhea), infertility, decreased libido, decreased vaginal secretions, breast atrophy, and osteoporosis. [pituitary.org]

• Vaginal Dryness

  dryness, absence of milk production in new mothers (Sheehan’s syndrome) In men: loss of libido and potency, reduced muscular strength, shrinking and softening of the testes, decreased secondary hair growth Hypopituitarism Diagnosis Patient history and [healthcommunities.com]

  Symptoms and Treatment of Gonadotropins deficiency: Women with hypogonadism develop: Menstrual irregularities Absence of periods (amenorrhea) Infertility Decreased libido Vaginal dryness Osteoporosis Our center individualizes care based on family history [pacificneuroscienceinstitute.org]

  Symptoms can include: In children, lack of growth In women, lack of menstrual periods and vaginal dryness In men, shrinking testicles and erectile dysfunction Confusion, weight gain, and constipation Weakness, low blood sugar, and feeling stressed Not [msdmanuals.com]

  In women, the symptoms may include: delayed menstrual periods reduction in libido vaginal dryness subfertility and infertility Affected women are also more likely to develop osteoporosis and weak bone structures prone to fractures later in life. [news-medical.net]

• Dyspareunia

  She takes no medications and has had no headaches, visual loss, dyspareunia, or decreased libido. A test for serum human chorionic gonadotropin is negative, the thyrotropin level is normal, and the serum prolactin level is 95 μg per liter. [oadoi.org]

  In women, sex hormone deficiency might lead to abnormal menses, diminish size of the breasts vaginal dryness, dyspareunia (painful intercourse), increased risk of urinary tract infections, depression, hot flashes and flushes, emotional lability, diminished [pituitaryworldnews.org]

  Premenopausal women present with altered menstrual function, ranging from regular anovulatory periods to amenorrhea, as well as hot flashes, decreased libido, breast atrophy, vaginal dryness, and dyspareunia. [emedicine.com]

• Headache

  Abstract A 50-year-old woman presented with a headache and nausea. A sellar and suprasellar mass was detected on MRI; the tumor was heterogeneously enhanced with gadolinium, and the pituitary stalk was slightly thickened. [ncbi.nlm.nih.gov]

  Women who are postmenopausal will not have obvious symptoms such as these and may first present with headache or loss of vision. Men may also suffer sexual dysfunction as a result of gonadotropin deficiency. [medical-dictionary.thefreedictionary.com]

  It is associated with the sudden onset of headache accompanied or not by neurological symptoms involving the second, third, fourth and sixth cranial nerves. [oadoi.org]

• Apathy

  Symptoms of ACTH and cortisol deficiency With gradual onset of deficiency over days or weeks, symptoms may include: Weight loss Fatigue Weakness Depression Apathy Nausea Vomiting Loss of appetite Abdominal pain As ACTH deficiency becomes more severe or [pacificneuroscienceinstitute.org]

  With gradual onset of deficiency over days or weeks, symptoms are often vague and may include weight loss, fatigue, weakness, depression, apathy, nausea, vomiting, anorexia and hyperpigmentation. [pituitary.org]

  With gradual onset of deficiency over days or weeks, symptoms may include weight loss, fatigue, weakness, depression, apathy, nausea, vomiting and loss of appetite. [california.providence.org]

• Asthenia

  • Loss of weight, asthenia, sensitivity to cold, mental torpor and absence of sweating. 18. Contd.. • Sexual maturation fails or regression • Atropy of gonads with amenorrhea and loss of pubic hair. • Growth slows dramatically. 19. [slideshare.net]

  At the age of 2, he presented significant asthenia after playing and somnolence accompanied by clumsiness and frequent falls; cortisol levels were 2.71μg/dL (normal range, 5-25); ACTH (7.7pg/mL, normal range, 5-46) and ion values were normal. [elsevier.es]

  […] infiltrative, vascular, etc, RT, trauma, postsurgery, encephalitis, hemochromatosis, stroke, dwarfism Clinical Sx and signs of pitutiary hormone deficiency are similar to those of a 1º defect of the target organ–eg, corticotropin deficiency is associated with asthenia [medical-dictionary.thefreedictionary.com]

  SIGNS AND SYMPTOMS Hormones affected Signs and symptoms Hypoadrenalism Postural symptoms, hypoglycaemia, hypotension and shock, hypothermia, asthenia, poor appetite and weight loss Hypothyroidism Low energy, fatigue, constipation, dry skin, hair loss [gponline.com]

  Asthenia, psychic torpor, cold intolerance (because of central hypothyroidism), hypothension (because of central hypocortisolism), and galactorrhea (because of hyperprolactinemia) may be variably associated. [academic.oup.com]

• Agitation

  A 52 years old female patient, was referred to the Department of Psychiatry for psychotic symptoms, manifested as auditory pseudohallucinations with delusional interpretation, significant psychomotor agitation, anosognosia, attempts of symptom dissimulation [ncbi.nlm.nih.gov]

Diagnosis of hypopituitarism is made based on various imaging and laboratory tests. Some of them are, MRI, CT Scan, levels of various hormones such as free thyroxin (FT4), thyroid-stimulating hormone (TSH), prolactin, luteinizing hormone (LH), testosterone and estradiol for men and women respectively in the blood.

Moreover the cortisol levels are assessed using provocative testing of the adrenal-pituitary axis. In some individuals the insulin tolerance tests may be required for a better assessment of the adrenocorticotropic hormone (ACTH), growth hormone (GH) and prolactin levels [9].

Treatment of hypothyroidism is based on replacing the deficient hormones. Glucocorticoids must be administered in case of ACTH deficiency, in the case of an emergency such as a pituitary apoplexy or an obstetric pituitary hemorrhage. Gonadotropin deficiency is corrected by replacing the sex appropriate hormones, such as testosterone in men and estrogen replacement in women with or without progesterone replacement.

Growth hormone is not replaced often in adults unless symptom of GH deficiency arises [10]. Growth hormones are replaced in children whenever appropriate. Secondary hypothyroidism can be treated efficiently by thyroid replacement. In hospitalized patients on corticosteroids, the dose can be simply doubled up in case of a surgery.

Prognosis is mostly good, if the hormones are replaced sufficiently [7]. Though there is an increased morbidity among hypopituitarism patients, the reason for morbidity is not yet clearly understood [8].

Complications

The complications associated with hypopituitarism depend on the severity of the deficiency. Infection may be a major cause for complications. Some of the complications of hypopituitarism include amenorrhea, hypothyroidism, hypotension, infertility, osteoporosis, failure to develop during puberty and short stature.

Hypopituitarism can usually develop into hypopituitary coma due to pituitary apoplexy. Some of the clinical features of hypopituitary coma include meningism, hormonal deficiencies, hypotension, ophthalmoplegia, reduced consciousness, visual field defects, hypoglycemia and hypothermia.

Hypopituitarism can be caused by several factors as given below.

• Trauma of the head
• Brain surgery [1]
• Brain tumor [2]
• Radiation therapy [3]
• Stroke
• Inflammation or an infection of the brain tissues
• Tumor of the pituitary gland or the hypothalamus 
• Subarachnoid hemorrhage [4]

Apart from this hypopituitarism can also be caused by rare immune or metabolic diseases such as hemochromatosis, histiocytosis X, lymphocytic hypophysitis, sarcoidosis and a very rare condition following a pregnancy called the Sheehan`s syndrome.

Hypopituitarism is listed under the rare diseases by the National institute of health (NIH), as less than 200,000 people are affected by this in the United States. It has been estimated that 4.2 cases per 100,000 people are being reported every year, internationally [5].

According to a study conducted by Regal et al, it has been estimated that there is a prevalence of 45.5 cases for every 100,000 of the adult population [6].

The pituitary gland produces the trophic stimulus to the target glands. Hence when the trophic stimulus is impaired, the hormone production from the target gland is impaired resulting in the secondary failure of the target glands.

In normal cases, the secretion of the tropic stimulus is based on the subphysiological hormonal levels, by a feedback mechanism. But in case of hypopituitarism the levels of the trophic hormones are suboptimal or absent, resulting in reduced production of the target gland hormones.

Hypopituitarism can never be prevented, though it can be treated efficiently if detected early. Trauma to the pituitary gland can be minimized if hypophyseal surgery is carried out under high resolution microscopes. Obstetric pituitarism can be minimized by proper postpartum care. Minimum exposure of the pituitary gland during radiation therapy is mandatory to prevent hypopituitarism due to radiation exposure.

Hypopituitarism is a condition, where there is a decrease in hormones secreted by the pituitary gland. The pituitary gland is a small gland located below the brain. It secretes a number of important hormones such as the growth hormone, thyroid stimulating hormone, follicle stimulating hormone, luteinizing hormone, prolactin and adrenocorticotropic hormone.

These hormones play a major role in growth and development of the body and regulating the blood pressure and metabolism. Insufficient secretion of any of these hormones, can result in a dysfunction of that particular area, and is manifested by specific symptoms. Treatment includes the replacement of the deficient hormones by hormone replacement therapy.

Definition

Pituitary is a small pea-sized gland situated at the base of the brain. It is connected to the hypothalamus of the brain by a small stalk. The pituitary gland secretes a number of hormones such as the adrenocorticotropic hormone (ACTH), growth hormone (GH), prolactin, antidiuretic hormone and thyroid-stimulating hormone (TSH). 

Cause

Hypopituitarism occurs when there is a deficient secretion of one or many of these hormones. Some of the causes for hypopituitarism include, a tumor of the pituitary gland, radiation therapy involving the pituitary gland, trauma of the pituitary due to road accidents, autoimmune disorders affecting the pituitary, surgery involving the pituitary gland, severe infections such as meningitis that can affect the pituitary and many such. 

Symptoms

Hypopituitarism is marked by various symptoms like fatigue, undue tiredness, blackouts, loose stools, low blood pressure and such as a result of deficient ACTH. Deficiency of growth hormone may result in stunted growth, weakness and tiredness in adults. Low sex hormones can result in less sex drive in women and loss of libido in men, impotence, and irregular or absent menstrual periods. Less thyroid hormone can result in dry skin and tiredness. Lack of antidiuretic hormone can result in increased thirst and copious urine output.

Diagnosis

Hypopituitarism is usually diagnosed using blood tests to detect the hormone levels, visual field checks for ruling out tumors of the pituitary gland, MRIs and CT scans. 

Treatment

Treatment of hypopituitarism is done mainly by hormone replacement therapy.

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