Anterior Pituitary

(Adenohypophysis)

Cells and hormones

Excess / Deficiency conditions

Manifestations

Lactotrope: PROLACTIN
(note: dopamine
inhibits prolactin)

EXCESS: Hyperprolactinemia
(physiologic in pregnancy and
lactation; PROLACTINOMA; also
seen in hypothyroidism due to
inc TSH; drug-induced:
antipsychotics, antidepressants,
risperidone, methyldopa,
verapamil)

amenorrhea, galactorrhea and infertility are

the hallmarks; diminished libido, visual loss
from optic nerve compression

Basal, fasting morning PRL

levels; Pituitary MRI

Diagnosis

For prolactinomas:
dopamine agonists
(cabergoline and
BROMOCRIPTINE)

Treatment

Weight gain, central obesity, rounded face,

fat pad on back of neck ("buffalo hump");
FACIAL PLETHORA, thin and brittle skin, EASY
BRUISING, broad and purple stretch marks,
acne, hirsutism; Osteopenia, osteoporosis
(vertebral fractures), decreased linear
growth in children; Weakness, PROXIMAL
MYOPATHY (prominent atrophy of gluteal
and upper leg muscles); Hypertension,
hypokalemia, edema, atherosclerosis;
Glucose intolerance/diabetes, dyslipidemia;
Decreased libido, in women amenorrhea
(due to cortisol-mediated inhibition of
gonadotropin release); Irritability, emotional
lability, depression, sometimes cognitive
defects, in severe cases, paranoid psychosis;
Increased susceptibility to infections,
increased white blood cell count,
eosinopenia, hypercoagulation with
increased risk of deep vein thrombosis and
pulmonary embolism

24-h urinary FREE

CORTISOL 3x above normal;
Dexamethasone overnight
SUPPRESSION test: cortisol
>50nmol/L at 8-9am after 1
mg dexamethasone at
11pm; Midnight plasma or
salivary cortisol
>130nmol/L; low dose DEX
SUPPRESSION test: cortisol
>50nmol/L after 0.5mg
dexamethasone q6h for 2
days; ACTH ELEVATED OR
NORMAL; Pituitary MRI (if
pituitary MRI is negative,
consider ectopic ACTH
secreting tumor eg lung
tumor)

SURGICAL REMOVAL of the

ACTH secreting pituitary
adenoma; metyrapone;
ketoconazole

DEFICIENCY: none
Corticotrope: ACTH

EXCESS: ACTH-dependent
Cushing's syndrome

Somatotrope: Growth
Hormone

DEFICIENCY: Secondary adrenal

insufficiency (post pituitary
surgeryl; tumor infiltration;
inflammatory; Sheehan's
syndrome)

Fatigue, lack of energy; Weight loss,

anorexia; Myalgia, joint pain; Fever; Anemia,
lymphocytosis, eosinophilia; Slightly
increased TSH (due to loss of feedback
inhibition of TSH release); Hypoglycemia
(more frequent in children); Low blood
pressure, postural hypotension;
Hyponatremia (due to loss of feedback
inhibition of AVP release); may present with
s/sx of mineralocorticoid deficiency (seen in
Primary AI only); Alabaster-colored pale skin
(secondary AI only) (due to deficiency of
POMC-derived peptides)

ACTH STIMULATION TEST:

Plasma cortisol 30-60 min
after 250 ug cosyntropin
IM or IV; Insulin tolerance
test

Glucocorticoid replacement:
hydrocortisone (prednisone
in the Phils)

EXCESS: Acromegaly in adults;

Gigantism in children

Acral bony overgrowth: frontal bossing,

increased hand and foot size, mandibular
enlargement with prognathism, widened
space between the lower incisor teeth. Heel
pad thickness, large fleshy nose.
Hyperhidrosis, deep voice, oily skin,
arthropathy, kyphosis, carpal tunnel
syndrome, proximal muscle weakness and
fatigue, acanthosis nigricans, skin tags.
Visceromegaly: cardiomegaly, macroglossia,
thyroid gland enlargement. CHD,
cardiomyopathy with arrhythmias, LVH,
decreased diastolic function, HPN. Upper
airway obstruction, central sleep
dysfunction. DM, colon polyps, colonic
malignancy.
Impaired quality of life (Decreased energy
and drive, Poor concentration, Low selfesteem, Social isolation); Body composition
changes (Increased body fat mass, Central
fat deposition, Increased waist-hip ratio,
Decreased lean body mass); Reduced
exercise capacity (Reduced maximum O2
uptake, Impaired cardiac function, Reduced
muscle mass); Cardiovascular risk factors
(Impaired cardiac structure and function,
Abnormal lipid profile, Decreased fibrinolytic
activity, Atherosclerosis, Omental obesity)

Increased IGF-1; GH not

useful for diagnosis;
CONFIRMATION: ORAL
GLUCOSE TOLERANCE
TEST: Failure of GH
suppression to <0.4ug/L
within 1-2h of an oral
glucose load (75g);
Pituitary MRI

SURGICAL REMOVAL OF GHSECRETING ADENOMA;

Radiation; Somatostatin
analogues eg octreotide,
sandostatin; GH-receptor
agonist eg pegvisomant;
dopamine agonists
bromocriptine and
cabergoline

Low IGF-1; INSULININDUCED HYPOGLYCEMIA

(PEAK GH RESPONSE OF
<3ug/L)

Somatotropin

DEFICIENCY: adult GH deficiency

in adults; pituitary dwarfism in
children

Thyrotropes: TSH

Gonadotrope: LH, FSH

Posterior pituitary
(Neurohypophysis)

Arginine vasopressin
(old name: ADH)

Oxytocin

EXCESS: secondary
hyperthyroidism (very rare!)

Thyrotoxicosis

Elevated FT4; elevated or

normal TSH; Pituitary MRI

SURGICAL REMOVAL OF
TSH-SECRETING ADENOMA

DEFICIENCY: Secondary
hypothyroidism (post pituitary
surgeryl; tumor infiltration;
inflammatory; Sheehan's
syndrome)

Hypothyroidism

Decreased FT4; decreased

or normal TSH

Levothyroxine

EXCESS: Gonadotropinproducing pituitary adenomas

Mostly hormonally asymptomatic; Rarely,

mentrual disturbances or ovarian
hyerstimulation;

Inceased LH, FSH, increased

testosterone or estrogen;
Pituitary MRI

Surgery if with risk for visual

loss due to tumor size

DEFICIENCY: hypogonadotropic
hypogonadism

Males: decreased libido, potency, infertility,

decreased muscles mass with weakness,
reduced beard and body hair growth, soft
testes, fine facial wrinkles; Premenopausal
females: oligomenorrhea, amenorrhea,
infertility, decreased vaginal secretions,
decreased libido, breast atrophy

Low testosterone /
estrogen; low or normal
LH, FSH; GhRH test

Males: testosterone:
Females: estrogen,
progesterone; for fertility:
menopausal gonadotropins,
hCG

EXCESS: Syndrome of
inappropriate antidiuresis (SIAD)

Euvolemic hyponatremia; decreased

volumes of more highly concentrated urine

Fluid restriction for mild

SIAD; demeclocycline,
fludrocortisone

DEFICIENCY: pituitary diabetes

insipidus

Urinary frequency, enuresis, nocturia,

and/or persistent thirst; hypernatremia

Diagnose after excluding

other causes of
hyponatremia; high urine
sodium
Fluid deprivation test

EXCESS: none
DEFICIENCY: none

Desmopressin