Algorithm(s)
PDF algorithm(s) available at www.arupconsult.com.
Hypopituitarism (Anterior Pituitary) Testing Algorithm
Central Diabetes Insipidus (Posterior Pituitary) Testing Algorithm
Clinical Background
The pituitary gland is often referred to as the master gland because it orchestrates complex functioning of multiple endocrine glands. Hypopituitarism is defined as either partial or complete deficiency of anterior or posterior pituitary hormone secretion.
Epidemiology
- Incidence - 45/100,000
- Age - incidence increases with age
Etiology
- Tumor - adenoma, lymphoma, metastatic infiltration
- Autoimmune disease
- Trauma - surgery, head injury, radiation
- Vascular event - hemorrhagic apoplexy, pregnancy-related (Sheehan syndrome), sickle cell disease
- Infections - histoplasmosis, tuberculosis, toxoplasmosis
- Infiltrative disease - sarcoidosis, hemochromatosis
- Genetic disease - Kallmann syndrome, Prader-Willi syndrome, Laurence-Moore-Biedl syndrome
Pathophysiology
- Anterior pituitary produces 6 major hormones
- Prolactin (PRL)
- Growth hormone (GH)
- Adrenocorticotropic hormone (ACTH)
- Luteinizing hormone (LH)
- Follicle-stimulating hormone (FSH)
- Thyroid-stimulating hormone (TSH)
- Posterior pituitary releases oxytocin and antidiuretic hormone (ADH)
- Any insult to gland or vascular supply may cause hypopituitarism
- Loss of any of these hormones will produce specific symptoms based on the particular hormones lost
Clinical Presentation
- Varied - dependent on which part of the pituitary gland is involved
- Nonspecific
- Headache
- Visual disturbances
- Anterior pituitary
- Gonadotropic hormones - sexual dysfunction and amenorrhea
- Growth hormone - fatigue, decreased muscle mass and strength
- Adrenal corticotrophic hormone - fatigue, nausea, vomiting
- Thyroid hormone - weight gain, coarse hair, fatigue
- Nonspecific - fatigue, memory disturbances, depression
- Posterior pituitary (hypothalamic)
- Central diabetes insipidus - polydipsia, polyuria, nocturia
Treatment
- Hormone replacement based on deficiencies
See Also
Algorithm(s)
PDF algorithm(s) available at www.arupconsult.com.
Hypopituitarism (Anterior Pituitary) Testing Algorithm
Central Diabetes Insipidus (Posterior Pituitary) Testing Algorithm
Diagnosis
Diagnosis
- Laboratory testing
- Based on specific symptoms
- PRL deficiency - basal measurement of PRL
- GH deficiency - basal morning measurement of insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-3 (IGFBP-3)
- In addition, test response to insulin-induced hypoglycemia (insulin tolerance test)
- ACTH deficiency (primary adrenal insufficiency) - basal measurement, ACTH and cortisol
- Metyrapone testing if ACTH deficiency is consideration
- ACTH stimulation testing if primary adrenal insufficiency is a consideration
- Gonadotropin deficiency (LH/FSH) - basal measurement LH, FSH, estradiol (female) or testosterone (male)
- TSH deficiency - basal thyroid function testing
- Thyroid stimulating hormone (TSH), free T4
- ADH deficiency - Diabetes insipidus testing
- Urine osmolality and serum/urine sodium, serum antidiuretic hormone (ADH)
- May require water deprivation testing
- Releasing hormones are not recommended for use in initial testing
- Imaging studies - MRI necessary to identify sellar and parasellar masses
Algorithm(s)
PDF algorithm(s) available at www.arupconsult.com.
Hypopituitarism (Anterior Pituitary) Testing Algorithm
Central Diabetes Insipidus (Posterior Pituitary) Testing Algorithm
Tests generally appear in the order most useful for common clinical situations
| Test name: Adrenocorticotropic Hormone
|
| ARUP #: 0070010 |
| Methodology: Chemiluminescent Immunoassay
|
| Use: Diagnose primary adrenal insufficiency |
| Limitations: |
| Follow-up:
|
| Test name: Cortisol, Serum or Plasma
|
| ARUP #: 0070030 |
| Methodology: Chemiluminescent Immunoassay
|
| Use: Diagnose ACTH deficiency |
| Limitations: |
| Follow-up:
|
| Test name: Corticotropin Releasing Hormone
|
| ARUP #: 0097646 |
| Methodology: Extraction Radioimmunoassay
|
| Use: Differentiate between adrenal and pituitary etiology of hypopituitarism |
| Test name: Thyroid Stimulating Hormone
|
| ARUP #: 0070145 |
| Methodology: Electrochemiluminescent Immunoassay
|
| Use: Diagnose TSH deficiency |
| Limitations: |
| Follow-up:
|
| Test name: Thyroxine, Free (Free T4)
|
| ARUP #: 0070138 |
| Methodology: Electrochemiluminescent Immunoassay
|
| Use: Diagnose TSH deficiency |
| Limitations: |
| Follow-up:
|
| Test name: Luteinizing Hormone and Follicle Stimulating Hormone
|
| ARUP #: 0070193 |
| Methodology: Electrochemiluminescent Immunoassay
|
| Use: Diagnose gonadotropin deficiency |
| Limitations: |
| Follow-up:
|
| Test name: Testosterone, Free & Total (Includes Sex Hormone Binding Globulin), Adult Male
|
| ARUP #: 0070109 |
Methodology: 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.
|
| Use: Diagnose gonadotropin deficiency |
| Test name: Estradiol, Adult Premenopausal Female, Serum or Plasma
|
| ARUP #: 0070045 |
| Methodology: Chemiluminescent Immunoassay
|
| Use: Diagnose gonadotropin deficiency |
| Test name: Prolactin
|
| ARUP #: 0070115 |
| Methodology: Chemiluminescent Immunoassay
|
| Use: Diagnose gonadotropin deficiency |
| Limitations: |
| Follow-up:
|
| Test name: IGF-1 (Insulin-Like Growth Factor I)
|
| ARUP #: 0070125 |
| Methodology: Chemiluminescent Immunoassay
|
| Use: Diagnose GH deficiency |
| Limitations: |
| Follow-up:
|
| Test name: IGF Binding Protein-3
|
| ARUP #: 0070060 |
| Methodology: Chemiluminescent Immunoassay
|
| Use: Diagnose GH deficiency |
| Limitations: |
| Follow-up:
|
| Test name: Growth Hormone
|
| ARUP #: 0070080 |
| Methodology: Chemiluminescent Immunoassay
|
| Use: Diagnose GH deficiency |
| Limitations: |
| Follow-up:
|
| Test name: Osmolality, Urine
|
| ARUP #: 0020228 |
| Methodology: Freezing Point
|
| Use: Diagnose diabetes insipidus, ADH deficiency and polydipsia |
| Limitations: |
| Follow-up:
|
| Test name: Osmolality, Serum or Plasma
|
| ARUP #: 0020046 |
| Methodology: Freezing Point
|
| Use: Diagnose diabetes insipidus, ADH deficiency and polydipsia |
| Test name: Sodium, Plasma or Serum
|
| ARUP #: 0020001 |
| Methodology: Ion-Selective Electrode
|
| Use: Diagnose diabetes insipidus, ADH deficiency and polydipsia |
| Test name: Immunohistochemistry Stain Offering
|
| ARUP #: arup005 |
| Methodology: Immunohistochemistry
|
| Use: For fixed tissue samples, consultative services as well as immunohistochemical staining for prolactin are available |
Additional Tests Available
| Test name: Testosterone Free, Adult Male
|
| ARUP #: 0070111 |
Methodology: 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.
|
| Comments: |
| Test name: Follicle Stimulating Hormone, Serum
|
| ARUP #: 0070055 |
| Methodology: Electrochemiluminescent Immunoassay
|
| Comments: |
| Test name: Luteinizing Hormone, Serum
|
| ARUP #: 0070093 |
| Methodology: Electrochemiluminescent Immunoassay
|
| Comments: |
| Test name: Adrenocorticotropic Hormone Stimulation, 0 Minutes
|
| ARUP #: 0070031 |
| Methodology: Chemiluminescent Immunoassay
|
| Comments: |
| Test name: Cyclic AMP, Plasma
|
| ARUP #: 0070180 |
| Methodology: Radioimmunoassay
|
| Comments: |
| Test name: Arginine Vasopressin Hormone
|
| ARUP #: 0070027 |
| Methodology: Radioimmunoassay
|
| Comments: |
References
General References
Agha A, Phillips J, Thompson CJ. Hypopituitarism following traumatic brain injury (TBI). Br J Neurosurg.
2007;
21(
2):
210-216.
Auernhammer CJ, Vlotides G. Anterior pituitary hormone replacement therapy--a clinical review. Pituitary.
2007;
10(
1):
1-15.
Corneli G, Ghigo E, Aimaretti G. Managing patients with hypopituitarism after traumatic brain injury. Curr Opin Endocrinol Diabetes Obes.
2007;
14(
4):
301-305.
Dejager S, Gerber S, Foubert L, Turpin G. Sheehan's syndrome: differential diagnosis in the acute phase. J Intern Med.
1998;
244(
3):
261-266.
Geller JL, Braunstein GD. Dermatologic manifestations of hypopituitarism. Clin Dermatol.
2006;
24(
4):
266-275.
Ghigo E, Masel B, Aimaretti G, Leon-Carrion J, Casanueva FF, Dominguez-Morales MR, 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):
711-724.
Hanberg A. Common disorders of the pituitary gland: hyposecretion versus hypersecretion. J Infus Nurs.
2005;
28(
1):
36-44.
Kelberman D, Dattani MT. Hypopituitarism oddities: congenital causes. Horm Res.
2007;
68 Suppl 5:
138-144.
Kelberman D, Dattani MT. Hypothalamic and pituitary development: novel insights into the aetiology. Eur J Endocrinol.
2007;
157 Suppl 1:
S3-14.
Kelestimur F. Sheehan's syndrome. Pituitary.
2003;
6(
4):
181-188.
Prabhakar VK, Shalet SM. Aetiology, diagnosis, and management of hypopituitarism in adult life. Postgrad Med J.
2006;
82(
966):
259-266.
Schmidt DN, Wallace K. How to diagnose hypopituitarism. Learning the features of secondary hormonal deficiencies. Postgrad Med.
1998;
104(
1):
77-77.
Schneider HJ, Aimaretti G, Kreitschmann-Andermahr I, Stalla GK, Ghigo E. Hypopituitarism. Lancet.
2007;
369(
9571):
1461-1470.
Smith JC. Hormone replacement therapy in hypopituitarism. Expert Opin Pharmacother.
2004;
5(
5):
1023-1031.
Takala RS, Katila AJ, Sonninen P, Perttila J. Panhypopituitarism after traumatic head injury. Neurocrit Care.
2006;
4(
1):
21-24.
Urban RJ. Hypopituitarism after acute brain injury. Growth Horm IGF Res.
2006;
16 Suppl A:
S25-S29.
Medical Reviewers
Meikle, A. Wayne, M.D. Medical Director, RIA and Endocrinology at ARUP Laboratories; Professor of Internal Medicine and Pathology, University of Utah
Perkins, Sherrie L. , M.D., Ph.D. Medical Director, Hematopathology at ARUP Laboratories; Professor, Anatomic Pathology, University of Utah
Roberts, William L. , M.D., Ph.D. Medical Director, Automated Core Laboratory at ARUP Laboratories; Professor, Pathology, University of Utah
Comprehensive Review: May 2008
Last Update: May 2008
