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Hypopituitarism - How is hypopituitarism treated?

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Hormone deficiency is treated by replacing the deficient hormones. The goals of treatment are to improve symptoms (see Table 2) and to replace the deficient hormone or hormones at a level that is as close to physiologically correct (“mother nature”) as possible. However, one rule of hormone replacement is that no one dose will suit every patient. Thus, when hormone replacement therapy is prescribed, the patient will need to be seen regularly after starting treatment to assess the effect. It often takes time and repeated dose changes to find the optimal dose for each patient. Typically, once the optimal dose is determined, the dose remains adequate for long-term treatment unless other medications are added or the patient’s condition changes in a way that alters the blood levels (e.g., introduction of GH therapy may require an increase in cortisol replacement, whereas pregnancy may require an increase in the dose of thyroid hormone).

Cortisol: On average, cortisol replacement therapy consists of giving approximately 15 mg of cortisol daily in divided doses. Approximately 2/3 of the dose is given in the morning and 1/3 in the late afternoon or evening. Excess cortisol can cause side effects (see the section on risks below), so it is best to use cortisol replacement in doses that are adequate but not too high.

Some endocrinologists prescribe prednisone instead of cortisol, and the dose of prednisone can be given once or twice a day. Patients with cortisol deficiency must always remember that during periods of stress their bodies may not be able to produce the increased level of cortisol needed. Therefore, patients should always carry a medical or steroid alert card or wear a medical alert bracelet or necklace to inform physicians that they are taking chronic steroid therapy. If patients have multiple pituitary hormone deficiencies, cortisol should always be the first hormone replaced as medications like thyroid hormone or GH can increase the body’s need for cortisol.

Thyroid hormone: Levothyroxine given daily is the therapy for thyroid hormone deficiency.

  1. Most people with hypothyroidism have disease directly in the thyroid gland and are said to have primary hypothyroidism. Patients with primary hypothyroidism have elevated levels of TSH and low levels of thyroid hormone. In this situation, treatment with thyroid hormone causes the level of thyroid hormone to increase and the level of TSH to decrease.
  2. Patients with hypothyroidism as a result of pituitary disease are said to have secondary hypothyroidism. Such patients have low levels of both TSH and thyroid hormone (see Figure 2). Although treatment with thyroid hormone should increase the level of thyroid hormone in the blood into the normal range, it would not change the level of TSH. Thus, TSH is not used to monitor dosing in patients with secondary hypothyroidism. Instead, the physician has to rely on signs and symptoms and measurement of thyroid hormone in blood.

Sex-related hormones: Women: Premenopausal women who have no menstrual cycles as a result of pituitary disease (secondary hypogonadism) should receive replacement therapy with estrogen and progesterone. Estrogen can be given orally, by patch or by gel. Progesterone equivalent is only required in woman who have an intact uterus. Women who have undergone a hysterectomy can be treated with estrogen alone.

Men: In testosterone-deficient men, testosterone is given by patch, gel or injection either daily (patch or gel) or every 2-4 weeks by intramuscular injection.

GH therapy: GH prescribing practices vary depending upon local customs, national guidelines and insurance coverage. It is important to do tests to prove that patients are indeed GH deficient. Human GH is administered by daily injection. Most pituitary endocrinologists start at relatively low doses to avoid side effects and increase as needed.

DI therapy: Desmopressin is usually given in tablet or spray form (nasal tube or nasal spray). Hospitalized patients may be given desmopressin by injection.

Table 2. 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, dry skin, sensitivity to cold, constipation
LH and FSH in Women Ovaries: estrogen, progesterone; ovulation Loss of periods, loss of sex drive, infertility
LH and FSH in Men Testes, testosterone, sperm production Loss of sex drive, erectile dysfunction, impotence, infertility
GH in Children & Adolescents Bone, muscle, fat Lack of growth (height); increased body fat, failure to achieve normal peak bone mass
GH in Adults Whole body Poor quality of life, increased body fat, decreased muscle and bone mass
PRL Breast Inability to breast feed
Oxytocin Breast, Uterus Complete deficiency could make breast feeding difficult
Antidiuretic hormone (vasopressin) Kidney Frequent urination (day & night), dilute urine, excessive thirst
Table 3. Hormone Replacement Options
Deficient Pituitary Hormone Medication How Taken
ACTH Usually hydrocortisone or prednisone Tablets, once or twice a day, depending on which drug
TSH Thyroid hormone - usually T4 (thyroxine) Tablets daily
LH and FSH in Women Estrogen, progesterone Tablets; skin patches, gels
LH and FSH in Men Testosterone Gel or skin patch, every day; injection in the buttock or thigh, every 2-4 weeks
GH in Children & Adolescents GH Daily injection under the skin (very small needle)
GH in Adults GH Daily injection under the skin (very small needle)
PRL None  
Oxytocin None  
Antidiuretic hormone (vasopressin) Desmopressin Tablet, once to three times daily; or through a nasal tube or by nasal spray