Treatment of Hypopituitarism
ACTH Deficiency
This is the most important hormone to test for and treat first, because its deficiency may be life threatening. It is much easier to give the adrenal gland hormone cortisol directly than to give ACTH and so various preparations of cortisol may be given orally. The most commonly used are hydrocortisone, given in doses of 10 - 40 mg daily and prednisone, given in doses of 2.5 - 7.5 mg daily. Both are usually given in divided doses two or three times per day. The doses are usually adjusted based on clinical symptoms. The dose will be adjusted upward if someone is still feeling very fatigued and dizzy. The dose is adjusted downward if there is substantial weight gain or puffiness. Although there may be side effects when this class of medication is given in large doses for other inflammatory conditions such as asthma or arthritis, the replacement doses used in people with hypopituitarism should not cause any problems after the initial dose adjustment period which may last several weeks. People with hypopituitarism who are found to need these medications must take them every day and should try not to miss a dose. If someone misses a dose and remembers later in the day, they should take it later. However, if they forget until the next day, then can just continue taking their regular dose. If there is some minor stress, such as a cold or a stomach flu, then they should double up on their dose for a day or two until they feel better. With greater stresses, the doses should be increased more and they should contact their physicians for guidance. In the event of a major stress such as surgery or severe illness, they should contact their physician immediately. People who do hiking or spend time away from close medical care should carry an injectable form of cortisone that they or a friend or family member can give in case of emergency. A MedicAlert (or another brand) bracelet/necklace/card specifying the medical condition and the need for cortisone should be worn or carried at all times in the event of emergency.
TSH Deficiency
When TSH deficiency is documented, patients will need to take oral thyroid hormone, usually in the form of l-thyroxine. If there is a combined ACTH and TSH deficiency, cortisone should always be started before the thyroxine. Depending upon the age of the person, the severity of the deficiency, and the duration of the deficiency, the dose may be started at very low levels and then gradually built up over many weeks or it may be started on near full replacement doses. The usual range for thyroxine dose is 0.05 - 0.2 mg per day, with most people in the 0.075 - 0.15 mg per day range. The dose is generally adjusted to get serum T4 levels in the mid-normal range and also may be adjusted by clinical symptoms. Unlike patients with the usual form of hypothyroidism, TSH levels are not used to adjust thyroxine doses in patients with hypopituitarism. It is important to stay with the same brand of thyroxine all the time as not all brands are exactly equal to each other.
LH and FSH Deficiency - Women
If fertility is not an issue, then replacement of estrogen and progesterone will be needed. This can be done with low-dose oral contraceptives or one of the usual hormone replacement therapy regimens used for menopause, such as conjugated estrogens plus medroxyprogesterone acetate. These hormones can be given cyclically to cause regular menstrual cycles or continuously to avoid menses, depending upon personal preference. Estrogen can also be administered through the skin using a patch. Estrogen replacement is needed, especially in younger women, to avoid osteoporosis. Beneficial effects on the heart and blood vessels are less clear. If the estrogen replacement does not fully restore sexual desire (libido), sometimes a small amount of testosterone may be added or, when there is associated ACTH deficiency, a small amount of an adrenal androgen called DHEA may be added. When fertility is an issue, then LH and FSH can be given by injection in combinations. When the hypopituitarism is caused by hypothalamic damage and fertility is desired, the hypothalamic hormone that stimulates LH and FSH, called gonadotropin releasing hormone (GnRH) can be given by repetitive injection using a pump with a small plastic needle that is place under the skin. Also other forms of in vitro fertilization (IVF) can be used.
LH and FSH Deficiency - Men
If fertility is not an issue, then replacement with testosterone will be needed. This can be given by an injection deep into the muscle of the thigh or buttock every 2 to 4 weeks with the dose being adjusted by measuring testosterone levels. Newer preparations have also become available in which testosterone can be given by a skin patch and the testosterone is absorbed through the skin. However, sometimes these patches fall off with exertion when there is a lot of perspiration and some people get a rash at the patch site. An even newer gel preparation that is applied to the skin has also become available. Although most men with hypopituitarism who take testosterone are infertile, a sperm count should be done to assess fertility because not all such men are infertile. When the sperm count is low and fertility is desired, then the testosterone is switched to an LH-like hormone called HCG, which has to be given by injection three times per week. Occasionally FSH also has to be given to restore the sperm count. Normal levels of testosterone are necessary to maintain normal libido and sexual function and to prevent osteoporosis.
GH Deficiency - Children
In children, GH is necessary for normal growth and GH treatment should be instituted in all who are may need adjustment by an experienced pediatric endocrinologist to avoid side effects and to insure proper growth. GH is usually stopped when growth has been completed and no further bone elongation is anticipated. At present GH is administered by daily injections into the fat below the skin but a newer intramuscular preparation that only has to be given once a month is beginning to be used in some patients.
GH Deficiency - Adults
The absolute need for GH in adults has not been established. In most adults shown to be GH deficient, daily injections of GH in much lower doses than those used in children have been shown to increase bone density, decrease fat mass and increase muscle mass and in many this also translates into increased strength and endurance. Some individuals also experience an improved sense of well-being. However, in other individuals these benefits are less dramatic and they may not wish to continue GH treatment. Discussion of whether to treat GH deficiency in adults should be discussed with an adult endocrinologist.
