Pituitary treatment

What problems can pituitary disorders cause?

The pituitary gland is located at the base of the brain and functions as the master control center for the body’s other hormone producing glands such as the thyroid, adrenal glands, testes, and ovaries. Pituitary tumors and/or pituitary disease can result in either an overproduction or a deficiency of key pituitary hormones. When these signaling hormone levels are not correct, they place the target endocrine organs out of proper balance producing hormonal disease states. 

High hormone levels:

• Symptoms are specific to the overproduce hormone

Hypopituitarism:

• Tiredness or fatigue
• Decreased sexual desire
• Menstrual irregularities (absence of periods and abnormal bleeding)

Mass tumor effect:

• Visual field disorders (tunnel vison or loss of vision)
• Headaches

How are pituitary disorders treated?

Because pituitary disorders can affect many different hormonal control systems in the body, the correct treatment for pituitary disorders first involves a definitive diagnosis of which hormonal systems have become dysregulated and what the underlying reason for this is. If you have a pituitary disorder you need to visit an Endocrinologist to complete this work-up before an effective treatment can be planned. Understanding the best treatment starts with understanding the pituitary hormones involved and may involve medication or surgery.

What are pituitary tumors?

Pituitary tumors are relatively common and are though to be present in approximately 10% of the population. These can be microadenomas (less than 1cm) or macroadenomas (greater than 1cm). Most pituitary tumors are not hormonally active, but some are. Hormonally active tumors can produce prolactin (prolactinomas), growth hormone (causing acromegaly), ACTH (causing Cushings) or rarely can be tsh or fsh/lh producing tumors. Macroadenomas can also cause pituitary deficiency by compressing normal pituitary tissue. 

What symptoms does a prolactin secreting pituitary tumor cause?

Prolactin normally causes a mother’s breast tissue to produce milk after a new baby is born. The most common type of hormonally active pituitary tumors are prolactinomas.  These make up 30-40% of pituitary tumors. The high prolactin level dysregulates the hormones that normally signal a woman’s ovaries or a man’s testes resulting in abnormal menstrual periods, fertility and sexual function.

How is a prolactinoma diagnosed?

Overproduction of prolactin and it’s impact on the body is assessed using blood tests to determine not only the prolactin level but also the levels of the other hormones that are controlled by prolactin. Prolactinomas typically cause prolactin levels to be over 100ng/mL. If this is present, imaging of the pituitary must also be completed to determine if a pituitary tumor is present.

What is the best treatment for a prolactin pituitary tumor?

When a prolactin producing tumor is present, effective therapy will be planned with several goals in mind. Treatment is intended to restore normal prolactin levels, normalize pituitary function, decrease the pituitary tumor size, and resolve tumor pressure symptoms such as visual problems to improve your quality of life. 

Fortunately, prolactinomas typically respond very well to oral medical treatment with either cabergoline or bromocriptine.  Taking the medication at night, can decrease side effects such as headaches, nausea and drowsiness. These medications can be effective to, over time, resolve the prolactinomas.  When this happens, the medication can be weaned off with careful monitoring of the prolactin level to make sure that it stays normal. The safety of these drugs is not known after the first few week of pregnancy. If you become pregnant while taking these drugs (they can increase fertility), you need to discontinue the medication and notify your Endocrinologist immediately.

What symptoms does a growth hormone producing tumor cause?

As it’s name implies, growth hormone (GH) is the hormone that normally causes children to grow and also helps to promote bone and muscle health in adults as well as limit fat tissue. When excessive growth hormone is produced in children gigantism results. When excessive growth hormone (GH) is produced in adults it results in enlargement of the hands and feet, coarsening of the facial features, thickening of the lips, wide spaced teeth, and protruding jaw and forehead. This condition is known as acromegaly. 

How is acromegaly treated?

When a person is suffering from acromegaly, elevated levels of growth hormone (GH) and IGF-1 may decrease their length and quality of life. Because of this it is important to seek specialty care with an Endocrinologist who will then work to diagnose and treat your condition by lowering GH and IGF-1 levels back into the normal range.  When a pituitary tumor is the source of acromegaly, surgery to attempt complete removal of the tumor is usually the primary treatment option.

However, if complete removal isn’t possible during surgery radiation or medications may be needed. Radiation can take up to 20 years to achieve the intended effect, but once achieved this is a permanent cure. In contrast, medications such as somatostatin analogues, GH receptor antagonists, and dopamine agonists are not curative and must be taken for life.

What are some disorders with adrenocortical hormone (ACTH)?

When the pituitary releases adrenocortical hormone (ACTH), this causes the adrenal glands to produce cortisol. Cortisol is used by the body to maintain blood sugar and blood pressure especially during times of stress. More cortisol is needed during times when the body is stressed by injury or illness. When excess ACTH is produced, excessive amounts of cortisol result in Cushing’s disease. When too little ACTH is produced, depressed cortisol levels result in secondary adrenal insufficiency (AI).

How is Cushing’s disease treated?

Cushing’s disease is specifically caused by pituitary tumors that produce too much ACTH and is different from Cushing’s syndrome which is simply caused by too much cortisol (including overmedicating with cortisol).  

Symptoms of Cushing’s disease include a round face or abdomen, rapid weight gain, especially in the neck and upper back, purple stretch marks, depression/memory/mood disorders, fatigue, diabetes, osteoporosis, menstrual cycle irregularities, high blood pressure, fractures, blood clots, and cardiovascular disease such as stroke and heart attack. Cushing’s disease can be difficult to diagnose because cortisol levels normally change throughout the day and multiple blood tests may be required. Additionally, imaging studies may be needed to locate the tumor source.

Cushing’s disease is treated by surgical removal of the tumor usually using the trans-sphenoidal approach to minimize scarring and complications. However, while surgery is curative when successfully, it is not successful 100% of the time. Gamma knife radiosurgery can be used in this setting. Radiation can then be used in some settings.

There are also medication options.  Medications used to treat Cushing’s disease may include direct adrenal blockers (ketoconazole, metyrapone, or mitotane), drugs that decrease both ACTH and cortisol (dopamine agonists or pasireotide), or drugs that decrease the effect of cortisol on the body (mifepristone). Rarely if all other measures fail, the adrenal glands can be removed to eliminate the excess cortisol that produces symptoms.  This is typically a last resort, as it necessitates life-long steroid replacement.