Education And Debate

Fortnightly Review: Diagnosis and management of pituitary tumours

BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6936.1087 (Published 23 April 1994) Cite this as: BMJ 1994;308:1087
  1. A Levy, Dr,
  2. S L Lightman
  1. University of Bristol, Department of Medicine, Bristol Royal Infirmary, Bristol BS2 8HW
  1. Correspondence to: Dr Levy
  • Accepted 25 November 1993

Pituitary tumours are mostly benign epithelial neoplasms that result from mutation and subsequent clonal expansion of single adenohypophyseal parenchymal cells.1 They account for 10-15% of intracranial neoplasms, and three quarters of them secrete inappropriate amounts of pituitary hormones. Although residual cells in parasellar structures may account for local recurrences that follow seemingly complete surgical clearances, metastatic spread and direct macroscopic invasion of surrounding structures is fortunately rare.2

Most patients with pituitary adenomas present with symptoms and signs of hormone hypersecretion, visual field defects, headaches, and hypopituitarism either alone or in combination (see box 1). Preoperative diabetes insipidus is extremely rare in primary pituitary disease and suggests involvement of the hypothalamus or pituitary infarction. Any visual disturbance can occur - from changes in the lateral fields that a patient typically finds hard to describe and which may go unrecognised for years to scotomas and complete blindness in one or both eyes. Many patients complain of vague peripheral shadows confined to the upper quadrants. Headaches are usually non-specific - annoying more than disabling and frequently helped by analgesia. In some patients they are relieved almost immediately by somatostatin or somatostatin analogues, only to recur as the peptide is cleared from the circulation. If panhypopituitarism is suspected (see box 2 for typical features) glucocorticoids should be replaced before thyroid hormones.

Box 1 - Typical presenting feature pituitary adenomas

  • Hormone hypersecretion

  • Visual field defects

  • Headaches

  • Hypopituitarism

  • Pituitary apoplexy

  • Hydrocephalus

  • Cranial nerve palsies

  • Temporal lobe epilepsy

Box 2 - Typical features of hypopituitarism Hypogonadism

Women
  • Oligomenorrhoea or amenorrhoea

  • Reduced libido

  • Dyspareunia

Men
  • Reduced libido and potency

  • Reduced facial and body hair

  • Gonadal atrophy

Hypoprolactinaemia
  • Failure to start and maintain lactation in women

  • No defined clinical entity in men

Hypothyroidism
  • Mild hypothyroidism with inappropriately low concentrations of thyroid stimulating hormone in otherwise well patient (should not be confused with sick euthyroid syndrome; depressed central thyroid axis drive in ill and catabolic patients)

Growth hormone deficiency
  • Poorly defined …

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