Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop trt?

[angrydad]

Hi guys I'm a 37 year old male and here is my story, sorry for being so long winded but it's been difficult trying to sum it all up! 6 months ago I was diagnosed with Low T. I went through a complete nightmare of getting a diagnosis. I was feeling fine about 2 years ago working overseas and was flying (commuting) alot. One flight I was coming in to land and felt that I had something like a stroke. Massive pain in the centre of my head and feeling really weird like I didn't know what was happening to me. Later that day I felt a bit better Gradually after this experience I noticed more fatigue, aching joints especially in hips and legs and finger joints. Dizzyness and light headed etc. This all coincided with getting laid off and I came back to the UK.

I wasn't working and was at home gardening, childcare etc. I felt that perhaps I had a bug or virus and would just get over it. Also I was hoping it would go away and I would start to feel better. After about a year I was feeling worse and it was getting me down. I was crying and called the GP to get seen.

Went in and had bloods done etc. The only thing that came back abnormal was my TSH at 6.3 they redid them and they kept coming back around the 4-6 area the range is <6 but they don't treat until greater than 10. The docs thought this was normal and I was imagining things.

I went back and they suggested maybe drinking too much or that I was depressed. I kept pushing them and then referred me to an endo (my GP's words were "Only referring you to shut you up and if you don't believe me you can believe him". They did further bloods that showed my prolactin to be too high (range 1-550 mu/L) mine was at 1200. They tested LH FSH and Testosterone.

My LH/FSH was low 2.0 and 2.7 my T was 5.2 (range 11-36 nmol/L)

The endo suspected a possible pituitary tumour. I had an MRI scan and they couldn't see much. No visible tumour but the gland looked flattened not pea shaped. It wasn't very clear in the image. Hence my diagnosis with empty sella syndrome.

So the Endo said my prolactin was too low for a microprolactinoma and they would monitor it. He recommended TRT about 5 months ago. I started on sustanon 250 every 3 weeks and was on it for 4 months until the sustanon worldwide dried up. No follow up bloods or anything had been done in the meantime. The endo's next appt was cancelled 3 times and I am due to see him in November (instead of August). My experience on sustanon was horrific. I felt awful about 30% of the time, really bad anxiety, panic, racing heart etc.

Been on Testogel for 4 weeks now and those panicky things have gone pretty much. Got my bloods checked before starting Testogel 5 days before my sustanon had run out. They came back with:

Test 10.3 range 11-36
SHBG 20
Free TEST 260
Prolactin in now 1966 (range 1-550)
estradiol 169 pmol/L
So it looks like my T was low while on Sustanon. Feel some of the Low T symptoms still on Testogel so the Doc has asked me to go back for more bloods to see how I am doing on 1 sachet a day. (Think he wants to try 2 a day after my bloods come back)

What I guess I am asking here is do you think my Prolactin is actually causing my Low T ? I cannot stand being on TRT. My doc was confused why this has been overlooked. I guess it's the usual NHS wait forever between appts and bloods and reappointments etc.

My testicles have shrunk over the last 4 months by about 30% and I really think that maybe if I get something like Cabergoline it may lower prolactin and actually let my boys work. (The endo said the results showed it wasn't my boys that were the problem but whats in my head).

I cannot believe that this option was not tried earlier. I mean it may be a long shot? but to pump me full of hormones and with no follow ups is pretty poor. I bet my dog would get better care at the vets!!

Going to try and push for it when I see my endo next. Do you think it's possible I can recover my Testicles? Will they offer HCG? I do have kids and I have had the snip. Just hope that you guys have some good advice. Just as a sidenote.. My TSH has come down to 2.6 so I don't think its thyroid related anyway. No family history or antibodies etc.

What should I do guys and what are my chances of getting off TRT and working again?

Sorry for the long winded post but it seems there really is no-one to talk to and the UK seems to really overlook mens hormone issues. But I have been an awful person at times, angry, moody, easily snap at people including my poor wife and kids. Plus my sex drive in only 20% of what it used to be.

When I look at it in laymans terms, I've been on treatment for 5 months and without follow ups etc t my T level is pretty much similar to where I started! And at least it was my own T !

I do realise that what I want and what the endo is willing to give may differ. But if need be I will self medicate if absolutely necessary to get right or at least better than I feel now.

Does anyone know of anyone else having improved by lowering prolactin?

Would my T recover naturally without HCG etc if my prolactin was dropped?

Could my e2 keep dropping if I kept on losing weight? I had put on all the fat and weight around my gut and I'm now about a 35 inch waist

Would my shrunken balls get bigger again and be enough to produce my own stuff? I will accept this TRT as lifelong if it doesn't work out for me but it really does seem a second best approach.

Please any advice would be welcome.

Thankyou

 

[Michael Scally MD]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

I apologize for needing to go back and read your post in detail, but I was struck right away by the TSH. Do you have thyroid function studies? BTW: A TSH over 5 is considered hypothyroid, particularly with the more precise assays.

 

[angrydad]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

Thankyou for your reply. I had various tests T3, T4, TSH all carried out various times. My TSH was 6.3 when I had not had any treatment. Before having that pain in my head during flying I had NO issues whatsoever. I guess my pituitary must have been going through a trauma hence the empty sella syndrome.

My doctor was concerned but here in the UK the range for TSH is <6 despite all the studies I read suggesting 95% of the global population were around 1. My Endo and doctor see no concern at all with that value and I was told they would never treat any suspect Hypothyroidism unless the TSH was 10 or over. That is a UK wide policy and my Endo/ doctor will put it all down to empty sella.

I have no family history of thyroid problems and I don't have Hashimotos. Both of my last TSH tests were around 2 or 3 since being on TRT. I also had a short synathen test and apparently this reading was ok.

I feel that I was put on TRT prematurely without trying to bring down my prolactin beforehand and seeing what that would do with my levels.

I am not sure but I don't think that they actually will try restart PCT's here in the UK under ou NHS system.

Would I be able to get back to normal if it was prolactin causing the low T ? Even if I had to crash could it come back naturally while keeping prolactin low? I will have been on TRT for 7 months at this point.

I probably would not get any HCG or Arimidex or any other drug through the health service. If I had to I would consider buying from an overseas pharmacy. My problem then would be my Endo would not allow it or assist me through it...

I just wanted to find out all of my options prior to seeing the Endo at the end of November.. forewarned is forearmed as they say!

Thanks for any advice offered.

 

[zkt]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

FUCK! I`m reading it for the third time.
My first impression is that you have a prolactin secreting tumor and this is at least partially responsible for your low T and some other symptoms.
If you were an electronic circuit the problem would be trivial to troubleshoot. But applying the cure befor the problem is confirmed is frowned upon in medicine. Never the less, cabergoline will control your PRL enought to observe the results diagnostically.

Hi guys I'm a 37 year old male and here is my story, sorry for being so long winded but it's been difficult trying to sum it all up! 6 months ago I was diagnosed with Low T. I went through a complete nightmare of getting a diagnosis. I was feeling fine about 2 years ago working overseas and was flying (commuting) alot. One flight I was coming in to land and felt that I had something like a stroke. Massive pain in the centre of my head and feeling really weird like I didn't know what was happening to me. Later that day I felt a bit better Gradually after this experience I noticed more fatigue, aching joints especially in hips and legs and finger joints. Dizzyness and light headed etc. This all coincided with getting laid off and I came back to the UK.

I wasn't working and was at home gardening, childcare etc. I felt that perhaps I had a bug or virus and would just get over it. Also I was hoping it would go away and I would start to feel better. After about a year I was feeling worse and it was getting me down. I was crying and called the GP to get seen.

Went in and had bloods done etc. The only thing that came back abnormal was my TSH at 6.3 they redid them and they kept coming back around the 4-6 area the range is <6 but they don't treat until greater than 10. The docs thought this was normal and I was imagining things.

I went back and they suggested maybe drinking too much or that I was depressed. I kept pushing them and then referred me to an endo (my GP's words were "Only referring you to shut you up and if you don't believe me you can believe him". They did further bloods that showed my prolactin to be too high (range 1-550 mu/L) mine was at 1200. They tested LH FSH and Testosterone.

My LH/FSH was low 2.0 and 2.7 my T was 5.2 (range 11-36 nmol/L)

The endo suspected a possible pituitary tumour. I had an MRI scan and they couldn't see much. No visible tumour but the gland looked flattened not pea shaped. It wasn't very clear in the image. Hence my diagnosis with empty sella syndrome.

So the Endo said my prolactin was too low for a microprolactinoma and they would monitor it. He recommended TRT about 5 months ago. I started on sustanon 250 every 3 weeks and was on it for 4 months until the sustanon worldwide dried up. No follow up bloods or anything had been done in the meantime. The endo's next appt was cancelled 3 times and I am due to see him in November (instead of August). My experience on sustanon was horrific. I felt awful about 30% of the time, really bad anxiety, panic, racing heart etc.

Been on Testogel for 4 weeks now and those panicky things have gone pretty much. Got my bloods checked before starting Testogel 5 days before my sustanon had run out. They came back with:

Test 10.3 range 11-36
SHBG 20
Free TEST 260
Prolactin in now 1966 (range 1-550)
estradiol 169 pmol/L
So it looks like my T was low while on Sustanon. Feel some of the Low T symptoms still on Testogel so the Doc has asked me to go back for more bloods to see how I am doing on 1 sachet a day. (Think he wants to try 2 a day after my bloods come back)

What I guess I am asking here is do you think my Prolactin is actually causing my Low T ? I cannot stand being on TRT. My doc was confused why this has been overlooked. I guess it's the usual NHS wait forever between appts and bloods and reappointments etc.

My testicles have shrunk over the last 4 months by about 30% and I really think that maybe if I get something like Cabergoline it may lower prolactin and actually let my boys work. (The endo said the results showed it wasn't my boys that were the problem but whats in my head).

I cannot believe that this option was not tried earlier. I mean it may be a long shot? but to pump me full of hormones and with no follow ups is pretty poor. I bet my dog would get better care at the vets!!

Going to try and push for it when I see my endo next. Do you think it's possible I can recover my Testicles? Will they offer HCG? I do have kids and I have had the snip. Just hope that you guys have some good advice. Just as a sidenote.. My TSH has come down to 2.6 so I don't think its thyroid related anyway. No family history or antibodies etc.

What should I do guys and what are my chances of getting off TRT and working again?

Sorry for the long winded post but it seems there really is no-one to talk to and the UK seems to really overlook mens hormone issues. But I have been an awful person at times, angry, moody, easily snap at people including my poor wife and kids. Plus my sex drive in only 20% of what it used to be.

When I look at it in laymans terms, I've been on treatment for 5 months and without follow ups etc t my T level is pretty much similar to where I started! And at least it was my own T !

I do realise that what I want and what the endo is willing to give may differ. But if need be I will self medicate if absolutely necessary to get right or at least better than I feel now.

Does anyone know of anyone else having improved by lowering prolactin?

Would my T recover naturally without HCG etc if my prolactin was dropped?

Could my e2 keep dropping if I kept on losing weight? I had put on all the fat and weight around my gut and I'm now about a 35 inch waist

Would my shrunken balls get bigger again and be enough to produce my own stuff? I will accept this TRT as lifelong if it doesn't work out for me but it really does seem a second best approach.

Please any advice would be welcome.

Thankyou

 

[imrj]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

i have this same condition of empty sella....PM me and I can give you details, i was born with it thou so its congential...as you can see from the MRI pic on a normal person the pit is suppose to filled the entire sella but in my case a cranial defect allows cerebo spinal fluid (which is under pressure) to enter the sella and compress the pit all the way against the well.....the pit can still function somewhat under this compressed condition however as you age the ability of the pit to keep up with demand under such compressed stress can leave it on a state where it barely functions, so in essence we are left with a barely functional pit....it should be noted thou that some people can still show totally normal pituitary function with empty sella....other factors influence this such as degree of CFS pressure, compression swath, etc......

anyways, PM me if you want more details, I have exhaustive research on this, but cant tell you that I have had success controlling it with hormone replacement, its a tough job to try to replace what the pit does with drugs, literally impossible.

I am surprised of your high TSH as this indicates your pit is at least signaling for thyroid hormones, so its functional to some level...in my case ALL pit signals are low-normal or low altogether.....the first thing you should have done is an ACTH stimulation, the most critical pit function on the anterior side is cortisol signaling...you HAVE to make sure this is working and dont even bother with TRT or anything else until you do so....

 

[angrydad]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

Thankyou Guys, really impressed with your replies and it is quite comforting to know that there are some really knowledgeable members.

So I am going to apologise for my EPIC tome. I know it's a pain to read, I had difficulty making it more concise. Especially when I'm not a medical expert and never thought I would have to actually try and learn this whole subject matter to try and arm myself with knowledge to assist with my treatment a hopefully recovery.

@Michael Scally MD Thankyou for replying I mentioned having thyroid tests being done. This could be a problem but I think it may have improved since the onset. Any GP in the UK will not treat anything unless a TSH over 10 !! Would you be able to answer any of my questions on PRL?

@ZKT Thanks so much for your reply. Being in engineering myself I completely understand your analogy regards fault finding a circuit board lol. I wish they would be more proactive in fault finding and not so keen to jump into TRT. It's set me back as now my testicles have atrophied slightly. Going back may be difficult. Lol I know what you mean by having read it over 3 times ;-)

@imrj You are the first person/ man? that I have spoke too who also has empty sella. Seems to me all I here is that it's quite rare in men but very common in older women! Aargh.

Thankyou so much for your kind offer of support/advice through PM's. I will certainly take you up on that offer. Certainly will owe you a beer anyways. PM coming soon.

Seriously guys I am grateful to you all.

Do you think that it's possible that I could physically recover still if I have been low T all this time and have been on TRT for 6 months...? Especially as here in the UK we do not get HCG as part of our TRT treatment. Can I grow them back lol? or naturally will they come back if I can get my PRL down (If Indeed that is the culprit!!)

Thankyou!

 

[Michael Scally MD]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

Do you have a follow up prolactin?

 

[angrydad]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

The last PRL was from 2 weeks ago. Range 1 to 550 my result is 1966. Before treatment it was around 1200. I am getting more bloods today to see how I am coping on testogel.
My own thoughts is that as the mri showed empty sella with no obvious tumour. I may have a small micro non functioning pit tumour. My endo thinks the earlier level of 1200 is too low for a prolactinoma. but it still seems to be slowly increasing? Any thoughts please?

 

[angrydad]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

Hi guys, please any further advice? Going to see my endo in 4 weeks and need to have the right questions for him. Really hoping lowering my prolactin will enable me to come off T. Really feeling down because of all this. Thanks in advance guys!

 

[imrj]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

you need to take your MRI to a neurosurgeon.....not an endo as they cant speak to brain/cranial lesions of this sort....make sure you do this.....its important

 

[angrydad]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

Thankyou imrj for your reply, unfortunately lol(as usual) I have never seen the MRI results, in fact at my follow up appt to discuss my mri scan. My endo hadn't even got the results, he had to go & chase the radiographer? To get an interpretation of the results etc. just said err empty sella etc can't see much, dont think you have any tumours etc. repeat in a year ( he also said he will mention my case in a meeting with neuros) but this was 6 mnths ago. Since had 3 appts cancelled by them. Next appt (if not cancelled again! Is 4 weeks away.
I just want to feel normal again, TRT is a joke when it's being so sloppily deployed. No libido, poor quality of life, just kept waiting dangling by docs and waiting times.. I don't think they will ever actually look further into any pituitary damage, seems too easy for them to just patch up with drugs etc. Because it's UK NHS they will not allow me to see a neuro unless the endo thinks it's appropriate. Whatever happened to me 2-3 years ago while flying has obviously caused the raised PRLand possible other hormone issues and I just hope this can be remedied. I really want to grab these people and shake them! Would you mind telling me why it's so urgent a neuro sees me? I would have thought they should have looked into it if they thought appropriate? Plus, is there anything they could do for me anyway? Gotta admit this is really getting me down..

 

[angrydad]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

Please, anyone got any good advice on this. Thanks iin advance.

 

[zkt]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

For reasons not fully understood PRL and T vary inversely.Get the PRL straightened out and TRT might not be needed. Unfortunately cabergoline is not a long term solution due to heart valve problems but it can be a useful diagnostic tool.

 

[Michael Scally MD]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

Hi guys I'm a 37 year old male and here is my story, sorry for being so long winded but it's been difficult trying to sum it all up! 6 months ago I was diagnosed with Low T. I went through a complete nightmare of getting a diagnosis. I was feeling fine about 2 years ago working overseas and was flying (commuting) alot. One flight I was coming in to land and felt that I had something like a stroke. Massive pain in the centre of my head and feeling really weird like I didn't know what was happening to me. Later that day I felt a bit better Gradually after this experience I noticed more fatigue, aching joints especially in hips and legs and finger joints. Dizzyness and light headed etc. This all coincided with getting laid off and I came back to the UK.

I wasn't working and was at home gardening, childcare etc. I felt that perhaps I had a bug or virus and would just get over it. Also I was hoping it would go away and I would start to feel better. After about a year I was feeling worse and it was getting me down. I was crying and called the GP to get seen.

Went in and had bloods done etc. The only thing that came back abnormal was my TSH at 6.3 they redid them and they kept coming back around the 4-6 area the range is <6 but they don't treat until greater than 10. The docs thought this was normal and I was imagining things.

I went back and they suggested maybe drinking too much or that I was depressed. I kept pushing them and then referred me to an endo (my GP's words were "Only referring you to shut you up and if you don't believe me you can believe him". They did further bloods that showed my prolactin to be too high (range 1-550 mu/L) mine was at 1200. They tested LH FSH and Testosterone.

My LH/FSH was low 2.0 and 2.7 my T was 5.2 (range 11-36 nmol/L)

The endo suspected a possible pituitary tumour. I had an MRI scan and they couldn't see much. No visible tumour but the gland looked flattened not pea shaped. It wasn't very clear in the image. Hence my diagnosis with empty sella syndrome.

So the Endo said my prolactin was too low for a microprolactinoma and they would monitor it. He recommended TRT about 5 months ago. I started on sustanon 250 every 3 weeks and was on it for 4 months until the sustanon worldwide dried up. No follow up bloods or anything had been done in the meantime. The endo's next appt was cancelled 3 times and I am due to see him in November (instead of August). My experience on sustanon was horrific. I felt awful about 30% of the time, really bad anxiety, panic, racing heart etc.

Been on Testogel for 4 weeks now and those panicky things have gone pretty much. Got my bloods checked before starting Testogel 5 days before my sustanon had run out. They came back with:

Test 10.3 range 11-36
SHBG 20
Free TEST 260
Prolactin in now 1966 (range 1-550)
estradiol 169 pmol/L
So it looks like my T was low while on Sustanon. Feel some of the Low T symptoms still on Testogel so the Doc has asked me to go back for more bloods to see how I am doing on 1 sachet a day. (Think he wants to try 2 a day after my bloods come back)

What I guess I am asking here is do you think my Prolactin is actually causing my Low T ? I cannot stand being on TRT. My doc was confused why this has been overlooked. I guess it's the usual NHS wait forever between appts and bloods and reappointments etc.

My testicles have shrunk over the last 4 months by about 30% and I really think that maybe if I get something like Cabergoline it may lower prolactin and actually let my boys work. (The endo said the results showed it wasn't my boys that were the problem but whats in my head).

I cannot believe that this option was not tried earlier. I mean it may be a long shot? but to pump me full of hormones and with no follow ups is pretty poor. I bet my dog would get better care at the vets!!

Going to try and push for it when I see my endo next. Do you think it's possible I can recover my Testicles? Will they offer HCG? I do have kids and I have had the snip. Just hope that you guys have some good advice. Just as a sidenote.. My TSH has come down to 2.6 so I don't think its thyroid related anyway. No family history or antibodies etc.

What should I do guys and what are my chances of getting off TRT and working again?

Sorry for the long winded post but it seems there really is no-one to talk to and the UK seems to really overlook mens hormone issues. But I have been an awful person at times, angry, moody, easily snap at people including my poor wife and kids. Plus my sex drive in only 20% of what it used to be.

When I look at it in laymans terms, I've been on treatment for 5 months and without follow ups etc t my T level is pretty much similar to where I started! And at least it was my own T !

I do realise that what I want and what the endo is willing to give may differ. But if need be I will self medicate if absolutely necessary to get right or at least better than I feel now.

Does anyone know of anyone else having improved by lowering prolactin?

Would my T recover naturally without HCG etc if my prolactin was dropped?

Could my e2 keep dropping if I kept on losing weight? I had put on all the fat and weight around my gut and I'm now about a 35 inch waist

Would my shrunken balls get bigger again and be enough to produce my own stuff? I will accept this TRT as lifelong if it doesn't work out for me but it really does seem a second best approach.

Please any advice would be welcome.

Thankyou

IMO, you are being shuttled around unnecessarily. As I read, you are suffering from hypogonadism, hyperprolactinemia, and hypothyroidism, although your doctors might disagree with the latter. When I see a constellation of pituitary hormone deficiencies there is likely a central concern. In your case, the Empty Sella. I agree there should be a second reading for confirmation, but from the hormone problems the diagnosis appears to wrap things up nicely.

However, this does not make you feel much better since the deficiencies are still in place. IMO, the treatment is inadequate. I would first direct attention to the hypothyoidism even though the doctor is doubtful. The reason being is this is possibly central to all of your problems.

Hypothyroidism may be associated with hyperprolactinemia. If hypothyroidism results in increased Thyrotropin-Releasing Hormone (TRH) production, then TRH (which can act as a prolactin-releasing factor (PRF)) could lead to hyperprolactinemia. Thus, treatment directed to lowering the TSH to <2 might alleviate the hyperprolactinemia AND hypogonadism. Or, at the minimum, lessen the effect. After observing the thyroid treatment effects, I would then tackle the hyperprolactinemia, if necessary. Both, hypothyroidism and hyperprolactinemia are known causes of hypogonadism. Finally, the hypogonadism, again, if needed. The treatment given is BACKWARDS! [Get GH/IGF-1 checked out!]


The following studies include the full-text links.

De Marinis L, Bonadonna S, Bianchi A, Maira G, Giustina A. Primary Empty Sella. Journal of Clinical Endocrinology & Metabolism 2005;90(9):5471-7. Primary Empty Sella

Context: The term primary empty sella (PES) refers to a number of endocrine and/or neurological disturbances that may be caused by the herniation of subarachnoid space within the sella.

Setting: The records of all patients with a diagnosis of empty sella between 1985 and 2002 seen at the Catholic University of Rome and University of Brescia were examined retrospectively.

Patients: We have observed 171 female and 42 male patients affected by PES (over 4:1 sex ratio). The mean age at diagnosis in our subjects was 51.8 ± 2.1 yr. Mean body mass index was 27.3 ± 3.5 kg/m2.

Main Outcome Measure: All the patients have been analyzed first either with sellar computed tomography scan or magnetic resonance imaging. All patients underwent neurological, ophthalmological, and baseline endocrine evaluation (appropriate stimulation tests were performed when hypopituitarism was suspected).

Results: In the overall population, 40 of 213 patients had documented endocrine abnormalities, specifically 31 females and nine males. Twenty-two patients (10.3% of total patients; 18 women, 10.5% of all women, with a mean age of 38.6 ± 1.1 yr and four males, with a mean age 46.5 ± 3.52 yr) presented with hyperprolactinemia. Global anterior hypopituitarism was confirmed in nine patients. Eight patients presented an isolated GH deficiency. One hundred thirty-eight of our patients presented a so-called partial empty sella at computed tomography scan/magnetic resonance imaging, and 75 had total PES.

Conclusions: PES may be associated with variable clinical conditions ranging from mild endocrine disturbances to severe intracranial hypertension and rhinorrhea. The need for treatment of hyperprolactinemia as well as for replacement hormone therapy must be assessed in PES. Symptomatic intracranial hypertension makes cerebrospinal fluid shunting procedures necessary.


Del Monte P, Foppiani L, Cafferata C, Marugo A, Bernasconi D. Primary "empty sella" in adults: endocrine findings. Endocr J 2006;53(6):803-9. http://www.jstage.jst.go.jp/article/endocrj/53/6/803/_pdf

Increasing evidence of impaired pituitary function in many subjects with primary empty sella (PES) has been reported. We conducted a retrospective analysis of our patients with PES, in order to ascertain presenting symptoms and endocrine status on diagnosis and during follow-up. Magnetic resonance imaging (MRI) of the pituitary leading to the diagnosis of PES was performed in 8 patients (5 F and 3 M, age: 60.1 +/- 3.3 years, M +/- SE; group 1) after the diagnosis of global anterior hypopituitarism (H), and in 20 patients (F, age 56.9 +/- 2.2 years, group 2) for other clinical reasons. Baseline determinations of pituitary and target gland hormones and of IGF-I were performed. GH response to GHRH plus arginine stimulation was also evaluated. Ten age- and BMI-matched subjects (7 F, 3 M, age: 53.0 +/- 4.0 years) with normal pituitary function served as controls (C). In group 1, the presenting symptoms leading to the diagnosis of H were consciousness disturbances, hyponatremia and chronic fatigue. The GH response to stimulation was absent (peak:1.0 +/- 0.3 ng/ml) and IGF-I levels (60.1 +/- 9.3 ng/ml) were significantly lower (p<0.001) than in C and group 2 PES patients. Among group 2 PES patients, the main presenting symptoms were headache and visual alterations. Baseline hormone levels proved normal in 17 subjects, while slight hyperprolactinemia was observed in 2 and hypogonadotropic hypogonadism in one. The GH response to stimulation (12.9 +/- 3.4 ng/ml) and IGF-I levels (141.7 +/- 12.0 ng/ml) were lower (p<0.05) than in C (GH: 33.4 +/- 8.8 ng/ml, IGF-I: 193.1 +/- 20.3 ng/ml). PES is a heterogeneous condition that ranges from hypopituitarism to various degrees of isolated GH deficiency, and which needs careful endocrine assessment, treatment and follow-up.

 

[Michael Scally MD]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

Melmed S, Casanueva FF, Hoffman AR, et al. Diagnosis and Treatment of Hyperprolactinemia: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism 2011;96(2):273-88. Diagnosis and Treatment of Hyperprolactinemia: An Endocrine Society Clinical Practice Guideline

Objective: The aim was to formulate practice guidelines for the diagnosis and treatment of hyperprolactinemia.

Participants: The Task Force consisted of Endocrine Society-appointed experts, a methodologist, and a medical writer.

Evidence: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence.

Consensus Process: One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of The Endocrine Society, The European Society of Endocrinology, and The Pituitary Society reviewed and commented on preliminary drafts of these guidelines.

Conclusions: Practice guidelines are presented for diagnosis and treatment of patients with elevated prolactin levels. These include evidence-based approaches to assessing the cause of hyperprolactinemia, treating drug-induced hyperprolactinemia, and managing prolactinomas in nonpregnant and pregnant subjects. Indications and side effects of therapeutic agents for treating prolactinomas are also presented.

 

[Michael Scally MD]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

Hekimsoy Z, Kafesciler S, Guclu F, Ozmen B. The prevalence of hyperprolactinaemia in overt and subclinical hypothyroidism. Endocr J 2010;57(12):1011-5. http://www.jstage.jst.go.jp/article/endocrj/57/12/1011/_pdf

The aims of this study were to: 1) determine the prevalence of hyperprolactinaemia in patients with newly diagnosed subclinical and overt hypothyroidism, and 2) investigate the change in PRL levels with treatment. In this observational study, patients with a new diagnosis of hypothyroidism in our endocrinology clinic were approached for participation, as were healthy controls. Patients with medical reasons for having elevated PRL levels, lactating and pregnant women were excluded from the study. No patient had kidney or liver disease.

After examination to determine if clinical causes of PRL elevation were present, serum levels of thyrotropin (TSH), free thyroxine, free triiodothyronine and PRL were measured and correlation of PRL levels with the severity of hypothyroidism (overt or subclinical) was performed. Fifty-three patients (45 women, 8 men, mean age 45.3 +/- 12.2 years) had overt hypothyroidism. One hundred forty-seven patients (131 women, 16 men, mean age 42.9 +/- 12.6 years) had subclinical hypothyroidism. One hundred healthy persons (85 women, 15 men, mean age 43.9 +/- 11.4 years) participated as controls. The same blood tests were repeated in patients after normalization of TSH levels with L-thyroxine treatment. PRL elevation was found in 36% of patients with overt hypothyroidism, and in 22% of patients with subclinical hypothyroidism.

PRL levels decreased to normal in all patients after thyroid functions normalized with L-thyroxine treatment. In the hypothyroid patients (overt and subclinical) a positive correlation was found between TSH and PRL levels (r=0.208, p=0.003). PRL regulation is altered in overt and subclinical hypothyroidism, and PRL levels normalize with appropriate L-thyroxine treatment.

 

[Michael Scally MD]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

Bolyakov A, Paduch DA. Prolactin in men's health and disease. Curr Opin Urol 2011;21(6):527-34. Prolactin in men's health and disease. [Curr Opin Urol. 2011] - PubMed - NCBI

PURPOSE OF REVIEW: To review physiology of prolactin (PRL), cause and managment of hyperprolactinemia, and discuss evolving diverse roles of PRL in men's health.

RECENT FINDINGS: Hyperprolactinemia can be physiologically found after sexual activities, exercise, lactation, during pregnancy, and after stressful venipuncture. Elevated PRL can be caused by medications use, renal failure, hypothyroidism, and by prolactinoma - PRL secreting tumors. Symptomatic hyperprolactinemia and prolactinomas should be treated to lower PRL levels, decrease tumor size, and restore gonadal function. Three modes of treatment are typically utilized: pharmacological, radiosurgery with gamma radiation, and external beam radiation. Pharmacological treatment of prolactinomas is mainly based on dopamine agonists. The most frequently used dopamine agonists are bromocriptine and cabergoline. Cabergoline becoming the preferred drug in the treatment of prolactinomas because of higher response rate and less side-effects. Bromocriptine has been recently approved to improve glycemic control in diabetes mellitus.

SUMMARY: PRL plays a diverse role in men's reproduction and health. Detecting and treating elevated PRL may not only improve infertility and hypogonadism but also have a positive effect on the metabolic profile of patient and control of glycemic control and metabolic profile - an important advantage considering dramatic and worldwide increase in obesity and diabetes.

 

[zkt]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

So this is the relationship between the thyroid hormone and testosterone: prolactin And TSH also acting as a PRL stimulating factor. Thyroid hormone is also a factor in LDL receptor regulation. One might assume that there is a sweet spot in thyroid hormone level- perhaps individually determined .

 

[angrydad]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

Firstly, I want to thank all you guys in particularly Dr Scally and ZKT. I was beginning to feel that I was going to remain stuck in this rut without any sage advice. I'm not knocking my Doc or Endo.. But I feel that I have been done a disservice with my current treatment and just put on TRT and left to fester.

So as I thought pretty much. It's likely that it's the Prolactin (also influenced by the thyroid issues) that is most likely causing my Low T.

Seeing as you guys are on a roll... What's my next logical step in 3 weeks time at my Endo appt. Do I print out these research articles and suggest he look at them if he's not already aware?

I think firstly I need to get off this shitty TRT. What would be the best way to do this? Cold turkey? I don't even know if the NHS in the UK will offer things for HPTA restarts? I probably won't know until I see him.

As per your advice, I will sound him out about trialling a low dost of thyroxine to see if this impacts my prolactin levels. But I am filled with doubt that he will give this a shot.

I guess the next thing is maybe look at Cabergoline if this is the only other option at lowering my Prolactin levels.

Just not sure on a roadmap out of this mess? Just wondering what the best order to do this in would be? Get off TRT first so that we get a baseline? If I come off TRT is it likely I will get my HPTA axis back up and running after 7 months of TRT without any restart drugs? most likely not without addressing the High Prolactin.

Please could you guys put the icing on the cake and help me formulate a simple roadmap with which I can go armed with to my Endo and see what he thinks.. At least it's ammo for me if he just says stay on TRT etc..

Basically how do I get of TRT and when should I start the other drugs etc? also how long is it likely to take for my T to raise naturally once I start this thing??

Thank you guys and looking forward to your replies.

 

[zkt]

Re: Diagnosed with empty sella syndrome,Low T,high prolactin can I restart and stop t

I`m not really sure what your best course of action is right now. Have to think about it. How far are you willing to go in taking responsibility for your own treatment?
I can guarantee you that printing out these research articles and suggesting that he look at them isnt going to get you anywhere.


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