MRI And Its Correlation with Hypogonadotropic Hypogonadism

[Michael Scally MD]

Das G, Surya A, Okosieme O, et al. PITUITARY IMAGING BY MRI AND ITS CORRELATION WITH BIOCHEMICAL PARAMETERS IN THE EVALUATION OF MEN WITH HYPOGONADOTROPIC HYPOGONADISM. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists 2019. https://journals.aace.com/doi/10.4158/EP-2018-0609 (An Error Occurred Setting Your User Cookie)

Objective: A significant ambiguity still remains about which patient deserves a MRI of the pituitary during evaluation of hypogonadotropic hypogonadism (HH) in men.

Methods: Retrospective case series of 175 men with HH referred over 6 years.

Results: 49.7% of men had total testosterone (TT) levels lower than the Endocrine Society threshold of 5.2 nmol/L. 142 patients (81.2%) had normal appearance of pituitary MRI whereas others had different spectrum of abnormalities [empty sella (n=16); macroadenoma (n=8); microadenoma (n=8) and pituitary cyst (n=1)]. In men with TT in the lowest quartile, MRI pituitary findings was not statistically different from men in the remaining quartiles (p=0.50).

Patients with raised prolactin had higher number of abnormal MRI findings (38.9% vs. 13.7%; p = 0.0014) and adenomatous lesions (macro and micro) (27.8% vs. 4.3%; p = 0.01) in comparison to men with normal prolactin.

The prolactin levels were highest in men with macroadenomas in both groups [9950 (915); p=0.007 and 300 (68.0) mU/L; p = 0.02 respectively] with concomitant lower level of other pituitary hormones. Multivariate logistic regression showed an association of abnormal pituitary MRI with IGF-1 SDS [OR: 1.78 (95% CI, 1.15 - 2.77); p=0.009] and prolactin [OR: 1.00 (1.00 -1.03); p=0.01].

Conclusion: MRI of pituitary is not warranted in all patients with HH as the yield of identifiable abnormalities is quite low. Anatomical lesions are likely to be present only when low levels of TT (<5.2 nmol/L) are found concomitantly with high levels of prolactin and/or low IGF-1 SDS scores.

 

[Michael Scally MD]

Pituitary Adenomas

What you need to know

· Check visual fields in patients presenting with headache coexisting with possible hypopituitary symptoms
· Consider the diagnosis in men with fatigue and ask about low libido or erectile dysfunction; check 9 am testosterone, prolactin, luteinising hormone (LH), and follicle stimulating hormone (FSH)
· Consider the diagnosis in women with oligo/amenorrhoea; check LH, FSH, oestradiol, and prolactin

A 58 year old man describes increasing fatigue and loss of motivation over a year. Routine blood tests are normal. He is going through a divorce and he and his GP agree that the symptoms are likely related to stress. On a routine eye check he is found to have a bitemporal hemianopia. Pituitary magnetic resonance imaging (MRI) reveals a 2.5 cm pituitary macroadenoma elevating and compressing the optic chiasm. On further questioning, the patient describes a four year history of erectile dysfunction.

Pituitary adenomas are often clinically silent or manifest with non-specific symptoms, which can lead to a delayed diagnosis. This article provides a summary of clinical features and investigations to help non-specialists and primary care doctors to recognise and diagnose pituitary adenoma.

How common are pituitary adenomas?

· Pituitary adenomas are very common (up to 16% from autopsy and imaging studies) but only 0.1% progress to cause morbidity21
· Previous population studies of pituitary adenomas have probably underestimated true prevalence. A community study of more than 80 000 inhabitants showed that prevalence of pituitary adenomas per 100 000 was fourfold higher than previous estimates at approximately 1:1000.22 Other population studies confirm this232425
· From the third decade onwards, pituitary adenoma is the most common cause of an intrasellar mass

Pal A, Leaver L, Wass J. Pituitary adenomas. BMJ (Clinical research ed) 2019;365:l2091. Pituitary adenomas

 

[Michael Scally MD]

Pituitary Imaging by MRI and Its Correlation with Biochemical Parameters in The Evaluation of Men with Hypogonadotropic Hypogonadism

Objective: A significant ambiguity still remains about which patient deserves a magnetic resonance imaging (MRI) scan of the pituitary during evaluation of hypogonadotropic hypogonadism (HH) in men.

Methods: Retrospective case series of 175 men with HH referred over 6 years.

Results: A total of 49.7% of men had total testosterone (TT) levels lower than the Endocrine Society threshold of 5.2 nmol/L. One-hundred forty-two patients (81.2%) had normal appearance of pituitary MRI, whereas others had different spectrum of abnormalities (empty sella [n = 16], macroadenoma [n = 8], microadenoma [n = 8], and pituitary cyst [n = 1]). In men with TT in the lowest quartile, MRI pituitary findings were not significantly different from men in the remaining quartiles (P = .50).

Patients with raised prolactin had higher number of abnormal MRI findings (38.9% vs. 13.7%; P = .0014) and adenomatous lesions (macro and micro) (27.8% vs. 4.3%; P = .01) in comparison to men with normal prolactin. The prolactin levels (median [interquartile range]) were highest in men with macroadenomas in both groups (9,950 [915]; P = .007 and 300 [68.0] mU/L; P = .02, respectively), with concomitant lower levels of other pituitary hormones.

Multivariate logistic regression showed an association of abnormal pituitary MRI with insulin-like growth factor 1 (IGF-1) standard deviation score (SDS) (odds ratio [OR], 1.78 [95% confidence interval (CI), 1.15 to 2.77]; P = .009) and prolactin (OR, 1.00 [95% CI, 1.00 to 1.03]; P = .01).

Conclusion: MRI of the pituitary is not warranted in all patients with HH, as the yield of identifiable abnormalities is quite low. Anatomic lesions are likely to be present only when low levels of TT (<5.2 nmol/L) are found concomitantly with high levels of prolactin and/or low IGF-1 SDS.

Das G, Surya A, Okosieme O, et al. PITUITARY IMAGING BY MRI AND ITS CORRELATION WITH BIOCHEMICAL PARAMETERS IN THE EVALUATION OF MEN WITH HYPOGONADOTROPIC HYPOGONADISM. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists 2019;25:926-34. https://journals.aace.com/doi/10.4158/EP-2018-0609 (An Error Occurred Setting Your User Cookie)

 

[Michael Scally MD]

Pituitary Dysfunction Among Men Presenting with Hypogonadism

Purpose of Review - Hypogonadism is a common endocrine dysfunction. This review focuses on the most up-to-date guideline for evaluation of pituitary function among men presenting with signs and symptoms of hypogonadism.

Recent Findings - The clinician must differentiate between primary (testicular) and secondary (pituitary-hypothalamic or central) hypogonadisms and be aware of adult-onset hypogonadism. If gonadotropins are low or inappropriately normal, the clinician must consider potential reversible causes in the hypothalamus-pituitary axis.

Also, it is critical to understand the pitfalls of testosterone testing. When clinically indicated, evaluation of other pituitary hormone functions as well as pituitary magnetic resonance imaging may be necessary. Furthermore, it is essential to recognize that pituitary incidentalomas are common.

Patients with microprolactinoma are more likely to present with symptoms of sexual dysfunction while those with macroprolactinoma are more likely to present with symptoms of mass effect. Some functional pituitary tumors respond to drug therapy while other nonfunctional tumors require surgical intervention.

Summary - It is important for the clinician to understand the proper work-up of the hypogonadal patient with pituitary dysfunction and when necessary to refer to an endocrinologist or a neurosurgeon.

Levy S, Arguello M, Macki M, Rao SD. Pituitary Dysfunction Among Men Presenting with Hypogonadism. Curr Urol Rep 2019;20:78. Pituitary Dysfunction Among Men Presenting with Hypogonadism

 

[Hugh Madbrah]

Das G, Surya A, Okosieme O, et al. PITUITARY IMAGING BY MRI AND ITS CORRELATION WITH BIOCHEMICAL PARAMETERS IN THE EVALUATION OF MEN WITH HYPOGONADOTROPIC HYPOGONADISM. Endocrine practice: official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists 2019. https://journals.aace.com/doi/10.4158/EP-2018-0609 (An Error Occurred Setting Your User Cookie)

Objective: A significant ambiguity still remains about which patient deserves a MRI of the pituitary during evaluation of hypogonadotropic hypogonadism (HH) in men.

Methods: Retrospective case series of 175 men with HH referred over 6 years.

Results: 49.7% of men had total testosterone (TT) levels lower than the Endocrine Society threshold of 5.2 nmol/L. 142 patients (81.2%) had normal appearance of pituitary MRI whereas others had different spectrum of abnormalities [empty sella (n=16); macroadenoma (n=8); microadenoma (n=8) and pituitary cyst (n=1)]. In men with TT in the lowest quartile, MRI pituitary findings was not statistically different from men in the remaining quartiles (p=0.50).

Patients with raised prolactin had higher number of abnormal MRI findings (38.9% vs. 13.7%; p = 0.0014) and adenomatous lesions (macro and micro) (27.8% vs. 4.3%; p = 0.01) in comparison to men with normal prolactin.

The prolactin levels were highest in men with macroadenomas in both groups [9950 (915); p=0.007 and 300 (68.0) mU/L; p = 0.02 respectively] with concomitant lower level of other pituitary hormones. Multivariate logistic regression showed an association of abnormal pituitary MRI with IGF-1 SDS [OR: 1.78 (95% CI, 1.15 - 2.77); p=0.009] and prolactin [OR: 1.00 (1.00 -1.03); p=0.01].

Conclusion: MRI of pituitary is not warranted in all patients with HH as the yield of identifiable abnormalities is quite low. Anatomical lesions are likely to be present only when low levels of TT (<5.2 nmol/L) are found concomitantly with high levels of prolactin and/or low IGF-1 SDS scores.

I've had injuries lately and have a 4mm pituitary adenoma so I was considering using HGH or BPC-157 for a few weeks to heal my tendons.

I've done some research on pituitary microadenomas and the use of HGH and it seems the studies show no progression of the tumors and this was usually over a long period of time, in your opinion do you think short term HGH supplementation is rather safe in patients with a pituitary microadenoma? Better yet, would BPC-157 be safe? BPC-157 seems to work very well on healing tendons but I know it also works on the brain tissue, not sure if that could promote growth but figured I'd post here to see if anyone has any information on this.