Magic Conference: Testing and Diagnosis Process for Pituitary Disorders

MEETING NOTES : Dr. Salvatori

Meeting Created: July 20, 2012 11:00 AM

Lombard

Testing and Diagnosis Process for Pituitary Disorders 

Pituitary disorders can be difficult to diagnose in many cases. Dr. Salvatori will discuss the

different testing and diagnostic procedures to determine the pituitary disorder. MAGIC
receives many calls asking about diagnostic procedures. This segment will be helpful in under-
standing what procedures are used today to provide the best treatment available. 

Dr. Cushing picture

Dr. S only sees diagnosed patients

Dr C 1932 description from Johns Hopkins, pre-MRI

Causes do CS

• Prescriptions, iatrogenic
• ACTH independent adrenal 20%
• ATCH dependent, 80%, 85%of those Cushings

Signs best to discriminate

• Bruisings
• Facial plethora, redness
• Weakness
• Striae

Symptoms

• Fat pads
• Moon face
• Thin skin
• Acne
• Depression
• Fatigue
• Weight gain
• Menstrual
• Decreased libido
• Irritability

diagnosis

• UFC
• Overnight sex
• Salivary
• Dex-CRF

Why bedtime cortisol?

Diurnal rhythm, changing time zones, what helps you wake up

Is CS ACTH-dependent?

Where is the ACTH coming from?

• Up to 30% not visible on MRI
• Up to 10% of normal people suggest pituitary incidentaloma
• MRI is not good test to diagnose

First do no harm, be sure before surgery

IPSS, not to diagnose Cushings, just to find where ACTH is coming from 

Lose more blood testing for Cushings than during surgery

Prolactinoma vs. pseudo-prolactinoma

• Pregnant
• Psychoactive drugs

Acromegaly: IGF-1 not whole story

Hugo brothers

Hypopituitarism

• Many undiagnosed
• 45/100,000 from Spanish study
• 94/100,000 from Belgian

Secondary, TSH isn't a good test

Testicle size

Adrenal insufficiency

AM cortisol less then 3 ug/dl

Random cortisol above 15 ug/dl rules it out

Tests

• ITT
• ACTH stimulation

Adrenals shrink

Pituitary apoplexy=acute adrenal insufficiency

GH deficiency

IGF-1 not good test

Glucagon used now at Hopkins.  Cutoff is 3

Heavier you are, lower GH on stimulation test

Pan-hypopituitary don't need stimulation testing

Causes of hypopituitary

Traumatic brain injury, mostly young men

Cancer, radiation to brain

Hypopituitary

• Undiagnosed
• Gradual symptoms
• Steroid replacement before thyroid replacement

Q & A