In pre-menopausal women, non-functioning pituitary adenomas can cause menstrual periods to become irregular or stop completely, and can cause infertility. In post-menopausal women, the effects can be more subtle because the woman is no longer menstruating regularly; in these patients, the symptoms are typically related to decreased sexual interest, or the effects of hypothyroidism as discussed before.
The most dangerous consequence of pituitary dysfunction is the loss of cortisol, which can be life-threatening, with symptoms such as low blood pressure, confusion, nausea, vomiting and fever. If a non-functioning pituitary adenoma continues to grow, it will eventually enlarge to the point where it is not only pressing on the normal pituitary gland, but also pressing on other nerves and arteries at the base of the brain that are near the pituitary gland.
In addition to causing pressure on the normal pituitary gland and adjacent nerves and brain, a non-functioning pituitary adenoma can cause pressure on the lining around the brain and the pituitary gland, leading to increasing headache usually behind the eyes.
It is always important to keep in mind that even large pituitary adenomas are not cancer, but if left untreated, it can cause serious illness because of its effects on the normal pituitary gland, optic nerves, and brain.
Most pituitary tumors are benign. Symptoms vary depending on the type of tumor and the affected area of the pituitary gland. Your health care provider may order blood and urine tests, CT scan, MRI, or biopsy to diagnose the tumor. Treatment may include surgery, radiation therapy, or medication. A pituitary tumor is an abnormal growth in the pituitary gland. The pituitary is a small gland in the brain. It is located behind the back of the nose.
It makes hormones that affect many other glands and many functions in your body. Most pituitary tumors are not cancerous benign. But they can cause the pituitary to make too few or too many hormones, causing problems in the body. Pituitary tumors that make too many hormones will cause other glands to make more hormones. That will cause symptoms related to each of the specific hormones. Many pituitary tumors will also press against the nearby optic nerves.
This can cause vision problems. As a result, they are not diagnosed. Or they are found only during a routine brain imaging test. These tumors are the most common type. You may not have any symptoms until the tumor is a certain size.
When the tumor is big enough, it may cause headaches and vision problems. Large pituitary tumors can crush normal pituitary cells. This leads to symptoms caused by decreased hormone production. These benign tumors are also common. They make too much prolactin. The only FDA approved medication for pregnancy, bromocriptine, has been given to several thousand women who wished to become pregnant. Cabergoline is not FDA approved for pregnancy; information on several hundred women who became pregnant while taking cabergoline showed no increase in risk above the normal risk of birth defects for the baby, Until there is more experience with cabergoline in women who become pregnant, it is prudent for women try to become pregnant to take bromocriptine.
The convenience of taking the medication is important for many patients who are busy with work and other activities. Bromocriptine is usually given three times a day with food, to minimize the risk of side effects such as nausea, lightheadedness, low blood pressure.
Some patients can be treated twice a day. Norprolac not available in the U. Cabergoline is a long acting drug that is given once or twice a week. There is no current information on risk for heart valve problems in patients with a prolactinoma treated with cabergoline or previously treated with pergolide who take much smaller doses.
Since most patients with a prolactinoma require long-term treatment, there is a concern that long-term treatment with cabergoline may cause problems with heart valve thickening. For this reason, I recommend an echocardiogram study to assess heart function, valve size and valve function. An echocardiogram is an ultrasound study that involves passing a probe over the chest heart and taking pictures of heart muscle and heart valves no needles; painless.
This is a personal decision. However, until more is known about the risk of taking cabergoline for many years, it is reasonable to consider taking bromocriptine instead of cabergoline. Please note: the cost of cabergoline and bromocriptine shown below are as of March, Bromocriptine, 2. Cabergoline, 0. Yes — if the only reason for infertility is the high prolactin level. There are many causes of infertility, but if high prolactin is the only reason, lowering prolactin to normal results in the same chances for pregnancy as the general age-matched population fertility declines with increasing age, especially after age Usually yes — if the prolactin is reduced with medication bromocriptine or cabergoline , then a birth control pill can be added.
A woman may become pregnant taking one of these medications even without having a menstrual period. Possibly, not. It is reasonable to stop medication after 5 years of treatment and follow the prolactin level — if prolactin increases above normal or if there is tumor growth on the MRI, medication bromocriptine or cabergoline should be re-started.
An unfortunate fact is that when most patients are diagnosed with acromegaly usually a delay of 7 to 8 years after the beginning of symptoms , the pituitary tumor is large and may invade areas that the surgeon cannot go into the arteries on each side of the pituitary gland or where the tumor has invaded surrounding structures bone below the gland or coverings around the pituitary gland [called dura mater].
Surgery is usually effective in removing the bulk of the tumor and reliving headaches and improving visual problems, but it may not be possible to remove the entire tumor. Additional treatments are necessary to lower growth hormone and IGF-1 levels to normal in order to reduce the risk of the complications of continued excessive growth hormone production. The tumor produces growth hormone but its action and effect is dependent on production of another hormone, IGF-1 insulin-like growth factor-1 ; IGF-1 is produced, primarily in the liver, in response to the amount of growth hormone made by the pituitary gland.
Growth hormone does not cause growth, the liver must respond to growth hormone to produce an adequate amount of IGF-1; IGF-1 is the effector of growth hormone action. The blood IGF-1 level is also a very reliable indicator of overall growth hormone production.
The blood IGF-1 level is the most reliable indicator of overall growth hormone production and is a reliable measure of activity in a patient with acromegaly. A normal blood IGF-1 level indicates remission or, in patients taking medication, control of acromegaly. Somatomedin C and IGF-1 are the same hormone, different names.
IGF-1 is more constant in the blood and is a much better and more accurate indicator of overall growth hormone production. The IGF-1 blood test is used to assess the effectiveness of all treatments surgery, radiation, medical treatment.
If a patient is treated with the growth hormone antagonist, see below for description pegvisomant Somavert , the only reliable test of effectiveness is the IGF-1 Somatomedin C level. Measurement of growth hormone in a patient receiving pegvisomant Somavert will result in extremely high growth hormone levels because pegvisomant is a modified growth hormone molecule and is measured as growth hormone in the blood test. Medical treatment is usually given if there is persistent overproduction of growth hormone after surgery.
Although medications can lower growth hormone and IGF-1 levels, they do not always cause the tumor to shrink. Because of this, the usual first treatment is surgical removal of as much of the tumor as possible. In the situation of a large tumor, particularly if it has grown into an area that is not accessible to the surgeon, the majority of the tumor may be removed, but a small portion remains — and continues to produce too much growth hormone.
Because of the long-term complications of excessive growth hormone joint problems, diabetes, high blood pressure, facial changes, sweating, risk of colon polyps and possible increased risk of colon cancer, and premature heart disease and premature death , it is important to reduce IGF-1 to normal.
Radiation therapy to the remaining tumor is given if surgery is not completely successful. Since it may take months or years before the radiation therapy is effective, medical treatment is used to control excessive growth hormone production while waiting for the radiation to become effective. Medications do not cure the problem — they control the situation. The medication is effective only as long as it is taken as prescribed.
Currently used drugs include: Dopamine agonist drugs: bromocriptine, cabergoline Somatostatin analogs: Sandostatin LAR, Somatuline Lanreotide Autogel Growth hormone receptor antagonist, pegvisomant Somavert. Cabergoline may be more effective than bromocriptine. Since these medications are taken as pills, it is reasonable to try this for months; if the IGF-1 remains high, another drug Sandostatin, Lanreotide, Somavert should be given.
Sandostatin LAR and Somatuline act on the pituitary gland to reduce inhibit growth hormone production, and, as a result, IGF-1 production.
Somatulinel is given as either a self-injection or by someone else at home, once a month. Short-acting octreotide must be given at least every 8 hours by a subcutaneous under the skin injection.
A very small needle insulin syringe and needle is used and the discomfort is usually not a problem for most patients. Some patients have a better response giving the injection every 6 hours. Somatuline is usually self-administered or administered by someone else once a month at home. Some patients have a better response to the combination of bromocriptine or cabergoline and octreotide Sandostatin, Somatuline , especially if the tumor makes too much of two hormones: growth hormone and prolactin.
Regardless of which regimen in used, these medications do not cure the disease; they control excessive growth hormone production by the tumor. Therefore, the medication s is effective only as long as it is taken regularly.
Pegvisomant Somavert : This medication does not act directly on the pituitary tumor — it blocks the action of growth hormone at the liver to reduce production of IGF This medication is given as an injection under the skin self-administered once a day.
Bromocriptine: nausea, vomiting, dizziness, nasal stuffiness, constipation. Side effects are minimized by always taking the medication with food. Sandostatin LAR, Somatuline: when beginning treatment: loose stools, light-colored stools, occasional diarrhea and abdominal cramping.
This side effect usually lessens or disappears within 1 to 2 weeks. The gallstones may not cause a problem, but there is always a risk of developing problems. When beginning treatment with Sandostatin LAR, the recommendation is to first take the short acting preparation octreotide as an injection 3 times a day for a week in case side effects are too bothersome.
If there are bothersome side effects, the long acting preparation, Sandostatin LAR, may not be suitable. In some centers and at U Va , the patient is given a single injection of the short-acting Sandostatin to make sure there are not side effects and then the patient is given an injection of long acting Sandostatin LAR later in the day.
Pegvisomant Somavert : Development of abnormal liver tests occurred in 2 of approximately patients treated with this drug. The tests returned to normal when the medication was stopped.
The reason for this side effect is not known. It is recommended that liver tests be measured before beginning treatment and every month for the first 6 months of pegvisomant treatment and at regular intervals afterward I suggest every 6 months.
Enlargement of remaining tumor has occurred in a few patients; this means that regular MRI studies are necessary to detect this. Previous radiation treatment to the tumor appears to reduce the risk of tumor growth, but regular MRI scans are still necessary to make sure there is no growth.
In this situation, surgery to remove as much of the tumor as possible is usually the first treatment. This is particularly important if the tumor is close to the eye nerves optic chiasm or if the tumor is pressing on the optic chiasm causing loss of vision. If the patient cannot undergo surgery, medical treatment, preferably with a somatostatin drug Sandostatin LAR, Somatuline is used because these medications act directly on the tumor and may prevent tumor growth.
In patients with a large tumor, surgery is recommended as the first treatment to remove as much as possible with medical treatment afterward if there is continued excessive growth hormone production. Pegvisomant Somavert : Does not cause tumor shrinkage. This medication does not act directly on the tumor — it acts to block the action of growth hormone on the liver and reduces IGF-1 production and does not cause reduction in tumor size.
Please note: the costs of the drugs are as of March, The manufacturer, Novartis, also has a home administration program in which a nurse comes to the home to administer the injection this does not apply to Medicare patients. Somatuline: May be administered as a deep subcutaneous below the skin by a partner or by the patient, once a month. Pegvisomant Somavert self-injection, under the skin, once a day: Please note: this medication is dispensed through the Pfizer Bridge Program, the prices quoted are the actual wholesale cost provided by Pfizer.
Since octreotide, Sandostatin LAR, Somatuline and pegvisomant Somavert are so expensive, is there any financial help available? Yes, possibly. Sandostatin LAR: Novartis has an assistance program for patients who qualify.
Pegvisomant Somavert : The Pfizer Bridge program works with PSI, and independent company, to provide assistance for patients who qualify for financial reasons. I have had surgery, why do I still have a problem and have to undergo radiation treatment and take medication? Some patients are not cured with surgery.
The reason for this is most commonly because of the size of the tumor: the larger the tumor, the less likely it can be removed completely.
Additionally, the tumor may have spread to nearby structures such as bone, the cavernous sinus location of carotid artery and the nerves controlling eye movements and the membrane surrounding the gland dura mater. In this situation, the neurosurgeon removes all that can be safely removed, but if the tumor has invaded surrounding structures such as bone or the cavernous sinus or the membrane covering the pituitary, excessive growth hormone production may persist.
Surgery is usually the first step to remove as much of the tumor as possible, since the medical treatments do not always shrink the tumor and, if present, relieve the pressure on the optic nerve or improve vision problems.
Yes and no. There are medications that can reduce cortisol production by the adrenal glands, but medication doesnot have any effect on the pituitary overproduction of the hormone ACTH the pituitary hormone that stimulates the adrenal glands to make too much cortisol.
Thus, medication is used to control adrenal gland cortisol overproduction, but does not treat the source of the problem — the pituitary gland. Ketoconazole is a medication that reduces adrenal gland cortisol production. If a drug to lower cortisol is prescribed, careful monitoring is necessary to determine if the dose is effective measure 24 hour urine cortisol level , to make sure it does not reduce cortisol to below normal measure morning blood cortisol level and to make sure there is no ill effect on the liver.
Another medication that reduces cortisol production by the adrenal glands is mitotane Lysodren. There are some experiments in mice that suggest that the diabetes medication, rosiglitazone, may reduce the size of implanted ACTH producing tumors and reduce cortisol production.
This is a potentially exciting area of research, but it is currently a research project. This drug is only available at centers that are participating in clinical trials. Ketoconazole: the most common side effect is nausea and abnormalities in liver function. Before this medication is taken, a blood test should be measured to make sure there are no liver abnormalities.
It is a good idea to have regular liver tests when taking ketoconazole. If fatigue or jaundice occurs, liver tests must be measured and if the liver tests are abnormal, the medication stopped immediately.
If liver tests become abnormal, they usually return to normal after the ketoconazole is stopped. Other side effects include vomiting, abdominal pain and itching. This is the best outcome after pituitary surgery. It may take several months for the normal ACTH producing cells to regain function to stimulate the adrenal glands to produce a normal amount of cortisol hormone necessary for life.
In the mean time, steroid replacement is necessary to protect against adrenal insufficiency. At a later date, the need for continued steroid replacement is determined by blood tests off of the steroid medication.
This is a common question and a very common problem. It is quite common for patients to still feel weak and have achy muscles and joint pains several months after successful surgery. Patients may also notice dry skin and itching — this is part of recovery.
Pituitary Tumor Experts. Most pituitary tumors do not cause symptoms. When symptoms do arise, it is usually because the tumor is: putting pressure on the brain affecting hormone production in the pituitary gland compressing the optic nerves.
Previous Pituitary Tumors. Next Pituitary Adenomas. Excess cortisol is associated with ACTH-secreting tumors Cortisol deficiency is associated with size and location of a pituitary tumor.
Excess IGF-1 is associated with growth hormone—secreting tumors IGF-1 deficiency is associated with size and location of a pituitary tumor. Enlarged hands or feet Other signs of acromegaly. Fatigue Loss of muscle mass.
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