nursing.elitecme.com Page 25 Complete Your CE Test Online - Click Here Etiology The most common cause of primary hypopituitarism in adults is pituitary tumor or adenomas. Additional causes include traumatic brain injury, infection, irradiation, partial or total hypophysectomy during surgery, chemical agents, and, more rarely, granulomatous disease such as tuberculosis[5] . In children, congenital defects, trauma, or other underlying conditions may lead to the disease[4,5] . Secondary hypopituitarism is caused by a deficiency of releasing hormones produced by the hypothalamus as a result of trauma, infection, tumor, or an unknown cause. Sometimes hypopituitarism may have no identifiable etiology[4,5] . Clinical presentation Primary hypopituitarism usually presents as a rather slow, predictable pattern of hormonal failures as the effects of anterior pituitary destruction become evident[4,5] . Clinical presentation depends on the severity of the disease and the number of hormones that are deficient. Clinical features usually begin with hypogonadism due to decreased FSH and LH levels [4,5] . In adults, this causes menstrual cessation in females and impotence in males[4,5] . Other effects include infertility and decreased libido[4] . Growth hormone (GH) deficiency usually follows next. In adults, this leads to[5] : ● ● Osteoporosis. ● ● Decreased lean-to-fat body mass index. ● ● Adverse lipid changes. ● ● Subtle emotional changes including dysphoria (feelings of unhappiness). ● ● Lethargy. Eventually failure of thyrotropin leads to decreased TSH levels and hypothyroidism, and, finally, adrenocorticotropic (decreased corticotropin levels) failure leads to adrenal insufficiency[5] . Additional symptoms of hypopituitarism in adults include[4,5] : ● ● Diabetes insipidus. ● ● Hypothyroidism as evidenced by fatigue, lethargy, sensitivity to cold, and menstrual problems. ● ● Adrenocortical insufficiency as evidenced by hypoglycemia, anorexia, nausea, abdominal pain, and orthostatic hypotension. Hypopituitarism alert! Acute cortisol insufficiency (adrenal crisis) is a life-threatening condition and requires immediate treatment[4] . Nursing consideration: Pathophysiology of the pituitary gland can cause life-threatening conditions. For example acute cortisol insufficiency (adrenal crisis) is a life-threatening condition. Therefore, it is essential that nurses recognize the signs and symptoms of pituitary pathology and take intervene promptly to ensure patients receive the necessary treatment. In children, lack of GH causes short stature, delayed growth, delayed puberty, and, possibly, dwarfism[4,5] . Dwarfism is not often evident at birth but initial signs and symptoms appear in the first few months of life, and by 6 months, growth retardation is apparent[5] . Children with dwarfism may appear chubby because of fat deposits in the lower trunk. They experience a delay in secondary tooth eruption and growth generally continues at less than half the normal rate, which can linger into the patient’s 20s or 30s. The average height of these individuals is 4 feet (122 cm), and body proportions are normal[5] . If hypopituitarism occurs prior to puberty, the development of secondary sex characteristics is prevented[4,5] . In males, these include [4,5] : ● ● Lack of facial and body hair. ● ● Undersized penis, testes, and prostate gland. ● ● Failure to initiate and maintain an erection. In females, these include[4,5] : ● ● Lack of pubic hair. ● ● Lack of axillary hair. ● ● Failure to develop mature breasts. ● ● Primary amenorrhea. Panhypopituitarism causes a significant number of both physiological and mental problems including[4,5] : ● ● Psychosis. ● ● Lethargy. ● ● Bradycardia. ● ● Orthostatic hypotension. ● ● Anorexia. ● ● Anemia. Tumors of the pituitary can cause headache, vision problems (even blindness), and hemianopia. Hypopituitarism related to infection or surgery causes fever, vomiting, hypotension, and hypoglycemia[5] . Hypopituitarism alert! Clinical signs and symptoms of hypopituitarism do not usually become apparent until 75% of the gland is destroyed[5] . EBP alert! Unfortunately, research shows that clinical signs and symptoms of hypopituitarism do not generally become apparent until 75% of the gland is destroyed[5] . So nurses must be aware of any conditions that can lead to hypopituitarism and be alert to any indication that such pathology exists. Diagnosis and epidemiology Hypopituitarism is a rare disorder. According to the National Institutes of Health (NIH), it affects less than 200,000 persons in the United States and has an international incidence of 4.2 cases per 100,000 annually[4] . In any suspected case of hypopituitarism it is essential to rule out organic, non-endocrine causes of short stature, decreased/delayed growth, and other presenting clinical manifestations. Thyroid function must be carefully evaluated to determine if, for example, decreased levels of thyroid hormone is related to dysfunction of the thyroid, pituitary, or hypothalamus[5,6] . Computed tomography (CT) scans or magnetic resonance imaging (MRI) are useful in determining the presence of tumor or other abnormal masses in the pituitary gland or hypothalamus. Radioimmunoassay may show decreased blood levels of pituitary hormones[5] . Diagnosis is confirmed by measuring levels of GH in the blood following administration of regular insulin to induce hypoglycemia or levodopa to induce hypotension. Administration of these drugs should stimulate increased secretion of GH. If GH hormones remain low, despite attempting stimulation by regular insulin and/or levodopa administration, GH deficiency is confirmed[5] . Treatment and nursing considerations Replacement of hormones secreted by the pituitary’s target glands is essential. Complete loss of all anterior pituitary hormones is fatal without treatment[5] . Treatment also involves treatment of any underlying cause, such as surgical removal of tumors. Hormone replacement therapy may include the following medications: ● ● Corticosteroids: Corticosteroids such as hydrocortisone or prednisone are used to replace adrenal hormones that are not