About adrenal and pituitary conditions
Problems arise when a gland makes too much hormone or too little. Cushing's syndrome is too much cortisol, most often from steroid medication but sometimes from a pituitary or adrenal tumour. Addison's disease is too little cortisol, usually autoimmune. High prolactin (hyperprolactinaemia) causes irregular periods, milk production and low libido and is often due to a small benign pituitary tumour or to medication. Primary aldosteronism is an under-recognised cause of high blood pressure.
Increasingly, adrenal and pituitary conditions are found by chance on scans done for another reason. An adrenal incidentaloma is a nodule seen on a CT of the abdomen; most are harmless, but each needs a hormone work-up and a judgement about follow-up. The same applies to small pituitary lesions found on brain MRI.
Symptoms we assess
Reasons for referral include:
- A nodule on the adrenal gland or pituitary found on a scan
- High blood pressure that is difficult to control, or with low potassium
- Weight gain around the trunk with thin limbs, easy bruising, purple stretch marks or muscle weakness
- Fatigue, weight loss, dizziness on standing and darkening of the skin
- Irregular periods, milk production when not breastfeeding, or low libido
- Headache with visual disturbance, or symptoms of several hormone deficiencies at once
- Episodes of palpitations, sweating and headache with very high blood pressure
How we diagnose it
Hormone levels vary through the day and in response to stress, so adrenal and pituitary testing is done carefully: early-morning cortisol, late-night salivary cortisol, 24-hour urine collections, and dynamic tests in which a hormone is given and the response measured. The consultant chooses the sequence that answers the question with the fewest tests, and explains how to prepare, since some medicines interfere with results.
Where a tumour is suspected, MRI of the pituitary or CT of the adrenals is arranged through the host hospital. Visual field testing is added for pituitary lesions near the optic nerves.
Treatment and follow-up
Treatment depends entirely on the diagnosis. Hormone deficiencies such as Addison's disease are treated by replacing the missing hormone, with education on adjusting doses during illness and carrying an emergency injection. Excess hormone from a benign pituitary tumour is often controlled with medication, particularly for prolactin, and surgery is reserved for tumours that are large, pressing on the optic nerves, or not responding to medicine.
Adrenal nodules that are not producing hormone and have benign features on imaging are monitored, not removed. Those producing excess cortisol or aldosterone, and any with suspicious features, are referred for surgery after the hormone excess has been controlled. Primary aldosteronism can often be treated with a specific tablet instead of surgery.
Because these conditions are uncommon and long term, the consultant coordinates with your GP, and where needed with pituitary surgeons and radiologists, and keeps you under review.
When to see a GP, and when to see a consultant
Adrenal and pituitary conditions almost always need a consultant endocrinologist, because the tests are specialised and the diagnoses are easy to miss. See your GP first for symptoms; ask for a referral if a scan has shown a nodule, if blood pressure is hard to control, or if your GP suspects a cortisol or prolactin problem. Collapse with vomiting and low blood pressure in someone on steroids or with known Addison's disease is an emergency.
