Pituitary hormone replacement
| DDAVP, 1-deamino(8-d-arginine) vasopressin; FSH, follicle stimulating hormone; GH, growth hormone; LH, luteinising hormone; QoL-AGHDA, quality of life adult growth hormone deficiency assessment. |
| • Glucocorticoid: |
| Hydrocortisone 15 mg am and a further 5 mg no later than 4 pm (or 10 mg on waking, 5 mg at lunchtime and 5 mg at 4 pm) to mimic normal diurnal variation in circulating cortisol. Patients are asked to double the dose for 2–3 days if stressed physically or psychologically. In practice, however, physiologically significant hypoadrenalism (adrenal crisis) in secondary hypoadrenalism is rare |
| • Thyroid hormone: |
| L-thyroxine 100-125 µg daily as a single dose. Average replacement is 112±19 µg daily |
| • Sex hormones: |
| Women |
| If fertility is not required, sex hormone replacement with cyclical oestrogens and progestogens is used until the age of the natural menopause (50–51 years). If fertility is required gonadotrophin treatment should be coordinated by a specialist centre |
| Men |
| Testosterone is replaced as a mixture of testosterone esters (Sustanon intramuscularly) or testosterone enanthate (100 mg every 2 weeks or 250 mg every 3 weeks). Testosterone implants last for up to 4–5 months. Transdermal gel or patches, or oral testosterone undecanoate, are generally less effective but may suit some patients |
| If fertility is required, spermatogenesis can be induced with chorionic gonadotrophin (LH) and FSH/human menopausal gonadotrophin injections 3 × weekly for at least 6 months. Semen samples can be frozen after successful induction |
| • Growth hormone: |
| GH is given by daily subcutaneous injection, titrated over 3 months to bring IGF-1 concentrations into the middle of the normal range and continued for a further 6 months. If an improvement of more than 7 points on the QoL-AGHDA questionnaire is elicited, the treatment can be continued in the longer term. Generally, symptoms of deficiency are non-specific, and the benefits of replacement subtle, slow to develop but nevertheless tangible (internet search term: “NICE start page” or “National Institute for Clinical Excellence”) |
| • Vasopressin: |
| DDAVP nasal spray (1–3 puffs daily) or tablets (200 µg once or twice daily) is not strictly necessary, as diabetes insipidus following pituitary surgery is usually mild and transient, but is useful temporarily if the patient is uncomfortable. Patients should be warned about over-replacement and treatment withdrawn at intervals to see whether the condition has resolved, as it does in most cases |