What is the approach to history taking for a patient with pituitary adenoma (Pituitary Adenoma)?

History Taking Approach for Pituitary Adenoma

A comprehensive history taking for pituitary adenoma should focus on symptoms of hormone excess or deficiency, mass effect, and genetic predisposition, as these directly impact patient morbidity and mortality.

Clinical Presentation Symptoms to Assess

Hormone-Related Symptoms

• For prolactinomas (most common in children and young people, especially after puberty):

  • Delayed or arrested puberty 1
  • Growth failure or short stature 1
  • Primary amenorrhea or menstrual disturbances in girls 1
  • Galactorrhea 1
  • Secondary amenorrhea in post-menarcheal girls 1
  • Gynaecomastia and decreased libido in boys/men 1, 2

• For growth hormone-secreting adenomas:

  • Rapid growth velocity (in children) 1, 3
  • Features of acromegaly in adults or gigantism in children 3, 4

• For ACTH-secreting adenomas (Cushing's disease):

  • Weight gain/obesity 1, 4
  • Hypertension 4
  • Features of hypercortisolism 3, 4

• For TSH-secreting adenomas:

  • Signs of hyperthyroidism 3, 4

Mass Effect Symptoms

• Headaches 1, 3
• Visual disturbances (field defects, decreased acuity) 1
• Symptoms of raised intracranial pressure 1
• Cranial nerve palsies 1
• Hypothalamic dysfunction 1

Hypopituitarism Symptoms

• Growth failure in children 1
• Delayed puberty 1
• Fatigue 3
• Cold intolerance 3
• Sexual dysfunction 2

Family History and Genetic Considerations

• Ask specifically about family history of:

  • Pituitary adenomas 1
  • Multiple endocrine neoplasia (MEN1) 1
  • Familial isolated pituitary adenoma (FIPA) 1
  • Other endocrine tumors 1

• Genetic testing considerations:

  • Offer genetic assessment to all children and young people with pituitary adenoma 1
  • Particularly important for GH and prolactin-secreting tumors due to high prevalence of genetic abnormalities 1

Duration and Progression

• Duration of symptoms before seeking medical attention (median 12 months in children) 1
• Pattern of symptom progression 1, 2
• Previous treatments and their effectiveness 2, 4

Associated Conditions

• Weight changes (46% of children with macroprolactinomas have overweight/obesity) 1
• Developmental delays (may be associated with certain genetic syndromes) 1
• Other endocrine abnormalities 3

Special Considerations for Pediatric Patients

• Growth patterns and pubertal development 1
• School performance 1
• Timing of symptoms in relation to expected developmental milestones 1
• Mass effects are more common at presentation in children than in adults 1

Diagnostic Approach Following History

• Laboratory assessment:

  • For suspected prolactinoma: single prolactin measurement at any time of day 1
  • Consider serial measurements for modestly elevated prolactin levels 1
  • Comprehensive pituitary hormone panel 3

• Imaging:

  • MRI with pre-contrast (T1 and T2) and post-contrast enhanced (T1) thin-sliced sequences 5
  • High-resolution focused field-of-view sequences 5

• Visual assessment:

  • Visual acuity (logarithm of minimum angle of resolution) 1
  • Visual fields (Goldmann perimetry) 1
  • Fundoscopy 1
  • Consider optical coherence tomography for baseline assessment 1

Pitfalls to Avoid

• Don't miss subtle presentations:

  • Prolactinomas are exceptionally rare before puberty; corticotrophinomas are more common in prepubertal children 1
  • Constitutional delay in growth and puberty can mimic pituitary disease 1

• Don't attribute common symptoms to pituitary disease without confirmation:

  • Obesity, gynaecomastia, and menstrual disturbances are common physiological variations rarely caused by prolactinoma 1

• Don't forget stress-related prolactin elevation:

  • Prolactin rises in response to stress; consider repeat testing for modestly elevated levels 1

• Don't miss genetic syndromes:

  • Even without family history, consider genetic testing due to potential for de novo mutations 1

History taking should be thorough and systematic, as early diagnosis and treatment of pituitary adenomas significantly impacts long-term morbidity, mortality, and quality of life outcomes 1, 3.