What hormones should be checked in a case of empty sella syndrome?

Hormonal Evaluation in Empty Sella Syndrome

Direct Answer

All patients with empty sella should undergo comprehensive hormonal screening including thyroid function tests (TSH, free T4), morning cortisol and ACTH, sex hormones (testosterone in males, estradiol in females, FSH, LH), prolactin, and IGF-1 to assess the growth hormone axis, regardless of whether they have symptoms. 1, 2, 3

Rationale for Comprehensive Screening

The evidence strongly supports universal hormonal testing in empty sella cases:

• Approximately 30% of patients with empty sella demonstrate some degree of hypopituitarism upon testing, though most remain asymptomatic 4, 1, 3
• Hormonal abnormalities occur in 37.5-52% of patients with empty sella, with affected-axis rates often exceeding 10% and potentially reaching 50% 3, 5, 6
• The most commonly affected hormones are cortisol (20-62.5% of cases), thyroid function (up to 48-50%), prolactin (elevated in 13.8-28%), and sex hormones 1, 7, 5

Specific Hormonal Panel to Order

Essential Baseline Tests

Morning (8 AM) measurements are critical for accurate assessment: 2

• Thyroid axis: TSH and free T4 to detect central hypothyroidism (low/normal TSH with low free T4) 1, 2
• Adrenal axis: Morning cortisol and ACTH to assess for secondary adrenal insufficiency 1, 2
• Gonadal axis: Testosterone (males), estradiol (females), FSH, and LH to detect hypogonadotropic hypogonadism 1, 2
• Prolactin: To identify hyperprolactinemia, which occurs in approximately 13.8-28% of cases 1, 7
• Growth hormone axis: IGF-1 to screen for GH deficiency 2, 6

Additional Considerations

• If baseline morning cortisol is equivocal (typically 3-15 mcg/dL), perform a 1 mcg cosyntropin stimulation test to definitively assess adrenal function 2
• These tests must be performed prior to initiating steroid therapy to avoid interference with results 2

Clinical Context Matters

Complete vs. Partial Empty Sella

Patients with complete empty sella (≥50% CSF filling, pituitary <2 mm) have significantly higher rates of hormonal dysfunction compared to partial empty sella: 5

• Secondary adrenal insufficiency and hypogonadism are significantly more common in complete empty sella (p = 0.021 and p = 0.041, respectively) 5
• Two or more affected axes occur more frequently in complete empty sella (p = 0.010) 5
• However, hormonal testing is advisable for all PES patients regardless of type, as affected-axis rates often exceed 10% even in partial cases 5

Interpretation Patterns

Central hormone deficiencies present differently than primary endocrine disorders: 2

• Central hypothyroidism: Low free T4 with low or inappropriately normal TSH (not elevated as in primary hypothyroidism) 2
• Central adrenal insufficiency: Low cortisol with low or inappropriately normal ACTH 2
• Hypogonadotropic hypogonadism: Low testosterone/estradiol with low or inappropriately normal FSH and LH 2

Critical Management Pitfall

If both adrenal insufficiency and hypothyroidism are detected, always initiate steroid replacement before thyroid hormone replacement to avoid precipitating an adrenal crisis 2

When to Refer to Endocrinology

Endocrinology referral is indicated if: 1, 3

• Any hormonal abnormalities are detected on screening 1, 3
• Patient has symptoms suggestive of pituitary dysfunction (fatigue, cold intolerance, sexual dysfunction, visual changes) 1
• Multiple hormone axes are affected 2

Imaging Confirmation

MRI using high-resolution pituitary protocols is the gold standard for confirming empty sella, and can be performed even without IV contrast 1, 2, 8