Evaluation and Management of Pituitary Adenoma

Diagnosis and Investigation

The Endocrine Society recommends investigating underlying causes of persistent mild prolactin elevation, including ruling out medication-induced hyperprolactinemia and checking for macroprolactinemia, especially with mild elevation 1
Measuring luteinizing hormone (LH) levels is indicated in the evaluation of hyperprolactinemia, and if LH is low or low/normal, pituitary imaging is recommended 2
The American Association of Clinical Endocrinologists suggests considering pituitary MRI to evaluate for prolactinoma or other adenomas in patients with hyperprolactinemia 1

The Endocrine Society recommends dopamine agonist (cabergoline preferred over bromocriptine) as first-line treatment for prolactinoma, and monitoring prolactin levels and tumor size with treatment 1
For ACTH-dependent Cushing's disease, the National Comprehensive Cancer Network recommends transsphenoidal surgery as first-line treatment, and medical therapy with ketoconazole if surgery is contraindicated 3
For adrenal adenoma, the National Comprehensive Cancer Network suggests laparoscopic adrenalectomy with postoperative corticosteroid supplementation 3
For adrenal carcinoma, the National Comprehensive Cancer Network recommends surgical resection with removal of adjacent lymph nodes, and considering adjuvant radiation therapy 3

Perioperative corticosteroid management is crucial to minimize risks and ensure optimal outcomes for patients undergoing surgery, with various guidelines and recommendations provided by societies such as the European Society of Gastrointestinal Endoscopy, the American Heart Association, and the Endocrine Society 4, 5, 6
The European Society of Gastrointestinal Endoscopy recommends minimizing or stopping corticosteroids preoperatively to reduce postoperative complications, especially for patients with inflammatory bowel disease having elective surgery 4
Patients on long-term glucocorticoid treatment should be assessed for potential contraindications or need for dose adjustment, including checking complete blood count, electrolytes, renal function, liver function tests, lipid profile, orthostatic blood pressure changes, weight, and BMI before starting steroid therapy 5, 7, 8
Patients who have been on oral corticosteroids for more than 4 weeks prior to surgery should receive equivalent intravenous hydrocortisone while nil by mouth, to prevent adrenal insufficiency 4
Standardized steroid-taper protocols should be implemented in the postoperative period for patients who have had complete resection of active disease, to minimize risks of adrenal insufficiency and disease relapse 4

The Endocrine Society recommends that patients with adrenal insufficiency should obtain and carry a medical alert bracelet, and that adrenal insufficiency must be identified and treated before thyroid hormone replacement, with patients starting glucocorticoid replacement first 6, 9
The diagnostic workup for adrenal insufficiency should begin with morning ACTH and cortisol levels, followed by an ACTH stimulation test for indeterminate results, with additional testing guided by the suspected etiology 9
The American College of Endocrinology recommends drawing AM cortisol levels between 7-9 AM to accurately reflect the normal diurnal peak of cortisol secretion, with cortisol levels following a diurnal rhythm and peak levels occurring in the early morning (7-9 AM) 10
Patients with adrenal insufficiency should be treated with hydrocortisone replacement therapy, typically administered in divided doses of 15-25 mg daily to mimic the natural cortisol rhythm, with the highest dose given in the morning 6
During minor illness, the usual dose of hydrocortisone should be doubled or tripled, and for severe illness, IV hydrocortisone 100 mg and IV normal saline should be administered 9
Patients with adrenal insufficiency should be monitored regularly, with monthly assessments for the first 6 months, every 3 months for the next 6 months, and every 6 months thereafter 11

The Anaesthesia guideline society recommends that the use of hydrocortisone at doses ≥5 mg of prednisolone equivalent (approximately 20 mg of hydrocortisone) in adults for a month or more can lead to secondary adrenal insufficiency, and the tapering process may take months to years depending on duration of prior steroid use, with the goal being complete withdrawal or the lowest effective dose that prevents both adrenal insufficiency and disease relapse 12, 13
Patients with comorbidities such as asthma and diabetes have a higher risk of adrenal crisis, and hydrocortisone requirements may increase during pregnancy, particularly in the third trimester, with parenteral hydrocortisone planned for during delivery 6, 12
The Endocrine Society recommends that MRI of the sella with pituitary cuts should be performed for all patients with suspected central hypothyroidism to look for pituitary abnormalities, such as stalk thickening and suprasellar convexity 11, 14, 13
Even topical steroids can cause systemic effects with long-term use, and discontinuation or switching to lower potency agents is recommended, with monitoring for adrenal insufficiency 6