Acromegaly

The syndrome of growth hormone excess caused by somatotroph adenomas of the pituitary. Also known as gigantism in childhood. Diagnosis is confirmed with failure of suppression of a glucose tolerance test.

Has the patient or their family noted any change in their facial appearance?

To diagnose acromegaly specifically ask about jaw size and shape, prominence of eye brows, size or shape of nose and puffiness of jowls.

If they wear hats, has their size changed?

Do they have any old photos available for comparison?

Has their voice or mouth changed? 

Specifically ask whether the voice has deepened or altered, and whether their tongue feels larger or different within the mouth.

Have teeth become more separated or have dentures needed to be changed?

Have their hands or feet changed? 

Specifically ask whether any rings have had to be re-sized or cut off - wedding rings are particularly useful as they tend to be worn permanently.

Increase in the size or width of shoes is also significant, and does not usually occur with aging, although patients may not realise this.

Do they complain of increased sweating? 

Patients may not proffer this symptom though it is common with acromegaly and tends to be diffuse and exertional - not in sudden flushes.

Have they noticed any skin changes? 

Skin tags, increased skin thickness and acanthosis nigricans may all occur in acromegaly with high IGF-I levels.

Other skin changes may indicate underlying conditions such as McCune Albright syndrome.

Has there been a change in weight or height? 

Growth hormone (GH) excess in childhood is associated with increased stature disproportionate to parental heights, which is usually obvious.

GH excess in adulthood does not lead to increased height as the epiphyses have fused, though weight can rise.

Weight loss is a worrying sign which may indicate the development of hypopituitarism or malignancy.

What is the quality of the patient's sleep?

Ask whether the patient snores, if they are refreshed by sleep, or whether they need to sleep during the day. Check whether apnoeic episodes have been witnessed. Assess their Epworth sleepiness score for possible obstructive sleep apnoea (OSA) which is common in acromegaly.

Identification and treatment of OSA is mandatory and will improve cardiovascular status.

Has the patient developed a new headache? 

Assess for red flag symptoms: headaches present on waking, and worsen on coughing or leaning forward, are suggestive of increased intracranial pressure.

Lancing pain across one section of the head or face only are suggestive of cranial nerve involvement, particularly with cavernous sinus disease.

Has there been any change of bowel habit? 

Untreated acromegaly is associated with developing a megacolon and with an increased risk of colon cancer.

Have they developed any new prostate symptoms? 

Untreated acromegaly is associated with prostatic hyperplasia and symptoms of prostatism should prompt clinical evaluation.

Has the patient noticed any visual symptoms? 

Loss of acuity or failing vision at night are worrying features suggesting optic nerve involvement.

Visual field loss is more common indicating chiasmal impingement. It is worth specifically asking whether patients drive and, if so, whether they have had trouble noticing street signs on either side of the road as this may be the first instance in which field loss is noticed.

Has there been any change in their menstrual cycle or breasts? 

GH secreting adenomas frequently co-secrete prolactin, leading to breast swelling, tenderness and galactorrhoea, as well as oligomenorrhoea.

Symptoms and signs indistinguishable from PCOS may also occur in patients with acromegaly.

Does the patient feel well in themselves?

Ask whether the patient has noticed new fatigue, nausea, dizziness or weight loss as panhypopituitarism may occur with macro-adenomas.

Has the patient experienced a loss of libido or erectile dysfunction?

Loss of gonadotropic function is common in acromegaly.

Does the patient complain of breathlessness, chest pain, palpitations or other cardiorespiratory symptoms? 

Cardiomyopathy may occur in untreated acromegaly which may present with features of congestive cardiac failure, or with unpredictable rhythm disturbance.