Non functioning pituitary adenoma

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

Visual field loss, for example homonymous hemianopia, is 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.

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

Headaches or lancing pain across one section of the head or face only are more suggestive of cranial nerve involvement particularly with disease in the cavernous sinus.

Weight loss may indicate the development of hypopituitarism but should also alert to the possibility of malignant disease with pituitary metastasis.

Vague symptoms of tiredness, nausea and dizziness may indicate the development of hypopituitarism with adrenocorticotropic hormone (ACTH) or thyroid stimulating hormone (TSH) deficiency.

This could indicate the possibility of underlying malignancy or loss of thyroid function.

Oligomenorrhoea may occur with modest elevations of prolactin.

Amenorrhoea and hot flushes indicate loss of gonadotropin release.

Previous successful pregnancies may help define duration of disease.

Post partum haemorrhage leading to Sheehan's syndrome is possible, rather than a pituitary tumour, if the patient was unable to breast feed and developed secondary amenorrhoea.

Loss of libido may have many causes but in this circumstance suggests loss of gonadotropin release.

Symptoms of erectile dysfunction may not be forthcoming and should be specifically asked about.

Diabetes insipidus is uncommon with intrinsic pituitary disease and suggests an alternative pathology.

DI is typified by unquenchable thirst for any fluid, with polyuria and nocturia. Ask specifically whether they take a glass of water to bed with them, how many times they get up at night to pass urine, and whether when they wake, do they have a drink before or after using the toilet.

If they have not kept a fluid input-output diary for a day, suggest it.

Pituitary metastases are common and may be the first presentation of malignant disease.

Ask specifically about change of bowel habit, new prostatic symptoms and breast lumps.

This is common with non functioning tumours due to disinhibition of prolactin release. However, it is essential to distinguish between this disinhibition and a true prolactin secreting tumour at the earliest stage since treatment strategies are entirely different though the conditions may have similar clinical presentations.

Ask about breast swelling, galactorrhoea, oligomenorrhoea, libido and erectile function.

Ask whether the patient or their family have noticed any change in their facial appearance. If their voice, mouth, hands or feet have changed, or if they have developed excessive sweating, this may indicate acromegaly.

A change in weight or body shape can indicate cortisol excess.

Diabetes, hypertension, depression, osteoporosis, acne, hirsuitism, oligomenorrhoea and muscle weakness are also potential symptoms.

Sweating, palpitations, tremor, weight loss, diarrhoea and oligomenorrhoea can all be features of thyroid hormone excess.

Estrogen replacement therapy of any preparation will lead to elevations in cortisol binding globulin and so effect serum cortisol results.

Inhaled and topical steroids also affect the hypothalamo-pituitary-adrenal axis, and steroids may occasionally be found in preparations thought by the patient to be 'natural' or 'herbal'.