Non functioning pituitary adenoma

Clinically non functioning pituitary tumours may be null cell adenomas or have positive staining for other peptides but with no clinically detectable sequelae. Diagnosis requires MRI scanning and assessment of pituitary function.

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, 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.

Has the patient developed a new headache or neuralgia? 

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.

Has the patient lost or gained weight?

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

Does the patient feel well in themselves? Have they noticed loss of energy, fatigue, nausea or dizziness?

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

Has there been any change in bowel habit? 

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

Has there been any change in menstrual cycle or any new hot flushes? 

Oligomenorrhoea may occur with modest elevations of prolactin.

Amenorrhoea and hot flushes indicate loss of gonadotropin release.

Has the patient previously sought fertility? Has this resulted in pregnancies, were there obstetric complications and were they able to breast feed? 

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.

Has the patient's libido changed? Has the patient developed erectile dysfunction or lost early morning erections? 

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.

Does the patient complain of excessive thirst or polyuria? 

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.

Are there any features to suggest underlying malignancy?

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.

Are there features to suggest elevated prolactin? 

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.

Are there any features of GH excess? 

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.

Are there any features of cortisol excess? 

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.

Are there any features of thyroid hormone excess? 

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

Are they taking any prescribed or non prescribed medications? 

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'.