Test Your Clinical Skills - Clinical Vignettes

Clinical Vignette #3

A 55 year old man presents to your office one year after transphenoidal resection of a 2.0 cm pituitary lesion that had caused significant preoperative pituitary destruction (biochemically proven). Acromegaly and Cushing's disease were adequately ruled out preoperatively. His peripheral vision has now returned to normal but he continues to "not feel normal" despite pituitary hormone replacement. His main complaints are memory loss, diminished vigor and social isolation. He is noticing mild central obesity. He denies temperature dysregulation, constipation or diarrhea, nausea or abdominal discomfort, orthostasis, decreased libido or decreased sexual function. His current medications include levothyroxine (150 mcg/day), hydrocortisone (20 mg q a.m.), and testosterone (7.5 g gel per day). You perform laboratory testing which reveals a normal basic metabolic panel and CBC. His testosterone level is 515 ng/dl (normal 270-1070) and free T4 is 1.2 (normal 0.7-1.8). His one year post-op MRI reveals no residual pituitary tumor.

What would your next step be? Choose one of the following-A, B or C:

A) Explain to the patient that these symptoms are not related to his history of pituitary problems. Since he has had all his significant pituitary hormones optimally replaced as reflected by the his lack of symptoms and normal laboratory testing, discuss with him other non-pituitary causes of his symptoms such as depression, etc.

B) Work to maximize his thyroid, cortisol and testosterone dosing. As you do so, many of these symptoms may resolve.

C) Consider adding growth hormone (GH) replacement in this patient.