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Did you know there is a pea sized gland inside your head that helps regulate processes throughout your body? The pituitary gland, located at the base of the human skull aids the brain in sending and receiving signals through hormones. Learn more about the pituitary in this episode of the DocTalks podcast with host Ian Gillespie and St. Joseph's Chief of Endocrinology, Dr. Stan vanUum.
Welcome to the DocTalks Podcast, a conversation on what’s new and relevant in the world of Canadian medicine and hospital health care. Join us for each episode, as we interview physicians, patients and caregivers to dive deep into what it’s like to treat and live with some of today’s most common health challenges. Hosted by Ian Gillespie.
Note: The content of St. Joseph's DocTalks Podcasts is for informational purposes only. The material is not intended for and should not be used as a substitute for direct medical advice from a licensed health care practitioner.
The DocTalks Podcast - The Pea Inside Your Head w/ Dr. Stan VanUum
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[00:00:00] Ian Gillespie: Welcome to The DocTalks Podcast, a conversation on what's new and relevant in the world of Canadian medicine and hospital healthcare. I'm your host, Ian Gillespie. And I'm here to ask the questions and find the answers you need to know. We want to help our listeners know how to prevent and detect illness and how to navigate our healthcare system.
Be sure to subscribe to The DocTalks Podcast to stay up to date on new episodes and follow us on Twitter @stjosephslondon, or visit sjhc.london.ca/podcast.
Hello. I'm Ian Gillespie. Welcome to The DocTalks Podcast brought to you by St. Joseph's healthcare. London on today's episode, we're talking about a tiny little pea sized gland that regulates more functions in our body than you might think possible. And here with me today to help me understand this remarkable thing called the pituitary gland is Dr. Stan Van Uum. He is the chief of endocrinology at St. Joseph's Healthcare, London, and chair of the department of endocrinology and metabolism at Western University. Dr. Van Uum. Welcome, sir.
[00:01:34] Dr. Stan Van Uum: Thank you. It's a pleasure to be here and talk about a gland that goes to my heart, pituitary gland.
[00:01:41] Ian Gillespie: So I I've read that it is often called the master gland of the human body. And I was just looking at a list of some of the things it does. It it's a, the center of human sexuality and reproduction. It controls, the life hormone, A.C.T.H., It controls and regulates the thyroid gland. It regulates metabolism.
It It's linked to mood and behavior, to size, shape, and height. It does so much. It's kind of astonishing. Is it fair to compare it to, if I was to use a sort of a computer analogy, does it, is it sort of like the body's CPU, the central processing unit? Is it, is it something like that?
[00:02:24] Dr. Stan Van Uum: I think it's something like that, although maybe the brain would compete with that as well, but it's part of it tries to integrate signals from the brain and then translate to all kind of functions in the body. And I think one of the challenges we face endocrinologists is that patients do not always link this gland to all kind of things throughout the body like you were describing.
And that's why we need to be very active in asking about various symptoms, related to the pituitary gland
[00:02:53] Ian Gillespie: And so, tell me again, so briefly.
what does it look like and where is it located?
[00:02:58] Dr. Stan Van Uum: So it's a very small gland, uh, sometimes described as the size of a P or maybe the nail of your pinky. it's located, behind the bridge of the nose, just in front of the ears. That's sort of the skull base and it's protected very well. It has a bony area around it. also called the turcica sella where it is very well protected.
And the fact that it's so well protected shows how important it is for the overall function of the, the human body.
[00:03:26] Ian Gillespie: Wow. Can you live without a pituitary?
[00:03:29] Dr. Stan Van Uum: you can live without the pituitary gland, as long as you replace the most important hormones that are regulated by the gland. So if you have, pituitary glands that is no longer functioning
and you don't replace the hormones, then you can get seriously ill or even die from that.
[00:03:46] Ian Gillespie: So I, I did list some of the things. It, it, It,
plays a part in, but I'll, I'll leave it to you. essentially, are the most important, things. The pituitary gland does for us?
[00:03:57] Dr. Stan Van Uum: Okay. So pituitary gland, like you said, is a master gland that regulates production by other hormonal glands. first as a principle, if you have a gland, there's three things that can happen with a gland in disease. It can produce too much hormone. It can produce too little hormone or it can grow and have mass effects as well.
Um, so for the pituitary gland, if it grows and it usually grows up first, just above the pituitary gland, is that the nerves that come from the eyes that go to the back of your brain. We're able to see they cross over just above the pituitary gland. And so if that gland enlarges, it can affect those nerve and actually cause visual field effects.
So some patients are identified having a pituitary issue because of their characteristic, typical visual field defect that they have. So that's one of the things that they can do. there are about six hormones that the pituitary gland produces and for each of them, or almost each of them that can be presentation of too much or too little.
[00:05:02] Ian Gillespie: This is you're alluding to hypopituitaryism and hyperpituitaryism?.
[00:05:08] Dr. Stan Van Uum: Yes. That's some way to describe. So hypopituitaryism
means that there is insufficient function of the pituitary glances produces too little hormones. Hyper means that it's overproduction, and sometimes you can even have a combination. For example, quite a common overproduction is the overproduction of prolactine. Prolactine is the hormone.
That plays a role, particularly in, in women, in nursing and breastfeeding as well. So when there is a growth of cells that produce prolactine, it can grow in size, and then because it's pituitary gland is bony area, the other tissues can be compressed by that growing pituitary autonoma.. And even though it's benign, it has effects that the other hormone levels may go low.
So you can have a mixed situation where one hormone is high and the other ones are low.
[00:05:57] Ian Gillespie: Wow
Like anything, I
suppose it's just complicated and is important there, as you were saying, there's so many things that can go wrong. Um, you've referred to a couple of them there. Can you talk about some of the main pituitary disorders? I know that there is, for instance, you can just develop a tumor, correct.
And there's also, well, there's something called Cushing's disease, I understand.
[00:06:17] Dr. Stan Van Uum:
Yeah. So maybe it's, it's helpful just from understand that we go over each of the hormones, what happens if there's too much production and then later can, we can talk about what happens if there's insufficiency, cause otherwise it may be confusing. So one of the important hormones is ACTH,, which is a hormone that stimulates the adrenal glands to make the hormone cortisol and cortisol is also known as the stress hormone.
So a normal cortisol goes up in the morning and then goes down, but it also goes up its situations of stress where you have a surgery, where you have a sickness, where you have some major stressful offense as well. But if there is consistent overproduction of ACTH and therefore consistent overproduction of cortisol, that starts to create negative effects, which is called Cushing syndrome.
And it's a rare, but classic syndrome in which patients develop weight gain, particularly in the abdominal area, you have muscle weakness. Um, they can have, uh, bruises that happen with, without understanding the reason why. So without bumping into anything or so it can also internally increase your blood sugar increases your blood pressure.
So it can result in developing diabetes, high blood pressure, and it can affect your bones creating osteoporosis. so there's a whole number of things that this hormone has that then affects what's called Cushing syndrome and together, that combination of things is what points to Cushing syndrome.
And that can often be pituitary, but can also be other reasons why it's produced too much.
[00:07:50] Ian Gillespie: Wow. So there must be an incredible array of symptoms that a patient experiences when something goes amiss, right? I mean, is it, what, what, what should people be on the lookout for.
[00:08:01] Dr. Stan Van Uum: So weight gain that is, particularly in the abdominal area, it's a diabetes and high blood pressure, which happened over a short time. And that not explained by sort of the general population. Bruises that happen. It's also profound muscle weakness. And it can be some patients who first present actually with depression.
So that can also be mental health system. And it's one of the characteristics of the hormonal systems is that they can also affect moods and initiative, et cetera, as well. So it can be a whole range of things. And it is the combination, the clustering of things that can make a clinician suspicion. Many patients when they have weight gain, look up and see Cushing syndrome.
And they say, I might have this. I must say given all the other consequences of Cushing, I'm always happy if I can tell them you don't have Cushing syndrome, because it has a lot more consequences.
[00:08:53] Ian Gillespie: Does it affect, one gender more than another, or a particular age group, more than another?
[00:08:57] Dr. Stan Van Uum: No, it's slightly more in women, but, uh, it is not, not majorly more as well. And it, it also, there can be other reasons as well. Sometimes it's the primary adrenal gland issue, sometimes other rare things. So the, the first step is to diagnose is this Cushing syndrome. The second is, is it indeed the pituitary,
that's the cause, which is in about 80% of patients. And most of them are, somewhere in the adult range. We occasionally see this in, in children. It's, it's quite rare where it can stop growth as well. Um, but it's mostly in the age range between 20, 30, and seventies, but it, it can be a whole range
So across the lifespan.
[00:09:36] Ian Gillespie: Right. And can you talk a little bit about, um, this, one stop pituitary clinic at St. Joseph's
[00:09:43] Dr. Stan Van Uum: Yeah. So when patients are diagnosed with a pituitary mass, we have to sort out, is there a hormonal overproduction? Is there a hormonal insufficiency? Is there something that causes vision defect? And also if that's happening, what's the way to treat that? Is that something we can treat medically or do we need a neurosurgical opinion?
Neurosurgical consult as well. Before we started this one stop clinic. Patients would see a neurologist or a, uh, neurosurgeon, otherwise who would do some part of the assessments. And we felt that was inconvenient for patient, that would slow down the process because you would have various waiting times.
So what we created is a one stop pituitary clinic, which like the name explains it's on one morning, we get all the information we need to have decisions where to go forward. So under one stop appointments patients will do a blood test at eight o'clock in the morning. They will do a visual field test that assesses their vision,
if it's affected by the pituitary growth or not. They will see an eye doctor specialized in eye and neurology, the combination of those, and they will see the endocrinologist. Most patients already have imaging done, if that has not been done. So a proper MRI scan, because it's a dedicated MRI, which gives most of the information.
Then we have that as well, which means that from the morning they come until, uh, early afternoon, when we have all the information, we then have all what we need to decide, which way to go forward. And the forward could be monitoring, could be treatment, could be surgery, could be medical treatment. But you need to first collect the information.
That's the nature of the one stop to put that one together. And many patients, especially when they come from further away, really like it's one visit rather than having to come back two or three times.
[00:11:32] Ian Gillespie: Wow. and then again, it's, an array of, symptoms, an array of problems, but what normally, what is the, what are some of the treatments that, um, ensue?
[00:11:44] Dr. Stan Van Uum: So it depends. So if there's a prolactin over production, which is about one in four patients who present with a pituitary, we call the pituitary adenoma and patients sometimes hear tumor. I should just say that even they would use the word tumor, they typically beign and not malignant. And that's one of the things patients worry about.
Um, but prolactinomas can mostly be treated about 90 percent of patients with medications. So we can, even, if that is a vision defect we can give medications that shrink that tumor that make that the vision recovers again. If there's other conditions, which is the overproduction of, uh, ACTH and cortisol, Cushings syndrome we talked about, or if it's acromegaly, which the overproduction of growth hormone and that's patients who then develop changes in facial features, uh, enlargement of the nose, the ears, the lips, the hands, the feet we ask about shoe size or ring size, whether it's changed.
Those patients, usually the first treatment is, uh, surgical. And trying to remove that tumor and the surgery is typically done by a combination of the ENT together with the neurosurgeon where the ENT creates access through the nose, then reaches the, the, the skull base area and then allows the neurosurgeon to get access to the, pituitary area.
And then those patients who have a tumor that does not produce any hormones, but that causes hormone efficiency, that all of those hormones are low, those will typically
require surgery, and occasionally afterwards we have to use radiation as
well.
[00:13:13] Ian Gillespie: And when you say surgery, again, possibly a dumb question. I mean, you don't ever replace the pituitary gland, do you.
[00:13:20] Dr. Stan Van Uum: No, no, that that's the very fair. So ideally a surgery will to remove the pituitary abnormal tissue, but leave the normal tissue in place. Sometimes that is not sufficient normal tissue left. So the patients already have hormone insufficiency. It will need to be a replacement. Sometimes the surgery in order to be successful and prevents the negative outcomes of the overproduction also removes the pituitary gland and it gets done usually with it's,
it's a very soft issue. It's not like a heart tissue. So. It sort of, the surgeon tells me that they circuit away with, rather than that, they actually cut around it. And you have to remember that the surgeon has to be very careful because right next to the pituitary glands are the two arteries that go to the brain and that provide the brain, Cutting into an artery, of course, is something you absolutely want to avoid. Which means that the surgery is sometimes limited to what's the access you can get because you can't go around an artery with the instruments you have, you have to just stay in a certain area. So that means that sometimes after the surgery, there will be some residual
tissue that we have to then follow or even, uh, use radiation.
[00:14:31] Ian Gillespie: Doctor, can you tell me approximately what percentage of the tumors are malignant or cancerous?
[00:14:36] Dr. Stan Van Uum: It's one to two percent, maybe.
There is some suggestion that patients who produce growth hormone in, too large amounts, so called acromegaly, that they have a bit more risk of any kind of, of tumors. because you can see that growth hormone might be stimulant for a tumor that's present somewhere.
that's the reason why we screen patients with acromegaly, for polyps in the colon, which is, uh, sort of a pre-cancerous lesion. There is also some suggestion that there is more thyroid cancer with that as well. Patients who make too much TSH, so the hormone that stimulates the thyroid glands, we typically see that there's over production of hormone, so too much, but not necessarily cancer, but that's quite rare.
So in my, uh, 20 years here, I've maybe seen six patients who had TSH producing adanoma and because we are a referral center for a region of about 2 million people, you can see that that's quite rare. So there are within the pituitary
disease, there are common ones and there are ones that are very rare. It's a whole stretch along that.
[00:15:43] Ian Gillespie: Dr, do the atanomas ever grow back?
[00:15:47] Dr. Stan Van Uum: They can grow back. So there's two ways of looking at that. First is after someone has had pituitary adenoma surgery, we will usually do an MRI scan three to six months later to get a new lay of the land. Is there anything left or not? Because like I said, sometimes there is parts that are a bit tucked away behind the artery that couldn't be reached.
So therefore there is a residual left and that can grow. and that's something which we typically will do an MRI scan every year for the first three years, and then maybe increase the interval. In somebody who's completely had removal of the adenoma and there's normal pituitary but nothing else left,
we will still do some imaging, but if there's no sign of it coming back in the first five years, it's
usually not coming back. So it depends on which scenario is as applicable to that patient.
[00:16:38] Ian Gillespie: Wow. is there any way that we can take care of our pituitary glands in like terms of diet or anything else that we can do to kind of prolong its health and operation?
[00:16:51] Dr. Stan Van Uum: I wish there was, but there is not. but there are some other factors that play a role, for example, uh, traumatic brain injuries. Can sometimes also affect the pituitary gland and whether it's a single by a motor vehicle accident, the car accident, or whether it's repetitive. Uh, for example, in, in professional boxing or other high level boxing, there can be damage that happens with multiple, blows to the pituitary gland that it causes an issue.
The other, which sometimes affects pituitary hormone is functional is the use of opioids that can also effect pituitary at a hormone level, particularly testosterone production in men as well, that can go low. And that's so again, so that the, the pituitary function is then affected by the use of these medications.
So there can be things like that, trying to avoid
minimize, traumatic brain injury, uh, minimize opioid use.
[00:17:44] Ian Gillespie: Right. And, and again, just to go back a step, I mean, obviously the, most of the patients at the one stop clinic have been seen and referred by a, a general practitioner, is that correct?
[00:17:54] Dr. Stan Van Uum: It could be a general practitioner. It could be a neurologist who did a CT scan of the heads for headaches and then find out something that's there in present as well. It could be because a patient had cataract surgery. But their vision didn't improve after the surgery, that there's a realization, that's something in the tissue behind the eyes, the nerves that is not conducting well.
So it is quite a range of areas where patients can
be, be picked up. And, uh, the realization is that it maybe there's something with the pituitary.
[00:18:21] Ian Gillespie: Right. So many people come to the one stop clinic. there's a vague understanding that something's wrong with pituitary, but perhaps specific diagnosis is lacking at the time?
[00:18:30] Dr. Stan Van Uum: Yeah. So it, it might be that it's related. It might be, that's what we call an incidentaloma. So it's found by coincidence without, particular symptoms. Other patients have very clear symptoms and are then, being assessed and, and coming forward because of that. So there's the whole range from zero symptoms to symptom that are totally clear that it's related to pituitary from the moment you lay eyes on someone.
[00:18:51] Ian Gillespie: Wow. And again, to sort of generalize, is the outlook generally positive for patients who have undergone some sort of treatment for problems?
[00:18:59] Dr. Stan Van Uum: Yeah, I think it's it's, most patients we can treat quite well. Um, The hormones that the pituitary, produces, we can replace most of them. We can never do it as well as a fully functioning body. This way we can get pretty close and we can, then prescribe those medications, whether it's, Cortes or replacement, whether it's cyro hormone replacement, whether it's testosterone replacement.
So there's replacements, we can do. With respect to the overproduction. Most patients we can treat it well with surgery about 60 to 70 will have success with the surgery alone. Others may need further treatments after that, that we, we work on. So it requires a pituitary board, which we, we have as a group.
We have a pituitary board with discussers, various patient presentation cases, where we bring in expertise from ophthalmology, from radiology, neurosurgery, radiation, oncology, to try to find the best cause for patients where
things are not as, as straightforward.
[00:19:54] Ian Gillespie: What about looking ahead? Is there any new, are there any new developments or new research that, you're excited about?
[00:20:01] Dr. Stan Van Uum: Yeah. There is research in various areas. We are involved in a project together with a group in Halifax, we have done a couple of parts together with respect to acromegaly, which is the overproduction of growth hormone. And one of the areas with respect to growth hormone is what has not as many well studies is the effect that it has on joints and looking at the negative effects on
joint function, joint pain that patients may experience. And we actually, we, we just presented a study at the endocrine society, which is the largest, global meeting for endocrine diseases, where we looked at patients who had pituitary surgery for acromegaly. So growth hormone overproduction and patients who had surgery for those nonfunctioning atanomas
and it was clear that patients acromegaly had way more joint problems, hip surgeries, knee surgeries, pain of the joints as well. So that's an area that requires more attention because that's something is, that's not reversible when once bones get misformed. on the effect of growth hormone, we cannot undo that. What if a patient has too much growth hormone that costs the blood sugar go up and get diabetes. If you normalize growth hormone, you can often control that better or normalize it. So there are various aspects that, that we are
working on.
[00:21:18] Ian Gillespie: Is there anything else, that we haven't touched on that you think is important to discuss?
[00:21:23] Dr. Stan Van Uum: I think what we have not touched on is the hormone deficiency and what is happening there. So, The most critical hormones here are the cortisol in the thyroids hormone. many people are aware of hypothyroidism where the thyroid hormone is low because that happens a lot when patients have no, no thyroid or no functioning thyroid glands, they know that in that situation, you can get weight, gain, feel cold, gets constipation, uh, feel tired as well.
And. Probably fairly well recognized by the audience. Adrenal insufficiency, if you don't make the cortisol or you don't get the stimulation, is actually a condition that can be life threatening because you need your cortisol, not for baseline, but particularly in stress situations, surgery, when you get sick with the flu or other times.
So that's something which the replacement is critical. And I mean, I saw a patient this morning who. Had, uh, lost the ability to produce cortisol and had lost 50 pounds, just by being unwell and nausea and vomiting because of the lack of cortisol. So it is a critical hormone in your normal functionality.
And like with most hormones when they function well, you, you don't realize what they do, but as when the function goes abnormal, then certainly becomes, clear how important they are.
[00:22:42] Ian Gillespie: Right. And, and just to put it in a broader context, perhaps, can can you gimme any sort of number of how many people, a percentage of people that are affected by pituitary disorders?
[00:22:54] Dr. Stan Van Uum: So that is, it's a very good question. There's two questions, if I may translate that. One is how many patients have anything in the pituitary, if you do imaging, but how many are affected and notice the effect of that and where that's important is that if you take a run of the mill male adults on the streets and you do MRI scans, you will find some small pituitary adenoma in 20 to 30%.
So it's, it's very common. Most of those about 90% do not ever have an awareness of that or have a pituitary hormone issue or a vision issue related to that. So it's a smaller group, uh, of about one to 5% of that who actually notice symptoms. And that's where then. The difficulty is if you have a pituitary that's smaller and you have symptoms, are they actually related or do they happen to be present at the same time?
Because a patient thinks if there's something there, it must be the cause of it. which is a logical assumption, but that actually turns out that's not always the case. And many, particularly if it's smaller atanomas, they do not cause issues. If it's larger one, it's a totally different story And then the other part is to be aware of that most pituitary disease is these atanomas , but that can also be other things.
People can have a bleed in there. They can have diseases that have spread through there. Sometimes it's metastasis from elsewhere from tumors elsewhere. Sometimes it is systemic inflammation, diseases that can affect the pituitary. So there can be a lot of other reasons why the pituitary function is affected.
Those are more rare. Most common is pituitary tumors, but it's not the only ones. And that's part of the expertise we bring is the ability to integrate the informations, say, is this atanoma, is this something else? How do we look at that further or not? And trying to, find the underlying cause in order
to have better ability to find the, most appropriate treatment for patients
[00:24:51] Ian Gillespie: So, can you describe some of the, the visual field symptoms that a person might experience?
[00:24:56] Dr. Stan Van Uum: Yeah. So actually that's a very good question. And, patients who have a pituitary related visual field have a distinctive visual field where it's the outside of the eyes, the temporal vision it's called for the lateral sides. That's what's lost. So if you close one eye, it might be the parts that is from the middle towards the right of if you close the other eye from the middle to the left.
So patients will not always be aware of that because. The part that's missing with one eye is covered by the other eye that still sees that. but I have had patients who became aware of missing those sides part because they were playing sports. So I had one person who played hockey and couldn't see the puck if it went to the right side of the field or played golf and couldn't see the golf ball when it went to the left side.
And that was the first sign of pituitary tumor. but sometimes patients may not see, for example, the sides next to a door and walk into the door post, because that's part of what they don't see, but because it develops gradually. There's not always the awareness of that. And, uh, that's require, that's why we want to test in everyone to see what's actually the deficiency situation.
And also that we can follow over time if the vision changes because there's pituitary tumor growths. That makes more the case, okay, now we have to do surgery in order to address that vision loss and hopefully regain the vision that was lost,
[00:26:20] Ian Gillespie: is there a link between hormonal changes in the pituitary gland and mental illness?
[00:26:25] Dr. Stan Van Uum: So, what you're asking about is really is the interplay between hormones and mental health issues. And that's always a challenge because it can go both ways. So you can have adenoma that results in too much cortisol. Cortisol over production that creates mental health disease. And we've had over the last year, a young woman who had, was admitted with a psychosis of psychiatry because there was too much cortisol production.
On the other hand, any form of significant depression will go with increased cortisol production. So it's our job to figure out is there overproduction of a hormone that causes mental health issues. In which case we want to normalize the hormone production or is the hormone production a response to underlying mental health disease, where you need to treat the mental health disease, and then assess that your hormone production gets normal.
And you can see that that can be quite a tricky interplay where we need to collaborate with the psychiatrist and look at treatment and sometimes try to use medical treatment to bring levels down to normal and see, does the mental health issue disappear or not, or does it stay and how does the patient respond to that?
So it can go both ways and it's, it's quite a tricky interplay of both, mental health, mental function,
physical function, and hormonal production.
[00:27:46] Ian Gillespie: And are are there any, um, particularly online resources, Dr. Van Uum, that you, you recommend that people might go to.
[00:27:53] Dr. Stan Van Uum: yeah, there is some good resources. There is a pituitary society, which actually has a lot of good patient information. They also have a newsletter as well. So there's a north American society. Um, a number of the, uh, well known clinics have good information. So whether it's the Cleveland clinic, whether it's the Mayo clinic, they will have some good information as well.
And there's also often some good videos about where is the pituitary blend and what does it do, because one of the struggles that patients have is that even if they have sort of learned what the pituitary is to then to explain to others around them, what they have and what the pituitary is, that is a whole different layer.
And that's the complexity that patients often feel. So having information of where to look at is also to share with the ones that are close to them as well is, is often very helpful.
[00:28:40] Ian Gillespie: well, thanks Dr. Van num. That was, incredible. Very good. Thank you, sir, for your time.
[00:28:44] Dr. Stan Van Uum: It's my pleasure.