Open Journal of Obstetrics and Gynecology, 2012, 2, 276-278 OJOG Published Online September 2012 (
Isolated gonadotropin deficiency with primary empty sella:
Causal or casual association?*
Shashank Shekhar1#, Chanderdeep Sharma1, Mukesh Surya2, Neeti Aggarwal3
1Department of Obs t e t r ics & Gynecology, Dr RPGMC Tanda, Kangra, India
2Department of Radi o d i a g n o s i s, Dr RPGMC Tanda, Kangra, India
3Indira Gandhi Medical College (IGMC), Shimla, India
Received 15 June 2012; revised 21 July 2012; accepted 1 August 2012
Empty sella is a radiological-anatomical entity cha-
racterised by a sella turcica filled partially or com-
pletely with cerebrospinal fluid, leading to varying
degrees of pituitary flattening. Literature reports a
5% - 20% incidence of empty sella in unselected au-
topsies leading many to argue that it is an extreme
normal variant. Endocrine dysfunction varies from
8% - 25% with primary empty sella and growth
hormone deficiency is most common. However iso-
lated gonadotropin deficiency with normal sized pri-
mary empty sella is rare if any. We are reporting a
case of isolated gonadotropin deficiency with primary
empty sella unable to confirm or refute the associa-
tion as causal or casual.
Keywords: Empty Sella; Empty Sella Syndrome;
Gonadotr o pi n Defi ci e ncy
Empty sella is a radiological-anatomical entity charac-
terised by a sella turcica filled partially or completely
with cerebrospinal fluid (CSF), leading to varying de-
grees of pituitary flattening [1]. Thus, sella turcica is no t
empty as the name suggests, rather filled by a flattened
pituitary, arachnoid and CSF. Based on eitio-pathogene-
sis empty sella is classified as primary and secondary.
Empty sella is secondary when seen after surgery, irra-
diation or medical treatment of pituitary tumors or due to
infective, autoimmune or traumatic causes. In the ab-
sence of such features empty sella is termed primary
[1,2]. Two other terms used loosely and interchangeably
in literature when describing empty sella are empty sella
syndrome (ESS) and enlarged empty sella (EES). Asso-
ciation of empty sella with varying combination of clini-
cal feature like hypopituitarism, headaches, visual dis-
turbances and non traumatic CSF rhinorrhea constitutes
the so called empty sella syndrome, whereas enlarged
empty sella refers to empty sella with sellar volume ex-
ceeding 1.2 cm2 and may be associated with other fea-
tures like marked asymmetry, ballooning, osseous ero-
sions or defects [3,4]. Therefore, an empty sella may be
of normal size and volume or enlarged when it is likely
to be associated with symptoms. We describe here a
normal sized empty sella associated with isolated go-
nadotropin deficiency presenting as primary amenorrhea
and infertility in a young female. Whether the association
was casual or causal could not be explained by radio-
logical and endocrinological findings alone.
A 23 year old woman of Nepalese origin was evaluated
for primary amenorrhea. Her developmental history was
normal. History was negative for eating disorder, neuro-
logical episode, ch ron ic illness or head trauma in th e past.
Subject denied history of chemo-irradiation or brain sur-
gery in the past. History of chronic drug use or substance
abuse was negative. Consanguinity in the family was
denied. There was no other family member affected by
absent puberty or infertility. Patient was 146 cm tall and
weighed 55 kg. Her breasts were Tanner’s Stage IV and
pubic hair was Tanner’s II. There was no breast activity.
Speculum examination revealed a healthy looking vagina
and cervix. A small uterus was palpable on bimanual
examination. Tests of olfaction were normal. Pelvic so-
nogram revealed a small uterus with normally visua-
lized ovaries. A thorough ophthalmic, neurological and
endocrine evaluation w as done. Ser um FSH (6 IU/L) an d
LH (4.6 IU/L) were normal. Fasting serum levels of GH
(3.2 ng/ml), TSH (2.3 µIU/ml), Prolactin (6 ng/ml),
ACTH (26 pg/ml) and IGF-1 (46 ng/ml) were normal.
Serum estradiol was 36 pg/ml. Serum cortisol (9.4 µg/d l)
and 24 hour free urinary cortisol was in normal range.
Serum screening for anti TPO antibodies was negative.
*Conflict of interest: The authors rep ort no conflicts of interest.
#Corresponding author.
S. Shekhar et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 276-278 277
Magnetic resonance imaging (MRI) revealed a flattened
anterior pituitary against th e floor of the sella turcica and
CSF filling more than 50% of the sellar volume. Stalk of
the pituitary was central. Posterior pituitary was normal
(Figures 1-3). Olfactory bulbs and tracts were normally
Figure 1. Post gadolinium T1 weighted magnetic resonance
image of pituitary in sagittal section showing cerebrospinal
filled sella turcica and a flattened anterior pituitary.
Figure 2. T1 weighted coronal magnetic resonance image of
pituitary showing sella turcica filled with suprasellar subara-
chnoid space and flattened anterior pituitary.
Figure 3. T2 weighted coronal magnetic resonance image of
pituitary showing empty sella turcica.
visualized. Ophthalmic examination revealed no abnor-
A number of hypotheses, explaining occurrence of pri-
mary empty sella (PES) include; necrosis/infarction of a
pituitary adenoma, pituitary apoplexy, rupture of intra-
sellar cyst and volumetric changes associated with re-
peated pregnancies and aging. One of the most accepted
explanation is congenitally deficient sellar diaphragm
being acted upon by a sustained or intermittently in-
creased intracranial pressure thus promoting herniation
of arachnoid membrane into sella turcica [5]. Endocrine
abnormalities are infrequent in subjects with PES. The
spectrum of endocrine dysfunctions varies from isolated/
partial or global pituitary hyposecretion to hyperse-
cretion. Whereas many authors [6] report up to 25% inci-
dence of hypopituitarism with PES, the largest clinical
case series of PES till date has reported 8% incidence of
global or partial pituitary hypofunciton [7]. In the same
largest clinical case series none had isolated gonado-
tropin deficiency. The most common endocrine dysfunc-
tion reported with PES is GH deficiency either isolated
or in combination with other anterior pituitary hormone
hyposecretion. Basal serum GH levels are not clearly
useful as most recent studies have demonstrated a
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S. Shekhar et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 276-278
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decreased pituitary GH reserves in 35% - 60% of adult
PES subjects [7-9]. IGF-1 levels and dynamic tests for
GH reserves are more informative and useful. Although
we could not perform dynamic tests of GH reserves
nonetheless IGF-1 value was normal. Hyper-prolacti-
nemia occurs in 10% of cases and theoretical explanation
is stalk dysfunction possibly due to remodelling of the
hypothalamo-pituitary region and altered CSF dynamics.
The reported cases of empty sella with isolated gona-
dotropin deficiency in literature are rare. It has been
postulated that different processes (vascular, autoim-
mune or genetic) which culminate in common final result
of empty sella cause pituitary hypoplasia, hence pitui-
tary insufficiency. In addition increased intrasellar pres-
sure causing unabated pituitary compression and stalk
distortion might lead to functional insufficiency of the
pituitary cells and hypothalamic signal interference [10].
Hence, theoretically it should lead to at least partial
pituitary insufficiency rather than an isolated hormonal
deficiency. However, isolated GH deficiency is explained
by the fact that somatotrophs constitute more than 50%
of normal pituitary gland volume; hence their function is
likely to be disturbed first in the case of pituitary damage.
It is further hypothesized that the anatomical distribution
of GH-secreting cells makes these cells more vulnerable
and that the neuro-regulatory mechanisms of GH sec-
retion may be particularly sensitive to increased in-
trasellar pressure [10]. However, isolated deficiency of
gonadotropins with other pituitary hormones being nor-
mal is a rare presentation in this patient, which could not
be explained well by the radiological findings alone.
Despite a thorough ophthalmic, neurological and endo-
crine evaluation we could not establish a causal rela-
tionship between PES and isolated gonadotropin defi-
ciency in this patient. As aptly quoted by someone “ab-
sence of proof is not proof of absence”, hence, subjects
with PES should be offered thorough clinical, hormonal
and radiological evaluation.
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