Multiparity as a risk factor inducing pituitary function failure in the elderly

ABSTRACT

Hypopituitarism is difficult to diagnose in eldery people. The presentation usually are non specific with symptoms such as lethargy, pallor, falls, urinary incontinence, confusion, fever and even coma. Hormone replacement therapy resulted in improving quality of life [1,2]. Physicians dealing with elderly patients should bear this easily treated condition in mind. Prompted by striking features in four females, all over 60 years admitted to ourhospital with unexplained lethargy, altered state of consciousness and loss or diminished pubic hair with normal obstetric history but gravida more than 7. Pituitary assessment was done which proved hypopituitarism in all the 4 cases. This attracts our attention to study the relation between multiparity and pituitary dysfunction. Patients and methods: This study was a semiprospective study, over 7 years between June1992 till April 2000. The study included 22 female patients, age between 60-79 years with parity ranged from 4-13 with the majority of cases [91%] have parity more than 5. The control group included 20 females of same age group but nullipara or have one parity only. All were admitted to the hospital due to unexplained lethargy, generalized weakness and altered sensorium. Endocrine disturbance was clinically suspected. Thorough physical examination and history was taking emphasizing on the obstetric history. Hormonal assay [RIA], LH, FSH, estradiol, cortisol, TSH, T3, FT4, ACTH and prolactin were measured, 800am along with Na and k.CT brain and /or MRI were done for pituitary glands. Hormonal assay showed statistically low mean level of LH, FSH in the multiparous group compared to the control group [P<0.01]. TSH was normal in both groups, while T3, FT4, estradiol and cortisol were slightly lower than the control but the difference was not statistically significant except for estradiol and cortisol. Similar results were found as regards ACTH and prolactin. MRI showed empty sella in the majority of multiparous group 15 cases [68%], while only in 5 cases [25%] of the control group. The difference was significant. Final clinical diagnosis, showed definite pituitary dysfunction in majority of multiparous group, 12 cases had hypogonadotrophine associated with secondary hypothyroid in 4 cases, or with secondary hypoadrenalism in 4 cases, three cases have hypopituitarism, one case with hyperprolactinemia and two cases with SIADH syndrome and three cases have normal hormonal assay in spite of some clinical signs suggesting hormonal deficiency. Control group had much less hormonal disturbance, only one case has hypogonadotrophine, one case has hyperprolactinemia and one case with primary hypothyroid. We found definite relation between number of parity and pituitary dysfunction, the risk ratio was 4.1, [95% CI 1.7-9.5]. We recommend that physician dealing with elderly patients should consider the possibility of hypopituitarism in ill elderly grand multipara female patients, when no obvious diagnosis can explain their conditions, especially if signs of hormonal disturbance were detected as absent or diminisihed pubic hair, pallor and buffy face. Hormonal study must done for these patients