A patient without a pituitary gland?

"Please see my MRI. Something is very wrong," my patient, Ms L. said to me.

I looked at her carefully. She appeared to be close to tears. Then I opened the large folder containing her MRI scan pictures and looked at the radiologist's report first. It read: Empty sella syndrome. There was no other abnormality in the scan.

"Who sent you for this scan?" I asked.

She looked embarrassed when she told me that she had been referred for the scan by a doctor in a private hospital because of her headaches. Of course I knew that she had been suffering from headaches because she had been my patient for over 2 years and I was treating her for migraine.

"I went to this doctor because some of friends told me that I should get a second opinion for my headaches," she explained.
"So, what did the doctor say after seeing this scan?"
"He said that I did not have a pituitary gland. He said I needed tests for different kinds of hormones." After a pause, she continued, "I cannot afford the costs of all those tests."

It was a familiar story. Patients are often attracted to doctors who "scan them" believing that scanned images of their bodies are better than clinical judgement.

I looked sympathetically at Ms L. How should I start explaining to her that she could not have lived all these years if she did not have a pituitary gland? Then I told her that the empty sella syndrome is a radiological diagnosis only. It simply means that the pituitary gland is not seen on MRI scans. Just because it is not seen on the scan, does not mean it is not there. Many people with the empty sella syndrome have normal pituitary function.

I ordered the tests for the relevant anterior pituitary hormones - TSH, FSH, LH, ACTH and Prolactin - and spent time reassuring her that her headaches were not due to a brain tumour. Two weeks later, I reviewed the results of these tests and found them all to be normal. Ms L was relieved.

"I wonder where my pituitary gland is hiding," she murmured.
With a straight face I told her, "We will not search for it with any more scans."

Even after she left, her question kept haunting me. Where was the gland if it was not in the sella tursica? I must find the answer to that.