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title: "Pituitary Hyperplasia"
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docid: "9696bc9e-f00b-4fa7-aa67-f039efd8fbed"
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authors:
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- key: "5cff4116-3654-4b3a-bb75-5ebe0b8c9850"
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value: "Anne G. Osborn, MD, FACR"
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breadcrumbs:
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-
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name: "Brain"
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slug: "brain"
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treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
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-
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name: "Diagnosis"
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slug: "diagnosis"
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treeNodeId: "51c00394-446e-4a38-94af-d3b1d14d34e8"
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-
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name: "Anatomy-Based Diagnoses"
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slug: "anatomy-based-diagnoses"
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treeNodeId: "529d3e33-f508-498c-bc70-cf962e81e629"
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-
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name: "Sella and Pituitary"
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slug: "sella-and-pituitary"
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treeNodeId: "9afaeeb6-661c-49be-b55f-5bdc1c98a53e"
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-
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name: "Miscellaneous"
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slug: "miscellaneous"
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treeNodeId: "7941c33d-0063-41a2-b035-39440c09b829"
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-
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name: "Pituitary Hyperplasia"
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slug: "pituitary-hyperplasia"
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treeNodeId: null
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category: "Brain"
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cmeTopicId: "10eb0985-d56e-4149-91b4-be614f820dd7"
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documentVersionId: "6f43163b-2ff5-428a-a535-d0b805a74a43"
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imageCount: 12
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lastUpdated: "06/08/20"
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pageDescription: "Pituitary Hyperplasia"
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pageKeywords: "Brain, Diagnosis, Anatomy-Based Diagnoses, Sella and Pituitary, Miscellaneous, Pituitary Hyperplasia"
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pageTitle: "Pituitary Hyperplasia | STATdx"
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enhancedTitle: "Pituitary Hyperplasia"
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type: "DX"
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references: true
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breadcrumbs:
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- "Brain"
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- "Diagnosis"
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- "Anatomy-Based Diagnoses"
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- "Sella and Pituitary"
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- "Miscellaneous"
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- "Pituitary Hyperplasia"
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---
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# KEY FACTS
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- ## Terminology
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- Normal maximal pituitary height varies with age, sex
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- Pregnant/lactating females: 12 mm
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- Young menstruating females: 10 mm
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- Males, postmenopausal females: 8 mm
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- Infants, children: 6 mm
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- Nonphysiologic hyperplasia seen with
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- Hypothyroidism, Addison disease, or other end-organ failure
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- Some neuroendocrine neoplasms
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- ## Imaging
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- Enlarged homogeneously enhancing pituitary gland with convex superior margin
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- Best technique: High-resolution MR
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- Sagittal/coronal T1; coronal T2
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- Dynamic coronal T1WI
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- Postcontrast T1 FS sagittal/coronal T1
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- 3- to 4-mm slice thickness
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- ## Top Differential Diagnoses
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- Pituitary macroadenoma
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- Pituitary microadenoma
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- Lymphocytic hypophysitis
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- Venous congestion (intracranial hypotension, dural arteriovenous fistula)
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- ## Pathology
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- Normal: Physiologic hyperplasia in pregnancy, lactation
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- Abnormal: Longstanding untreated primary hypothyroidism
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- Loss of thyroxine feedback inhibition, overproduction of thyrotropin-releasing hormone
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- Secondary pituitary hyperplasia
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- Orthotopic or ectopic production of hypothalamic-releasing hormones
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- Orthotopic: Response to end-organ failure
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- Ectopic: Related to neuroendocrine tumors
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# TERMINOLOGY
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- ## Definitions
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- Upper limit of normal pituitary height varies with age, sex
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- Pregnant/lactating females: 12 mm
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- Young menstruating females: 10 mm
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- Males, postmenopausal females: 8 mm
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- Infants, children: 6 mm
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- Nonphysiologic pituitary hyperplasia seen with
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- Longstanding untreated primary hypothyroidism
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- Addison disease, end-organ failure, some neuroendocrine neoplasms
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# IMAGING
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- ## General Features
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- ### Best diagnostic clue
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- Enlarged homogeneously enhancing pituitary gland with convex superior margin
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- > 10 mm up to 15 mm
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- May be nodular, mimic pituitary adenoma
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- ### Location
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- Sella; may extend into suprasellar region, compress adjacent structures
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- ## CT Findings
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- ### NECT
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- Noncalcified pituitary gland enlargement
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- ### CECT
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- Homogeneous enhancement
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- ## MR Findings
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- ### T1WI
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- Isointense with remainder of pituitary gland
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- ### T2WI
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- Isointense with remainder of pituitary gland
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- ### T1WI C+
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- Diffusely enhancing gland is typical
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- Rare = may cause focal nodular enlargement
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- Dynamic MR: Enhances similar to remainder of gland
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- ## Imaging Recommendations
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- ### Best imaging tool
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- MR with 3- to 4-mm slices, small FOV
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- ### Protocol advice
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- Sagittal/coronal T1; coronal T2
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- Dynamic enhanced coronal T1WI
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- Postcontrast T1 FS sagittal/coronal
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# DIFFERENTIAL DIAGNOSIS
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- [Pituitary Macroadenoma](/document/pituitary-microadenoma/283f3068-d369-4f79-bf01-0f2b82c6e49b)
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- May be indistinguishable
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- Rare: May occur secondary to primary hypothyroidism
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- [Pituitary Microadenoma](/document/pituitary-microadenoma/283f3068-d369-4f79-bf01-0f2b82c6e49b)
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- May be indistinguishable
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- Enhances slower than normal gland on dynamic study
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- [Lymphocytic Hypophysitis](/document/lymphocytic-hypophysitis/f30774c3-cbd0-4ab3-b3d1-e0574106db1f)
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- Enlarged gland &/or stalk
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- Pregnant or postpartum females
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- ## Venous Congestion
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- [Can occur with intracranial hypotension](/document/intracranial-hypotension/818a7972-1032-4d3e-a65a-97c494334aac)
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- [Dural arteriovenous fistulas](/document/dural-av-fistula/628fd160-1e22-4b55-83f9-c25464d05bd6)
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# PATHOLOGY
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- ## General Features
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- ### Etiology
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- Normal: Physiologic hyperplasia in pregnancy, lactation
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- Longstanding untreated primary hypothyroidism
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- Loss of thyroxine feedback inhibition, overproduction of thyrotropin-releasing hormone
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- Secondary pituitary hyperplasia
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- Orthotopic or ectopic production of hypothalamic-releasing hormones
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- Orthotopic: Response to end-organ failure
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- Ectopic: Related to neuroendocrine tumors
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- ## Microscopic Features
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- Nodular hyperplasia characterized by marked expansion of acini, architectural distortion
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- Diffuse hyperplasia requires formal cell count
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- Growth hormone cell hyperplasia usually diffuse, occurs with neuroendocrine tumors
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- Pancreatic islet cell tumor, pheochromocytoma, and bronchial and thyroid carcinoid tumors
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- Associated with McCune-Albright syndrome, multiple endocrine neoplasia syndrome, and Carney complex
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- Prolactin cell hyperplasia: Diffuse > nodular
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- May be seen with pregnancy and lactation, estrogen treatment, primary hypothyroidism, Cushing disease
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- Corticotroph hyperplasia: Nodular or diffuse
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- Associated with Cushing disease, neuroendocrine tumors, untreated Addison disease
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- Thyrotroph hyperplasia
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- Longstanding primary hypothyroidism, may have associated prolactin hyperplasia
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- Gonadotroph hyperplasia (e.g., Turner, Klinefelter syndromes)
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# CLINICAL ISSUES
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- ## Presentation
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- ### Most common signs/symptoms
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- Varies with cell type of hyperplasia
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- ## Demographics
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- ### Age
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- Typically adults (rare in children)
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- ### Sex
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- No predilection
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- ## Treatment
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- If related to hypothyroidism, regression after thyroid hormone therapy common
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- Treat end-organ failure or neuroendocrine tumor
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# DIAGNOSTIC CHECKLIST
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- ## Consider
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- Hyperplasia may mimic adenoma
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- Clinical information can help differentiate
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- If imaging looks like adenoma in prepubescent male, consider end-organ failure
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f1e3a750-ebdd-439c-8134-0efe1099c891
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## References
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# Selected References
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1. [Du J et al: Pituitary adenoma secondary to primary hypothyroidism: two case reports. Medicine (Baltimore). 99(8):e19222, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=32080117%5Bpmid%5D)
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1. [Takayasu S et al: Presence of aberrant adrenocorticotropic hormone precursors in two cases of McCune-Albright syndrome. Endocr J. 67(3):353-9, 2020](http://www.ncbi.nlm.nih.gov/pubmed/?term=31801917%5Bpmid%5D)
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1. [Cossu G et al: Comprehensive evaluation of rare pituitary lesions: a single tertiary care pituitary center experience and review of the literature. Endocr Pathol. 30(3):219-36, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31209729%5Bpmid%5D)
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1. [Kinoshita Y et al: Physiologic pituitary hyperplasia causing visual disturbance during adolescence. J Clin Neurosci. 61:279-81, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30470648%5Bpmid%5D)
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1. [Shivaprasad KS et al: Pituitary hyperplasia from primary hypothyroidism. N Engl J Med. 380(8):e9, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=30786191%5Bpmid%5D)
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1. [Shukla P et al: Pituitary hyperplasia in severe primary hypothyroidism: a case report and review of the literature. Case Rep Endocrinol. 2019:2012546, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31341683%5Bpmid%5D)
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1. [Biswas SN et al: Physiological pituitary hyperplasia misinterpreted and treated as lymphocytic hypophysitis. BMJ Case Rep. 2018, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=30139788%5Bpmid%5D)
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1. [Cao J et al: Primary hypothyroidism in a child leads to pituitary hyperplasia: a case report and literature review. Medicine (Baltimore). 97(42):e12703, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=30334955%5Bpmid%5D)
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1. [Nachawi N et al: Pituitary 'pseudotumor': an under-recognised complication of undertreated primary hypothyroidism. BMJ Case Rep. 2018, 2018](http://www.ncbi.nlm.nih.gov/pubmed/?term=29950371%5Bpmid%5D)
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## Images
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### Selected Images
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*Coronal graphic shows physiologic pituitary hyperplasia. The gland is uniformly enlarged and has a mildly convex superior margin.*
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*Coronal graphic shows physiologic pituitary hyperplasia. The gland is uniformly enlarged and has a mildly convex superior margin.*
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*Coronal graphic shows physiologic pituitary hyperplasia. The gland is uniformly enlarged and has a mildly convex superior margin.*
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*Sagittal T1 C+ MR in a 38-year-old woman undergoing infertility treatment imaged for headache shows a homogeneously enhancing pituitary measuring 12 mm.*
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*Sagittal T1 C+ MR in a 38-year-old woman undergoing infertility treatment imaged for headache shows a homogeneously enhancing pituitary measuring 12 mm.*
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*Coronal T1 C+ MR shows typical physiologic pituitary hyperplasia in a 28-year-old lactating woman. The gland has a mildly convex superior margin and measures nearly 14 mm in height.*
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*Coronal T1 C+ MR shows typical physiologic pituitary hyperplasia in a 28-year-old lactating woman. The gland has a mildly convex superior margin and measures nearly 14 mm in height.*
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*At follow-up 1 year later, coronal T1 C+ MR reveals a normal appearance to the pituitary gland with interval resolution of the postpartum physiologic enlargement.*
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*At follow-up 1 year later, coronal T1 C+ MR reveals a normal appearance to the pituitary gland with interval resolution of the postpartum physiologic enlargement.*
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### Additional Images
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*Sagittal T1 MR in a 53-year-old hypothyroid female patient shows a rounded, upwardly convex pituitary gland <img src='img/arrows/WC.png'/>. The gland measured 12 mm in height.*
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*Sagittal T1 MR in a 53-year-old hypothyroid female patient shows a rounded, upwardly convex pituitary gland <img src='img/arrows/WC.png'/>. The gland measured 12 mm in height.*
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*Coronal T2 MR shows the upwardly convex pituitary gland <img src='img/arrows/WC.png'/> is isointense with brain.*
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*Coronal T2 MR shows the upwardly convex pituitary gland <img src='img/arrows/WC.png'/> is isointense with brain.*
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*Sagittal T1 C+ FS MR in the same case shows the enlarged pituitary gland <img src='img/arrows/WC.png'/> enhances intensely and uniformly.*
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*Sagittal T1 C+ FS MR in the same case shows the enlarged pituitary gland <img src='img/arrows/WC.png'/> enhances intensely and uniformly.*
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*Coronal T1 C+ FS MR obtained after dynamic contrast-enhanced imaging shows the pituitary gland <img src='img/arrows/WC.png'/> enhances uniformly. This is physiologic pituitary hyperplasia as a response to hypothyroidism and does not represent an adenoma.*
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*Coronal T1 C+ FS MR obtained after dynamic contrast-enhanced imaging shows the pituitary gland <img src='img/arrows/WC.png'/> enhances uniformly. This is physiologic pituitary hyperplasia as a response to hypothyroidism and does not represent an adenoma.*
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*Sagittal T1 C+ MR in a 19-year-old female patient shows a very rounded appearing pituitary gland <img src='img/arrows/WC.png'/>. Although it appears somewhat enlarged, it measures only 8 mm in height. The bony sella are unusually shallow, giving the appearance of pituitary enlargement.*
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*Sagittal T1 C+ MR in a 19-year-old female patient shows a very rounded appearing pituitary gland <img src='img/arrows/WC.png'/>. Although it appears somewhat enlarged, it measures only 8 mm in height. The bony sella are unusually shallow, giving the appearance of pituitary enlargement.*
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*Coronal CECT shows diffuse enlargement and enhancement of the pituitary gland with a convex margin in this 42 year old with ovarian failure.*
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*Coronal CECT shows diffuse enlargement and enhancement of the pituitary gland with a convex margin in this 42 year old with ovarian failure.*
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*Coronal T1 MR shows nodular hyperplasia and an upward convex margin of the pituitary gland in this patient with Cushing disease. The mild hypointensity is atypical.*
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*Coronal T1 MR shows nodular hyperplasia and an upward convex margin of the pituitary gland in this patient with Cushing disease. The mild hypointensity is atypical.*
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*Coronal T1 C+ MR in the same case shows diffuse enhancement of the hyperplasia, similar to the pituitary gland.*
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