Referral to emergency

If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

  • suspected pituitary tumour with concerning features including:
    • acute new visual field loss (usually temporal and classically bitemporal superior quadrantinopia/hemianopia)
    • thunderclap headache
    • symptomatic cortisol insufficiency

For clinical advice, please telephone the relevant metropolitan Local Health Network switchboard and ask to speak to the relevant specialty service.

Central Adelaide Local Health Network

Northern Adelaide Local Health Network 

Southern Adelaide Local Health Network

Category 1 - appointment clinically indicated within 30 days

  • adrenal insufficiency or hypopituitarism
  • pituitary mass greater than 10mm with pathological headaches
  • serum prolactin greater than 10 times upper limit of normal range
  • suspected diabetes insipidus
  • visual field defects

Category 2 — appointment clinically indicated within 90 days

  • hyperprolactinaemia

Category 3 — appointment clinically indicated within 365 days

  • nil

For information on referral forms and how to import them, please view general referral information.

Essential referral information

Completion required before first appointment to ensure patients are ready for care. Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.

  • identifies as Aboriginal and/or Torres Strait Islander
  • relevant social history, including identifying if you feel your patient is from a vulnerable population and/or requires a third party to receive correspondence on their behalf
  • interpreter requirements
  • history:
    • past medical/surgical history
    • onset, duration, and progression of symptoms
  • current medications and dosages
  • use/frequency of alcohol, tobacco, and other drugs
  • allergies and sensitivities
  • plans regarding pregnancy if relevant, or male fertility
  • management history including treatments trialled/implemented prior to referral
  • relevant diagnostic/imaging reports including location of company and accession number

Examination

  • examination results
  • height/weight
  • body mass index (BMI)

Pathology

  • urea, electrolyte, and creatinine (UEC)
  • estimated glomerular filtration rate (eGFR)
  • serum prolactin with repeat level
    • measure macroprolactin (asymptomatic people)
  • thyroid function test (TFT):
    • thyroid stimulating hormone (TSH)
    • free thyroxine (FT4)
  • luteinizing hormone (LH)
  • follicle-stimulating hormone (FSH)

Suspected or confirmed pituitary mass

  • complete anterior pituitary function with morning cortisol (8.00 to 9.00 am)
  • adrenocorticotropic hormone
  • thyroid stimulating hormone
  • free thyroxine
  • insulin-like growth factor-1
  • luteinizing hormone
  • follicle-stimulating hormone
  • testosterone or oestradiol

Men

  • 8.00 to 9.00 am serum testosterone
  • sex hormone binding globulin (SHBG)

Women

  • oestradiol
  • human chorionic gonadotropin (ßhCG) for pre-menopausal women

Additional information to assist triage categorisation

Pituitary magnetic resonance imaging (MRI) only if:

  • serum prolactin after macroprolactin adjustment is at least x3 upper limit normal off relevant drugs
  • neurological features or headaches
  • pathological menstrual disturbance
  • galactorrhea or male androgen deficiency is present

Clinical management advice

Significant symptoms are galactorrhea, gonadal steroid deficiency (manifesting as menstrual irregularities, hypogonadism, and infertility). Frequent triggers include:

  • pregnancy
  • breastfeeding
  • unexplained causes
  • pituitary tumours
  • medications such as antipsychotic agents
  • anti-emetics.

If feasible, discontinue any medications that may elevate serum prolactin levels. Exclude hypothyroidism and renal failure as potential underlying conditions. For asymptomatic/inconsistent presentations, consider retesting serum prolactin levels and assessing macroprolactin levels (a less active form of prolactin).

Computerised tomography (CT) is not the preferred imaging modality for pituitary imaging. Magnetic resonance imaging (MRI) only if:

  • serum prolactin after macroprolactin adjustment is at least x3 upper limit normal off relevant drugs
  • neurological features or headaches
  • pathological menstrual disturbance
  • galactorrhea or male androgen deficiency is present

Please ensure that recent pathology results are available. Consider providing the patient with a repeat pathology form at the time of referral.

Patients who have previously received care from a specialist should be encouraged to return to their care for additional assessment if needed.

Referrals are subject to the evaluation of the triaging clinician. If you believe your patient necessitates specialist assessment but may not meet the provided criteria, feel free to connect with the specialist team to discuss your concerns.

Clinical resources

Consumer resources