Introduction

The sella turcica is a sunken saddle shape at the base of the human skull, with the function of protecting the pituitary gland, its pathology linked to multiple endocrine and genetic disorders.¹ The pituitary gland is vital to bodily functions ² (it is also known as the “master gland”, emphasising its importance) and is found in the bony sella turcica. It is attached to the base of the brain and has a connection with the hypothalamus. The pituitary gland is involved in producing hormones to regulate vital processes such as metabolism, stress response, growth, and water balance.³

Empty Sella Syndrome (ESS) is a condition where the sella turcica appears empty in an imaging scan and does not show the pituitary gland because it is filled with cerebrospinal fluid (CSF) instead. A concern linked to ESS is hypopituitarism, which happens when the pituitary gland does not make enough hormones, affecting metabolism, growth, stress response, and reproduction. Because the symptoms are often subtle, early detection is difficult but crucial to prevent long-term health problems.⁴ Hormone problems do not affect everyone with ESS. However, with those that it does affect, it has significant issues such as hormonal imbalances, weight gain, infertility, headaches, and fatigue. 

What is empty sella syndrome?

ESS is a radiologic finding (CT and MRI brain imaging) where the sella turcica looks empty as cerebrospinal fluid fills up the space, which causes the pituitary gland, found in the sella turcica, to be flattened or compressed and the pituitary stalk to be stretched.⁵ ESS is put into two categories: primary empty sella (PES) and secondary empty sella (SES), which can both present as either complete or partial. 

Primary empty sella (PES)

• Less common than SES
• The cause is not fully understood
• Possible explanations include:
  • A weak or missing membrane covering the sella turcica
  • Raised pressure in the brain (intracranial hypertension), which can push fluid (CSF) into the sella and flatten the pituitary gland
  • Small blood vessel disease affecting the area
  • Changes in pituitary size over time, for example, if the gland enlarges during pregnancy and breastfeeding, then shrinks later (postmenopause), leaving space for CSF to fill
• PES is strongly linked with pseudotumour cerebri (pressure builds up in the skull, increasing pressure presses on the pituitary, which makes the sella look empty in scans) 

Secondary empty sella (SES)

• More common type
• Happens after the pituitary gland has been directly damaged or treated
• Causes include:
  • Surgery, radiotherapy or medication for pituitary tumours
    Spontaneous shrinkage of the pituitary gland
  • Sheehan’s syndrome (postpartum pituitary necrosis (tissue death) after heavy bleeding in childbirth)
  • Autoimmune inflammation of the pituitary (called lymphocytic hypophysitis)

The endocrine impact: how pituitary hormone loss affects the body

ESS can cause hypopituitarism, which is a condition characterised by the pituitary gland's insufficient hormone production. This condition can lead to severe morbidity if it is left untreated. One or more of these hormones could be affected:

Connection between ESS and hypopituitarism

As the pituitary gland is compressed, it affects the production of hormones by reducing their production. When this occurs, patients have symptoms of tiredness, low blood pressure, dizziness, or a change in metabolism because of the low hormone levels. In rare cases, hormone deficiency can be life-threatening, causing low body temperature, severe low blood pressure, or even leading to intensive care admission.⁷

However, not all people with Empty Sella Syndrome develop hormone problems. Some people remain completely symptom-free. Because it is not possible to predict who will be affected, hormone testing is essential whenever ESS is found on a scan.⁸ This helps doctors identify hidden hormone deficiencies early, before they cause serious complications.

Diagnosis of empty sella syndrome

Empty Sella Syndrome (ESS) is often found by accident during brain scans done for other reasons. Even though many people with ESS have no symptoms, it has been seen in:

• About 40% of people with hormone problems, and
• Up to 94% of people with Intracranial Hypertension (IH), where high pressure inside the skull can push fluid into the sella and squash the pituitary gland

Because the pituitary gland controls many body hormones, this pressure can sometimes lead to low hormone levels (hypopituitarism), affecting things like energy, growth, reproduction, and stress response.

How ESS is confirmed

Doctors usually do several checks to see if ESS is affecting hormone function:

• Medical history and physical exam (to look for possible causes, like previous head injury, brain surgery, pregnancy, or radiation)
• Hormone blood tests to see if the pituitary glands are making enough hormones. Sometimes, extra stimulation tests are done to check how well the glands respond
• Brain scans (MRI or CT)  show a flattened pituitary with fluid filling the sella
• Eye checks: if there are headaches, vision changes, or double vision, as the pituitary gland is close to the optic nerves

Even if someone feels well, doctors usually recommend these tests if ESS is seen on a scan to catch hormone problems early, before they cause serious health issues.

Management and multidisciplinary care

• Treatment depends on symptoms and hormone levels:
  • Asymptomatic ESS with normal hormones → usually no treatment, just regular monitoring
  • Symptomatic ESS or proven hypopituitarism → treat the specific hormone deficiencies with replacement therapy:
    • Hydrocortisone (for cortisol deficiency)
    • Levothyroxine (for thyroid hormone deficiency)
    • Oestrogen/testosterone (for reproductive hormones)
    • Somatropin (growth hormone) in selected adults
  • If idiopathic (meaning with no obvious cause) intracranial hypertension → options like lumbar peritoneal shunt or weight reduction
• Surgical treatment is only considered if:
  • There is an ongoing cerebrospinal fluid (CSF) leak
  • There is progressive vision loss from pressure on the optic nerve or nearby structures
• A multidisciplinary approach is key:
  • Endocrinology → to manage hormone deficiencies and monitor replacement therapy
  • Neurology → to assess raised intracranial pressure or neurological symptoms
  • Ophthalmology → to monitor and protect the eyes

Because ESS is being recognised more often and can present with more symptoms than previously thought, clinicians must be alert to subtle signs, screen for hormone abnormalities and coordinate care to improve patient outcomes.

FAQs

Q: What are the treatment options for empty sella syndrome?

A: Treatment depends on the symptoms. Hormone replacement therapy may be needed for hypopituitarism, while other cases may be monitored with regular check-ups. Rarely, surgical treatment is considered if pressure-related symptoms occur.

Q: Can ESS be prevented?

A: There’s no known way to prevent ESS, but early diagnosis and monitoring can help prevent complications and manage hormone-related issues effectively.

Q: Who is most at risk of empty sella syndrome (ESS)?

A: ESS is more common in women (especially middle-aged) and in people who are overweight or have intracranial hypertension, which increases pressure inside the skull.

Q: Does ESS always cause hypopituitarism?

A: No, many people with ESS have normal hormone levels. Hypopituitarism only develops if the pituitary gland becomes too compressed to function properly.

Q: How can ESS affect mental health?

A: Hormonal imbalances can lead to symptoms like low mood, anxiety, brain fog and fatigue, which may impact mental well-being and quality of life.

Q: Is ESS life-threatening?

A: ESS itself is not life-threatening, but untreated severe hormone deficiencies can lead to serious complications like adrenal crisis or thyroid crisis, so follow-up care is essential.

Summary 

Empty Sella Syndrome (ESS) is a condition where the space that normally houses the pituitary glands (inside the sella turcica) appears empty on brain scans because it fills with cerebrospinal fluid, flattening the gland. The pituitary is the body’s “master gland,” producing hormones that control growth, metabolism, reproduction and stress response. In some cases, ESS can lead to hypopituitarism, where the pituitary doesn’t release enough hormones, causing issues like fatigue, weight gain, infertility and hormonal imbalances. Early detection is important to prevent long-term health problems and guide treatment.