Introduction

Empty sella syndrome is an incidental radiological finding that can have significant effects on pituitary and other endocrine functions. While some patients remain symptomless, others develop hormone deficiencies that may go undetected without regular check-ins with the doctor. This article explains when and what to observe in empty sella syndrome, offering hands-on advice for safe and effective management.

What is empty sella syndrome?

Empty sella syndrome occurs when the sella turcica, a bony structure covering the pituitary gland, is fully or partially filled with cerebrospinal fluid on imaging. This squeezes the pituitary gland, which may or may not reduce its function.¹

There are two types:

• Primary empty sella syndrome: Caused by an inborn or acquired defect of the diaphragma sellae (which forms the roof of the pituitary gland), often related to increased intracranial pressure
• Secondary empty sella syndrome: Results from trauma, infection, pituitary surgery, radiotherapy, or blockage of blood supply to the pituitary gland^1,2

Although many patients remain symptom-free, about 40% of them may show some hormonal imbalance.

Pathophysiology of empty sella syndrome

The exact mechanism differs between the types:

• In Primary Empty Sella Syndrome, increased intracranial pressure forces cerebrospinal fluid into the sella, flattening the pituitary gland against its walls. Over time, this mechanical pressure can lead to reduced pituitary function. Obesity, high blood pressure, and female sex are recognised risk factors
• In Secondary Empty Sella Syndrome, injury or removal of pituitary tissue (e.g. after tumour resection or infarction) leaves the sella partially empty. These patients are at higher risk of developing permanent hormonal deficiencies because true pituitary damage has occurred

The pituitary gland controls vital body functions through multiple hormonal pathways. Compression or scarring can impair one or more of these pathways, resulting in progressive hormone loss.

Clinical features of empty sella syndrome

Many cases are found incidentally on magnetic resonance imaging performed for unrelated reasons, such as headache or other symptoms. However, up to 50% of the patients may have some hormonal imbalance.

Possible symptoms include persistent headaches, visual disturbances, absence of normal menstrual flow, infertility, impotence, reduced sex drive, fatigue, dizziness, low blood pressure, weight changes, profuse urination or weakening of bones.

Because these symptoms are vague, they may be overlooked unless targeted hormonal testing is performed.^1,3

Why endocrinological follow-up matters

The importance of follow-up lies in preventing missed or late diagnoses of pituitary failure. Pituitary hormone deficiencies can emerge slowly and remain unnoticed until complications occur. In some studies, nearly one-third of patients with empty sella syndrome had at least one hormonal insufficiency at diagnosis. These can include deficiencies of pituitary hormones, cortisol, thyroxine, sex hormones, or growth hormone. Early follow-up prevents life-threatening emergencies such as adrenal crisis and improves quality of life by addressing hidden but important issues, including reduced fertility, bone weakening, or fatigue.

When to monitor in empty sella syndrome

• Baseline (at diagnosis):

Complete pituitary hormone panel along with magnetic resonance imaging of the sella turcica.

• Short-term (6–12 months):

Repeat hormones in patients with abnormalities or evolving symptoms.

• Long-term (every 1–2 years):

Reassess hormonal function routinely, even if the hormone levels at the time of diagnosis were normal.

• Urgent reassessment:

If the patient presents with signs such as headache, absence of normal menstrual flow, loss of sex drive, unexplained fatigue, low blood pressure, or visual disturbance, immediate testing is required.

What to monitor in empty sella syndrome

Hormonal levels

This includes levels of pituitary hormones, thyroxine, cortisol and other adrenal hormones, sex hormones, prolactin, growth hormone and levels of sodium and other dissolved particles in the body fluids.^4,5 

Systemic health parameters

These include weight, blood pressure, blood glucose, lipids and bone scan.

Imaging

Magnetic resonance imaging of the sella turcica at the time of diagnosis. It can also be repeated after some time for long-term monitoring.⁹

Patient education and management

Patients should be informed about symptoms of hormone deficiency (e.g. dizziness, fatigue, menstrual changes, and profuse urination.  Hormone replacement therapy should be started when deficiencies are confirmed.^3,4,6,7 Patients with adrenal crisis should carry a steroid emergency card and receive stress-dose steroids from the attending doctor when unwell. Coordination between the treating doctors within the specialities of endocrinology, brain, and eye improves results in patients with empty sella syndrome.

Future directions and research

Although empty sella syndrome is well recognised on imaging, its natural history is less clearly understood.

Current challenges include:

• Predicting which patients with normal levels of hormones at the time of diagnosis will develop deficiencies later
• Understanding the role of obesity and increased intracranial pressure in the progression of empty sella syndrome
• Assessment of practical follow-up schedules
• Exploring advanced imaging markers to differentiate high-risk from low-risk cases

Ongoing research aims to establish guidelines that make follow-up efficient, but they often lack important clinical details.

FAQs

How common is empty sella syndrome?

It is seen in up to 8% of the routine brain MRIs, but not all cases cause problems.

Do all patients need hormone replacement therapy?

No. Only those with proven deficiencies require replacement, but all patients with empty sella syndrome should be monitored by the clinician.

I’m diagnosed with empty sella syndrome. Will I need repeated magnetic resonance imaging scans?

No. Repeat imaging is only required if symptoms change or in secondary empty sella syndrome.

Can empty sella syndrome affect fertility?

Yes. If a deficiency of sex hormones occurs, it may lead to infertility and require specialist care⁷

What is the most common hormone deficiency in ESS?

Growth hormone and sex hormone deficiencies are the most frequent ones^5,7

Summary

Empty sella syndrome is often an incidental radiological finding that can have significant effects on pituitary and other endocrine functions.⁸ Regular hormonal follow-up is essential, which includes full hormone testing at diagnosis, reassessment at 6–12 months, and long-term monitoring every 1–2 years. This includes levels of pituitary hormones, thyroxine, cortisol and other adrenal hormones, sex hormones, prolactin, growth hormone and levels of sodium and other dissolved particles in the body fluids when clinically indicated. Radiological investigation, such as magnetic resonance imaging, should be guided by symptoms.

By adopting a structured approach and educating patients about red-flag symptoms, clinicians can prevent life-threatening problems and improve long-term quality of life.