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ICAO Preliminary Unedited Version — March 2010 III-4-7
hormone in more than 80 per cent of patients but gall stones have been documented on long term
treatment.
Operational implications
An applicant with a symptomatic excess growth hormone due to tumour is unfit for all aviation duties.
Aeromedical considerations
After treatment the individual must be carefully reviewed to assess the efficacy of the treatment.
Those with gross physical changes which do not regress are unlikely to be fit for medical certification.
Specialist endocrinological and ophthalmic review would be required before any assessment by the
aeromedical authority.
Overproduction of prolactin
Prolactinomas are the most common functional pituitary adenoma and account for approximately 25 per
cent of asymptomatic pituitary adenomas diagnosed at post mortem examinations.
Symptoms and signs
The classic symptoms of hyperprolactinaemia in the female are:
a) amenorrhoea, oligomenorrhoea or infertility
b) galactorrhoea
c) decreased libido
d) vaginal dryness/dyspareunia
e) delayed menarche
Although less common, hyperprolactinaemia presents in the male with:
a) decreased libido
b) impotence
c) galactorrhoea
d) reduced body and facial hair
e) small soft testis
f) apathy
g) weight gain
The diagnosis is confirmed by raised prolactin levels. A prolactin level of >5000 mU/L suggests a
prolactinoma while a level of < 2500 mU/L is more likely to be the result of compression of the pituitary
stalk by an inactive adenoma.
Radiological views of the pituitary fossa should be undertaken to look for any disruption to the sella.
Treatment
The dopamine agonist bromocriptine reduces galactorrhoea, restores menstruation and returns serum
prolactin to normal in the majority of patients, and results in visual field improvement in approximately
75 per cent of cases. Although it is a highly effective drug, the side-effects - nausea, vomiting, fatigue,
ICAO Preliminary Unedited Version — March 2010 III-4-8
mood changes - can be dose limiting. The side-effect profile can be minimized by starting with a low dose
at bedtime. If symptoms persist, the newer dopamine agonists, such as cabergoline, can be used. Although
there is no evidence of teratogenicity, most physicians stop bromocriptine when pregnancy is diagnosed
and monitor the visual fields carefully. Long term treatment with bromocriptine or an alternative agonist
is the most common regime for microprolactinomas. In some centres with good neurosurgical facilities
transphenoidal surgery is the treatment of choice, although the majority of endocrine units generally
advocate surgery only in those patients who cannot tolerate dopamine agonists or whose tumour does not
respond. The advantage of micro-neurosurgery, however, is that it is curative. Surgery in macroadenomas
is rarely curative and carries the risk of hypopituitarism and, thus, dopamine agonists are the
treatment of choice in the macroadenoma group.
Operational implications
An applicant with an active pituitary tumour with or without an enlarged sella turcica is unfit for all
aviation duties.
Aeromedical considerations
An applicant on continuing medication or following successful surgery may be considered for medical
certification after three months if closely supervised by an aviation medicine specialist and an
endocrinologist and, if visual problems have been present, by an ophthalmologist.
Continued treatment with bromocriptine will probably have to be lifelong on the basis of current
evidence.
Over-production of
adrenocorticotrophic hormone (ACTH)
An over-production of ACTH — usually caused by a microadenoma in the pituitary gland — can cause
Cushing’s syndrome4 by hyperstimulation of the adrenal cortex which produces an excess primarily of
cortisol.
Symptoms and Signs
Typical features of excess cortisol production are:
a) weight gain and trunkal obesity
b) moon face
c) plethora
d) menstrual irregularity
e) hirsuitism
f) thinning of the skin with easy bruising
g) depression and psychosis
h) purple striae
i) proximal myopathy
j) oedema
k) diabetes mellitus
Diagnosis
4 Cushing’s syndrome: Hyperadrenocorticism caused by a neoplasm of the adrenal cortex or adenohypophysis, or by
excessive intake of glucocorticoids. Named after Harvey Williams Cushing, American surgeon (1869-1939).
ICAO Preliminary Unedited Version — March 2010 III-4-9
Screening for Cushing’s syndrome is most easily performed by measuring urinary free cortisol. Assays
vary between laboratories, but in Cushing’s syndrome, the level is usually >275 nmol/24 hours. If this is
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Manual of Civil Aviation Medicine 1(125)
