Empty Sella Syndrome (ESS)

Empty sella syndrome (ESS) is a condition where the small bony space in the skull that holds the pituitary gland (the sella turcica) looks “empty” on brain scans. In reality, it is not truly empty. The space is filled with cerebrospinal fluid (CSF), the clear fluid that surrounds the brain and spinal cord. The fluid pushes on the pituitary gland so the gland becomes flat and hard to see on imaging. Cleveland Clinic+1

The pituitary gland is a tiny organ that controls many hormones in the body, including growth, thyroid, stress, sex, and water balance hormones. When the gland is flattened, some people still have normal hormone function. In other people, the gland does not work well, and they develop symptoms such as headaches, vision problems, or hormone imbalance. When the empty sella appearance is linked with symptoms or hormone problems, doctors call it empty sella syndrome. NCBI+1

Empty sella syndrome happens when brain scan images show that the bony “seat” for the pituitary gland (the sella) looks partly or mostly filled with fluid and the pituitary looks flat or very small. Some people have no symptoms and need no treatment at all. Others can have hormone problems, headaches, vision changes, or signs of high pressure in the brain. In those cases, treatment focuses on replacing missing hormones, controlling symptoms, and sometimes surgery. endocrinepractice.org+4MSD Manuals+4Cleveland Clinic+4

Doctors usually start with careful hormone blood tests. If your pituitary is not making enough hormones, they replace only the hormones that are low, such as thyroid hormone, cortisol, sex hormones, growth hormone, or the water-balance hormone (vasopressin). If vision is at risk, or if pressure in the brain is too high, surgery or shunt procedures can be used. Many people do well with regular follow-up and simple medicines. endocrinepractice.org+4NCBI+4National Organization for Rare Disorders+4

Empty sella syndrome has several other names used in medical articles. It may be called “empty sella,” “empty sella turcica,” “empty pituitary fossa,” or “arachnoidocele”. These terms describe the same basic idea: CSF from the space around the brain herniates (bulges) down into the sella and compresses the pituitary gland. NCBI+2Russian Open Medical Journal+2

Types of empty sella syndrome

Doctors usually divide empty sella into types based on cause and on how much of the sella is filled with CSF. NCBI+2Russian Open Medical Journal+2

1. Primary empty sella (PES)
   Primary empty sella happens when there is no clear previous disease or surgery of the pituitary gland. There is often a small natural weakness or gap in the thin membrane (the diaphragma sellae) that covers the sella. CSF slowly pushes through this weak area and flattens the pituitary gland. PES is often seen in middle-aged, overweight women and may be linked with idiopathic intracranial hypertension (pseudotumor cerebri), a condition with high pressure around the brain. NCBI+2Bangladesh Journals Online+2

2. Secondary empty sella (SES)
   Secondary empty sella occurs when the pituitary gland was previously damaged, reduced, or removed. This can happen after a pituitary tumor, surgery, radiation therapy, bleeding into the gland (pituitary apoplexy), severe infection, or trauma. After the gland shrinks or is removed, the sella space is filled with CSF, giving an empty appearance. SES is more likely to be associated with hormone deficiencies. NCBI+2MedlinePlus+2

3. Partial empty sella
   In partial empty sella, less than about half of the sella is filled with CSF and the pituitary gland is still partly visible and thicker. This may cause fewer or no symptoms and is often found by chance on scans done for other reasons. Russian Open Medical Journal+1

4. Complete empty sella
   In complete empty sella, more than about half of the sella is filled with CSF, and the pituitary gland is very thin against the bone. People with complete empty sella are more likely to have hormone imbalance or vision problems, but some still remain asymptomatic. Russian Open Medical Journal+1

5. Asymptomatic empty sella vs. empty sella syndrome
   Many people have an empty sella on MRI or CT and no symptoms at all. This is called an asymptomatic empty sella and may need only observation. When the empty sella is linked to symptoms such as headaches, visual changes, or pituitary hormone problems, the term empty sella syndrome is used. Cleveland Clinic+2NCBI+2

Causes of empty sella syndrome

1. Congenital weakness of the diaphragma sellae
   Some people are born with a thin or incomplete diaphragma sellae, the small membrane over the sella. This weakness allows CSF to slowly push down into the sella over time and flatten the pituitary gland, causing primary empty sella. NCBI+1

2. Idiopathic intracranial hypertension (pseudotumor cerebri)
   Idiopathic intracranial hypertension is a condition with high pressure of CSF around the brain without a visible mass. The high pressure pushes CSF into the sella and leads to pituitary flattening. This is a well-known association, especially in young obese women. Bangladesh Journals Online+2MedlinePlus+2

3. Obesity-related raised intracranial pressure
   Obesity can increase the risk of raised CSF pressure. Extra body weight may change venous blood flow and CSF absorption, leading over time to chronic pressure on the sella and empty sella formation. Bangladesh Journals Online+1

4. Multiple pregnancies and hormonal changes
   During pregnancy, the pituitary gland enlarges to support hormonal needs. After childbirth, the gland shrinks back. Repeated pregnancies and hormonal swings may contribute to long-term changes in pituitary size and pressure dynamics, making primary empty sella more likely in some women. NCBI+1

5. Long-standing high blood pressure (systemic hypertension)
   Chronic high blood pressure can affect blood vessels inside the skull and may be linked with idiopathic intracranial hypertension. Over time, this may indirectly increase CSF pressure on the sella and contribute to primary empty sella in susceptible people. Bangladesh Journals Online+1

6. Pituitary adenoma treated with surgery
   A benign pituitary tumor (adenoma) may be removed through surgery. When part or all of the tumor and gland are removed, the leftover space in the sella is later filled with CSF. This classic pattern is a cause of secondary empty sella. MedlinePlus+1

7. Pituitary radiation therapy
   Radiation used to treat pituitary or nearby brain tumors can damage pituitary tissue. The gland may shrink months or years later, leaving an enlarged sella partly or fully filled with CSF. This can cause secondary empty sella and hypopituitarism. MedlinePlus+1

8. Pituitary apoplexy (sudden bleeding or infarction in the gland)
   Pituitary apoplexy is a sudden event where the gland bleeds or loses blood supply. The damaged tissue shrinks or scars, and the sella cavity widens and fills with CSF. After this, imaging may show secondary empty sella. NCBI+2SpringerLink+2

9. Sheehan’s syndrome (post-partum pituitary necrosis)
   Severe bleeding during childbirth can cause low blood flow to the pituitary gland. The gland may die and shrink (Sheehan’s syndrome), often leading to hormone failure and, later, a secondary empty sella on imaging. NCBI+1

10. Craniopharyngioma or other suprasellar tumor treatment
    Tumors near the pituitary, such as craniopharyngiomas, may require surgery or radiation. After treatment, the pituitary may be compressed, damaged, or partially removed, leaving an enlarged sella filled with CSF and secondary empty sella. SpringerLink+1

11. Traumatic brain injury with skull base damage
    Head trauma that affects the base of the skull can disturb the sellar region or the diaphragma sellae. After healing, scarring and changes in CSF flow can cause herniation of CSF into the sella and pituitary flattening. NCBI+1

12. Meningitis or subarachnoid hemorrhage
    Infection or bleeding in the membranes around the brain can change CSF pathways and pressures. Scarring of the arachnoid layer may pull CSF into the sella and compress the pituitary, leading to a secondary empty sella appearance. NCBI+1

13. CSF leak and repair procedures
    Chronic CSF leaks from the nose or ear and their repair surgeries can alter CSF pressure patterns. In some cases, these changes in CSF flow and pressure may contribute to empty sella development as the system re-balances. ajnr.org+1

14. Venous sinus stenosis and chronic venous hypertension
    Narrowing of the large brain veins (e.g., lateral sinus stenosis) can cause increased intracranial pressure. This raised pressure may push CSF into the sella, so empty sella can be a sign of such venous problems. ajnr.org+1

15. Hydrocephalus or long-standing CSF shunting
    Conditions with excess CSF (hydrocephalus) or long-term shunt treatment change CSF pressure over years. These changes can reshape the sella and produce pituitary flattening and empty sella on imaging. Russian Open Medical Journal+1

16. Inflammatory hypophysitis
    Autoimmune or inflammatory conditions can attack the pituitary (hypophysitis), causing it to swell and then shrink. After the active inflammation, a small scarred gland may remain, with CSF filling the remaining sella space. NCBI+1

17. Rathke’s cleft cyst and its treatment
    Rathke’s cleft cysts are benign cysts near the pituitary. When they are drained or removed, the sella space may enlarge and then fill with CSF, giving a secondary empty sella pattern on follow-up MRI. MDPI+1

18. Congenital pituitary hypoplasia in children
    Some children are born with a small or under-developed pituitary gland. As they grow, MRI may show a relatively large sella partly or completely filled with CSF and only a thin rim of pituitary tissue, which looks like empty sella. SAS Publishers+1

19. Systemic connective tissue or meningeal disorders
    Rare connective tissue diseases that affect the meninges (the brain coverings) can alter the structure and stiffness of the diaphragma sellae and arachnoid membrane, allowing CSF to herniate into the sella and cause pituitary flattening. NCBI+1

20. Unknown or idiopathic causes
    In many people, doctors cannot find a clear reason for empty sella syndrome. In these idiopathic cases, a combination of mild congenital weakness of the sellar diaphragm and subtle long-term CSF pressure changes may be responsible. NCBI+2Russian Open Medical Journal+2

Symptoms of empty sella syndrome

1. No symptoms (asymptomatic cases)
   Many people with an empty sella have no symptoms at all. The finding is discovered by chance on MRI or CT done for other reasons, and hormone tests are normal. These people may not need treatment, only periodic follow-up. Cleveland Clinic+1

2. Headache
   Headache is the most common symptom reported. The pain is often dull or pressure-like and may be related to raised CSF pressure or stretching of structures around the sella. In some patients, headaches improve after treating underlying intracranial hypertension. Cleveland Clinic+2National Organization for Rare Disorders+2

3. Blurred vision
   The optic nerves and the optic chiasm lie just above the pituitary gland. If CSF pressure or structural change in the sella pushes on these structures, people may experience blurred or dim vision, especially when reading or looking at distant objects. NCBI+1

4. Visual field defects (missing parts of the side vision)
   Compression of the optic chiasm can cause bitemporal hemianopia, a loss of outer (temporal) parts of the visual field in both eyes. People may bump into objects or notice difficulty seeing things to the side while walking or driving. NCBI+1

5. Double vision or eye movement problems
   If nearby cranial nerves are affected by pressure changes, people may see double images or have trouble moving the eyes fully. This may come with headaches and usually needs urgent evaluation by an eye doctor and neurologist. National Organization for Rare Disorders+1

6. Papilledema (swelling of the optic disc)
   High CSF pressure can cause swelling where the optic nerve enters the eye, seen on eye examination as papilledema. Patients may notice brief episodes of visual dimming, flashes, or “graying out” of vision, especially when bending over or straining. Bangladesh Journals Online+1

7. Fatigue and general weakness
   If the pituitary gland does not produce enough adrenal, thyroid, or growth hormones, people often feel very tired, weak, and unable to tolerate exercise. This is a sign of possible hypopituitarism and needs hormone testing. NCBI+2ScienceDirect+2

8. Low blood pressure, dizziness, or fainting
   Deficiency of cortisol and other adrenal hormones can lead to low blood pressure, dizziness on standing, and even fainting. In more serious cases, this can be life-threatening and needs urgent hormone replacement. NCBI+1

9. Irregular or absent menstrual periods
   Women with empty sella syndrome may have low levels of gonadotropins (LH and FSH) and sex hormones. This can cause irregular cycles, very light periods, or complete absence of menstruation (amenorrhea), and may also lead to difficulty becoming pregnant. National Organization for Rare Disorders+1

10. Reduced sex drive and sexual dysfunction
    Men may notice reduced libido, erectile dysfunction, or infertility due to low testosterone. Women may notice low sexual desire and vaginal dryness due to low estrogen. These changes result from pituitary hormone deficiency. NCBI+1

11. Unexplained weight gain or difficulty losing weight
    Low thyroid hormone (secondary hypothyroidism) and low physical energy from hormone problems can cause people to gain weight or have trouble losing weight despite normal diet and activity. NCBI+1

12. Cold intolerance and dry skin
    Pituitary-related hypothyroidism may cause people to feel cold all the time, have dry or rough skin, thinning hair, and slowed thinking or speech. These signs show that thyroid function must be checked. NCBI+1

13. Excessive thirst and urination
    Rarely, empty sella syndrome is associated with diabetes insipidus, in which the pituitary cannot release enough antidiuretic hormone (ADH). People drink large amounts of water and pass large volumes of very dilute urine, even at night. NCBI+1

14. Milk leakage from the breast (galactorrhea)
    If the pituitary stalk is stretched, prolactin levels may rise. High prolactin can cause breast milk leakage in women who are not breastfeeding and may cause menstrual and fertility problems. NCBI+1

15. Short stature or delayed growth in children
    In children, empty sella with pituitary hormone deficiency can show up as poor height gain, delayed puberty, or other growth problems. This requires careful endocrine evaluation and long-term monitoring. SAS Publishers+1

Diagnostic tests for empty sella syndrome

Doctors diagnose empty sella syndrome by combining clinical examination, detailed hormone testing, and imaging of the pituitary region. The tests below are grouped as requested: physical exam, manual tests, lab and pathological tests, electrodiagnostic tests, and imaging tests. NCBI+2endocrinepractice.org+2

1. Full physical examination and vital signs (Physical exam)
   The doctor checks height, weight, body mass index (BMI), blood pressure, heart rate, and overall appearance. They look for signs of hormone problems such as pale or dry skin, swelling, abnormal fat distribution, and stretch marks. This basic exam helps decide which pituitary hormone axes may be affected. NCBI+1

2. Detailed neurological examination (Physical exam)
   A neurological exam evaluates strength, reflexes, coordination, sensation, and mental status. It helps detect problems caused by increased intracranial pressure or compression of brain structures near the sella, such as cranial nerve deficits or balance problems. NCBI+1

3. Ocular and cranial nerve examination (Physical exam)
   The doctor checks eye movements, pupil responses, facial sensation, and facial muscle strength. Abnormal findings may suggest compression of cranial nerves around the sella and guide the need for urgent imaging or ophthalmologic referral. National Organization for Rare Disorders+1

4. Growth and pubertal assessment (Physical exam)
   In children and teenagers, height, weight, body proportions, and pubertal stage (Tanner staging) are recorded. Slow growth or delayed puberty can suggest growth hormone or gonadotropin deficiency related to empty sella. SAS Publishers+1

5. Confrontation visual field testing (Manual test)
   The doctor sits facing the patient and asks them to cover one eye. The doctor moves fingers in different directions to see if the patient can see them. This simple bedside visual field test can pick up bitemporal vision loss caused by optic chiasm compression. NCBI+1

6. Manual visual acuity testing with a chart (Manual test)
   Using a Snellen or similar eye chart, the clinician measures how well the patient can read letters at a standard distance. Changes in visual acuity alongside other findings may support the need for urgent pituitary imaging. National Organization for Rare Disorders+1

7. Funduscopic (ophthalmoscopic) examination (Manual test)
   With a handheld ophthalmoscope, the doctor looks at the back of the eye to see the optic disc. Swelling of the disc (papilledema) is a sign of raised intracranial pressure and may be found in patients with idiopathic intracranial hypertension and empty sella. Bangladesh Journals Online+1

8. Orthostatic blood pressure measurement (Manual test)
   Blood pressure and heart rate are measured lying down and then standing. A large drop in blood pressure or rise in pulse may indicate adrenal insufficiency, a possible complication of pituitary hormone deficiency in empty sella syndrome. NCBI+1

9. Comprehensive pituitary hormone panel (Lab / pathological test)
   Blood tests measure pituitary and target hormones, including ACTH, cortisol, TSH, free T4, prolactin, LH, FSH, estradiol or testosterone, and IGF-1. This panel helps detect hypopituitarism or stalk effects in people with empty sella. NCBI+2ScienceDirect+2

10. Morning serum cortisol and ACTH stimulation test (Lab / pathological test)
    A sample of blood taken early in the morning measures baseline cortisol. An ACTH (cosyntropin) stimulation test then checks how well the adrenal glands respond. Poor response suggests secondary adrenal insufficiency due to pituitary dysfunction. NCBI+1

11. Thyroid function tests (Lab / pathological test)
    Blood tests for TSH and free T4 evaluate thyroid function. In pituitary disease, TSH may be inappropriately low or “normal” despite low free T4, signaling central hypothyroidism related to empty sella. NCBI+1

12. Gonadal hormone testing (Lab / pathological test)
    Measuring LH, FSH, estradiol in women and testosterone in men helps identify central hypogonadism. This explains problems such as irregular periods, infertility, or low libido in patients with empty sella syndrome. NCBI+1

13. Prolactin level (Lab / pathological test)
    A single blood test for prolactin can show hyperprolactinemia, which may occur if the pituitary stalk is stretched by CSF in empty sella. Elevated prolactin can cause galactorrhea and menstrual or sexual dysfunction. NCBI+1

14. Serum sodium and osmolality with urine osmolality (Lab / pathological test)
    These tests help diagnose diabetes insipidus or SIADH when there is abnormal water balance. Very dilute urine with high serum sodium suggests diabetes insipidus from pituitary hormone problems, sometimes seen with empty sella. NCBI+1

15. Growth hormone stimulation or suppression tests (Lab / pathological test)
    Special tests using medicines such as insulin or arginine are used to see how much growth hormone is released. Reduced response suggests growth hormone deficiency, which may occur in adults or children with empty sella and hypopituitarism. NCBI+2ScienceDirect+2

16. Lumbar puncture with opening pressure (Lab / pathological / procedure)
    A lumbar puncture (spinal tap) measures the opening pressure of CSF and analyzes fluid content. High opening pressure supports a diagnosis of idiopathic intracranial hypertension, which is often associated with primary empty sella. Bangladesh Journals Online+1

17. Visual evoked potentials (Electrodiagnostic test)
    Visual evoked potential testing records the brain’s electrical response to visual stimuli (flashing lights or patterns). Delayed or abnormal responses can indicate damage to the optic pathways from chiasmal compression near the sella. NCBI+1

18. Electrophysiologic assessment of visual fields / automated perimetry (Electrodiagnostic / psychophysical test)
    Automated perimetry uses a machine to map visual fields in detail. The patient presses a button when they see lights. This test precisely shows bitemporal or other visual field defects caused by pituitary region compression. NCBI+1

19. Pituitary MRI with contrast (Imaging test)
    Magnetic resonance imaging (MRI) of the brain and pituitary is the gold standard test. It shows the sella filled with CSF, a thin rim of flattened pituitary tissue, and the position of the optic chiasm. MRI also helps distinguish primary from secondary empty sella and checks for tumors or other lesions. NCBI+2Barrow Neurological Institute+2

20. CT scan of the brain and skull base (Imaging test)
    Computed tomography (CT) can show enlargement of the bony sella and help detect bone changes or calcified tumors. CT is less detailed than MRI for soft tissue, but it is useful when MRI is not available or cannot be done. In many cases, CT first raises suspicion of empty sella, later confirmed by MRI. Cleveland Clinic+2MedlinePlus+2

Non-pharmacological treatments

1. Regular endocrinology follow-up
   Seeing an endocrinologist at regular intervals helps track hormone levels, symptoms, blood pressure, weight, and vision changes over time. Small changes in thyroid, cortisol, or sex hormones can be fixed early before they make you very sick. Regular reviews are a core part of empty sella syndrome care and are recommended in expert reviews and guidelines. NCBI+2PubMed+2

2. Monitoring with MRI or CT scans
   Repeat brain imaging is sometimes used to watch the size of the sella, pituitary gland, and nearby optic nerves. The aim is not to “cure” the empty sella but to be sure no new tumor, bleeding, or shift of the optic chiasm appears. Imaging also helps decide if surgery is needed when vision is threatened. MSD Manuals+2pituitary.org+2

3. Headache management program
   Many people with empty sella syndrome report chronic headaches. A structured plan with a neurologist may include simple pain relief, migraine-style treatment, hydration, posture advice, and trigger tracking. Learning to avoid overuse of pain pills helps prevent rebound headaches and improves quality of life. MSD Manuals+1

4. Stress-reduction and relaxation techniques
   Chronic illness and hormone-related symptoms can increase stress, anxiety, and poor sleep, which in turn worsen headaches and fatigue. Breathing exercises, mindfulness, yoga, and gentle stretching lower stress hormones, help mood, and may indirectly improve pain and sleep. These lifestyle tools are widely recommended in chronic neurological and endocrine conditions. NCBI+1

5. Sleep hygiene and regular sleep schedule
   Pituitary hormone problems often make people feel tired or “foggy.” A fixed bedtime, dark and quiet bedroom, limited screen time before bed, and avoiding late caffeine can improve restorative sleep. Good sleep also stabilizes appetite, weight, and mood, which are important in hormone disorders. NINDS+1

6. Healthy physical activity
   Low-to-moderate exercise such as walking, cycling, or swimming helps blood pressure, weight, bone health, and mood. In people receiving hormone replacement (for example thyroid or sex hormones), activity can further support bone density and muscle strength. Exercise plans should be discussed with the doctor if adrenal or heart problems are present. endocrinepractice.org+1

7. Weight management and nutrition counselling
   Empty sella syndrome can be linked with obesity or high intracranial pressure in some patients. Working with a dietitian to follow a balanced, calorie-appropriate diet can help lower intracranial pressure, improve blood pressure, and reduce stress on the heart and joints. This is especially important when steroids or growth hormone are used. NCBI+2endocrinepractice.org+2

8. Low-salt diet when blood pressure is high
   Some people with empty sella syndrome also have high blood pressure. A lower-salt diet (less processed food, fewer salty snacks, and more fresh foods) can help manage pressure without adding more drugs. Careful salt control is particularly important when steroids or fludrocortisone are used, because those can raise blood pressure and fluid retention. FDA Access Data+2FDA Access Data+2

9. Vision checks and eye-strain reduction
   Regular eye exams check for visual field loss, blurry vision, or signs of optic nerve pressure. Good lighting, taking breaks from screens, and using correct glasses can reduce eye strain and headaches. Fast referral to an eye specialist is key if vision suddenly worsens, because this can signal chiasm prolapse or raised intracranial pressure. pituitary.org+2Surgical Neurology International+2

10. Fluid-intake planning for water-balance issues
    If the posterior pituitary is affected, some people develop diabetes insipidus (passing large volumes of dilute urine) or, less often, inappropriate water retention. Doctors may advise a structured fluid plan and urine/weight monitoring to prevent dehydration or water overload, especially when desmopressin is used. FDA Access Data+2FDA Access Data+2

11. Education about hormone “sick day rules”
    People taking steroid replacement for adrenal insufficiency must learn how to increase their dose during fever, surgery, or major stress, and when to seek emergency care. Education reduces the risk of adrenal crisis, a life-threatening condition, and is strongly recommended in endocrine practice. endocrinepractice.org+2FDA Access Data+2

12. Medical alert card or bracelet
    A medical alert tag that states “pituitary disease / steroid-dependent” tells emergency teams that the patient may need urgent stress-dose steroids. This small step can prevent delays in life-saving treatment after accidents or sudden illness. NCBI+1

13. Psychological counselling or support groups
    Living with a chronic, rare condition can feel scary and lonely. Talking therapy and peer support groups help patients cope with long-term medication use, body-image changes, fertility worries, and uncertainty. Better mental health often leads to better treatment adherence and self-care. NCBI+1

14. Fall-risk assessment and home safety
    People with low blood pressure, visual field loss, or steroid-related muscle weakness are at higher risk of falls. Simple changes such as removing loose rugs, improving lighting, and using handrails make the home safer. Physical therapy can add balance and strength exercises when needed. pituitary.org+1

15. Avoiding unnecessary head trauma
    Wearing helmets in sports, using seat belts, and avoiding high-risk activities without protection reduces the chance of new brain injury that could worsen pituitary damage. This is especially important if the pituitary has already been injured by surgery, bleeding, or radiation. National Organization for Rare Disorders+1

16. Careful planning of pregnancy
    Women with pituitary hormone problems who wish to become pregnant should plan with an endocrinologist and obstetrician. Hormone doses might need adjustment before and during pregnancy to keep mother and baby safe. Visual checks and imaging may also be important if there is existing chiasm crowding. Cleveland Clinic+2pituitary.org+2

17. Limiting alcohol and avoiding smoking
    Smoking and heavy alcohol use can harm blood vessels, brain tissue, and bone health and may worsen headaches and blood pressure. Cutting down or stopping helps overall health, reduces medication interactions, and supports hormone balance and bone strength. MSD Manuals+1

18. Bone-health strategies
    If you use steroids, have low sex hormones, or growth hormone deficiency, you are at higher risk of weak bones (osteoporosis). Weight-bearing exercise, adequate calcium and vitamin D, fall prevention, and sometimes bone-specific medicines help protect the skeleton and reduce fracture risk. endocrinepractice.org+2FDA Access Data+2

19. Co-management with neurology and neurosurgery
    For people with high intracranial pressure, vision changes, or cerebrospinal fluid (CSF) leaks, close teamwork between endocrinology, neurology, and neurosurgery is essential. This team decides if and when surgery, lumbar shunt, or CSF leak repair is needed. NCBI+2ResearchGate+2

20. Structured health diary
    Keeping a diary of symptoms (headache, vision, thirst, urination), blood pressure, weight, and medication times helps doctors see patterns and adjust treatment. This low-tech tool improves communication and can quickly show if a new hormone problem is starting. MD Searchlight+1

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Drug treatments

These medicines do not treat the “empty sella” image itself. They treat the hormone problems and symptoms that can happen in empty sella syndrome. Doses below are typical patterns from FDA labels and endocrine practice, but your own dose must always be set by your doctor.

1. Levothyroxine (thyroid hormone)
   Levothyroxine replaces missing thyroid hormone when empty sella causes central hypothyroidism. It is usually taken once every morning on an empty stomach. FDA-approved labels describe use in primary and secondary hypothyroidism, with doses adjusted every 4–6 weeks based on blood tests to keep thyroid levels normal. Common side effects of too much include palpitations and anxiety. You & Your Hormones+3FDA Access Data+3FDA Access Data+3

2. Hydrocortisone tablets (Cortef and generics)
   Hydrocortisone replaces cortisol when the pituitary does not stimulate the adrenal glands. It is usually taken two to three times per day, with higher morning doses to mimic natural rhythm. FDA labeling for Cortef lists primary and secondary adrenal insufficiency as key uses. Side effects at high doses include weight gain, high blood pressure, mood changes, and infection risk. FDA Access Data+2FDA Access Data+2

3. Fludrocortisone acetate (Florinef)
   Fludrocortisone is a synthetic mineralocorticoid that helps the body hold salt and water when aldosterone is low, as can happen in adrenal failure linked to pituitary disease. It is usually taken once daily in very small doses (such as 0.1 mg) and requires monitoring of blood pressure and potassium. FDA documents describe its strong mineralocorticoid activity and risk of hypertension. endocrinepractice.org+3FDA Access Data+3FDA Access Data+3

4. Desmopressin (DDAVP, Stimate, other brands)
   Desmopressin is a vasopressin analogue used for central diabetes insipidus when the posterior pituitary is damaged, causing excessive urination and thirst. It can be given as nasal spray, tablets, or injection, usually once or twice daily, with dose tailored to stop excessive urine without causing low sodium. FDA labels warn about hyponatremia and fluid overload if taken with too much water. NINDS+5FDA Access Data+5FDA Access Data+5

5. Somatropin (growth hormone injections; Genotropin, Saizen, Humatrope, Zomacton, others)
   In adults with proven growth hormone deficiency causing low energy, increased fat, and low bone density, somatropin may be used as a nightly or several-times-per-week injection. FDA labels describe recombinant human growth hormone for growth failure and for adult GH deficiency, with doses slowly titrated based on IGF-1 levels and side effects like fluid retention and joint pain. NCBI+5FDA Access Data+5FDA Access Data+5

6. Cabergoline (Dostinex and generics)
   Cabergoline is a dopamine D2 receptor agonist used for prolactin-secreting pituitary tumors or high prolactin levels, which can coexist with empty sella changes. It is taken once or twice weekly in very low doses. FDA documents for Dostinex describe its role in treating hyperprolactinemic disorders and warn about possible heart valve and fibrotic complications at high cumulative doses. endocrinepractice.org+4FDA Access Data+4FDA Access Data+4

7. Bromocriptine
   Bromocriptine is another dopamine agonist used to lower high prolactin levels, especially when cabergoline is not tolerated. It is usually taken once or twice daily with food and requires gradual dose increase to reduce nausea, dizziness, and low blood pressure. FDA labeling supports its use in hyperprolactinemia. FDA Access Data+1

8. Estrogen-progestin combined oral contraceptives
   For premenopausal women with hypogonadotropic hypogonadism from pituitary dysfunction, combined pills can replace missing estrogen and progesterone, regulate cycles, and protect bone. They are taken once daily in a monthly cycle. Side effects may include nausea, breast tenderness, and small risks of clotting in susceptible women. FDA labels list prevention of pregnancy as the main indication but also describe hormone content and risks, which endocrinologists use when replacing sex hormones. Barrow Neurological Institute+2endocrinepractice.org+2

9. Transdermal estrogen patches or gels
   Transdermal estrogen can be used in women with pituitary-related estrogen deficiency, especially if they cannot take pills. Patches or gels release steady estrogen through the skin, with doses chosen to match normal premenopausal levels. They are usually combined with a separate progesterone if the uterus is present to protect the womb lining. Side effects resemble those of oral estrogen but with less impact on clotting risk in some studies. Barrow Neurological Institute+1

10. Micronized progesterone or synthetic progestins
    Progesterone is used along with estrogen to protect the uterus from overgrowth and cancer. It can be taken for part of each month or continuously depending on the plan. Side effects may include mood change, bloating, or drowsiness. In women without a uterus, progesterone is usually not required. Barrow Neurological Institute+1

11. Testosterone injections
    In men with pituitary-related low testosterone (hypogonadism), intramuscular testosterone injections every one to several weeks can restore normal levels, improving sexual function, strength, and mood. Doses and timing follow FDA-approved labels and blood-test targets. Side effects include acne, red blood cell rise, and possible worsening of sleep apnea or prostate issues, so regular monitoring is essential. Barrow Neurological Institute+2endocrinepractice.org+2

12. Testosterone gels or patches
    Topical testosterone offers a daily alternative to injections. The gel or patch delivers hormone through the skin; blood levels are checked to adjust the dose. Care must be taken to avoid transfer to others by skin contact. Side effects are similar to injectable testosterone and must be watched closely. endocrinepractice.org+1

13. DHEA (dehydroepiandrosterone) prescription products
    In some women with pituitary-related adrenal insufficiency, DHEA can be used to improve energy, mood, and sexual well-being, although evidence is mixed and not all guidelines recommend it. Prescription-grade DHEA is sometimes used at low doses under specialist supervision, and adrenal and sex hormone levels must be monitored. endocrinepractice.org+1

14. Acetazolamide
    Acetazolamide is a carbonic anhydrase inhibitor used for idiopathic intracranial hypertension, a condition that can coexist with empty sella and cause headaches and visual problems. It reduces cerebrospinal fluid production and may lower pressure around the optic nerves. Side effects can include tingling, taste change, kidney stones, and low potassium, so careful medical monitoring is required. ResearchGate+2Surgical Neurology International+2

15. Topiramate for migraine-like headaches
    Topiramate is an anti-seizure drug often used in chronic migraine prevention. In patients with empty sella and migraine-type headaches, neurologists may prescribe it to reduce headache frequency. It is taken once or twice daily, with slow dose increase to limit cognitive side effects, weight loss, or tingling. MD Searchlight+1

16. Simple analgesics (paracetamol/acetaminophen)
    For mild to moderate headaches, acetaminophen is often tried first because it does not raise blood pressure or cause stomach bleeding the way some NSAIDs do. Doses must stay within safe daily limits to protect the liver, and long-term daily use is discouraged to avoid rebound headaches. MSD Manuals+1

17. Non-steroidal anti-inflammatory drugs (NSAIDs)
    Ibuprofen or naproxen may be used short term for more intense headaches or musculoskeletal pain, but they can irritate the stomach and raise blood pressure. In people already on steroids or with kidney problems, doctors use NSAIDs carefully or avoid them entirely. MSD Manuals+2FDA Access Data+2

18. Antihypertensive medicines
    If blood pressure stays high, standard medicines such as ACE inhibitors, ARBs, beta-blockers, or calcium-channel blockers may be prescribed. These do not treat empty sella directly but lower stroke and heart-attack risk. Drug choice depends on age, other illnesses, and any steroid or fludrocortisone therapy. MSD Manuals+1

19. Proton pump inhibitors (PPIs)
    When high-dose steroids or NSAIDs are needed, PPIs like omeprazole may be used to protect the stomach lining and lower ulcer risk. They reduce stomach acid production and are usually taken once daily. Long-term use needs review because of possible effects on minerals and infection risk. FDA Access Data+2FDA Access Data+2

20. Anti-depressants or anti-anxiety medicines (when needed)
    Some people with chronic endocrine illness develop depression or anxiety. In that case, doctors may use SSRIs or other antidepressants along with counselling. The goal is not to treat empty sella itself but to support mental health and treatment adherence. These drugs require regular follow-up for side effects and dose adjustment. NCBI+2MD Searchlight+2

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Dietary molecular supplements

Evidence for supplements in empty sella syndrome is limited. They may support general health but do not replace hormone therapy. Always ask your doctor before starting anything new, especially if you take prescription medicines.

1. Vitamin D – Supports bone health, immune function, and mood. Many people with pituitary disease and long-term steroid or sex-hormone replacement have low vitamin D and benefit from supplementation under guidance.

2. Calcium – Adequate calcium plus vitamin D helps maintain strong bones, especially when steroids, growth hormone deficiency, or low sex hormones are present. Excess calcium can cause kidney stones, so doses must be individualized.

3. Omega-3 fatty acids (fish oil) – May modestly improve triglycerides, support heart and brain health, and reduce low-grade inflammation. They can be useful if steroid therapy or weight gain raises cardiovascular risk.

4. Vitamin B12 – Helps red blood cells and nerve function. Deficiency can mimic fatigue and cognitive problems seen in endocrine disease. Supplementation is important in people with low levels or poor absorption.

5. Folate (vitamin B9) – Works with B12 in red blood cell production and homocysteine control. Adequate folate comes from leafy greens and fortified foods, but some people require additional supplementation.

6. Magnesium – Involved in muscle relaxation, nerve function, and sleep quality. Low magnesium can worsen cramps, headaches, and fatigue, so doctors may suggest supplements if blood levels or diet are poor.

7. Zinc – Supports immune function and wound healing. Mild deficiency is common in people with chronic illness or poor appetite, and replacing it may support overall recovery.

8. Selenium – Plays a role in thyroid hormone metabolism and antioxidant defence. In people with thyroid issues, adequate selenium intake is important, but high doses can be toxic, so medical advice is essential.

9. Probiotic supplements – A healthy gut microbiome can improve digestion, mood, and possibly inflammation. Probiotics may be useful in people taking frequent steroids or acid-suppressing drugs that disturb gut flora.

10. Coenzyme Q10 (CoQ10) – An antioxidant that supports mitochondrial energy production. Some people with fatigue from chronic endocrine disorders feel better with CoQ10, although research is still limited.

(General evidence for these supplements comes from endocrine and bone-health literature rather than empty sella studies specifically.) FDA Access Data+4endocrinepractice.org+4MSD Manuals+4

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Immunity-booster and regenerative / stem-cell-related drugs

There are no established stem-cell or immune-booster drugs specifically approved for empty sella syndrome. All options below are supportive or experimental and must only be used under specialist care. endocrinepractice.org+2PubMed+2

1. Physiologic steroid replacement (hydrocortisone) – Correct replacement of cortisol actually helps normalize immune response rather than “boost” it. Too little steroid causes severe infection risk, and too much suppresses immunity. The regenerative goal is a balanced, normal cortisol profile. FDA Access Data+2FDA Access Data+2

2. Growth hormone replacement (somatropin) – In proven GH deficiency, somatropin can improve body composition, bone formation, and quality of life, which are forms of “functional regeneration.” It is not a general anti-aging drug and must be carefully dosed to avoid side effects like edema and joint pain. NCBI+3FDA Access Data+3FDA Access Data+3

3. Sex-hormone replacement (estrogen, progesterone, testosterone) – Restoring normal sex-hormone levels supports bone remodelling, muscle mass, and sometimes mood and libido. This can feel regenerative for patients but remains strict hormone replacement, not enhancement. Doses and forms are chosen based on age, sex, and cancer risk. Barrow Neurological Institute+2endocrinepractice.org+2

4. DHEA in selected patients – Low-dose DHEA may help some adrenal-insufficient patients with fatigue and low libido, but evidence is mixed. Because it is a weak androgen, it can cause acne and hair growth at higher doses, so doctors use conservative dosing and close monitoring. endocrinepractice.org+1

5. Vaccination programs – While not a “drug booster,” appropriate vaccines (influenza, COVID-19, pneumonia, etc.) are vital in people on steroid replacement or with chronic illness, because infections can trigger adrenal crisis and hospitalizations. Vaccines are timed and chosen according to national schedules and individual risk. endocrinepractice.org+2NINDS+2

6. Experimental stem-cell or regenerative therapies – Some research groups are studying stem-cell-based regeneration for pituitary damage, but this is experimental and not standard clinical care. These therapies should only be accessed in approved clinical trials with ethics oversight, never through unregulated clinics. endocrinepractice.org+2PubMed+2

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Surgeries for empty sella syndrome

1. Transsphenoidal surgery for associated pituitary tumors
   If a tumor around the pituitary causes hormone excess, vision problems, or bleeding, neurosurgeons may remove it through the nose (transsphenoidal route). This surgery treats the tumor, not the empty sella itself, but can prevent further damage and may improve vision and hormone balance. pituitary.org+2ResearchGate+2

2. Chiasmapexy (optic chiasm elevation procedures)
   In some secondary empty sella cases, the optic chiasm sags into the empty space, causing visual field loss. Chiasmapexy uses grafts or packing material to lift and support the chiasm. Systematic reviews suggest intradural approaches can improve vision while limiting complications, but this surgery is reserved for clearly symptomatic cases. ResearchGate+2Surgical Neurology International+2

3. Repair of cerebrospinal fluid (CSF) leaks
   Empty sella can sometimes be linked with CSF leaking from the nose. Surgeons may repair the skull base and seal the leak using endoscopic techniques. This prevents persistent leakage, infection (meningitis), and worsening brain pressure problems. MSD Manuals+2Surgical Neurology International+2

4. Lumbar–peritoneal (LP) shunt
   When raised intracranial pressure is severe and not controlled with medicines, a shunt can divert CSF from the spine to the abdomen. Case reports show that LP shunts can improve vision and headaches in selected patients with secondary empty sella and high pressure. Surgical Neurology International+2ResearchGate+2

5. Ventriculoperitoneal (VP) shunt or other CSF diversion
   In some situations, a VP shunt is used instead of an LP shunt to continuously drain CSF from the brain’s ventricles to the abdomen. The aim is to control long-term pressure, protect the optic nerves, and reduce headaches. Choice of shunt type depends on anatomy, surgeon preference, and prior surgeries. Surgical Neurology International+2pituitary.org+2

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Prevention and self-care

1. Treat blood pressure, diabetes, and cholesterol early to protect blood vessels in the brain and reduce risk of strokes or bleeding near the pituitary. MSD Manuals+1

2. Use helmets, seat belts, and safe practices to avoid head trauma that could damage the pituitary region. National Organization for Rare Disorders+1

3. Keep regular follow-up appointments with endocrinology and eye specialists, even when you feel well, so problems are caught early. NCBI+2pituitary.org+2

4. Learn your hormone deficiencies and replacement doses and carry an updated medication list at all times. endocrinepractice.org+1

5. If you use steroids, understand “sick day rules” and have an emergency plan for vomiting, surgery, or serious infection. endocrinepractice.org+2FDA Access Data+2

6. Maintain a healthy weight through diet and exercise to lower intracranial pressure risk and heart strain. NCBI+2MSD Manuals+2

7. Do not stop hormone replacement suddenly without medical advice, as this can be dangerous (especially steroids or desmopressin). endocrinepractice.org+2FDA Access Data+2

8. Avoid smoking and limit alcohol to support heart, bone, and brain health. MSD Manuals+1

9. Keep vaccines up to date to reduce the risk of serious infections that can trigger adrenal crisis or hospitalisation. NINDS+1

10. Manage stress, sleep, and mental health with healthy routines and, when needed, professional support. NCBI+2MD Searchlight+2

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When to see a doctor

You should see a doctor, preferably an endocrinologist or neurologist, if you have an empty sella on imaging and notice headaches, visual changes, fatigue, low blood pressure, sexual problems, missed periods, infertility, excessive thirst and urination, or unexplained weight changes. These can signal pituitary hormone problems or raised intracranial pressure that need treatment. ScienceDirect+4MSD Manuals+4Cleveland Clinic+4

Seek urgent or emergency care if you develop sudden severe headache, double vision, loss of part of your visual field, vomiting with low blood pressure, confusion, or collapse. These could indicate pituitary apoplexy, severe adrenal crisis, or dangerously high intracranial pressure. endocrinepractice.org+2MSD Manuals+2

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What to eat and what to avoid

1. Eat: Plenty of vegetables and fruits for vitamins, minerals, and fibre that support immune system and bowel health.

2. Eat: Lean protein sources (fish, poultry, beans, lentils) to support muscle and repair, especially if you are on steroids or growth hormone.

3. Eat: Low-fat dairy or fortified alternatives for calcium and vitamin D to protect bone health.

4. Eat: Whole grains instead of refined grains to stabilize blood sugar and energy.

5. Eat: Healthy fats from nuts, seeds, and olive oil to support heart and brain function.

6. Avoid: Very salty processed foods (chips, instant noodles, fast food) if you have high blood pressure or take fludrocortisone or high-dose steroids. FDA Access Data+2FDA Access Data+2

7. Avoid: Excess sugar and sugary drinks that worsen weight gain and diabetes risk, especially if on steroids or growth hormone.

8. Avoid: Heavy alcohol use, which can disturb sleep, worsen headaches, and damage liver and bone.

9. Avoid: Smoking and exposure to tobacco smoke to reduce cardiovascular and stroke risk.

10. Avoid: Unregulated “hormone boosters,” body-building hormones, and online “stem-cell” products; they may be unsafe and can interfere with proper pituitary treatment. FDA Access Data+3MSD Manuals+3endocrinepractice.org+3

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Frequently asked questions

1. Is empty sella syndrome always serious?
   No. Many people have an “empty sella” on scans but no symptoms or hormone problems, and they may never need treatment. It becomes “empty sella syndrome” when you also have symptoms, hormone changes, or vision issues that need medical care. MSD Manuals+2Cleveland Clinic+2

2. Can empty sella syndrome be cured?
   The scan picture of an empty sella usually does not go back to normal, but symptoms can often be well controlled. Hormone replacement, headache treatment, and, if needed, surgery allow many people to live normal lives even though imaging still shows an empty sella. NCBI+2endocrinepractice.org+2

3. Will I need hormone tablets forever?
   If the pituitary damage is permanent and causes hormone deficiency (like cortisol or thyroid), replacement is usually lifelong. However, doses can change over time, and some mild deficiencies may improve. Your endocrinologist will review this regularly with blood tests and symptom checks. endocrinepractice.org+2Medic Sciences+2

4. Is hormone replacement dangerous?
   When dosed correctly, hormone replacement aims to mimic normal body levels and is generally safe. Problems usually come from under- or over-replacement, which is why regular follow-up and blood tests are so important. FDA Access Data+3endocrinepractice.org+3FDA Access Data+3

5. Can empty sella syndrome affect my vision?
   Yes, in some people the optic chiasm can sag into the empty sella or be compressed by high pressure, causing blurred or missing areas in the visual field. Regular eye exams and quick review of any new visual symptoms are vital and sometimes lead to surgery to protect the optic nerves. pituitary.org+2ResearchGate+2

6. Is pregnancy possible with empty sella syndrome?
   Many people can have successful pregnancies with careful planning. Hormone doses may need adjustment before and during pregnancy, and some medicines (like certain dopamine agonists or hormone pills) may be changed or stopped. A joint plan with endocrinology and obstetrics is needed. Barrow Neurological Institute+2endocrinepractice.org+2

7. Does empty sella syndrome shorten life expectancy?
   On its own, empty sella on imaging does not usually shorten life. However, untreated severe hormone deficiencies (especially cortisol or thyroid) can be life-threatening. With good hormone replacement and blood pressure and cardiovascular risk control, many patients have near-normal life expectancy. endocrinepractice.org+2MSD Manuals+2

8. Can lifestyle changes replace hormone medicines?
   No. Lifestyle changes like healthy diet, exercise, and stress management are very helpful but cannot replace missing hormones. They work together with prescribed medicines to keep you stable and reduce complications. endocrinepractice.org+2MSD Manuals+2

9. Will I always need brain scans?
   You may need scans at the beginning and sometimes later to check for tumors, changes in the sella, or optic nerve position. If everything is stable and there are no symptoms, the interval between scans often becomes longer, decided by your specialist. NCBI+2Semantic Scholar+2

10. Can children have empty sella syndrome?
    Yes, children can have empty sella as a radiologic finding, sometimes linked with pituitary hormone problems. In children, growth and puberty must be monitored closely, and growth hormone or other hormones may be needed if tests show deficiency. NCBI+2ScienceDirect+2

11. Is empty sella syndrome a kind of brain tumor?
    No. Empty sella syndrome is a structural and hormonal problem, not a tumor by itself. However, tumors can sometimes lead to a secondary empty sella after surgery, radiation, or tumor shrinkage. pituitary.org+2National Organization for Rare Disorders+2

12. Can I play sports if I have empty sella syndrome?
    Most people can play sports, especially low- to moderate-impact activities, once hormone levels and blood pressure are stable. Avoiding head trauma is important, so contact sports may require extra protection or advice from your doctor. MSD Manuals+2endocrinepractice.org+2

13. Does empty sella syndrome cause mental health problems?
    Hormone imbalances, chronic pain, and uncertainty can contribute to anxiety and depression. This is not “in your head”; it is part body and part mind. Combined treatment with hormone correction plus counselling and, when needed, medicines, can help a lot. NCBI+2MD Searchlight+2

14. Can empty sella syndrome come back after treatment?
    The imaging finding usually remains, but the symptoms can come and go depending on hormone control and pressure changes. Sometimes new hormone problems develop years later, so long-term follow-up is still needed even when you feel well. endocrinepractice.org+2Semantic Scholar+2

15. What is the most important thing I can do for my health with empty sella syndrome?
    The single most important step is to stay in regular care with an endocrinologist, take medicines exactly as prescribed, and seek help early if symptoms change. Combining medical treatment with healthy lifestyle habits gives you the best chance of living well with this condition. NCBI+2endocrinepractice.org+2

Disclaimer: Each person’s journey is unique, treatment plan, life style, food habit, hormonal condition, immune system, chronic disease condition, geological location, weather and previous medical  history is also unique. So always seek the best advice from a qualified medical professional or health care provider before trying any treatments to ensure to find out the best plan for you. This guide is for general information and educational purposes only. Regular check-ups and awareness can help to manage and prevent complications associated with these diseases conditions. If you or someone are suffering from this disease condition bookmark this website or share with someone who might find it useful! Boost your knowledge and stay ahead in your health journey. We always try to ensure that the content is regularly updated to reflect the latest medical research and treatment options. Thank you for giving your valuable time to read the article.

The article is written by Team RxHarun and reviewed by the Rx Editorial Board Members

Last Updated: December o2 , 2025.