Introduction: Functional hypothalamic amenorrhea is a diagnostic challenge, especially in association with structural pituitary changes. We present the case of a patient with functional amenorrhea and pituitary microadenoma, evaluated in multiple medical centres. Case report: A 27-year-old female was referred to our clinic for secondary amenorrhea installed 18 months prior, insomnia, polydipsia (around 4-6 l water intake/day) and polyuria. Clinical examination revealed an underweight patient, with BMI (Body Mass Index) of 17.5 kg/m2, normal secondary sex characteristics, pallor of the skin and mucosa. The hormonal profi le revealed normal FSH (Follicle Stimulating Hormone) levels, low LH - Luteinizing Hormone (of 0.15 U/L, normal: 1.20-12.8 U/L), estradiol (of 11.2 pg/mL, normal: 49-291 pg/mL) and progesterone (of 1.13 ng/mL, normal: 5.16-18.56 ng/mL). No pathological changes were recorded at somatotropic, lactotropic, thyrotropic and corticotropic levels. The Diphereline stimulation test revealed functional integrity of the pituitary gland and ovaries. The progesterone with drawal test was negative. There were no pathological findings on biochemical workup and the water deprivation test excluded diabetes insipidus. Morphological exploration of the hypothalamic-pituitary region by contrast-enhanced MRI (Magnetic Resonance Imaging) scan revealed a left pituitary microadenoma measuring 5 mm in diameter. Adequate diet and oral contraceptive treatment were recommended. Conclusion: Functional hypothalamic amenorrhea (FHA) is the most common cause of neuroendocrine amenorrhea. Identifying the context and causative factors is essential for making an appropriate therapeutic decision.

Introduction: Cushing’s disease (CD) is characterized by multiple complications, particularly due to the condition itself, but also as a result of curative treatment. Nowadays, transsphenoidal surgery is considered the first-line therapy. Persistent hypercortisolism requires the initiation of medical therapy in order to limit the consequences of the disease. A common complication of pasireotide treatment is type 2 diabetes mellitus. We present a case of persistent Cushing’s disease after transsphenoidal adenomectomy and pasireotide therapy, evaluated in several medical centers. Case presentation: A 27-year-old female was referred to our clinic for weight gain, hypertension, transient headache and recurrent depression. Clinical examination revealed plethoric moon face, purple striae, hirsutism with a Ferriman-Gallwey score of 14, acanthosis nigricans. The hormonal profi le showed high ACTH (adrenocorticotropic hormone) levels (of 110.6 pg/mL, normal: 7.2-63.3 pg/mL), high urinary free cortisol (UFC) (of 846.5 μg/24h, normal: 50-190 μg/24h) and serum cortisol, accompanied by non-suppression of cortisol after the 1 mg DXM (Dexamethasone) suppression test (of 26.6 μg/dL, normal: 18 μg/dL) and adequate suppression after the overnight 8 mg DXM test. Pituitary MRI (Magnetic Resonance Imaging) revealed a microadenoma measuring 4.3/4.4/6.2 mm. Transsphenoidal adenomectomy was recommended. After surgery, the patient developed multiple pituitary hormone deficiency, without significant remission of hypercortisolism. Pasireotide therapy was initiated, followed by inadequate control of hypercortisolism and the onset of type 2 diabetes mellitus, requiring oral antidiabetic agents and insulin. Conclusion: In persistent Cushing’s disease, the challenge lies in identifying the optimal therapeutic methods in order to achieve a cure while, at the same time, limiting their side effects. Careful long-term follow-up by a multidisciplinary team is required.