Getting the Right Diagnosis: MRI and Hormone Testing

An MRI finding of an “empty sella” is the beginning of a diagnostic conversation, not the end. Because the image only shows the shape of the gland—not how well it is working—doctors must use a combination of blood tests and clinical exams to determine if you have a harmless finding or Empty Sella Syndrome (ESS) ^[1][2].

Why the MRI Isn’t Enough

It is a common misconception that a “more empty” sella means a higher risk of disease. However, research shows that the sella turcica volume and the physical degree of “emptiness” on a scan do not reliably predict whether your hormones are functioning correctly ^[3][4].

The pituitary gland is remarkably resilient; even when flattened into a very thin layer against the walls of the sella, it can often produce all the hormones your body needs ^[3]. For this reason, your doctor will prioritize your blood chemistry over the visual “emptiness” of the scan ^[5].

The Baseline Hormone Checklist

When an empty sella is first discovered, guidelines recommend a comprehensive “baseline” evaluation to check your hormone health ^[6][5]. This usually involves a morning blood draw to test the following:

• Adrenal Function: Morning cortisol and ACTH (checks the stress-response system).
• Thyroid Function: TSH and Free T4 (checks metabolism).
• Reproductive Health: LH, FSH, and either Testosterone (men) or Estradiol (women).
• Growth and Metabolism: IGF-1 (checks growth hormone levels) and Prolactin.
• Fluid Balance: Checking for symptoms of Diabetes Insipidus, and reviewing electrolytes like sodium.

Evaluating Brain Pressure (IIH)

Because an empty sella can be caused by increased pressure of the fluid around the brain (Idiopathic Intracranial Hypertension or IIH), your doctor may look for signs of high pressure elsewhere ^[7][8]:

1. Eye Exam: An ophthalmologist may check for papilledema (swelling of the optic nerve behind the eye), which is a classic sign of high brain pressure ^[9].
2. Lumbar Puncture: In some cases, a spinal tap may be used to measure the “opening pressure” of your cerebrospinal fluid to confirm if IIH is present ^[10][11].

Follow-Up: The “One and Done” Rule vs. Chronic Monitoring

Your follow-up plan depends entirely on your specific diagnosis:

• Primary/Incidental Empty Sella: For patients who have an incidental Primary Empty Sella and show normal pituitary function at their first evaluation, the risk of developing a hormone deficiency later in life is very low ^[12]. In these cases, routine follow-up MRIs or repeated hormone testing are generally not justified unless new symptoms appear ^[12][6].
• Secondary Empty Sella (SES): If your empty sella is secondary to a surgery, tumor, or radiation, the risk of progressive hormone loss is much higher. You will likely need regular, long-term monitoring by an endocrinologist even if your baseline tests were initially normal ^[13][5].

Once diagnosed, patients requiring care will move onto Treatment Strategies and Long-Term Management.