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PubMed This is a summary of 16 peer-reviewed journal articles Updated
Endocrinology · Empty Sella Syndrome

Symptoms and the Hormonal Cascade

At a Glance

Empty Sella Syndrome (ESS) occurs when a flattened pituitary gland fails to produce enough hormones or affects nearby nerves. The most important takeaway is that gland size on an MRI does not predict its function, making blood tests essential for diagnosing any hormonal deficiencies.

While an empty sella is often a silent finding on an MRI, it can sometimes lead to Empty Sella Syndrome (ESS). This happens when the flattened pituitary gland cannot produce enough hormones, or when the physical changes in the skull base affect nearby nerves and brain fluid pressure [1][2].

The Hormonal Cascade

The pituitary gland is the “command center” for your body’s hormones. When it is compressed, one or more of its “production lines” may slow down, leading to hypopituitarism [3]. It is important to note that if you have multiple deficiencies, your symptoms might be a confusing mix (for example, one deficiency might cause weight gain while another causes weight loss).

  • ACTH (The Stress Hormone): This is the most critical hormone. A lack of ACTH leads to Central Adrenal Insufficiency. Because this hormone tells your body how to handle stress, a deficiency can be life-threatening if you become ill or injured [4][5].
    • Symptoms: Extreme fatigue, nausea, low blood pressure, and weight loss [6].
  • TSH (The Metabolism Hormone): Low TSH causes Central Hypothyroidism.
    • Symptoms: Feeling cold all the time, sluggishness, and unexplained weight gain [3].
  • Gonadotropins (LH/FSH): These regulate reproductive health.
    • Symptoms: In women, this may cause irregular or stopped periods and infertility [7]. In men, it can lead to low libido and loss of muscle mass.
  • Growth Hormone (GH): While famous for childhood growth, adults need it for energy and heart health.
    • Symptoms: General fatigue and changes in body composition, such as increased belly fat.
  • ADH (Antidiuretic Hormone): Typically affected in Secondary Empty Sella, a lack of this posterior pituitary hormone leads to Diabetes Insipidus.
    • Symptoms: Unquenchable thirst and excessive, frequent urination [8].

Neurological and Vision Symptoms

Because the sella turcica sits directly beneath the optic chiasm (where the optic nerves from your eyes cross), physical changes in this area can affect your sight [9].

  • Tethered Optic Chiasm: In rare cases, the membrane covering the sella is so weak that the optic nerves actually “sink” or herniate into the empty space. This creates mechanical traction (pulling) on the nerves, which can cause blurry vision or “missing” spots in your side vision (visual field defects) [9][10].
  • Headaches: Headaches are a very common complaint among patients with an empty sella [11]. While the empty sella itself may not cause the pain, it is often a sign of Idiopathic Intracranial Hypertension (IIH)—a condition of high fluid pressure inside the skull that causes persistent, often “pressure-like” headaches [1][12].
  • Other Symptoms: Some patients experience rhinorrhea (a “runny nose” that is actually brain fluid leaking through the skull base) or dizziness and mood changes associated with hormone or salt imbalances [13][1].

Why “Normal” Tests Matter

It is important to know that the physical size of the gland on the MRI does not predict how well it works [14]. Some people with a tiny sliver of a gland have perfect hormone levels, while others with more tissue may have significant deficiencies [15]. This is why doctors emphasize blood tests over imaging when diagnosing your symptoms [16].

Common questions in this guide

What are the common symptoms of empty sella syndrome?
Symptoms depend on which hormones are affected, but common signs include extreme fatigue, unexplained weight changes, feeling cold all the time, and irregular periods. Some patients also experience persistent headaches or changes in their side vision.
Why do I have headaches with an empty sella?
While the empty sella itself may not cause pain, headaches are a common sign of Idiopathic Intracranial Hypertension (IIH). This is a condition where high fluid pressure inside the skull causes persistent, pressure-like headaches.
Can empty sella syndrome affect my vision?
Yes, in rare cases the optic nerves can sink into the empty sella space, creating a pulling effect called a tethered optic chiasm. This mechanical pulling can cause blurry vision or blind spots in your peripheral vision.
Does a small pituitary gland on an MRI mean I have a hormone deficiency?
No, the physical size of the pituitary gland on an MRI does not predict how well it works. Many people with a small, flattened gland have completely normal hormone levels, which is why blood tests are necessary for an accurate diagnosis.
What is central adrenal insufficiency in empty sella syndrome?
Central adrenal insufficiency happens when the pituitary gland stops making enough ACTH, the hormone that helps your body handle stress. This deficiency can cause extreme fatigue and low blood pressure, and it requires careful medical management.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Which of my pituitary hormones were tested, and were any of them at the low end of the normal range?
  2. 2.Based on my MRI, is my optic chiasm 'herniated' or 'tethered' into the sella turcica?
  3. 3.Do my headaches have the characteristics of high intracranial pressure (IIH), such as being worse in the morning?
  4. 4.Do I need to carry a medical alert bracelet or an emergency injection kit for adrenal insufficiency?
  5. 5.Should I have a specialized 'visual field test' to check for blind spots I might not notice yet?

Questions For You

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Related questions

Does Empty Sella Syndrome Cause Infertility? ExplainedWhat Are CSF Leak Symptoms in Empty Sella Syndrome?

References

References (16)
  1. 1

    Empty sella syndrome: Multiple endocrine disorders.

    Chiloiro S, Giampietro A, Bianchi A, De Marinis L

    Handbook of clinical neurology 2021; (181()):29-40 doi:10.1016/B978-0-12-820683-6.00003-8.

    PMID: 34238465
  2. 2

    A Comprehensive Review of Empty Sella and Empty Sella Syndrome.

    Lundholm MD, Yogi-Morren D

    Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists 2024; (30(5)):497-502 doi:10.1016/j.eprac.2024.03.004.

    PMID: 38484938
  3. 3

    Anterior hypopituitarism due to primary empty sella syndrome in a critically unwell patient.

    Rajesh M, Omer T, Chinniah S

    BMJ case reports 2023; (16(12)) doi:10.1136/bcr-2023-255879.

    PMID: 38081743
  4. 4

    Comparative Mortality in Adrenal Insufficiency Patients.

    Sun GEC

    Journal of insurance medicine (New York, N.Y.) 2025; (52(2)):55-60 doi:10.17849/insm-52-2-1-6.2.

    PMID: 40049219
  5. 5

    Iatrogenic adrenal insufficiency in adults.

    Martin-Grace J, Tomkins M, O'Reilly MW, Sherlock M

    Nature reviews. Endocrinology 2024; (20(4)):209-227 doi:10.1038/s41574-023-00929-x.

    PMID: 38272995
  6. 6

    Isolated adrenocorticotrophic hormone (ACTH) deficiency presenting with recurrent hypoglycemia and hyponatremia.

    Rehman SU, Aisha M, Badshah A, et al.

    Annals of medicine and surgery (2012) 2025; (87(2)):908-911 doi:10.1097/MS9.0000000000002943.

    PMID: 40110332
  7. 7

    Successful Pregnancy in a Woman With Primary Infertility Associated With Isolated Hypogonadotropic Hypogonadism and Partial Empty Sella Syndrome: A Case Report.

    Houjjaj D, Mouhmouh S, Benbella A

    Cureus 2026; (18(5)):e109372 doi:10.7759/cureus.109372.

    PMID: 42333326
  8. 8

    Radiographic pituitary stalk disruption: A rare sequela of secondary empty sella syndrome.

    Winograd E, Kortz MW, Lillehei KO

    Surgical neurology international 2021; (12()):385 doi:10.25259/SNI_530_2021.

    PMID: 34513152
  9. 9

    Symptomatic Primary Tethered Optic Chiasm: Technical Case Report.

    Byrne N, Kochanski RB, Tajudeen B, Byrne RW

    Operative neurosurgery (Hagerstown, Md.) 2020; (19(4)):E440-E445 doi:10.1093/ons/opaa093.

    PMID: 32386310
  10. 10

    Spontaneous improvement of secondary empty sella syndrome due to re-expansion of an intrasellar cyst: A case report.

    Yamada S, Yagi K, Hirano K, Uno M

    Surgical neurology international 2020; (11()):282 doi:10.25259/SNI_212_2020.

    PMID: 33033644
  11. 11

    Arginine vasopressin deficiency (central diabetes insipidus) with partial empty sella: a case report.

    Belay KE, Jemal RH, Kebede AH, et al.

    BMC endocrine disorders 2024; (24(1)):211 doi:10.1186/s12902-024-01741-y.

    PMID: 39379916
  12. 12

    The Pre-Lumbar puncture Intracranial Hypertension Scale (PLIHS): A practical scale to identify subjects with normal cerebrospinal fluid pressure in the management of idiopathic intracranial hypertension.

    Raggi A, Bianchi Marzoli S, Ciasca P, et al.

    Journal of the neurological sciences 2021; (429()):118058 doi:10.1016/j.jns.2021.118058.

    PMID: 34461550
  13. 13

    Psychosis in Secondary Empty Sella Syndrome following a Russell's Viper Bite.

    Ratnakaran B, Punnoose VP, Das S, Kartha A

    Indian journal of psychological medicine 2016; (38(3)):254-6 doi:10.4103/0253-7176.183079.

    PMID: 27335524
  14. 14

    Pituitary Volume in Patients with Primary Empty Sella and Clinical Relevance to Pituitary Hormone Secretion: A Retrospective Single Center Study.

    Akkus G, Sözütok S, Odabaş F, et al.

    Current medical imaging 2021; (17(8)):1018-1024 doi:10.2174/1573405617666210525111218.

    PMID: 34036923
  15. 15

    Relationship Between Radiological Features of Primary Empty or Primary Partial Empty Sella and Pituitary Hormone Levels.

    Kałuża B, Furmanek M, Domański J, et al.

    Biomedicines 2025; (13(3)) doi:10.3390/biomedicines13030722.

    PMID: 40149698
  16. 16

    Clinical presentation, evaluation and case management of primary empty sella syndrome: a retrospective analysis of 10-year single-center patient data.

    Ekhzaimy AA, Mujammami M, Tharkar S, et al.

    BMC endocrine disorders 2020; (20(1)):142 doi:10.1186/s12902-020-00621-5.

    PMID: 32943019

This page provides educational information about Empty Sella Syndrome symptoms and hormonal deficiencies. Always consult an endocrinologist or healthcare provider to interpret your specific MRI findings and hormone blood tests.

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