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PubMed This is a summary of 15 peer-reviewed journal articles Updated
Endocrinology · Empty Sella

Primary vs. Secondary Empty Sella: Causes and Subtypes

At a Glance

Primary empty sella occurs spontaneously and usually has a low risk of hormone issues. Secondary empty sella results from damage to the pituitary gland, such as from surgery or radiation, and carries a much higher risk of hormone deficiencies requiring regular testing.

Not all cases of empty sella are the same. Doctors divide this finding into two main categories: Primary Empty Sella (PES) and Secondary Empty Sella (SES). Distinguishing between them is important because the cause, the risk of developing hormone problems, and the long-term monitoring strategy differ significantly between the two [1][2].

Primary Empty Sella (PES)

Primary Empty Sella occurs spontaneously and is often discovered by chance during an MRI for an unrelated issue [3]. In this type, there is no history of surgery or injury to the pituitary gland itself.

  • Risk Factors: PES is most frequently found in women who are middle-aged or older [3][4]. Other common factors include a history of multiple pregnancies (multiparity), obesity, and high blood pressure (hypertension) [5][4].
  • The Pressure Link: Many researchers believe PES is related to Idiopathic Intracranial Hypertension (IIH)—a condition where the pressure of the fluid surrounding the brain (cerebrospinal fluid) is too high [6][7]. This increased pressure can slowly push against the diaphragma sellae (the membrane covering the pituitary), eventually flattening the gland [6].
  • Outlook: Most people with PES have normal hormone levels and may not require long-term treatment [2].

Secondary Empty Sella (SES)

Secondary Empty Sella happens because the pituitary gland was damaged, reduced in size, or removed by an external factor [8]. Unlike the primary type, the “emptiness” is the result of a known medical event.

Common causes of SES include:

  • Surgery: The surgical removal of a pituitary tumor (adenoma) [9].
  • Radiation: Radiation therapy to the head or neck area can cause the pituitary gland to shrink over time [1].
  • Infarction or Hemorrhage: Severe blood loss during childbirth (Sheehan’s Syndrome) or internal bleeding in a pituitary tumor (pituitary apoplexy) can lead to the loss of pituitary tissue [10][11].

Because the entire pituitary gland (both the front and back parts) can be damaged in SES, patients are also at risk for deficiencies involving the posterior pituitary, such as antidiuretic hormone (ADH), which can lead to a condition called Diabetes Insipidus [9].

Comparing the Risks

The most significant difference between the two types is the risk of hypopituitarism (hormone deficiency).

Feature Primary Empty Sella (PES) Secondary Empty Sella (SES)
Prevalence More common; often found by chance [12]. Less common; follows a specific event [8].
Hormone Risk Usually low; hormones often remain normal [2]. Highest risk of developing hormone deficiencies [2].
Progression Generally stable over time [13]. Can be progressive; function may decline over years [13].

Regardless of the type, every patient with an empty sella finding should receive a thorough hormonal evaluation at the time of diagnosis [14][15]. If you have SES, your care team will likely recommend more frequent monitoring to catch any gradual changes in your hormone production [13][15].

Common questions in this guide

What is the difference between primary and secondary empty sella?
Primary empty sella happens spontaneously, often related to increased fluid pressure around the brain. Secondary empty sella occurs when the pituitary gland is directly damaged by a specific event like surgery, radiation, or severe bleeding.
Which type of empty sella is more likely to cause hormone problems?
Secondary empty sella carries a much higher risk of hormone deficiencies. Because the pituitary gland has been directly damaged, patients with the secondary type usually need closer, long-term monitoring of their hormone levels.
Do I need hormone testing if I have primary empty sella?
Yes. While the risk of hormone deficiency is lower in primary empty sella, every patient with an empty sella finding on an MRI should receive a baseline hormonal evaluation to ensure their pituitary gland is working properly.
How do obesity and high blood pressure relate to empty sella?
Obesity and high blood pressure are common risk factors for primary empty sella. They are often linked to increased fluid pressure around the brain, which can gradually push down on and flatten the pituitary gland.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Which type of empty sella do I have: primary or secondary?
  2. 2.Given my medical history (such as previous pregnancies or surgeries), what is the most likely cause for this finding?
  3. 3.Does my BMI or blood pressure play a role in this finding, and should we address those as part of my management?
  4. 4.Are my headaches or other symptoms related to high intracranial pressure (IIH), and do I need a lumbar puncture or eye exam to check?
  5. 5.Since I have the secondary type, how often should we re-test my hormone levels to catch any progressive changes?

Questions For You

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Related questions

How Does Body Weight Relate to Primary Empty Sella?What Is Primary vs. Secondary Empty Sella Syndrome?

References

References (15)
  1. 1

    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
  2. 2

    Pituitary function in patients with primary and secondary empty sella.

    Steckel L, Gizewski ER, Kaser S

    Frontiers in endocrinology 2025; (16()):1632824 doi:10.3389/fendo.2025.1632824.

    PMID: 40741178
  3. 3

    Analysis of clinical features of primary empty sella.

    Lu M, Ye J, Gao F

    Annales d'endocrinologie 2023; (84(2)):249-253 doi:10.1016/j.ando.2023.01.003.

    PMID: 36642370
  4. 4

    Primary empty sella

    Leon NS, Sosa S, Coronel-Restrepo N, et al.

    Revista de la Facultad de Ciencias Medicas (Cordoba, Argentina) 2025; (82(3)):544-554 doi:10.31053/1853.0605.v82.n3.46309.

    PMID: 41032433
  5. 5

    Primary empty sella: The risk factors and associations with the cerebral small vessel diseases-An observational study.

    Chen T, Li G, Wu D, et al.

    Clinical neurology and neurosurgery 2021; (203()):106586 doi:10.1016/j.clineuro.2021.106586.

    PMID: 33730618
  6. 6

    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
  7. 7

    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
  8. 8

    Secondary chiasmal herniation after pituitary adenoma treatment: a diagnostic pitfall.

    Vivas M, Pargana J, Sagarribay A, et al.

    BMJ case reports 2026; (19(7)) doi:10.1136/bcr-2026-273965.

    PMID: 42481138
  9. 9

    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
  10. 10

    A Rare Case of Sheehan Syndrome With Cardiac Tamponade.

    Zain A, Sivakumar A, Akah O, et al.

    Cureus 2022; (14(4)):e24329 doi:10.7759/cureus.24329.

    PMID: 35607582
  11. 11

    Russell's viper bite and the empty sella syndrome.

    Yerawar C, Punde D, Pandit A, Deokar P

    QJM : monthly journal of the Association of Physicians 2021; (114(4)):255-257 doi:10.1093/qjmed/hcaa197.

    PMID: 32539122
  12. 12

    Primary Empty Sella.

    Mehla S, Chua AL, Grosberg B, Evans RW

    Headache 2020; (60(10)):2522-2525 doi:10.1111/head.13987.

    PMID: 33038281
  13. 13

    Changes overtime in primary and secondary empty sella: a comparative real-world study.

    Bacchi N, Paglia F, Caccin V, et al.

    Journal of endocrinological investigation 2026; doi:10.1007/s40618-026-02931-2.

    PMID: 42258025
  14. 14

    Empty sella syndrome: an update.

    Padovano Sorrentino F, Chiloiro S, Giampietro A, et al.

    Pituitary 2024; (28(1)):13 doi:10.1007/s11102-024-01475-z.

    PMID: 39738761
  15. 15

    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 explains the differences between primary and secondary empty sella for educational purposes. It does not replace professional medical advice. Always consult your endocrinologist for a personalized evaluation of your pituitary function.

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