Empty Sella Syndrome (ESS)

What is empty sella syndrome (ESS)?

Empty sella syndrome (ESS) is a rare condition in which your pituitary gland becomes flattened or shrinks due to issues with the contents within the sella turcica. The sella turcica is a bony structure at the base of your brain that surrounds and protects your pituitary gland.

The sella turcica is a saddle-like compartment. In Latin, it means “Turkish seat.” ESS causes certain symptoms, including hormonal imbalances, frequent headaches and vision changes.

Your pituitary gland is a small gland located at the base of your brain below your hypothalamus. It’s a part of your endocrine system and is in charge of making many different important hormones. These hormones affect and control other glands in your endocrine system.

What’s the difference between empty sella and empty sella syndrome?

Some information sources use “empty sella syndrome” and “empty sella” interchangeably, but they’re slightly different. In short, empty sella is a radiological finding and empty sella syndrome is a condition.

Empty sella is a radiological finding of a flattened pituitary gland. When your pituitary gland shrinks or becomes flattened, your healthcare provider can’t see it on imaging scans. This makes the area of the pituitary gland — the sella turcica — look empty, hence the name “empty sella.”

However, the sella turcica isn’t actually empty. It’s often filled with cerebrospinal fluid (CSF). CSF is fluid that surrounds your brain and spinal cord. With empty sella, CSF has leaked into the sella turcica, which puts pressure on your pituitary gland. This causes the gland to shrink or flatten.

Often, healthcare providers discover empty sellas by chance (incidentally) on a computed tomography (CT) scan or magnetic resonance imaging (MRI) scan when people are being evaluated for other reasons.

People can have an empty sella on their imaging results without having any symptoms — their pituitary gland functions as it should.

If someone has an empty sella and their pituitary gland isn’t functioning properly, it’s called empty sella syndrome (ESS). A syndrome is a set of medical signs and symptoms that are correlated with each other and often associated with a particular condition. People with ESS can experience hormonal imbalances, vision changes and frequent headaches.

What are the two types of empty sella?

When your healthcare provider identifies an empty sella on your imaging scans, they categorize it as one of two types: primary or secondary.

Primary empty sella (PES) means that your provider can’t identify the underlying cause of your flattened pituitary gland. Primary empty sella doesn’t usually cause empty sella syndrome. In other words, it doesn’t usually cause symptoms.

Secondary empty sella (SES) is caused by an identifiable underlying condition that changes the anatomy of your pituitary gland and/or the sella turcica. This is usually due to some kind of damage as a result of a condition or incident.

Secondary empty sella (SES) more often leads to empty sella syndrome than PES.

Is empty sella syndrome (ESS) life-threatening?

Empty sella syndrome (ESS) isn't life-threatening. It’s treatable with hormone medications and sometimes surgery.

Having an empty sella show up on your brain imaging scan is also not life-threatening. Most cases of empty sella don't lead to empty sella syndrome or any symptoms.

What does the pituitary gland do?

Your pituitary gland is an important endocrine gland that’s in charge of making many different hormones. It also tells other endocrine system glands to release hormones, including your:

• Adrenal glands.
• Ovaries or testicles.
• Thyroid gland.

Hormones are chemicals that coordinate different functions in your body by carrying messages through your blood to your organs, muscles and other tissues. These signals tell your body what to do and when to do it.

Your pituitary gland is connected to your hypothalamus through a stalk of blood vessels and nerves. This is called the pituitary stalk. Through the stalk, your hypothalamus communicates with your pituitary gland and tells it to release certain hormones. Your hypothalamus is the part of your brain that controls functions like blood pressure, heart rate, body temperature and digestion.

Your pituitary gland makes the following hormones:

• Adrenocorticotropic hormone (ACTH or corticotropin).
• Antidiuretic hormone (ADH, or vasopressin).
• Follicle-stimulating hormone (FSH).
• Growth hormone (GH).
• Luteinizing hormone (LH).
• Oxytocin.
• Prolactin.
• Thyroid-stimulating hormone (TSH).

Your pituitary gland doesn’t produce and release all of these hormones continuously. Most are released in bursts every one to three hours.

Who does empty sella syndrome (ESS) affect?

Though it’s rare, both children and adults can develop empty sella syndrome (ESS).

People assigned female at birth (AFAB) are four times more likely to have primary empty sella (PES) — not necessarily empty sella syndrome — than people assigned male at birth (AMAB).

PES most commonly occurs between the ages of 30 and 40 years old. It sometimes develops earlier in people AFAB than people AMAB.

People AFAB are even more likely to have PES if they’ve had a full-term pregnancy.

PES occurs less frequently in children than in adults. In these cases, it’s often associated with other conditions, including:

• Turner syndrome.
• Moyamoya disease.
• Bartter’s syndrome.
• Nevoid basal cell carcinoma syndrome.
• Hunter syndrome.
• Prader–Willi syndrome.
• Alstrom syndrome.
• Meniere’s Disease.
• Erdheim–Chester disease.

How common is empty sella syndrome (ESS)?

Empty sella syndrome (ESS) is rare. Some researchers have estimated that less than 1% of people with an empty sella develop symptoms (develop empty sella syndrome).

Having an empty sella without symptoms is much more common. Reports estimate that 8% to 35% of the population have an empty sella. Based on results from neuroimaging testing, other reports estimate that empty sella occurs in 12% of people.

What are the symptoms of empty sella syndrome (ESS)?

The most common symptom potentially associated with empty sella syndrome (ESS) is chronic headaches. However, researchers don’t know for sure if headaches develop because of ESS or are simply coincidental. Many people with ESS have high blood pressure (hypertension), which can itself cause headaches if it’s severe.

ESS usually causes hormonal imbalances due to damage to your pituitary gland. People with ESS may have different symptoms depending on which hormone(s) are affected. If you have ESS, you may have any of the following symptoms:

• Irregular nipple discharge (galactorrhea).
• Erectile dysfunction.
• Irregular menstruation (periods) or absent periods (amenorrhea).
• Decreased or no desire for sex (low libido).
• Fatigue.

In rare cases, some people with empty sella syndrome have the following symptoms:

• Increased pressure within their skull (benign intracranial pressure).
• Leakage of cerebrospinal fluid from the nose (cerebrospinal rhinorrhea).
• Swelling of the optic disk due to increased cranial pressure (papilledema).
• Vision changes, such as loss of clarity of vision.

Again, you can have an empty sella appear on an imaging scan of your brain without having any symptoms. In fact, most people who have an empty sella don’t have symptoms and never develop symptoms.

Does empty sella syndrome (ESS) cause weight gain?

Empty sella syndrome (ESS) can potentially cause weight gain if your pituitary gland isn’t releasing enough thyroid-stimulating hormone (TSH).

TSH stimulates your thyroid — an endocrine gland that’s located in the front of your neck under your skin — to release thyroid hormone. Your thyroid’s main job is to release (secrete) thyroid hormones that control the speed of your metabolism (metabolic rate), which is the process of how your body transforms the food you consume into energy.

If your pituitary gland isn’t releasing enough TSH due to ESS, then your thyroid may not release enough thyroid hormone. Having lower-than-normal levels of thyroid hormone can slow down your metabolism, which can lead to weight gain.

What causes empty sella syndrome (ESS)?

Empty sella syndrome (ESS) can result from primary empty sella (PES) or secondary empty sella (SES), though it’s much more common to develop ESS from secondary empty sella.

Causes of primary empty sella syndrome (PES)

Primary empty sella (PES) happens when one of the layers (arachnoid) covering the outside of your brain bulges down into the sella turcica and presses on your pituitary gland.

Healthcare providers still don’t know the exact cause of primary empty sella syndrome.

One theory is that primary empty sella happens when a congenital defect in the tissue lining your brain creates the potential for cerebrospinal fluid to enter the sella turcica, flattening your pituitary gland. In these cases, the pituitary gland itself, while difficult to see on an imaging scan, is almost always functioning normally and doesn’t result in empty sella syndrome.

Causes of secondary empty sella (SES)

Secondary empty sella (SES) happens when your pituitary gland or the sella turcica is somehow damaged as a result of another condition or incident. For this reason, many things can cause SES. The general causes of damage include:

• A tumor.
• Radiation therapy.
• Brain surgery in the region of the pituitary gland.
• Head trauma (injury), such as a traumatic brain injury.

Some specific causes of secondary empty sella include:

• Brain tumors: Sometimes, brain tumors can cause increased pressure around your brain (intracranial pressure), which can lead to herniation of the subarachnoid space. This can lead to compression of your pituitary gland.
• Idiopathic intracranial hypertension (IIH): IIH is increased pressure in your skull that occurs because of cerebrospinal fluid (CSF) buildup around your brain. This extra pressure can lead to compression of your pituitary gland.
• Pituitary adenomas: A pituitary adenoma is a growth or tumor on your pituitary gland. They’re often noncancerous (benign). These adenomas can put pressure on your pituitary gland and damage it.
• Sheehan’s syndrome: Sheehan's syndrome is a condition that affects people who lose a life-threatening amount of blood during childbirth, which can deprive their bodies of oxygen. This lack of oxygen causes damage to their pituitary gland.

How is empty sella syndrome (ESS) diagnosed?

In many cases, healthcare providers discover empty sella by chance (incidentally) when a person is undergoing head or brain imaging tests for another reason. And in most cases, people who have an empty sella don’t have or develop empty sella syndrome.

If you’re experiencing symptoms related to empty sella syndrome, such as frequent headaches and hormone imbalances, your provider will ask you about your medical history, perform a physical exam and will likely order an imaging procedure of your head and brain.

Imaging procedures that providers use to diagnose ESS include:

• A brain CT (computed tomography) scan: A brain CT scan uses X-rays and a computer to create detailed images of your brain and pituitary gland.
• A brain MRI (magnetic resonance imaging): MRI scans use radio waves and strong magnets to create detailed images of particular organs, tissues and structures inside your body, such as the sella turcica.

Your provider may order additional tests, such as blood tests, to check your hormone levels.

Sometimes, providers may perform tests to check for elevated pressure in your brain, including:

• Examination of your retina (the layer of tissue at the back of your eye) by an ophthalmologist.
• Lumbar puncture (spinal tap).

How is empty sella syndrome (ESS) treated?

If your healthcare provider found an empty sella on your imaging scans but your pituitary gland is functioning properly, you won’t need treatment. This is most often the case.

If your pituitary gland is not functioning properly due to empty sella syndrome (ESS), treatment typically involves medication that treats abnormal hormone levels, depending on which hormones are affected.

If ESS is causing cerebrospinal fluid to leak from your nose (CSF rhinorrhea), you may need surgery to repair your sella turcica.

What are the risk factors for empty sella syndrome (ESS)?

Healthcare providers aren’t sure what causes some people with an empty sella to develop empty sella syndrome. However, you’re more likely to develop empty sella syndrome from secondary empty sella than primary empty sella.

What is the outlook (prognosis) for empty sella syndrome (ESS)?

The outlook (prognosis) for empty sella syndrome (ESS) is generally good. Medications are available to treat hormonal imbalances. If you have hormonal imbalances from ESS, you may have to take medication for the rest of your life.

When should I see my healthcare provider if I have empty sella syndrome?

If you’ve been diagnosed with empty sella syndrome and are experiencing new or worsening symptoms, contact your healthcare provider.

If you take medication to correct hormone imbalances due to empty sella syndrome, it’s important to see your provider regularly to make sure your medication is working properly.

A note from Cleveland Clinic

Empty sella syndrome is a very rare condition. However, finding out you have an empty sella from imaging procedures of your brain is fairly common. There’s no need to worry if your healthcare provider tells you this. The vast majority of people with an empty sella don’t develop empty sella syndrome. If you have any questions about your imaging results, don’t be afraid to ask your provider questions. They’re available to help.