Empty sella syndrome is a condition in which the bony cradle housing the pituitary gland at the base of the brain appears partially or completely empty on imaging, because cerebrospinal fluid has pushed into that space and flattened the gland against its walls. The pituitary itself is usually still present, just compressed, and the consequences range from none at all to significant hormonal deficiencies, chronic headaches, and vision problems. It turns up on brain scans far more often than most people expect, and whether it requires treatment depends entirely on what it is doing to the pituitary and surrounding structures.
How an Empty Sella Develops
The pituitary gland sits inside a small pocket of bone called the sella turcica, which is Latin for “Turkish saddle” because of its shape. A sheet of tissue called the diaphragma sellae normally roofs over this pocket, keeping the cerebrospinal fluid above it separate from the gland below. When that tissue is weak or incomplete, fluid can herniate downward into the sella, gradually compressing the pituitary until imaging shows what looks like an empty cavity filled with fluid rather than gland tissue.1Translational Research in Anatomy. Cadaveric case analysis of primary empty sella with clinical literature review of empty sella syndrome
Doctors split the condition into two categories. Primary empty sella happens without any prior pituitary disease. The most common associated condition is idiopathic intracranial hypertension, a disorder of chronically elevated pressure inside the skull. Secondary empty sella develops after something damages or shrinks the pituitary, including surgery, radiation therapy, medication that shrinks a pituitary tumor, pituitary apoplexy (sudden bleeding into the gland), infection, or Sheehan syndrome, a form of pituitary damage caused by severe blood loss during childbirth.2Endocrine Practice. Evaluation and Management of Empty Sella and Empty Sella Syndrome The distinction matters because secondary cases often have a clearer history pointing to the cause, while primary cases can be trickier to explain and may signal an underlying pressure problem.
Who Gets It
Primary empty sella is disproportionately found in middle-aged women, especially those who are overweight and have had multiple pregnancies. In a review of 175 patients, roughly 86 percent were female, the average age at diagnosis was about 48, and headaches, obesity, and high blood pressure were present in about 59, 50, and 27 percent of cases respectively.3PubMed. Primary empty sella (PES): a review of 175 cases The demographic overlap with idiopathic intracranial hypertension is not a coincidence: both conditions share obesity and female sex as strong risk factors, and elevated intracranial pressure is thought to be a driving force behind many primary cases.
That said, the condition is not exclusive to any one group. Men develop it too, and so do children. Because empty sella is frequently discovered incidentally during brain imaging ordered for unrelated reasons, the true prevalence in the general population is hard to pin down. Many people live their entire lives with a partially empty sella and never know it.
What Happens to Hormones
This is where the clinical stakes get real. A compressed pituitary gland can still function normally, but it often does not. A pooled analysis of studies found that roughly half of patients with primary empty sella had some degree of pituitary hormone deficiency.4PubMed Central. Primary Empty Sella Syndrome and the Prevalence of Hormonal Dysregulation A more recent study reported an even higher figure, with about 83 percent of patients showing at least one hormonal deficit at diagnosis, most commonly involving the adrenal, gonadal, and growth hormone axes.5PubMed Central. Empty Sella Syndrome: long-term impact on pituitary function The wide range between studies reflects differences in how thoroughly hormone testing was done and which patient populations were studied; the key point is that deficiencies are common enough that every patient with empty sella should be screened.
The practical effects of these deficiencies depend on which hormones are affected:
- Adrenal axis: Low cortisol production can cause fatigue, low blood pressure, nausea, and in severe cases, life-threatening adrenal crisis during illness or surgery.
- Gonadal axis: Low sex hormone levels show up as irregular or absent menstrual periods in women and low testosterone in men. Women appear more prone to gonadal dysfunction than men, and higher body weight seems to compound the problem.6PubMed Central. Empty Sella Syndrome: long-term impact on pituitary function
- Growth hormone: In adults, deficiency leads to reduced energy, increased body fat, decreased muscle mass, and lower bone density. In children, it causes growth failure.
- Thyroid axis: Central hypothyroidism produces the classic symptoms of sluggishness, weight gain, cold intolerance, and dry skin, though it can be subtler than the more common primary form caused by thyroid gland disease.
- Prolactin: About 10 percent of patients in one large series had elevated prolactin levels, which can cause milk discharge from the breasts and menstrual irregularities.7The Journal of Clinical Endocrinology & Metabolism. Primary Empty Sella This happens because the compressed pituitary stalk loses its ability to deliver the dopamine signal that normally keeps prolactin in check.
Not every patient develops all of these problems, and some show no hormonal disturbance at all. But the frequency is high enough that a full pituitary hormone panel is considered standard once empty sella is identified on imaging.
Headaches, Vision, and Other Neurological Symptoms
Headache is the single most common complaint in patients who have symptoms. The typical clinical picture of primary empty sella syndrome includes headache, irregular periods, obesity, and visual disturbances, a constellation that often points to underlying intracranial hypertension.8European Journal of Endocrinology. DIAGNOSIS OF ENDOCRINE DISEASE: Primary empty sella: a comprehensive review The headaches can be persistent, disabling, and frustratingly nonspecific in character, which sometimes delays diagnosis.
Visual problems deserve special attention. When the sella is empty, the optic chiasm, the crossing point of the optic nerves sitting just above the pituitary, can sag downward into the vacant space. This prolapse stretches the nerve fibers and can cause progressive loss of visual acuity or visual field defects.9PubMed Central. Primary empty sella syndrome associated with visual deterioration salvaged by chiasmapexy The damage is not always dramatic; it sometimes starts as difficulty reading or subtle peripheral vision loss that a person adapts to without realizing something is wrong. Regular ophthalmologic testing is part of the monitoring plan for anyone with known empty sella.
A similar mechanism explains visual deterioration in secondary empty sella. When a pituitary tumor is treated with medication and shrinks, the optic apparatus that was previously propped up by the tumor can herniate into the newly empty sella. One reported case involved a man whose prolactinoma had been successfully treated with cabergoline; as the tumor shrank, his optic chiasm dropped into the sella and caused progressive visual field loss, requiring surgical correction.10World Neurosurgery. Transnasal Transsphenoidal Elevation of Optic Chiasm in Secondary Empty Sella Syndrome Following Prolactinoma Treatment
The Intracranial Pressure Connection
Empty sella and elevated intracranial pressure are deeply intertwined. An empty sella on imaging is considered a radiologic sign of chronically raised pressure inside the skull, and it is especially common in patients with idiopathic intracranial hypertension.11PubMed. Factors determining the clinical significance of an “empty” sella turcica The relationship runs in both directions: the elevated pressure may be what pushes cerebrospinal fluid into the sella in the first place, and the resulting empty sella becomes a marker that prompts clinicians to investigate pressure further.
One clinically important consequence is spontaneous cerebrospinal fluid leaks. When intracranial pressure is chronically high, it can erode thin spots in the skull base, allowing fluid to drip into the nasal passages. Studies have found a strong association between spontaneous CSF leaks and the radiographic finding of an empty sella, particularly in obese women.12PubMed. Significance of empty sella in cerebrospinal fluid leaks The thinking is that the same elevated pressure that flattens the pituitary also pushes fluid through weak spots in the bone.13PubMed. Spontaneous nasal cerebrospinal fluid leaks and empty sella syndrome: a clinical association In one documented case, continuous pressure monitoring showed intermittent spikes in intracranial pressure, and after a shunting procedure brought the pressure down, the CSF leak stopped for weeks.14PubMed. A dynamic pressure study of spontaneous CSF rhinorrhea in the empty sella syndrome
The picture is not entirely straightforward, though. Research has found that empty sella also shows up in patients with symptomatic narrowing of the brain’s lateral venous sinuses who do not meet the full criteria for intracranial hypertension. In those patients, the enlarged fluid spaces in the sella appear to result from a venous drainage problem rather than globally elevated pressure.15American Journal of Neuroradiology. Empty Sella Is a Sign of Symptomatic Lateral Sinus Stenosis and Not Intracranial Hypertension The practical takeaway is that finding an empty sella should prompt a careful look at what is driving it, because the underlying cause shapes the treatment strategy.
Empty Sella in Children
While the classic patient is a middle-aged woman, children develop empty sella too, and it tends to present differently. Rather than headaches and obesity, the most common reason a child comes to medical attention is growth failure or delayed puberty stemming from pituitary hormone deficiencies.16PubMed Central. Empty sella syndrome in a male child with failure to thrive In a small series of 17 pediatric patients, about 88 percent had evidence of pituitary gland underdevelopment based on age-adjusted measurements. Short stature was the leading complaint, and five of those short children had confirmed growth hormone deficiency.17The Turkish Journal of Pediatrics. Clinical course of primary empty sella in children: a single-center experience
Interestingly, the same pediatric series found that none of the children had adrenal insufficiency, hypothyroidism, or abnormal prolactin levels, a contrast with the pattern seen in adults where those deficits are relatively common. This may partly reflect the different causes at work. In children, an empty sella more often results from congenital underdevelopment of the pituitary or its surrounding structures rather than from acquired pressure-related compression. The clinical message for parents and pediatricians is that unexplained short stature or pubertal delay warrants brain imaging and hormone testing, because catching a hormonal deficit early allows treatment that can make a significant difference in growth and development.
Connections to Chronic Pain and Fatigue
A growing body of work has noticed overlapping features between primary empty sella, fibromyalgia, and chronic fatigue syndrome. All three conditions share several characteristics: they affect women far more than men, they are associated with headaches and migraines, and patients in all three groups report fatigue, widespread pain, visual disturbances, and balance problems at rates higher than the general population. A review of the literature found that increased cerebrospinal fluid pressure was a common thread linking the three conditions, along with obesity, small-fiber neuropathy, and neurosensory hearing loss.18PubMed Central. The Link Between Empty Sella Syndrome, Fibromyalgia, and Chronic Fatigue Syndrome: The Role of Increased Cerebrospinal Fluid Pressure
Whether these conditions share a causal mechanism or merely overlap in demographics and symptoms is still an open question. The hypothesis that mildly elevated cerebrospinal fluid pressure could be a unifying factor is intriguing but far from proven. For patients, the practical relevance is that if you carry a diagnosis of fibromyalgia or chronic fatigue and also have persistent headaches, visual changes, or unexplained hormonal symptoms, it may be worth asking whether brain imaging has ever looked at the sella. An empty sella does not explain fibromyalgia, but finding one could uncover treatable hormonal deficiencies layered on top of a chronic pain condition.
How It Is Found
Most cases of empty sella are discovered by accident. A person gets an MRI for migraines, dizziness, or an unrelated neurological complaint, and the radiologist notes that the sella turcica appears empty or partially empty. MRI is the gold standard for identifying the condition because it provides clear soft-tissue contrast, showing exactly how much pituitary tissue remains and whether the optic chiasm has sagged into the sella.
The early recognition of the condition actually came from autopsy studies and an older imaging technique called pneumoencephalography, in which air was injected into the spinal fluid spaces to outline brain structures on X-ray. That technique demonstrated how the subarachnoid space could extend into the sella, producing the “empty” appearance.19Radiology. The “empty” sella turcica–a manifestation of the intrasellar subarachnoid space Modern MRI has made diagnosis far simpler and less invasive.
Once empty sella is found on imaging, the recommended workup typically includes a complete pituitary hormone panel covering cortisol, thyroid hormones, sex hormones, growth hormone (or its surrogate marker, IGF-1), and prolactin. Visual field testing is added when the imaging suggests the optic chiasm may be drooping, and if there is clinical suspicion of elevated intracranial pressure, further evaluation with lumbar puncture or venous imaging may follow.
Treatment and Monitoring
Many people with an incidental finding of empty sella and normal hormone levels need nothing more than periodic reassessment. Current expert guidance suggests re-evaluation at roughly two to three years if no hormonal or visual abnormalities are present, given the low risk of progression in patients who are asymptomatic at baseline.20PubMed. Empty sella syndrome: an update
When hormone deficiencies are identified, treatment follows the same principles used for any form of pituitary insufficiency. Adrenal insufficiency and central hypothyroidism are considered urgent to treat: patients with low cortisol are started on steroid replacement promptly because of the risk of adrenal crisis during physical stress, and those with thyroid hormone deficiency receive levothyroxine to prevent severe hypothyroidism. Sex hormone and growth hormone replacement are more discretionary and depend on the patient’s symptoms, age, and whether there are contraindications.21Endocrine Practice. Evaluation and Management of Empty Sella and Empty Sella Syndrome
Surgery is uncommon and reserved for specific situations. The most clear-cut surgical indication is progressive visual loss caused by the optic chiasm herniating into the sella. A procedure called chiasmapexy involves placing material beneath the chiasm through a transsphenoidal approach, essentially propping the nerve structure back up. Various techniques have been used, including tissue grafts, inflatable balloons, and silastic coils inserted into the sellar space to fill the void.22Alexandria Journal of Medicine. Review of empty sella syndrome and its surgical management When the underlying problem is elevated intracranial pressure, managing that pressure through weight loss, medication such as acetazolamide, or in refractory cases a cerebrospinal fluid shunt, can address both the symptoms and the root cause.
Living With the Diagnosis
Getting told your pituitary looks empty on a brain scan is understandably alarming, but for many people the finding turns out to be clinically benign. The anxiety often comes from the word “syndrome” and from uncertainty about what a compressed pituitary gland means for long-term health. A few things are worth keeping in mind. If your hormone levels are normal and you have no visual symptoms, the odds of developing significant problems over time are low, though not zero, which is why periodic follow-up is recommended. If you do have hormone deficiencies, replacement therapy is well-established and effective; most patients on appropriate replacement live without major limitations.
Weight management is worth emphasizing because obesity both increases the risk of developing empty sella in the first place and worsens outcomes by raising intracranial pressure and compounding hormonal disruptions. For patients with coexisting idiopathic intracranial hypertension, even modest weight loss can reduce intracranial pressure enough to improve headaches and slow disease progression. Medical alert identification is important for anyone on cortisol replacement, because the body cannot mount a normal stress response without it, and emergency providers need to know to administer stress-dose steroids in a crisis. Beyond these practical steps, most people with empty sella continue with their usual lives, checking in with an endocrinologist on a schedule their doctor sets based on their individual risk profile.