Empty sella syndrome is a condition in which the bony pocket at the base of your skull that normally cradles the pituitary gland appears partly or completely empty on brain imaging, because cerebrospinal fluid has pushed in and flattened the gland against the floor of its enclosure. Despite the alarming name, the pituitary is still there; it has been compressed rather than removed. Most people with the finding on a scan never develop symptoms, but a meaningful minority do experience hormonal disruptions, headaches, or visual problems that warrant medical attention.
The Sella Turcica and Why It Can Look “Empty”
The sella turcica is a saddle-shaped depression in the sphenoid bone, right behind your nose and between your ears. It houses the pituitary gland, a pea-sized structure that orchestrates hormones controlling growth, metabolism, reproduction, and the stress response. Normally a membrane called the diaphragma sellae stretches over the top of this pocket like a roof, keeping brain fluid out and the gland snug inside.
When that membrane is incomplete or unusually thin, cerebrospinal fluid can herniate downward into the sella. Over time the fluid pressure flattens the pituitary against the sellar floor. On an MRI the space looks filled with fluid rather than gland tissue, giving the appearance of an “empty” sella. The classic radiologic picture is a thin crescent of pituitary tissue along the bottom of an enlarged sellar space, with more than half of the cavity occupied by cerebrospinal fluid and the gland compressed to two millimeters or less in thickness.1Endocrine Practice. A Comprehensive Review of Empty Sella and Empty Sella Syndrome
Primary Versus Secondary Forms
Doctors separate empty sella into two categories depending on the cause. The distinction matters because the two types tend to affect different groups of people and carry different risks for hormonal problems.
Primary empty sella develops without any prior surgery, radiation, or known pituitary disease. The main predisposing factor is a gap or weakness in the diaphragma sellae, which allows cerebrospinal fluid to gradually push into the sella.2PubMed. Treatment of empty sella associated with visual impairment: a systematic review of chiasmapexy techniques It is far more common than the secondary form and is frequently discovered by accident when an MRI is done for an unrelated reason, such as a headache workup or a head injury evaluation. Reported prevalence in the general population ranges from roughly 8 to 35 percent depending on the imaging criteria used and the population studied.3PubMed Central. Partial empty sella syndrome: a case report and review
Secondary empty sella results from something that damaged or shrank the pituitary first: surgery to remove a pituitary tumor, radiation therapy aimed at the gland, a pituitary stroke (called apoplexy), or medication that reduced a hormone-secreting tumor. Because the gland has already been injured, hormonal deficiencies are more common in the secondary form. In one study comparing the two, about a third of patients with primary empty sella had some degree of pituitary insufficiency, whereas nearly two-thirds of those with the secondary form did.4PubMed Central. Pituitary function in patients with primary and secondary empty sella
What Causes It
The exact chain of events is still debated, but several mechanisms are thought to contribute. Chronically elevated cerebrospinal fluid pressure is probably the biggest driver: the fluid pushes through any weakness in the diaphragma sellae and compresses or displaces the gland over months or years. This is why empty sella shows up so frequently in people with idiopathic intracranial hypertension, a condition defined by high brain-fluid pressure without an obvious cause like a tumor.5PubMed Central. Reversible empty sella in idiopathic intracranial hypertension: an indicator of successful therapy?
Other proposed contributors include autoimmune inflammation of the pituitary (lymphocytic hypophysitis), chronic arachnoiditis, and disrupted signaling between the hypothalamus and the pituitary when the stalk connecting them gets stretched or compressed by the invading fluid.6AACE Endocrinology and Diabetes. Primary Empty Sella Presenting With Anterior Hypopituitarism: Reframing a Benign Radiologic Finding Through Its Endocrine Consequences In some people the diaphragma sellae was simply never fully formed; in others, years of elevated pressure gradually stretched it open.
Who Gets It
Primary empty sella is overwhelmingly more common in women, with ratios reported around five to one compared with men.3PubMed Central. Partial empty sella syndrome: a case report and review It is most often diagnosed in middle-aged adults, and obesity is a major associated factor. Excess body weight raises intracranial pressure, which in turn increases the hydrostatic force pushing fluid into the sella. One study of over 900 consecutive obese outpatients being evaluated for growth hormone deficiency found that the condition was concentrated among women with a mean age in the mid-forties.7PubMed. Severe growth hormone deficiency and empty sella in obesity: a cross-sectional study High blood pressure is another commonly reported association, possibly through a similar mechanism of chronically increased intracranial pressure.
Secondary empty sella does not show the same strong demographic skew. It can occur at any age and in either sex, because it follows whatever event damaged the pituitary gland in the first place.
Symptoms People Experience
Many people with an empty sella on imaging feel perfectly fine and never need treatment. When symptoms do develop, they tend to fall into a few categories.
- Headaches: The most commonly reported complaint. These are often chronic, can mimic migraine, and probably relate to changes in cerebrospinal fluid dynamics rather than to the flattened gland itself.
- Visual disturbances: If the optic chiasm (the crossing point of the optic nerves just above the sella) sags downward into the empty space, you can develop blind spots or reduced visual acuity. In severe cases the chiasm becomes stretched over the rim of the sella, damaging nerve fibers.2PubMed. Treatment of empty sella associated with visual impairment: a systematic review of chiasmapexy techniques
- Hormonal deficiencies: The compressed pituitary can lose some or all of its hormone-producing capacity. Which hormones are affected determines the symptoms.
- Fatigue and pain: Overlap with conditions like fibromyalgia and chronic fatigue syndrome has been documented, with shared features including increased cerebrospinal fluid pressure, bodily pain, and vestibular disturbances.8PubMed Central. The Link Between Empty Sella Syndrome, Fibromyalgia, and Chronic Fatigue Syndrome: The Role of Increased Cerebrospinal Fluid Pressure
The pattern of hormonal loss differs between the two forms. In people with primary empty sella, hypogonadism (low sex hormones) is the most frequent hormonal finding, affecting about a quarter of patients. In secondary empty sella, adrenal insufficiency is the most common deficiency, affecting more than half of patients.4PubMed Central. Pituitary function in patients with primary and secondary empty sella Thyroid hormone, growth hormone, and prolactin production can also be impaired in either form.
Cerebrospinal Fluid Leaks
One complication that catches people off guard is a spontaneous cerebrospinal fluid leak, usually through the nose. When the same elevated intracranial pressure that flattened the pituitary also erodes thin spots in the skull base, clear watery fluid can drip from one nostril, especially when you lean forward or strain. The fluid is cerebrospinal fluid leaking through a defect in the bone.
The association between empty sella and spontaneous CSF leaks is striking. In one study, every patient with a spontaneous nasal CSF leak who had sella imaging turned out to have either a completely or partially empty sella, compared with only about one in ten patients whose leaks had an identifiable cause like trauma or surgery.9PubMed. Significance of empty sella in cerebrospinal fluid leaks CSF pressure measurements in these patients ran roughly double the normal range.10PubMed. Spontaneous nasal cerebrospinal fluid leaks and empty sella syndrome: a clinical association The profile of these patients was familiar: predominantly obese, middle-aged women.
CSF leaks are not just an annoyance. They create an opening between the brain’s sterile environment and the bacteria-rich nasal cavity, raising the risk of meningitis. Surgical repair is generally considered mandatory. The endoscopic transnasal approach, in which surgeons work through the nose to patch the defect using tissue or fat grafts, has become the preferred technique because of high success rates and relatively low morbidity.11International Journal of Research and Scientific Innovation. Primary Empty Sella Syndrome Presenting with CSF Rhinorrhea: Successful Endoscopic Repair
How It Is Diagnosed and Evaluated
Most empty sella diagnoses begin with an MRI done for something else entirely. When the characteristic crescent of flattened pituitary tissue appears on the scan, the question becomes whether the finding is clinically meaningful or an incidental curiosity.
There are no formal society guidelines dictating exactly which tests to run, but endocrinologists generally agree on a morning blood panel to check the pituitary’s major output: cortisol (and its stimulating hormone ACTH), thyroid hormones, IGF-1 as a proxy for growth hormone, prolactin, and the sex-hormone axis appropriate to the patient’s sex.12Endocrine Practice. A Comprehensive Review of Empty Sella and Empty Sella Instead – Section: Evaluation for Empty Sella Syndrome A German review reached essentially the same conclusion, recommending basic neuroendocrine testing for anyone found to have an incidental empty sella, even though they acknowledged the evidence base for this approach is thin.13PubMed Central. Primary Empty Sella Syndrome and the Prevalence of Hormonal Dysregulation
If the initial blood work comes back with borderline cortisol values or if other hormone levels are already low, additional stimulation tests can be used to probe the pituitary more rigorously. A visual field exam is also worthwhile when imaging suggests the optic chiasm might be sagging into the sella.
Prognosis and When Treatment Is Needed
For most people with an incidental empty sella, the outlook is reassuring. The majority never become symptomatic, and when symptoms do arise, they usually have limited impact on daily life.14PubMed Central. Asymptomatic Empty Sella: A Literature Review and Suggestions for Evaluation in Clinical Practice In a follow-up study of patients with primary empty sella, only about 10 percent progressed from a partial to a total empty sella over an average of more than two years, while nearly three-quarters were unchanged and about one in six actually improved. Fewer than 2 percent of previously asymptomatic patients developed a new hormonal abnormality during years of follow-up. Re-evaluation at 24 to 36 months after diagnosis, or sooner if new symptoms appear, is a reasonable approach.12Endocrine Practice. A Comprehensive Review of Empty Sella and Empty Sella Instead – Section: Evaluation for Empty Sella Syndrome
When hormone deficiencies are confirmed, treatment is straightforward: you replace what is missing. Low thyroid hormone gets levothyroxine. Adrenal insufficiency gets hydrocortisone. Low sex hormones may call for testosterone or estrogen replacement depending on age, symptoms, and fertility goals. Growth hormone deficiency can be treated with recombinant growth hormone when symptoms justify it.
Surgery enters the picture in two specific scenarios. First, when a CSF leak develops, endoscopic repair is the standard of care, as discussed earlier. Second, when the optic chiasm has prolapsed into the empty sella and is causing progressive visual loss, a procedure called chiasmapexy can lift and stabilize the chiasm. Results depend on how advanced the damage is: younger patients and those with less severe preoperative visual loss tend to do better.15PubMed. Chiasmapexy for secondary empty sella syndrome: diagnostic and therapeutic considerations When significant optic nerve atrophy has already set in, the window for meaningful visual recovery narrows considerably.
Empty Sella in Children
Although most discussions of empty sella focus on middle-aged adults, the condition appears in children and adolescents too, particularly those being evaluated for hormonal problems. In a large pediatric study, about 11 percent of children referred for various hypothalamic-pituitary disorders had an empty sella on imaging. The finding was especially concentrated among children with multiple pituitary hormone deficiencies, where it appeared in roughly a third of cases.16The Journal of Clinical Endocrinology & Metabolism. Empty sella in children and adolescents with possible hypothalamic-pituitary disorders
Children with empty sella can present with failure to thrive, short stature, or delayed puberty, all of which reflect inadequate pituitary hormone production.17PubMed Central. Empty sella syndrome in a male child with failure to thrive The good news is that when growth hormone deficiency is the main issue, treatment with replacement growth hormone works about as well in children with empty sella as it does in children whose pituitary looks normal on imaging.18PubMed Central. Children with isolated growth hormone deficiency: Empty sella versus normal sella The shape of the gland on a scan does not dictate how well a child responds to therapy.
Interestingly, the pediatric data also challenge the assumption that empty sella always means too little hormone output. Some children with precocious puberty, a condition of early hormonal overactivity, also had empty sella on imaging. The mechanism behind that apparent paradox is not well understood, but it underscores that the presence of an empty sella does not automatically mean every pituitary function is suppressed.16The Journal of Clinical Endocrinology & Metabolism. Empty sella in children and adolescents with possible hypothalamic-pituitary disorders
Fertility and Pregnancy
Because the pituitary controls the hormones that drive ovulation and menstrual cycles, empty sella syndrome can complicate fertility. Hypogonadism in women with primary empty sella can mean irregular or absent periods, reduced egg reserve, or difficulty conceiving naturally. However, the condition does not make pregnancy impossible, even in more challenging cases.
Case reports show that women with empty sella can conceive through assisted reproductive technology. One documented case involved a woman with a normal ovarian reserve who became pregnant after frozen embryo transfer, while another woman with severely diminished ovarian reserve achieved pregnancy through an egg donation program.19International Journal of Reproduction, Contraception, Obstetrics and Gynecology. Clinical management and successful pregnancy outcomes in women with empty Sella syndrome undergoing assisted reproductive technology: a case-based approach The takeaway is that the degree of fertility impairment depends on how much residual pituitary function remains, not simply on the presence of an empty sella. Close collaboration between a reproductive endocrinologist and an endocrinologist familiar with pituitary disease tends to produce the best outcomes.
The Connection to Idiopathic Intracranial Hypertension
Empty sella and idiopathic intracranial hypertension share such overlapping demographics and mechanisms that researchers increasingly view them as related expressions of the same underlying process. Both conditions disproportionately affect obese women of childbearing age. Both involve chronically elevated cerebrospinal fluid pressure. And in people with intracranial hypertension, an empty sella is one of the most consistent radiographic findings, caused by the same herniation of fluid through a deficient diaphragma sellae.
What makes this clinically relevant is that treating the elevated pressure can sometimes reverse the empty sella. Two patients described in one study presented with headache, swelling of the optic discs, and visual disturbances typical of intracranial hypertension. After treatment to lower their cerebrospinal fluid pressure, follow-up imaging showed improvement in the empty sella appearance.5PubMed Central. Reversible empty sella in idiopathic intracranial hypertension: an indicator of successful therapy? This reversibility is an important concept: it means the condition is not always a one-way street of progressive compression. Reducing the pressure driving the process can allow the anatomy to partially recover.
The same overlap with elevated intracranial pressure explains the clustering of symptoms that can make empty sella syndrome frustrating to live with. Headaches, fatigue, dizziness, hearing changes, and widespread pain all show up more frequently in people with primary empty sella than in matched controls, and they track with findings seen in fibromyalgia and chronic fatigue syndrome as well.8PubMed Central. The Link Between Empty Sella Syndrome, Fibromyalgia, and Chronic Fatigue Syndrome: The Role of Increased Cerebrospinal Fluid Pressure Whether elevated CSF pressure is the common thread tying all these conditions together remains an open question, but it is one of the more compelling hypotheses in a field that does not have many tidy answers.