In this essay
- How Acromegaly Hides in Plain Sight
- What Excess Growth Hormone Does to an Adult Body
- When a Pituitary Tumour Presses on the Optic Nerves
- The Acromegaly Diagnosis Hidden in Old Photographs
- Transsphenoidal Surgery: Removing a Pituitary Tumour Through the Nose
- Life After Acromegaly Surgery, and How the Body Recovers
The bangles would not pass her knuckles.
Sara had worn them since her wedding. Thin gold, six on each wrist, the sound of them part of how she moved through a room. One morning they stopped at the base of her hand. She pushed. They held. She told herself she had eaten too much salt.
She was thirty-eight. For four or five years the changes had been arriving so slowly that no one, least of all Sara, had thought to add them up. Her nose had broadened. Her jaw sat heavier in her face. Her footwear, bought a half-size larger each year, no longer felt like vanity. Her voice had dropped and thickened, as though she were speaking through a cold that never quite got better. Her periods had turned irregular. The skin across her cheeks had coarsened and darkened. Her friends were kind. Her family physician was kind. Everyone agreed it was probably the start of menopause, a little early, nothing to fear.
It was not menopause. It was acromegaly — a small growth hormone–secreting tumour of the pituitary gland at the base of her brain, and it had been quietly rewriting her body for years.
How Acromegaly Hides in Plain Sight
The body changes too gradual to notice
Acromegaly is a disease of slowness. It is caused, in almost every case, by a small benign tumour of the pituitary gland that pours out too much growth hormone. The hormone does its work by fractions. A millimetre here. A half-size there. The face you meet each morning is never very different from the face you met the morning before, and so the change escapes you. By the time it announces itself, it has usually been at work for years. Across large studies, the gap between the first sign of acromegaly and the diagnosis runs to seven, eight, sometimes ten years.
The face you meet each morning is never very different from the one you met the morning before. That is how acromegaly hides.
The early signs are easy to explain away. Rings that no longer turn. Bangles that catch at the knuckle. Footwear bought a size larger, then larger again. A wedding band sent to the jeweller to be cut. These are the classic first complaints of acromegaly, and they are almost always blamed on something else — weight, water, age. Sara’s were blamed on early menopause. She was the right age for the suspicion to seem reasonable. It was not an unkind guess. It was simply the wrong one.
What Excess Growth Hormone Does to an Adult Body
Growth, after the body has finished growing
Growth hormone is made in the pituitary, a gland the size of a pea that sits in a bony hollow beneath the brain. In childhood, the hormone builds height. Once the growth plates of the long bones close, that door shuts for good. A child with too much growth hormone grows very tall. An adult cannot grow taller. So the hormone turns instead to what can still enlarge — the bones of the hands, the feet and the face, and the soft tissues everywhere beneath the skin. Growth hormone does much of this through a messenger it raises in the liver, which keeps the tissues growing long after they should have stopped.
The result is a face remade by degrees. The brow grows heavier. The nose broadens. The lower jaw lengthens and juts. The lips thicken. The tongue itself enlarges, and the voice deepens and roughens as the soft tissues of the throat swell. The hands broaden into something that looks borrowed from a larger person. The skin coarsens, oils and darkens. Sweating increases. The joints begin to ache. None of it arrives as an event. All of it arrives as a slow tide.
When a Pituitary Tumour Presses on the Optic Nerves
The peripheral vision you lose without knowing it is gone
A pituitary tumour has somewhere to grow. The path of least resistance leads upward, and just above the gland lies the optic chiasm — the crossroads where the two optic nerves meet and trade fibres. When a growing tumour lifts into this crossing, it presses first on the fibres that carry the outer edges of sight. The result is a slow narrowing from the sides. Doctors call it bitemporal hemianopia: the loss of the outer, temporal halves of both visual fields.
It is a cruel defect, because the person rarely notices it. The centre of vision stays sharp. Only the margins fade. Sara changed her spectacles twice, certain the fault lay in the lens. She began to clip the doorframe with her shoulder. She missed the cup set down at the edge of the table. Then her blood pressure climbed, sharply and without explanation, and her physician — uneasy at last — sent her for an MRI of the brain. The scan showed the tumour. The hormone tests that followed showed the cause. Her growth hormone was far above where it should be.
The Acromegaly Diagnosis Hidden in Old Photographs
A face changed by acromegaly, one year at a time
When Sara and her husband Surya came to us, much of the explaining had already been done by the scan. What remained was for Sara to see it. We went through the symptoms of growth hormone excess one by one — the bangles, the footwear, the deepening voice, the coarsening skin, the irregular cycles, the vanishing edges of her sight. She listened with the particular stillness of someone recognising her own life in a description she had never been offered.
No single mirror had shown her the change. The photographs, laid side by side, revealed it all at once — the slow years written plainly in her face.
That evening she did what so many patients with acromegaly eventually do. She took down the old photographs. She laid them in order — a wedding, a festival, a birthday, the years in a row — and she looked.
The next morning Surya arrived with a folder. Inside were the scans in sequence, a list of questions written down the margin of a notebook, and the names of the few centres in the country that treat these tumours often. He had made calls. He had read late into the night. He had decided that the nearest hospital was not the same thing as the right one. I have met this kind of family before. They are the ones who travel the extra distance, who understand that for a tumour wrapped around the body’s most delicate wiring, the experience of the surgeon, a modern operating microscope and endoscope, and image guidance matter more than the length of the drive.
Transsphenoidal Surgery: Removing a Pituitary Tumour Through the Nose
What the microscope and endoscope reveal
There is an elegant route to the pituitary that leaves no visible mark. The gland sits directly behind the bridge of the nose, beyond a thin shell of bone. Through the nostril, through the sphenoid sinus, a surgeon can reach it without ever opening the skull. This is transsphenoidal surgery — transnasal surgery, in plainer words — and for a growth hormone–secreting pituitary tumour it is the first and best treatment.
Sara had the operation under general anaesthesia. The corridor to the tumour is no wider than the passages of the nose, with the carotid arteries running close on either side and the optic nerves waiting just above. Two instruments make the difference here. The operating microscope gives depth and a steady, magnified line of sight. The endoscope, passed through the nostril, carries bright light into the deepest recess and shows what lies around the corners, beyond the microscope’s straight view. Between them, the tumour declares itself — softer, paler, subtly wrong against the normal gland. The task is to take all of it and leave the healthy pituitary behind.
In three decades of removing these tumours through the nose, I have learned what a complete excision feels like — the moment the last of the tumour lifts away and the normal gland sits clean and unhurt beneath the light. Sara’s tumour came out whole.
Life After Acromegaly Surgery, and How the Body Recovers
The body remembers how to be itself
She spent a couple of days in hospital and went home.
The first gift came within those days, before she had even left the ward. Her vision widened. The edges of the world, gone so gradually she had forgotten they were missing, came back. She could take in the whole of a room again — the people at its far sides, the cup at the edge of the table.
Then came the lightness. Growth hormone holds water and thickens tissue throughout the body, and when it falls, the body begins to shed what it had been carrying. Patients often feel their rings loosen within days. By two months Sara had lost a few kilos she had never meant to gain, and her bangles turned freely on her wrist again.
We repeated the hormone tests and the MRI at two months. The scan was clean; the tumour was completely removed. The growth hormone had fallen to near normal. Most of what the disease had done had begun to undo itself. The swelling in her face and hands had eased. Her skin had quietened. Her voice had lifted. Not everything reverses — bone that has thickened keeps its shape, and so a trace of the years remains. But the soft tissues, which carry most of what we read in a face, return.
We are not built to watch ourselves change. We stand too close, and each day asks too little of our attention. The mirror shows only the small distance between this morning and the last, which is almost nothing at all — and so a face can be quietly remade over years, in full view, and still go unseen. It takes the old photographs, the past laid gently beside the present, to let us finally look.
Perhaps that is the tenderest lesson this disease leaves behind. The changes that matter most in a life are rarely the loud ones. They are slow, and patient, and easy to miss — in our own faces, and in the faces of the people we love. Sometimes we need another pair of eyes, or a kinder one, to notice what has been happening all along. Sara walked out of the clinic seeing the full width of the room she entered — and seeing, at last, herself.
A note from me
I have spent a working life in the narrow spaces of the skull, and acromegaly has taught me a particular patience. It harms so gently that by the time anyone thinks to look, years have already gone. So if I may ask one thing of you, it is this: when something in the body changes, and keeps changing — a ring that no longer fits, a shoe half a size larger, a face in an old photograph you almost fail to recognise — do not explain it away too quickly. Take it to someone. Ask the question aloud. These tumours are almost always kind enough to be curable, if only we are asked in time.
— Dr. Jaydev Panchawagh
