Figure 3. Diagnosis and management of primary hypophysitis. 1 Check random ACTH and cortisol if acute adrenal insufficiency is suspected. Consider confirmatory testing (e.g., Synacthen) if equivocal or borderline results. The Synacthen test can give false-positive results in the early stages of central adrenal insufficiency. During pregnancy and in patients receiving oral estrogens, the rise of corticosteroid-binding globulin (CBG) leads to falsely elevated cortisol levels and the normal reference ranges and stimulated cortisol cut-offs do not apply. 2 Pituitary surgery can also provide histology for definitive diagnosis.