Sheehan Syndrome


Step 1: View clinicals

A 32-year-old gravida 1, para 1 (G1P1) woman is yet to recommence menstruating, around a year after delivery. She has also been suffering from hot flashes and decreased libido for around six months. She stopped breastfeeding around nine months ago because she found it too painful. Her obstetric history is significant for a low transverse cesarean section at term, for secondary arrest of labor. She subsequently required uterine artery embolization due to intractable bleeding and was transfused six units of packed red blood cells in total. She is not on any medications including contraceptives, over-the-counter drugs, or herbal medicines. There is no history of antipsychotic or antidepressant use. She has not consumed alcohol since the start of her pregnancy. There is no history of recreational drug use. She hopes to have another child in the future. A urine HCG test is found to be negative.

Step 2: Order all relevant investigations

Endocrine profile

T3: 0.2 nmol/L (0.9 - 2.8) T4: 40 nmol/L (58 - 161) TSH: 0.1 mIU/L (0.5 - 4.7) FSH: undetectable (luteal: 1.4-5.5; follicular: 3.1-7.9; ovulation peak: 2.3-18.5) LH : 0.2 mIU/mL (luteal: 0.4-20.0; follicular: 1-18; mid-cycle: 20-105) Prolactin: 5 µg/L (2 - 29) GH: 1.5 ng/mL (0.01-3.61) Cortisol (morning): 2 µg/dL (7-28) ACTH (morning): 7 µg/dL (10-50)

Pelvic ultrasound

The ovaries are normal in appearance and volume, with no follicular cysts. The uterus shows normal endometrial echotexture, with no evidence of adhesions. No other significant sonographic findings are present.

GnRH stimulation test

LH levels are measured 20 and 60 minutes after stimulation. No elevations are noted.

Pituitary MRI

The MRI scan shows the sella turcica to be partially empty.

Step 3: Select appropriate management

Start glucocorticoids first
Start levothyroxine first
Hormone replacement therapy
Ovulation induction

Score: ★★☆