11/14/24, 10\:44 AM Sheehan’s Syndrome

Sheehan’s Syndrome

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Sheehan’s syndrome\: complication of severe postpartum haemorrhage (PPH) and hypovolaemic shock, leading to
ischaemic necrosis of the anterior pituitary gland. Extremely rare, seen in around 5/100,000 births.
Aetiology\: anterior pituitary supplied by low-pressure hypothalamo-hypophyseal portal system, making it vulnerable to
rapid blood pressure drops. Posterior pituitary is less a
Anterior pituitary hormones\: FSH, LH, TSH, GH, ACTH, prolactin.
Posterior pituitary hormones\: ADH, oxytocin (typically not a
Risk factors\: pregnancy (particularly multiple pregnancy), placental abruption, placenta praevia, pre-eclampsia, severe
PPH, history of autoimmune disease.
Clinical features\: reduced milk production (agalactorrhea), amenorrhoea, hypothyroidism, adrenal insu
adrenal crisis. Symptoms can present acutely or chronically, often months to years after the initial event.
Symptoms of hypothyroidism\: fatigue, weight gain, constipation, depression, loss of libido, cold intolerance.
Symptoms of adrenal insu
pain.
Clinical examination\: bradycardia, dry skin, sti
skin pigmentation (adrenal insu
Di
Investigations\: blood tests for anterior pituitary hormones (TFTs, FSH, LH, ACTH, prolactin), plasma cortisol, serum IGF-1,
GH provocation test, pituitary hormone stimulation tests. Imaging includes MRI (to rule out other causes) and CT if MRI is
inconclusive.
Management\: lifelong hormone replacement therapy guided by an endocrinologist, including HRT (oestrogen and
progesterone), growth hormone, levothyroxine (for hypothyroidism), hydrocortisone (for adrenal insu
Complications\: hypothyroidism, Addisonian crisis, death.
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Introduction

Sheehan’s syndrome is a complication of severe post-partum haemorrhage (PPH) and hypovolaemic shock, in which
there is ischaemic necrosis of the anterior pituitary gland.
Sheehan’s syndrome is extremely rare, seen in around 5/100,000 births.
1

Aetiology

The pituitary gland is located within a depression of the sphenoid bone, called the pituitary (hypophyseal) fossa or sella
turcica.
The blood supply to the anterior pituitary gland is from the hypothalamo-hypophyseal portal system, which is a low-
pressure system. This means that it is vulnerable to rapid blood pressure reductions.
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In contrast, the posterior pituitary gland has a rich blood supply from various arteries, so it is not susceptible to ischaemia
during drops in blood pressure.
2
The hormones that the anterior pituitary releases are\:
Follicle-stimulating hormone (FSH)
Luteinising hormone (LH)
Thyroid-stimulating hormone (TSH)
Growth hormone (GH)
Adrenocorticotropic hormone (ACTH)
Prolactin
The hormones that the posterior pituitary gland releases (which are typically not a
Antidiuretic hormone (ADH)
Oxytocin

Risk factors

Risk factors for Sheehan’s syndrome include\:
Pregnancy, particularly multiple pregnancy
Placental abruption
Placenta praevia
Pre-eclampsia
Severe PPH
History of autoimmune disease

Clinical features

The clinical features seen in Sheehan’s syndrome are associated with the lack of hormone production by the anterior
pituitary gland.
Patients can present acutely or chronically. Commonly, women present months to years after the initial event.
3
Clinical features of Sheehan’s syndrome include\:
Reduced milk production (agalactorrhea)\: due to the lack of prolactin
Amenorrhoea\: due to lack of FSH and LH
Hypothyroidism\: due to lack of TSH
Adrenal insu and adrenal crisis\: due to lack of ACTH

History

The
amenorrhea.
Symptoms typically re
relate to de
Symptoms of hypothyroidism include\:
Fatigue
Weight gain
Constipation
Depression
Loss of libido
Cold intolerance
Symptoms of adrenal insu include\:
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Fatigue
Muscle cramps & weakness
Thirst and craving salt
Dizziness and fainting
Abdominal pain

Clinical examination

Clinical hypothyroidism on examination include\:
Bradycardia
Dry skin
Sti
Cold peripheries
Hair loss
Clinical signs of adrenal insuy include\:
Hypotension (particularly postural hypotension)
Bronze pigmentation of the skin, commonly in skin creases
Other signs on clinical examination may include\:
Breast tissue atrophy
Decreased axillary and pubic hair growth

Di

Di
Addison’s disease\: patients will present with adrenal insu
Pituitary tumour\: patients will present very similar to those with Sheehan's syndrome
Hypothyroidism\: patients will present with symptoms of hypothyroidism alone
Menopause\: patients will present with amenorrhoea alone

Investigations

Laboratory investigations

Relevant laboratory investigations include\:
Blood tests for the hormones produced by the anterior pituitary\: TFTs, FSH, LH, ACTH, prolactin
Plasma cortisol level
Serum IGF-1\: low in hypothyroidism and GH de
GH provocation test\: GH level is measured after clonidine and arginine are administered, which stimulates GH secretion
Pituitary hormone stimulation tests\: metoclopramide and clomiphene citrate stimulation tests

Imaging

Relevant imaging investigations include\:
MRI scan\: may show acute changes of ischaemia or an empty sella turcica, also to rule out other causes of the
symptoms (e.g. a pituitary tumour)
CT scan\: if the MRI scan is inconclusive

Management

Management of Sheehan’s syndrome will be guided by a specialist endocrinologist, and it will be lifelong.
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Medical management

The main aim is to replace the missing hormones\:
HRT including oestrogen and progesterone for female sex hormones until menopause
Growth hormone
Levothyroxine for hypothyroidism
Hydrocortisone for adrenal insu

Complications

Complications of Sheehan’s syndrome include\:
Hypothyroidism
Addisonian crisis
Death

References

Schury MP, Adigun R. Sheehan Syndrome. Treasure Island (FL)\: StatPearls Publishing. January 2024. Available from\: [LINK]
Karaca, Z., Laway, B., Dokmetas, H. e t a l . Sheehan syndrome. Nat Rev Dis Primers. December 2016.
Diri, H., Karaca, Z., Tanriverdi, F. e t a l . Sheehan’s syndrome\: new insights into an old disease. Endocrine. January 2016.

Reviewer

Mr Obinna Mba
Obstetrics and Gynaecology consultant

Related notes

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Antepartum Haemorrhage (APH)
Breech Presentation
Caesarean Section

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Contents

Introduction
Aetiology
Risk factors
Clinical features
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Di
Investigations
Management
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