A 29-year-old para 2 delivered at home 14 months ago with massive postpartum haemorrhage requiring transfusion. Since then she has failed to lactate, has not resumed menses, and reports fatigue and loss of pubic and axillary hair. Serum prolactin is 2 ng/mL, FSH 1.5 IU/L, LH 0.8 IU/L, TSH 0.2 mIU/L, cortisol low. MRI pituitary shows an empty sella. What is the diagnosis?

• A Sheehan syndrome ✓
• B Functional hypothalamic amenorrhoea
• C Pituitary microadenoma
• D Premature ovarian insufficiency

Explanation

Postpartum pituitary necrosis from obstetric haemorrhage produces panhypopituitarism. Failure of lactation is typically the earliest clue because prolactin secretion is lost first, followed by loss of gonadotropins, TSH and ACTH, giving amenorrhoea, hair loss and central hypothyroid and adrenal insufficiency. Premature ovarian insufficiency shows elevated FSH and LH, whereas this patient has panhypopituitarism with undetectable gonadotropins.

Reference: Dutta's Textbook of Gynecology, 6th ed.

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