A 29-year-old woman who had a massive postpartum haemorrhage requiring 6 units of blood transfusion now presents 8 months later with failure of lactation since delivery, loss of pubic and axillary hair, and secondary amenorrhoea. Serum prolactin is 2 ng/mL, FSH 1.5 IU/L, LH 1 IU/L, TSH 0.2 mIU/L with low free T4. What is the most likely diagnosis?

• A Premature ovarian insufficiency
• B Asherman syndrome
• C Prolactinoma with stalk effect
• D Sheehan syndrome ✓

Explanation

Postpartum pituitary necrosis from obstetric haemorrhage causes panhypopituitarism: failure of lactation (low prolactin), amenorrhoea with low gonadotropins, loss of axillary and pubic hair, and central hypothyroidism. Asherman syndrome also causes postpartum amenorrhoea but the pituitary axes remain intact, so prolactin and thyroid function are normal and lactation is unaffected. Premature ovarian insufficiency gives high FSH, not low. The combination of failed lactation with multiple axis failures localises the lesion to the pituitary.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.