A Decade With Sheehan's Syndrome: A Case Report and Personal Experience

Abstract

Objective: Sheehan's syndrome (SS) is a rare endocrine disorder caused by ischemic necrosis of the anterior pituitary gland secondary to massive postpartum hemorrhage (PPH) and shock. It commonly leads to multiple hormonal deficiencies, such as adrenal insufficiency, hypothyroidism, and hypopituitarism. Affected individuals may present with signs and symptoms including weight gain or loss, cold intolerance, hair loss, menstrual irregularities, and hypotension. Diagnosis is often delayed due to its nonspecific presentation and overlap with conditions like postpartum depression and chronic fatigue syndrome. This case report highlights the clinical presentation, management challenges, and complications associated with the delayed diagnosis of SS.

Case presentation: A 35-year-old female was diagnosed with SS in 2016, at the age of 26, following severe PPH and hemorrhagic shock after a vaginal delivery in 2013. Initially, she experienced failure to lactate, followed by amenorrhea, frontal balding, weight loss, hypotension, chronic fatigue, mood swings, and polyuria. For several years, her symptoms were misattributed to postpartum depression, resulting in delayed diagnosis and treatment. A comprehensive endocrine evaluation revealed secondary adrenal insufficiency, central hypothyroidism, and hypogonadotropic hypogonadism, as evidenced by low levels of ACTH, cortisol, TSH, free T4, FSH, LH, and prolactin. Magnetic resonance imaging (MRI) confirmed partial empty sella, supporting the diagnosis of SS. She was started on lifelong hormone replacement therapy (HRT) consisting of hydrocortisone, levothyroxine, and estrogen. She remained highly sensitive to hormone doses, requiring frequent adjustments every other month. Despite modifications, she continued to experience persistent symptoms, including fatigue, hair loss, extreme mood swings, night sweats, and gastrointestinal symptoms such as abdominal discomfort, epigastric pain (worsened on an empty stomach), nausea, vomiting, bloating, and passage of blood in stool, likely related to long-term medication use. Pregnancy was later achieved through ovulation induction using human chorionic gonadotropin (HCG) and human menopausal gonadotropin (HMG). She developed an adrenal crisis during pregnancy, which was managed through hydrocortisone dose modification. The immediate postpartum period was uneventful under treatment, but she required close endocrine follow-up for ongoing metabolic and reproductive concerns.

Conclusion: This case highlights the typical clinical presentation of SS in a postpartum patient, including lactation failure, fatigue, and amenorrhea, which can facilitate early diagnosis of this serious and potentially life-threatening condition. Delayed diagnosis is often linked to prolonged morbidity, affecting both quality of life and fertility. Lifelong HRT, regular endocrinological monitoring, and individualized treatment plans are essential for managing endocrine dysfunction, osteoporosis risk, and cardiovascular complications. Awareness, early screening, and multidisciplinary collaboration among endocrinologists, obstetricians, and reproductive specialists are pivotal in improving long-term outcomes and reducing diagnostic delays.

Keywords: Sheehan's syndrome; adrenal insufficiency; delayed diagnosis; endocrine dysfunction; fertility challenges; hormone replacement therapy (HRT); hypopituitarism; hypothyroidism; metabolic instability; postpartum pituitary necrosis.

Figure 1

Imaging of the pituitary gland in Sheehan's syndrome: MRI showing empty sella turcica. Magnetic resonance imaging (MRI) is considered the gold standard for diagnosing Sheehan's syndrome. The pituitary gland resides within the sella turcica, a depression in the sphenoid bone. In cases of pituitary necrosis, this space often appears partially or completely empty on imaging. Studies suggest that around 70% of Sheehan's syndrome cases demonstrate a fully empty sella turcica. While MRI provides the most detailed visualization, computed tomography (CT) scans can also aid in the diagnostic process (Figure 1).

Figure 2

Hormonal trends over time in Sheehan's syndrome. This chart shows fluctuations in TSH, free T4, and cortisol levels between 2016 and 2024. TSH and free T4 are plotted on the left y-axis, while cortisol is plotted on the right y-axis. The chart illustrates the effect of hormone replacement therapy and dose adjustments over time. Note: Data from 2018 to 2021 are unavailable due to loss of personal medical records during a relocation period. Additionally, routine endocrine follow-up was inconsistently documented during this time. Some test intervals also reflect clinical necessity (e.g., symptom worsening, treatment changes) rather than standardized timelines. This emphasizes real-world challenges in maintaining continuous endocrine monitoring in limited-resource settings.