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Postpartum Hypopituitarism / Sheehan's Syndrome

Definition:
Sheehan's syndrome, also referred to as postpartum hypopituitarism, is a delayed effect of intrapartum or postpartum hemorrhage — life-threatening blood loss during or after childbirth.

Severe blood loss deprives body tissues and organs of oxygen, causing areas of tissue death. In Sheehan's syndrome, this damage affects the pituitary gland — a small, bean-shaped gland at the base of your brain. The result, which may not be apparent for months or even years, is permanent underproduction of pituitary hormones.

Pituitary hormones regulate the rest of the endocrine system, signaling other glands to increase or decrease production of the hormones that control metabolism, fertility, wound healing and many other vital processes. When the regulatory hormones from the pituitary are in short supply, the signs and symptoms may affect almost any part of your body — although they may develop so gradually that they escape notice. Hypopituitarism may seem to cause no symptoms at all. At the other extreme, though, Sheehan's syndrome and other forms of hypopituitarism can cause an adrenal crisis — a sudden, potentially fatal undersupply of the hormone cortisol.

Thanks to improved prenatal care and medically supervised childbirth, Sheehan's syndrome has become rare in parts of the world where access to medical care is available.

Causes:
Severe blood loss occurring specifically in the context of childbirth causes Sheehan's syndrome. Blood loss at that time can be particularly damaging to the pituitary gland, destroying hormone-producing tissue so that the gland doesn't function properly. Experts aren't sure exactly why this happens. One theory is that since the pituitary gland enlarges during pregnancy, it's more prone to damage. The severe drop in blood pressure (hypotension) that occurs during hemorrhage could also damage the pituitary.

Sheehan's syndrome is the most common cause of hypopituitarism in women of childbearing age.

Risk Factor :
Any condition that increases the likelihood of severe blood loss during childbirth, such as being pregnant with multiples or having an abnormality of the placenta, may increase your risk of Sheehan's syndrome. However, hemorrhage is a rare childbirth complication, and Sheehan's syndrome is even more uncommon. Both risks are significantly diminished with proper care and monitoring during labor and delivery.

When to seek medical advice :
If you had severe blood loss during childbirth — in the recent past or many years ago — and you're experiencing any of the signs and symptoms of Sheehan's syndrome, consider seeing your doctor. Although the chances of being diagnosed with Sheehan's syndrome are slim, your doctor may be able to determine another cause of your signs and symptoms.

Symptoms:
In most cases, the signs and symptoms of Sheehan's syndrome appear slowly, after a period of months or even years. But sometimes — such as in a breast-feeding mother — problems may appear right away.

Signs and symptoms of Sheehan's syndrome include :

  • Slowed mental function, weight gain and difficulty staying warm, as a result of an underactive thyroid (hypothyroidism)
  • Difficulty breast-feeding or an inability to breast-feed
  • No menstrual periods (amenorrhea) or infrequent menstruation (oligomenorrhea)
  • Loss of pubic or underarm hair
  • Low blood pressure
  • Fatigue
  • Weight loss

For many women, the symptoms of Sheehan's syndrome are nonspecific and often attributed to other things. Fatigue, for instance, goes hand in hand with being a new mother. A woman might not realize she has Sheehan's syndrome until she requires treatment for thyroid or adrenal insufficiency.

It's also possible to remain symptom-free with Sheehan's syndrome. Some women unknowingly live for years with pituitary insufficiency, then go into adrenal crisis triggered by extreme physical stressors, such as severe infection or surgery.

Diagnosis:
Diagnosis of Sheehan's syndrome can be difficult. Your doctor may base the diagnosis in part on your medical history, so it's important to mention any childbirth complications you may have had, no matter how long ago you gave birth. If your history, signs and symptoms suggest pituitary insufficiency, you'll have blood tests that check your pituitary hormone levels.

You may also need imaging tests, such as magnetic resonance imaging or computerized tomography, to check the size of your pituitary and to look for other possible causes of pituitary malfunction, such as a pituitary tumor.

Treatment:
Treatment for Sheehan's syndrome is lifelong hormone replacement therapy. Your doctor may recommend one or more of the following medications :

  • Corticosteroids. These drugs, such as hydrocortisone or prednisone, replace the adrenal hormones that aren't being produced because of an adrenocorticotropic hormone (ACTH) deficiency. You take them by mouth.
  • Levothyroxine (Levoxyl, Synthroid, others). This medication boosts deficient thyroid hormone levels caused by low or deficient thyroid-stimulating hormone (TSH) production.
  • Estrogen. This may include estrogen alone in women who have had their uterus removed (hysterectomy) or a combination of estrogen and progesterone in women who still have a uterus. Estrogen replacement can be administered with either pills or patches.

If you've become infertile, preparations containing luteinizing hormone (LH) and follicle-stimulating hormone (FSH), also called gonadotropins, can be administered by injection to stimulate ovulation.

A doctor who specializes in endocrine disorders (endocrinologist) may test your blood regularly to make sure you're getting adequate — but not excessive — amounts of these hormones.

If you become seriously ill or experience major physical stress, your doctor will advise you to adjust your dosage of corticosteroids. During these times, your body would ordinarily produce extra cortisol — a stress hormone. The same kind of dosage fine-tuning may be necessary when you have the flu, experience diarrhea or vomiting, or have surgery or dental procedures. Adjustments in dosage may also be necessary during pregnancy or with marked weight gain or weight loss.

 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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