The vanishing diagnosis: a comprehensive review of late-onset hypopituitarism due to Sheehan syndrome in resource-limited settings, diagnostic nosography and persistent barriers to endocrine care

Abstract

Sheehan syndrome (SS), or postpartum pituitary necrosis, is a preventable consequence of obstetrical hemorrhage. Although its incidence has declined in high-income countries, it persists as a major cause of maternal morbidity in low-resource regions, often with diagnostic delays of decades. This review critically analyzes the epidemiological shift of SS, delineates mechanisms permitting delayed presentation, and explores factors contributing to diagnostic oversight in developing nations. We performed a narrative synthesis of literature from 2015-2025, including case series, cross-sectional studies, and reviews on hypopituitarism and neuroimaging, with emphasis on chronic glucocorticoid and thyrotrophin deficiency as clinical masqueraders. In areas with high home-delivery rates, SS prevalence may reach 3% among parous women over 20 years. Mean diagnostic delay ranges from 10-20 years, with extremes up to 50 years postpartum. Common findings include partial empty Sella on magnetic resonance imaging (MRI) and panhypopituitarism, with normocytic normochromic anemia and hyponatremia from adrenal insufficiency as predominant laboratory features. In developing nations, SS serves as a silent marker of obstetric disparities. Its nonspecific symptoms-chronic asthenia, hyponatremia, secondary hypothyroidism-are often misattributed to aging, malnutrition, or psychiatric illness. A high index of suspicion, combined with targeted hormonal assays and appropriate imaging, remains essential to reduce preventable morbidity from this overlooked endocrinopathy.