Endocrinology: Sheehan syndrome: practice question

A General Medicine question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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General Medicine · Endocrinology: Sheehan syndrome

Sample item

A 30-year-old woman who had major postpartum haemorrhage 6 months ago has failed to lactate, remains amenorrhoeic and has fatigue and hypotension. Free T4 is low with an inappropriately low TSH, and morning cortisol is low. What should be started first?

ALevothyroxine, then hydrocortisone after a weekBHydrocortisone, then levothyroxineCOestrogen-progestin therapy aloneDLevothyroxine alone

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

B. Hydrocortisone, then levothyroxine

Sheehan syndrome is postpartum pituitary necrosis causing hypopituitarism, with failure of lactation often the earliest sign. Glucocorticoid is replaced before thyroxine, because thyroid hormone increases cortisol clearance and can precipitate an adrenal crisis in an unreplaced patient. Levothyroxine is titrated to free T4, as TSH is unreliable.

Option by option

A. Levothyroxine, then hydrocortisone after a week
Thyroxine first speeds cortisol metabolism and can unmask or worsen adrenal insufficiency.
B. Hydrocortisone, then levothyroxine (correct)
Glucocorticoid first protects against adrenal crisis when thyroxine is later started.
C. Oestrogen-progestin therapy alone
Sex hormone replacement does not address the life-threatening deficiencies.
D. Levothyroxine alone
Thyroxine alone leaves life-threatening cortisol deficiency untreated.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

Questions about this General Medicine question

What is the answer to this General Medicine question?

The best answer is B, Hydrocortisone, then levothyroxine. Sheehan syndrome is postpartum pituitary necrosis causing hypopituitarism, with failure of lactation often the earliest sign.

Why is "Levothyroxine, then hydrocortisone after a week" not the answer?

Thyroxine first speeds cortisol metabolism and can unmask or worsen adrenal insufficiency.

Why is "Oestrogen-progestin therapy alone" not the answer?

Sex hormone replacement does not address the life-threatening deficiencies.

Why is "Levothyroxine alone" not the answer?

Thyroxine alone leaves life-threatening cortisol deficiency untreated.

What concept does this question test?

It tests Endocrinology: Sheehan syndrome in General Medicine. Glucocorticoid is replaced before thyroxine, because thyroid hormone increases cortisol clearance and can precipitate an adrenal crisis in an unreplaced patient. Levothyroxine is titrated to free T4, as TSH is unreliable.

How hard is this question?

We tag it as a multi-step question: it asks you to combine more than one idea. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Endocrinology: Sheehan syndrome?

For each disease know the classic presentation, the best test, and the first-line treatment. Then use the flashcards and the other General Medicine questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.