A 26-year-old woman comes to the physician due to a 5-month history of absent menstrual periods and increased facial hair growth. She also reports a recent deepening of her voice and increased muscle mass. Her menstrual cycles had previously occurred every 28 to 30 days and lasted 5 days. Her blood pressure is 112/72 mmHg, pulse is 78/min, and body mass index is 23 kg/m². Physical examination reveals severe acne on the face and back, coarse terminal hair growth on the upper lip and chin, temporal balding, and clitoromegaly. Pelvic examination shows no palpable adnexal masses. A urine pregnancy test is negative. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?
- Measurement of serum testosterone and dehydroepiandrosterone sulfate levelsAnswer
- BMeasurement of serum 17-hydroxyprogesterone level
- CInitiation of combined oral contraceptive pills
- DMeasurement of serum prolactin and thyroid-stimulating hormone levels
- EEndometrial biopsy
Answer
Measurement of serum testosterone and dehydroepiandrosterone sulfate levels
The correct answer identifies the need to evaluate for an androgen-secreting tumor. The patient's severe, rapidly progressive symptoms of hyperandrogenism, specifically virilization (clitoromegaly, temporal balding, deepening of the voice, increased muscle mass), are red flags for an androgen-producing neoplasm. The most appropriate initial step is to measure serum total testosterone (predominantly ovarian origin) and dehydroepiandrosterone sulfate (DHEAS, predominantly adrenal origin). Markedly elevated testosterone suggests an ovarian source, prompting pelvic ultrasonography, while elevated DHEAS suggests an adrenal source, prompting abdominal CT.
Step-by-Step Solution
Key Concept
Patients with rapid-onset virilization must be evaluated for an androgen-secreting tumor of the ovary or adrenal gland using serum testosterone and DHEAS levels.