A 26-year-old nulligravid woman comes to the clinic reporting a lack of menstrual periods … — USMLE Step 2 CK

A $26$ -year-old nulligravid woman comes to the clinic reporting a lack of menstrual periods for the past $6$ months. Previously, her menstrual cycles were regular, occurring every $28$ days. Over the last $4$ months, she has noticed rapid development of severe acne, increased hair growth on her face and chest, and deepening of her voice. Her past medical history is notable for migraines with aura, for which she occasionally takes sumatriptan. She takes no other medications. Her blood pressure is $118/76$ mm Hg, pulse is $72$ /min, and BMI is $24$ kg/m $^2$ . Physical examination shows terminal hair on the upper lip, chin, and chest, as well as distinct clitoromegaly. A urine pregnancy test is negative. Serum thyroid-stimulating hormone (TSH) and prolactin levels are within normal limits. The patient asks if she can start a birth control pill to help regulate her periods and clear her acne. Which of the following is the most appropriate next step in management?

Measurement of serum testosterone and dehydroepiandrosterone sulfateAnswer
B
Prescription of combined oral contraceptives
C
Endometrial biopsy
D
Measurement of serum free thyroxine
E
Prescription of oral spironolactone

Answer

Measurement of serum testosterone and dehydroepiandrosterone sulfate

The correct next step is the measurement of serum testosterone and DHEAS. This patient's presentation of secondary amenorrhea accompanied by rapid-onset, severe virilization (clitoromegaly, deepening voice, receding hairline) over just

4

months is highly suspicious for an androgen-secreting tumor. Markedly elevated testosterone suggests an ovarian tumor, while elevated DHEAS suggests an adrenal tumor. Identifying the specific elevated hormone directs the subsequent imaging (pelvic ultrasound versus abdominal CT).

Step-by-Step Solution

Evaluate the timeline and severity of the patient's hyperandrogenic symptoms.

The patient exhibits rapid-onset (

4

months) and severe signs of virilization, including clitoromegaly and voice deepening.

Differentiating between the slow, progressive hirsutism typical of PCOS and the rapid, severe virilization characteristic of androgen-secreting tumors is critical for triaging the diagnostic workup.

Determine the diagnostic test required to evaluate for an androgen-secreting tumor.

Measurement of serum testosterone and dehydroepiandrosterone sulfate (DHEAS) is indicated.

Markedly elevated testosterone levels point toward an ovarian source (e.g., Sertoli-Leydig cell tumor), whereas markedly elevated DHEAS levels point toward an adrenal source (e.g., adrenal adenoma or carcinoma).

Review the patient's medical history for contraindications to her requested therapy (birth control pills).

The patient has a history of migraines with aura.

According to the WHO Medical Eligibility Criteria, estrogen-containing combined oral contraceptives are an unacceptable health risk (Category

4

) in patients with migraines with aura due to an elevated risk of ischemic stroke.

Key Concept

Patients presenting with rapid-onset, severe virilization (e.g., clitoromegaly, voice deepening) require immediate measurement of serum testosterone and DHEAS to rule out an androgen-secreting tumor of the ovary or adrenal gland.

Estimated Time:1m 30s

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