A 26-year-old woman comes to the office due to the absence of menstrual periods for the pa… — USMLE Step 2 CK

A $26$ -year-old woman comes to the office due to the absence of menstrual periods for the past $7$ months. Previously, she had regular $28$ -day cycles with normal bleeding. Over the same $7$ -month period, she has noticed worsening acne, increased thick hair growth on her face and abdomen, and a deepening of her voice. She has no significant past medical history and takes no medications. A urine pregnancy test obtained in the clinic is negative. Vital signs are temperature $36.8^\circ\text{C}$ , blood pressure $122/78 \text{ mmHg}$ , pulse $76/\text{min}$ , and respirations $14/\text{min}$ . BMI is $24 \text{ kg/m}^2$ . Physical examination reveals temporal hair thinning and terminal hair on the upper lip, chin, and linea alba. Pelvic examination shows clitoromegaly and a normal-sized, mobile uterus. Adnexae are difficult to palpate. 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
Measurement of serum thyroid-stimulating hormone and prolactin
D
Endometrial biopsy
E
Reassurance and clinical observation

Answer

Measurement of serum testosterone and dehydroepiandrosterone sulfate

The correct answer identifies that the patient is experiencing rapid-onset virilization, evidenced by clitoromegaly, a deepened voice, and temporal hair thinning over just

7

months. While hirsutism (increased body hair) can be seen in benign conditions like PCOS, true virilization is a red flag for an androgen-secreting tumor (ovarian or adrenal). The most appropriate next step in management is measuring serum testosterone and dehydroepiandrosterone sulfate (DHEAS) levels to differentiate between an ovarian and adrenal source before proceeding with targeted imaging.

Step-by-Step Solution

Analyze the patient's presenting symptoms and timeline.

The patient has secondary amenorrhea and rapid-onset virilization (clitoromegaly, deepening voice, temporal hair thinning) that developed over a short

7

-month period.

Establishing the pace and severity of symptom onset helps differentiate between benign hyperandrogenic states and malignant causes.

Differentiate the clinical picture from common benign etiologies like Polycystic Ovary Syndrome (PCOS).

PCOS typically presents with mild hirsutism and irregular menses starting around puberty with a slow, progressive course. True virilization (clitoromegaly, male-pattern balding, deepened voice) strongly points away from PCOS.

Rapid virilization in a reproductive-aged woman is the hallmark presentation of an androgen-secreting tumor.

Determine the next best step to investigate the suspected etiology.

Immediate biochemical localization of the androgen source using serum testosterone (typically elevated in ovarian tumors) and dehydroepiandrosterone sulfate (DHEAS) (typically elevated in adrenal tumors) is required.

Biochemical testing guides subsequent appropriate imaging (pelvic ultrasound vs. abdominal CT) to locate the mass.

Key Concept

Secondary amenorrhea accompanied by rapid-onset virilization (e.g., clitoromegaly, deepening voice) is highly suspicious for an androgen-secreting tumor and requires immediate evaluation with serum testosterone and DHEAS levels.

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