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Difficulty: EasyReproductive Endocrinology and Infertility

A 28-year-old nulligravid woman presents to the clinic with a 4-month history of rapidly worsening facial hair growth, deepening of her voice, and male-pattern baldness. She has not had a menstrual period for the past 5 months. Previously, her menses were regular, occurring every 28 days. Her body mass index is 23 kg/m2. Vital signs are within normal limits. Pelvic examination reveals clitoromegaly and a normal-sized, non-tender uterus. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Clinical diagnosis of polycystic ovary syndrome and initiation of oral contraceptives
  2. B
    Measurement of serum thyroid-stimulating hormone and prolactin levels
  3. Measurement of serum testosterone and dehydroepiandrosterone sulfate levelsAnswer
  4. D
    Endometrial biopsy to evaluate for endometrial hyperplasia
  5. E
    Reassurance that these are normal physiological changes of hormone fluctuation

Answer

Measurement of serum testosterone and dehydroepiandrosterone sulfate (DHEAS) levels.
The correct next step is evaluating serum androgen levels. Rapid-onset virilization (clitoromegaly, voice deepening, male-pattern baldness) over a short period of time is a classic red flag for an androgen-secreting tumor. Measuring testosterone (which is typically elevated in ovarian tumors) and dehydroepiandrosterone sulfate (which is exclusively produced by the adrenal glands and elevated in adrenal tumors) is necessary to confirm the hyperandrogenic state and localize the source before pursuing targeted imaging.

Step-by-Step Solution

1
Analyze the patient's presentation
The patient has a 4-month history of amenorrhea coupled with severe, rapidly progressive virilization (clitoromegaly, deepening of voice, male-pattern baldness).
Identifying the severity and timeline of hyperandrogenic symptoms is critical for differentiating benign from malignant etiologies.
2
Determine the most likely underlying etiology based on the timeline
Rapid-onset virilization is highly suspicious for an androgen-secreting neoplasm rather than a chronic condition like polycystic ovary syndrome.
Tumors produce extreme amounts of hormones autonomously and quickly, leading to severe physical changes that benign disorders typically do not cause.
3
Select the appropriate diagnostic workup
Measure serum testosterone and dehydroepiandrosterone sulfate (DHEAS) levels.
Elevated testosterone suggests an ovarian source (e.g., Sertoli-Leydig cell tumor), whereas elevated DHEAS points to an adrenal source. This guides subsequent imaging.

Key Concept

Rapid-onset hyperandrogenism with signs of virilization (clitoromegaly, voice deepening) requires immediate evaluation for an androgen-secreting tumor of the ovary or adrenal gland by measuring testosterone and DHEAS levels.
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Topics

Reproductive Endocrinology and Infertility

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