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Difficulty: MediumEndocrinology and Metabolism

A 24-year-old woman is brought to the endocrinology clinic by her sister due to distressing changes in her appearance over the past three months. She has developed thick, dark hair on her chin and chest, and she notes her voice has become noticeably deeper. Her menstrual periods, previously regular, have been absent for four months. She takes no medications. Her blood pressure is 118/76 mmHg and her body mass index is 23 kg/m223 \text{ kg/m}^2. Physical examination reveals severe hirsutism, cystic acne on her back, temporal hair thinning, and clitoromegaly. A bedside pelvic ultrasound demonstrates multiple small follicles peripherally arranged in both ovaries. Which of the following is the most appropriate next step in management?

  1. Measurement of serum testosterone and dehydroepiandrosterone sulfateAnswer
  2. B
    Initiation of a combined estrogen-progestin oral contraceptive
  3. C
    Measurement of early morning 17-hydroxyprogesterone
  4. D
    Computed tomography scan of the abdomen and pelvis
  5. E
    Reassurance and initiation of spironolactone

Answer

Measurement of serum testosterone and dehydroepiandrosterone sulfate
The correct answer identifies the essential initial biochemical workup for suspected androgen-secreting tumors. Rapid-onset virilization (deep voice, clitoromegaly) requires measuring testosterone (to check for ovarian tumors) and DHEAS (to check for adrenal tumors) to guide subsequent targeted imaging.

Step-by-Step Solution

1
Analyze the patient's symptoms and time course.
The patient has a 3-month history of rapid-onset hyperandrogenism with signs of true virilization, including a deepened voice, temporal balding, and clitoromegaly.
Differentiating between simple hirsutism and frank virilization is the critical first step in evaluating hyperandrogenism.
2
Differentiate benign etiologies from potential malignancies.
Benign causes like PCOS present with a gradual onset of hirsutism. Rapid-onset virilization is a red flag that strongly suggests an androgen-secreting tumor.
Recognizing red flags prevents inappropriate symptomatic treatment and prompts urgent diagnostic workup.
3
Determine the appropriate diagnostic sequence for a suspected androgen-secreting tumor.
Biochemical testing with serum testosterone and DHEAS must precede imaging to localize the tumor's origin (ovarian vs. adrenal).
Elevated testosterone points to an ovarian source (indicating pelvic ultrasound), whereas elevated DHEAS points to an adrenal source (indicating adrenal CT).

Key Concept

Rapid-onset virilization in a female patient requires immediate evaluation for an androgen-secreting tumor by measuring serum testosterone and DHEAS levels to localize the source before imaging.
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Topics

Endocrinology and Metabolism

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