A 27-year-old female presents to the gynecology clinic for contraceptive counseling. She r… — USMLE Step 2 CK

A $27$ -year-old female presents to the gynecology clinic for contraceptive counseling. She reports that she has not had a menstrual period for the past $7$ months. Previously, her menses were regular. Over the last $3$ months, she has noticed rapidly increasing coarse facial hair, worsening acne, and a deepening of her voice. She has a history of bipolar disorder, which has been well controlled on valproic acid for the past $2$ years. She and her partner do not desire pregnancy, and she requests a reliable form of contraception to start immediately.

Vital signs are:
Temperature: $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ )
Blood pressure: $118/76\text{ mmHg}$
Pulse: $78\text{/min}$
BMI: $28\text{ kg/m}^2$

Physical examination reveals coarse hair on her upper lip, chin, and chest. Temporal balding and clitoromegaly are clearly present. Pelvic examination is otherwise unremarkable.

Laboratory studies show:

Laboratory Test	Patient Result	Reference Range
Urine $\beta$ -hCG	Negative	-
Thyroid-stimulating hormone (TSH)	$0.3\text{ \mu U/mL}$	$0.5 - 5.0\text{ \mu U/mL}$
Free thyroxine (T4)	$0.6\text{ ng/dL}$	$0.9 - 1.7\text{ ng/dL}$
Prolactin	$12\text{ ng/mL}$	$< 25\text{ ng/mL}$

Pelvic ultrasonography demonstrates normal-sized ovaries with multiple small, peripherally arranged cysts bilaterally.

Before initiating a contraceptive method, which of the following is the most appropriate next step in the management of this patient?

Measurement of serum testosterone and dehydroepiandrosterone sulfate (DHEAS) levelsAnswer
B
Prescription of a combined oral contraceptive pill
C
Performance of an endometrial biopsy
D
Prescription of levothyroxine
E
Measurement of serum $17$ -hydroxyprogesterone levels

Answer

The correct answer is the measurement of serum testosterone and dehydroepiandrosterone sulfate (DHEAS) levels.

The most appropriate next step in management is the measurement of serum testosterone and dehydroepiandrosterone sulfate (DHEAS) levels. This patient presents with secondary amenorrhea and rapid-onset virilization, evidenced by clitoromegaly, temporal balding, and voice deepening occurring over just 3 months. While she is requesting a reliable form of contraception and her ultrasound shows polycystic-appearing ovaries, rapid virilization is a major red flag for an androgen-secreting tumor of the ovary (e.g., Sertoli-Leydig cell tumor) or adrenal gland. The WHO Medical Eligibility Criteria dictate that unexplained menstrual abnormalities and suspected underlying pathologies must be evaluated prior to initiating hormonal contraception. Measuring testosterone and DHEAS is the critical first step to identify the source of the excess androgens before any symptomatic treatment is given.

Step-by-Step Solution

Identify the primary clinical problem and red flag symptoms.

The patient has secondary amenorrhea and desires contraception, but crucially, she exhibits rapid-onset virilization (clitoromegaly, deepening voice, temporal balding) over just 3 months.

Distinguishing between simple hyperandrogenism (hirsutism, acne) and true virilization is critical, as rapid virilization is highly suspicious for a malignant androgen-secreting tumor.

Evaluate the proposed management strategies against the clinical presentation.

Although the patient requests contraception and has ultrasound findings resembling polycystic ovary syndrome (PCOS), her severe symptoms cannot be solely attributed to PCOS or valproic acid use.

An androgen-secreting tumor must be ruled out before initiating any treatments (such as combined oral contraceptives) that could delay diagnosis by artificially inducing withdrawal bleeds and masking symptoms.

Determine the most appropriate diagnostic test for the suspected etiology.

Measurement of serum testosterone and DHEAS is indicated as the immediate next step.

These tests differentiate between an ovarian tumor (which typically secretes markedly elevated testosterone) and an adrenal tumor (which typically secretes markedly elevated DHEAS), guiding subsequent targeted imaging.

Rule out other distractors based on laboratory findings.

The low free T4 is accompanied by a low TSH.

This indicates a central process or euthyroid sick syndrome (potentially due to cortisol co-secretion from an adrenal tumor), rather than primary hypothyroidism. Initiating levothyroxine is inappropriate without further evaluation of the pituitary-adrenal axis.

Key Concept

In patients presenting for contraception or menstrual irregularities with rapid-onset virilization, an androgen-secreting tumor must be ruled out with serum testosterone and DHEAS levels before initiating any hormonal therapies.

Estimated Time:2m 0s

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