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Zorluk: KolayMenstrual Cycle Abnormalities and Contraception

During a routine visit to the university health center, a 24-year-old female college student reports that she has not had a menstrual period for the past 5 months. She previously experienced predictable 28-day cycles. Additionally, she expresses significant distress over rapidly worsening, dark hair growth on her face and chest that began roughly at the same time her periods stopped. Recently, she also noticed that her voice has become noticeably deeper. She takes no medications and has no significant past medical history. Vital signs are temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, pulse 78/min, and respirations 14/min. BMI is 24 kg/m². A urine pregnancy test is negative. Physical examination reveals terminal hair on the chin and abdomen, temporal balding, and clitoromegaly. Bimanual pelvic examination is unremarkable. Which of the following is the most appropriate next step in management?

  1. Measurement of serum testosterone and dehydroepiandrosterone sulfateCevap
  2. B
    Initiation of combined oral contraceptives
  3. C
    Performance of an endometrial biopsy
  4. D
    Measurement of serum free thyroxine without thyroid-stimulating hormone
  5. E
    Prescription of oral minocycline

Cevap

Measurement of serum testosterone and dehydroepiandrosterone sulfate
The correct answer is the measurement of serum testosterone and dehydroepiandrosterone sulfate (DHEAS). This patient presents with secondary amenorrhea and rapid-onset (5 months) hirsutism accompanied by signs of severe virilization, including temporal balding, a deepening voice, and clitoromegaly. While polycystic ovary syndrome (PCOS) is the most common cause of hirsutism and irregular menses in young women, it typically has a slow, gradual onset starting near menarche and rarely causes severe virilization. A rapid onset of virilization is a major red flag for an androgen-secreting tumor. Therefore, the immediate next step in management is to measure serum testosterone (which is typically markedly elevated in ovarian tumors) and DHEAS (which is typically markedly elevated in adrenal tumors). These initial laboratory values will guide further imaging to locate the neoplasm.

Adım Adım Çözüm

1
Analyze the patient's presenting symptoms and timeline.
The patient has secondary amenorrhea, new-onset hirsutism, and severe virilization (clitoromegaly, deepening voice) that developed rapidly over 5 months.
Establishing the pace and severity of hyperandrogenism is critical for determining the underlying etiology.
2
Differentiate the clinical picture from common, benign causes of irregular menses.
The presentation is inconsistent with classic polycystic ovary syndrome (PCOS), which typically features a gradual onset beginning around menarche and lacks severe virilizing signs.
Rapid onset and marked virilization strongly suggest an autonomous androgen-secreting neoplasm.
3
Select the diagnostic test to localize the source of excess androgens.
Serum testosterone (to evaluate for an ovarian source) and dehydroepiandrosterone sulfate (DHEAS, to evaluate for an adrenal source) are indicated.
These laboratory markers guide subsequent imaging (pelvic ultrasound vs. abdominal CT) to locate and surgically remove the tumor.

Anahtar Kavram

Evaluation of rapid-onset hyperandrogenism and severe virilization requires immediate screening for androgen-secreting tumors of the ovaries or adrenal glands.
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Menstrual Cycle Abnormalities and Contraception

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