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Zorluk: OrtaReproductive Endocrinology and Infertility

A married couple presents to the reproductive endocrinology clinic seeking assistance with conception after actively trying for 16 months without success. The female partner, who is 32 years of age, states that her menstrual cycles were previously regular but have occurred only three times in the past year. During this period, she has developed significant, dark hair growth on her face, chest, and lower abdomen. She is particularly distressed because she recently noticed a distinct deepening of her voice and a receding hairline. Physical examination reveals a body mass index of 22 kg/m². Pelvic examination demonstrates marked clitoromegaly. A urine β-hCG test is negative. Which of the following is the most appropriate initial laboratory evaluation for this patient?

  1. Measurement of serum testosterone and dehydroepiandrosterone sulfateCevap
  2. B
    Assessment of fasting blood glucose and a serum lipid profile
  3. C
    Measurement of serum thyroid-stimulating hormone and prolactin
  4. D
    Measurement of serum 17-hydroxyprogesterone
  5. E
    Assessment of the luteinizing hormone to follicle-stimulating hormone ratio

Cevap

Measurement of serum testosterone and dehydroepiandrosterone sulfate
The patient's presentation of rapid-onset voice deepening, temporal balding, and clitoromegaly indicates severe virilization. Unlike simple hirsutism (excess terminal body hair in a male pattern), virilization implies massively elevated androgen levels, which are highly suspicious for an androgen-secreting tumor. The initial evaluation must include serum testosterone (to screen for an ovarian tumor source, such as a Sertoli-Leydig cell tumor) and dehydroepiandrosterone sulfate (DHEAS, to screen for an adrenal source, such as an adrenal adenoma or carcinoma).

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1
Identify the core clinical presentation.
The patient has oligomenorrhea, infertility, and signs of severe virilization (voice deepening, temporal balding, clitoromegaly) developing rapidly over one year.
Establishing the severity and timeline of hyperandrogenism is crucial for the differential diagnosis.
2
Differentiate between simple hirsutism and true virilization.
The presence of clitoromegaly and voice changes confirms true virilization, which is a red flag.
Simple hirsutism suggests benign conditions like Polycystic Ovary Syndrome (PCOS), whereas true, rapid-onset virilization suggests an androgen-secreting tumor.
3
Determine the appropriate diagnostic workup for the suspected etiology.
To evaluate a suspected androgen-secreting tumor, the source (ovarian versus adrenal) must be determined.
Testosterone is primarily secreted by the ovaries, while dehydroepiandrosterone sulfate (DHEAS) is specifically secreted by the adrenal glands. Measuring both identifies the tumor's location.

Anahtar Kavram

Evaluation of Severe Hyperandrogenism and Virilization
Tahmini Süre:1m 15s
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Konular

Reproductive Endocrinology and Infertility

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