A 31-year-old female presents to the physician reporting a lack of menstrual periods for t… — USMLE Step 2 CK

A 31-year-old female presents to the physician reporting a lack of menstrual periods for the past 5 months. Prior to this, her menses occurred regularly every 29 to 32 days. Over the same 5-month period, she has noticed rapid growth of thick hair on her chin and chest, a noticeable deepening of her voice, and an increase in muscle mass. She has no significant past medical history and takes no medications. Her vital signs include a blood pressure of $122/76$ mm Hg, heart rate of $74$ /min, and respiratory rate of $14$ /min. Her BMI is $22 \text{ kg/m}^2$ . Physical examination reveals temporal hair thinning, coarse terminal hairs on the face and sternum, and significant clitoral enlargement. A point-of-care urine pregnancy test is negative. Which of the following is the most appropriate next step in the diagnosis of this patient?

Measurement of serum testosterone and dehydroepiandrosterone sulfateCevap
B
Prescription of a combined estrogen-progestin contraceptive
C
Measurement of serum thyroid-stimulating hormone and prolactin
D
Outpatient tissue sampling of the uterine lining
E
Administration of an oral progestin to induce withdrawal bleeding

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 signs of frank virilization (clitoromegaly, deepening of the voice, temporal balding, and increased muscle mass) that have developed rapidly over a short 5-month period. This clinical picture is a classic presentation for an androgen-secreting neoplasm of either the ovaries (such as a Sertoli-Leydig cell tumor) or the adrenal glands. The essential first step in evaluating rapid-onset virilization is measuring serum testosterone and DHEAS levels to biochemically differentiate the source before obtaining targeted imaging. A markedly elevated testosterone level typically indicates an ovarian tumor, whereas a significantly elevated DHEAS level suggests an adrenal tumor.

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Assess the timeline and severity of the patient's presenting symptoms.

The patient has secondary amenorrhea paired with rapid-onset virilization (deep voice, clitoromegaly, male-pattern hair loss) over a short 5-month period.

Differentiating between chronic hyperandrogenism (like PCOS) and rapid, severe virilization is crucial for identifying potential malignancies.

Determine the most likely etiology based on the clinical presentation.

Rapid-onset frank virilization in a reproductive-aged female is highly suspicious for an androgen-secreting tumor of the ovary or the adrenal gland.

Benign conditions like PCOS typically present with a slow, chronic course of hirsutism starting around menarche, without frank virilization.

Select the appropriate initial diagnostic evaluation.

Measurement of serum testosterone and dehydroepiandrosterone sulfate (DHEAS) is indicated.

Markedly elevated testosterone suggests an ovarian source (e.g., Sertoli-Leydig cell tumor), while markedly elevated DHEAS points to an adrenal source, which dictates the subsequent imaging choice.

Anahtar Kavram

Evaluation of rapid-onset virilization and secondary amenorrhea

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