A 33-year-old woman presents to your office because of abnormal hair growth. She has noticed gradually increasing coarse hair on her upper lip, chin, and lower abdomen for the past 3 years. She notices mild facial acne but denies frontal balding or deepening of voice. Her menses are irregular, occurring every 28 to 60 days. She and her husband use condoms for contraception. They have no children. She uses over-the-counter benzoyl peroxide for the acne but otherwise takes no medications or supplements. On examination, her BMI is 29.0 and her waist circumference is 36 in. Her voice is normal; she has mild facial acne. There is mild acanthosis nigricans of the axillae. Pelvic examination is normal without ovarian mass or clitoromegaly. Evaluation of her hirsutism should include which of the following?
Abnormal growth of terminal hair in androgen-dependent areas in a woman is termed hirsutism. It is a common problem, affecting 5% to 10% of premenopausal women. Hirsutism should be distinguished from virilization, which includes frontal balding, deepening of the voice, and clitoromegaly in addition to hirsutism Virilization (especially of recent onset) is worrisome for an androgen producing tumor of the adrenal gland or ovary. Women with moderate hirsutism (as in this case) or any evidence of virilization should undergo endocrine testing with DHEA-S (to rule out adrenal androgen overproduction), testosterone (to rule out ovarian androgen overproduction), TSH, prolactin, and follicular phase 17-hydroxy progesterone (to rule out late-manifesting congenital adrenal hyperplasia).This woman likely has polycystic ovarian syndrome (PCOS). PCOS and idiopathic hirsutism are the two most common causes of hirsutism in women. PCOS is classically diagnosed with any 2 of these 3 criteria: oligomenorrhea (with anovulatory bleeding), clinical or biochemical evidence of hyperandrogenism (excluding other causes of hyperandrogenemia), and polycystic ovaries by ultrasound. Most women with PCOS will have elevated serum DHEA-S and testosterone concentrations; facial acne is common but full virilization is rare. Hyperinsulinemia and insulin resistance, seen clinically as acanthosis nigricans, are also common findings. Women with PCOS are at increased risk of metabolic syndrome, diabetes, and cardiovascular disease. Exercise and weight loss are first-line recommendations and may restore normal ovulation without medications. Treatment for women not pursuing pregnancy includes oral contraceptives (which improve the hirsutism) or metformin (which improves insulin resistance and often restores ovulatory periods).Although checking fasting blood glucose is reasonable, glucose tolerance test is not part of the first-line workup for hirsutism. The overnight dexamethasone suppression test is sometimes used for the diagnosis of Cushing syndrome, but in the absence of other features of hypercortisolism (ecchymoses, purplish abdominal striae) it would not be recommended. In addition, 24-hour urine free cortisol should be the first test for suspected Cushing syndrome. Women with testosterone levels of >200 ng/dL or DHEA-S levels of >700 mg/dL should have imaging of the ovaries and adrenal glands but ordering a CT scan of the adrenals would be premature until the hormone levels are available. Spironolactone (which has antiandrogenic as well as anti-mineralocorticoid properties) is often used to treat idiopathic hirsutism, but by definition patients with this condition have normal menses and normal androgen levels. Starting spironolactone before ruling out other, more serious conditions would be premature.
Glucose tolerance test
Serum testosterone and dehydroepiandrosterone-sulfate (DHEA-S) level
Overnight dexamethasone suppression test with 8 am cortisol level
CT scan of adrenals
Endocrinology