A 23-year-old woman comes to the office due to excess facial hair that she finds embarrassing. She has had this problem for years and has tried different methods of hair removal, with unsatisfactory results. The patient has no chronic medical conditions and has regular menstrual periods. She is not sexually active and takes no medications.
BMI is 29 kg/m². On physical examination, there is coarse, dark hair on her upper lip, chin, midsternum, and buttocks. The rest of the examination is unremarkable.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_97e5_09de_853d_7155acb7edad_MD0002_00 Nearly 5%-10% of women will develop hirsutism, defined as excess terminal hair growth (dark, coarse hair) in androgen-dependent areas (eg, chin, upper lip, upper abdomen, chest, back). Hirsutism should be differentiated from hypertrichosis, which is increased growth of light unpigmented hair in nonsexual areas that can be due to systemic conditions (eg, hypothyroidism) or medications (eg, phenytoin). Mildly increased facial hair is also seen in certain ethnicities (eg, Hispanic) and can be considered a normal variant. Common causes of hirsutism include polycystic ovary syndrome (PCOS), idiopathic hirsutism, and nonclassic 21-hydroxylase deficiency. PCOS is the most common and is associated with oligomenorrhea, obesity, type 2 diabetes mellitus, and dyslipidemia. All women with hirsutism require a serum total testosterone level to evaluate for an underlying androgen disorder. Additional testing (eg, 17-hydroxyprogesterone) may be required depending on additional clinical features (eg, irregular menses, virilization). Very high testosterone levels (>150 mg/dL) suggest a possible androgen-secreting ovarian tumor and require pelvic ultrasound (Choice B). (Choice A) Patients who do not wish to become pregnant are treated with combination estrogen/progestin oral contraceptive pills, which can reduce androgenic symptoms (eg, hirsutism, acne). Serum testosterone levels are measured first to rule out a more serious cause. (Choice D) Spironolactone is used as second-line therapy for hyperandrogenic symptoms that do not improve with oral contraceptives. (Choice E) Thyroid function tests can diagnose hypo- or hyperthyroidism. This patient has no other findings (eg, fatigue, weight changes) to suggest thyroid disease. Educational objective: Hirsutism is excess terminal hair growth in androgen-dependent areas (eg, chin, upper lip, upper abdomen, chest, back). All women with hirsutism require a serum total testosterone level to evaluate for possible underlying androgen disorders. __________ References: Evaluation and treatment of hirsutism in premenopausal women: an Endocrine Society clinical practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/18252793) The hirsute woman: challenges in evaluation and management. (http://www.ncbi.nlm.nih.gov/pubmed/21856600) Hirsutism: an evidence-based treatment update. (http://www.ncbi.nlm.nih.gov/pubmed/24889738)

A 23-Year-Old Woman Comes to the Office Due to Excess