A 26-year-old woman comes to the office due to concerns about worsening symptoms of polycystic ovary syndrome (PCOS). The patient was diagnosed with PCOS 6 years ago after evaluation of abnormal uterine bleeding and lip and chin hair. She was prescribed daily combined estrogen/progestin oral contraceptives, which regulated her menses. However, for the last 2 months, she has had irregular menstrual bleeding despite taking her pills as directed. The patient has had no changes in hair growth, weight gain, or galactorrhea but has noticed some deepening in her voice. She has no other chronic medical conditions and takes no other daily medications. Blood pressure is 132/84 mm Hg, and pulse is 78/min. BMI is 33 kg/m². Velvety, pigmented plaques are on the back of the neck and the axilla. A few coarse hairs are noted on the upper lip and chin. Multiple small comedones are on the forehead but not on the chest or upper back. The abdomen is soft and nontender with no palpable masses or terminal hair. An ultrasound is ordered due to suspicion of an ovarian tumor. Which of the following findings is most concerning for an ovarian tumor in this patient?

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11ec25c8_d9d7_10de_bc81_cb71f12313e3_MD0003_00 This patient had previously well-controlled polycystic ovary syndrome (PCOS) based on the regulation of menses with combined estrogen/progestin oral contraceptives. Her new onset of abnormal uterine bleeding despite therapy (ie, worsening symptoms) is unusual for PCOS and requires evaluation for an alternate etiology of her symptoms. The most likely cause of this patient's symptoms is an androgen-secreting tumor considering her new-onset voice deepening, a sign of virilization (ie, severe hyperandrogenism). Voice deepening is a common (and possibly irreversible) sign of frank virilization as excess androgens (eg, testosterone >150 ng/dL, dehydroepiandrosterone sulfate [DHEAS] >700 µg/dL) lengthen and thicken the vocal cords, thereby changing their acoustic frequency and changing the voice. Other clinical features of virilization include male-pattern baldness (eg, temporal hair loss), increased muscle bulk, and clitoromegaly. Patients with virilization require evaluation for ovarian and adrenal sources of androgen production with total testosterone, 17-hydroxyprogesterone, and DHEAS levels. This patient's virilization and ovarian mass are most likely due to a Sertoli-Leydig cell tumor, a type of sex cord-stromal tumor that secretes high testosterone levels. (Choice A) Acanthosis nigricans causes a velvety hyperpigmentation of intertriginous areas (eg, neck, axillae). Although it is often seen concurrently with hirsutism in patients with PCOS, acanthosis nigricans is due to insulin resistance (eg, diabetes mellitus), rather than hyperandrogenism. Acanthosis nigricans (Choice B) Hirsutism, hair growth in an androgen-dependent distribution (eg, chest, back, abdomen), is common in women with PCOS due to slight elevations in testosterone levels, and typically progresses gradually (ie, over years). In contrast, patients with an androgen-secreting tumor typically have a rapid onset of worsening hirsutism (over a few months) often associated with male-pattern baldness. Hair on the upper lip and chin (as in this patient) is a normal variant and chronic. (Choice D) Androgens can stimulate sebaceous glands and cause nodulocystic acne (particularly on the back and chest); however, acne is not a sign of virilization. In addition, this patient's forehead comedones are a mild, normal form of acne. (Choice E) Although menstrual irregularities are seen with androgen-secreting tumors, they are not specific, as irregular cycles occur with other endocrine and metabolic etiologies (eg, thyroid, PCOS). Educational objective: Clinical features of an androgen-secreting tumor (eg, Sertoli-Leydig cell tumor) include signs of frank virilization such as voice deepening, male-pattern baldness, increased muscle bulk, and clitoromegaly. References: Ovarian Sertoli-Leydig tumor: a tricky tumor. (http://www.ncbi.nlm.nih.gov/pubmed/29398147) Ovarian sex cord-stromal tumors. (http://www.ncbi.nlm.nih.gov/pubmed/27858560)

A 26-Year-Old Woman Comes to the Office Due to Concerns