A 19-year-old woman comes to the office due to severe acne. She had expected the acne to improve after high school, but instead, it is worsening. The patient has tried multiple remedies without significant improvement. She is concerned that the acne is scarring her face. Since the patient started college last year, she has gained 13.6 kg (30 lb). She sings in a local church choir and has not noticed any voice changes. The patient has no chronic medical conditions, has had no surgeries, and takes no medications. BMI is 29 kg/m². Physical examination shows nodulocystic acne on the face, arms, back, and forehead. The scalp is normal, with no alopecia. Tanner stage is 5. There is no skin discoloration or striae. No masses are palpable on abdominal examination. A urine pregnancy test is negative. Which of the following additional information is required to establish the most likely diagnosis?

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11ec25c8_d0ca_a156_bc81_f5d29271087d_MD0003_00 Severe nodulocystic acne occurring on the arms and upper back is a sign of hyperandrogenism. A common cause of hyperandrogenism in young women, particularly in conjunction with obesity, is polycystic ovary syndrome (PCOS). In addition to either clinical (eg, severe acne, hirsutism, androgenic alopecia) or laboratory (eg, elevated serum testosterone) evidence of hyperandrogenism, the diagnosis of PCOS requires a history of irregular menses indicating anovulation and/or polycystic ovaries on ultrasound. When 2 of these 3 criteria are met and other causes of hyperandrogenism (eg, Cushing syndrome, nonclassical congenital adrenal hyperplasia) are excluded, the diagnosis of PCOS is established. Severe nodulocystic acne (Choice A) Autoimmune hypothyroidism is linked to family history and may cause irregular menses and weight gain. Typical skin findings are coarse hair, skin discoloration, and, occasionally, alopecia, not nodulocystic acne. (Choices B and C) Patients with eating disorders do not typically have signs of hyperandrogenism. In addition, there is no established causal relationship between certain foods and acne. (Choice D) Intravenous drug use may cause localized skin infections (eg, folliculitis) but not diffuse nodulocystic acne. (Choice F) The number of lifetime sexual partners is used to assess the risk for cervical dysplasia and sexually transmitted infections; it is not relevant in the differential diagnosis of acne. Educational objective: Severe nodulocystic acne may be the initial sign of hyperandrogenism in patients with polycystic ovary syndrome. The diagnosis is based on the presence of 2 of 3 manifestations: clinical or laboratory evidence of hyperandrogenism, menstrual irregularities, and polycystic ovaries on ultrasound. References: Genetic, hormonal and metabolic aspects of PCOS: an update. (http://www.ncbi.nlm.nih.gov/pubmed/27423183)

A 19-Year-Old Woman Comes to the Office Due to Severe