A 27-year-old woman comes to the office due to a 2-month history of dark hair growth on her cheeks, chin, and upper lip. Her last menstrual period was 12 weeks ago, but she did not seek medical care because a home pregnancy test was negative. The patient is gravida 0 para 0; her menstrual cycles began at age 11 and have previously been regular. She has no associated weight changes, visual disturbances, skin striae, headaches, or proximal muscle weakness. She takes no medications, including over-the-counter medications. Family history is unremarkable. Physical examination shows a BMI of 24 kg/m². Her skin is oily with acne on the forehead and cheeks. Dark terminal hairs are noted on the upper lip, cheeks, chin, chest, and lower abdomen. Examination of the genitals shows clitoromegaly. Abdominal examination is normal. Pelvic ultrasound reveals a normal uterus and ovaries. CT scan of the abdomen reveals a left adrenal mass. Which of the following patterns of plasma hormone levels is likely to be present in this patient?

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Quizplus · Accepted Answer

11ec25c8_d12d_332a_bc81_2707315b3021_MD0003_00 Women normally produce a number of androgens, including testosterone (T), androstenedione (AS), dehydroepiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DHEAS). AS, DHEA, and T are produced by both the ovaries and the adrenals. In contrast, DHEAS is produced predominantly in the adrenal glands. This patient has an adrenal mass with rapidly progressive (ie, over weeks) hirsutism (excess terminal hair growth) and virilization (eg, clitoromegaly), suggesting very high androgen levels due to an androgen-producing neoplasm. Most androgen-producing adrenal tumors overproduce DHEAS. Although DHEA and DHEAS are used as diagnostic markers, they have negligible androgenic activity, and the clinical features are due to the conversion of DHEA and DHEAS to more potent androgens (ie, AS and T). Therefore, this patient would most likely have elevated DHEAS and T levels. LH would be low due to negative feedback by T. (Choice B) Low androgen with low LH levels would be seen in hypopituitarism with hypogonadotropic hypogonadism, which can cause amenorrhea but would have other manifestations of ovarian insufficiency (eg, hot flashes, vaginal dryness) rather than hirsutism and virilization. (Choice C) Virilizing ovarian tumors can release large amounts of T, leading to suppression of LH release. DHEAS would be normal as adrenal androgen secretion is regulated primarily by ACTH rather than LH. However, this patient's pelvic ultrasound does not reveal an ovarian tumor. (Choice D) Polycystic ovary syndrome (PCOS) can cause hyperandrogenism with ovulatory dysfunction. T and LH would be increased, and some patients have increased adrenal androgen production as well. However, this patient's ovaries have normal morphology, and rapidly progressive hirsutism with virilization would be unusual in PCOS. (Choice E) Patients with idiopathic hirsutism have normal androgen and LH levels. However, symptoms would be more slowly progressive, and menstrual cycles would be normal. Educational objective: Rapidly progressive hirsutism with virilization suggests very high androgen levels due to an androgen-producing neoplasm. Elevated dehydroepiandrosterone sulfate levels are seen in androgen-producing adrenal tumors.

A 27-Year-Old Woman Comes to the Office Due to a 2-Month