A 25-year-old woman comes to the office due to hair loss. For the past 6 months, she has noticed thinning hair on her head and an increased amount of hair in the shower drain. The patient is not currently sexually active but has had 5 lifetime partners. Menarche was at age 11. She has light periods every 35-50 days. She takes an over-the-counter sleep aid, but does not use tobacco, alcohol, or illicit drugs. The patient's mother is age 56 and has endometrial carcinoma; her paternal grandmother died from metastatic breast cancer diagnosed at age 72. Review of systems is negative except for extensive facial and back acne. BMI is 33 kg/m². Physical examination shows thinning hair at the forehead with a receding hairline. The thyroid is nonenlarged with no nodules. Cardiac examination shows a regular rate and rhythm; there are no murmurs. The abdomen is obese with no palpable masses. A urine pregnancy test is negative. Serum prolactin and thyroid function tests are normal. Which of the following additional tests is indicated in this patient?

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11ec25c8_d25c_64d3_bc81_75b9722d1260_MD0003_00 This patient has clinical evidence of hyperandrogenism, irregular menses, and obesity typical of polycystic ovary syndrome (PCOS). Hyperandrogenism is manifested by male pattern hair loss (eg, androgenic alopecia), hirsutism, and severe acne (eg, nodulocystic, acne on the back). These findings alone are sufficient to make a diagnosis of PCOS. In addition, ultrasound may show polycystic ovaries. Patients with PCOS are at increased risk for multiple comorbidities, including dyslipidemia, hypertension, and type 2 diabetes mellitus (eg, metabolic syndrome) and should undergo screening for these conditions. An oral glucose tolerance test is the gold standard for diagnosing type 2 diabetes mellitus in patients with PCOS as it is more sensitive in detecting glucose intolerance than standard screening tests (eg, fasting glucose, HbA1c). Due to obesity and metabolic syndrome, patients are at risk for developing obstructive sleep apnea, nonalcoholic fatty liver disease, and endometrial cancer. (Choice A) BRCA mutation testing is indicated for patients with a family history of ovarian cancer at any age or personal/family history of breast cancer at age ≤50 in a first-degree relative. It is not indicated for a family history of endometrial cancer or breast cancer at an advanced age. (Choice B) A diagnostic laparoscopy would demonstrate enlarged polycystic ovaries in a patient with PCOS, but it is not required for this diagnosis. Polycystic ovaries can also be incidental findings in some patients without hyperandrogenism or menstrual irregularities (eg, no PCOS). (Choice C) Excessive menstrual bleeding can cause iron deficiency, which in severe cases may lead to diffuse hair loss (eg, telogen effluvium). However, this patient has oligomenorrhea with minimal vaginal bleeding, making anemia unlikely. (Choice E) Rapid plasma reagin serology is used to detect syphilis, a sexually transmitted infection. Secondary syphilis may present with patchy or "moth-eaten" alopecia, but typical presentation also includes constitutional symptoms (eg, malaise, fever, weight loss) and a maculopapular rash. Educational objective: Polycystic ovary syndrome (PCOS) may present with androgenic alopecia (male-pattern hair loss), irregular menses, and obesity. Patients with PCOS are at increased risk of developing type 2 diabetes mellitus and should be screened with an oral glucose tolerance test. References: Pathophysiology, risk factors, and screening methods for prediabetes in women with polycystic ovary syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/27570464)

A 25-Year-Old Woman Comes to the Office Due to Hair