MKSAP: 32-year-old woman is evaluated for increased hair growth

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 32-year-old woman is evaluated for increased hair growth on the face and chest and a 3-month history of irregular menses. She has a 5-year history of hypothyroidism. Her only medication is levothyroxine.

On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 110/72 mm Hg, and pulse rate is 80/min; BMI is 26. Terminal hair growth of the upper lip, chin, sides of the face, and middle of the chest is noted. No acanthosis nigricans or galactorrhea is detected. Palpation of the abdomen reveals no masses. Pelvic examination reveals clitoromegaly.

Laboratory studies:

Dehydroepiandrosterone sulfate 2.78 µg/mL (7.5 µmol/L)
Prolactin 17 ng/mL (17 µg/L)
Total testosterone 279 ng/dL (9.7 nmol/L)
Thyroid-stimulating hormone 1.5 µU/mL (1.5 mU/L)

Which of the following is the most appropriate next diagnostic test?

A: Adrenal CT
B: Free testosterone measurement
C: Pituitary MRI
D: Transvaginal ultrasonography

MKSAP Answer and Critique

The correct answer is D: Transvaginal ultrasonography.

The most appropriate next diagnostic test is transvaginal ultrasonography to examine this patient’s ovaries. Her history and physical examination findings are consistent with hyperandrogenism. Her total testosterone level is elevated, and her dehydroepiandrosterone sulfate (DHEAS) level is normal. In healthy women, the ovaries and adrenal glands contribute equally to testosterone production. However, a testosterone level greater than 200 ng/dL (6.9 nmol/L) in a woman with rapid onset of hyperandrogenic symptoms (increased hirsutism in a short period of time and clitoromegaly) suggests an ovarian neoplasm, which is best diagnosed with a transvaginal ultrasound.

Dehydroepiandrosterone is produced primarily in the adrenal glands and is sulfated in the adrenal glands, liver, and small intestine to become DHEAS. Levels greater than 7.0 micrograms/mL (18.9 micromoles/L) strongly suggest an adrenal source of androgens. In this patient, whose DHEAS level is only 2.9 micrograms/mL (7.8 micromoles/L), imaging of the adrenals would be the next step only if the transvaginal ultrasound showed no ovarian neoplasm.

A free testosterone measurement is not needed because this patient’s history and physical examination findings do not suggest an abnormality in her sex hormone–binding globulin level that would make the total testosterone measurement suspect.

Because elevated androgen levels in women have either an ovarian or an adrenal source, a pituitary MRI would not be useful in this patient.

Key Point

  • In a woman with rapid onset of hyperandrogenic symptoms, especially if her testosterone level is greater than 200 ng/dL (6.9 nmol/L), an ovarian neoplasm is likely and is best diagnosed with a transvaginal ultrasound.

This content is excerpted from MKSAP 16 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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