A 26-year-old G0P0 comes to your office with a chief complaint of being “too hairy.” She reports that her menses started at the age of 13 years, and have always been very irregular, occurring every 2 to 6 months. She also complains of acne, but reports no other medical problems. Her only surgery was an appendectomy at the age of 8 years. Her height is 5 ft 5 in, her weight is 180 lb, and her blood pressure is 100/60 mm Hg. On physical examination, there are a few coarse, dark hairs around the nipples, chin, and upper lip. No galactorrhea, thyromegaly, or temporal balding is noted. Pelvic examination is normal and there is no evidence of clitoromegaly.
Which of the following is the most likely explanation for this patient’s problem?
PCOS is the most common cause of androgen excess and hirsutism. Women with this syndrome often have irregular menstrual cycles due to anovulation. Given the history and physical examination in this patient, PCOS is the most likely diagnosis. Sertoli-Leydig cell tumors, also known as androblastomas, are testosterone-secreting ovarian neoplasms. These tumors usually occur in women between the ages of 20 and 40, tend to be unilateral, and can reach a size of 7 cm to 10 cm. Women with a Sertoli-Leydig cell tumor tend to have very high levels of testosterone (> 200 ng/dL) and rapidly develop virilizing characteristics such as temporal balding, clitoral hypertrophy, voice deepening, breast atrophy, and terminal hair between the breasts and on the back. A total testosterone level can help differentiate between PCOS (elevated testosterone, but not as high as with a Sertoli-Leydig cell tumor). Very high levels of total testosterone would indicate the presence of an androgen-secreting ovarian tumor. Elevated levels of DHEA-S would be consistent with PCOS. There is no role for ordering an isolated estrone level in the workup and evaluation of hirsutism. Women with idiopathic hirsutism have greater activity of 5α-reductase than do unaffected women. They have hirsutism with a diagnostic evaluation that gives no explanation for the excess hair. Women with late-onset congenital adrenal hyperplasia are hirsute due to an increase in adrenal androgen production caused by a deficiency in 21-hydroxylase. In order to rule out congenital adrenal hyperplasia caused by a deficiency in 21-hydroxylase, a 17α-hydroxyprogesterone level should be drawn. Thyroid dysfunction and hyperprolactinemia can both be associated with hirsutism, and therefore it is important to check levels of TSH and prolactin.
Which of the following blood tests has no role in the evaluation of this patient?
A patient in your practice calls you in a panic because her 14-year-old daughter has been bleeding heavily for the past 2 weeks. The daughter experienced menarche about 6 months ago, and since that time her periods have been irregular and very heavy. You instruct the mother to bring her daughter to the emergency department so that you can evaluate her. When they arrive, you note that she appears fatigued. Her blood pressure and pulse are 110/60 mm Hg and 70 beats per minute, respectively. When you stand her up, her blood pressure and pulse remain stable. While in the emergency room, you obtain a more detailed history. She reports no medical problems or prior surgeries, and is not taking any medications. She says that she has never been sexually active. On physical examination, her abdomen is soft and nontender. She will not let you perform a speculum examination, but the bimanual examination is normal. She is 5 ft 4 in tall and weighs 95 lb.
Which of the following blood tests is not indicated in the evaluation of this patient?
The case presented is a typical representation of a patient with AUB due to ovulatory dysfunction.
This is a very common etiology of AUB during adolescence. The onset of menarche in young women is typically followed by approximately 12 to 18 months of irregular cycles that result from anovulation secondary to immaturity of the hypothalamic-pituitary-gonadal axis. Obesity is becoming an increasingly important contributor to anovulatory cycles in adolescents. The differential diagnosis for AUB in the adolescent patient is similar to that of other age groups, except that the risk of endometrial hyperplasia or malignancy is very low. Pregnancy should always be considered as a possible cause in all women of reproductive age. Appropriate laboratory tests to order in the emergency department would be a BHCG (to rule out pregnancy), a bleeding time (20% of adolescents with dysfunctional uterine bleeding have a coagulation defect, most commonly Von Willebrand disease), and blood type and screen (since she is orthostatic she may require a blood transfusion). A CBC will show the degree of blood loss this patient has suffered. Measuring an estradiol level would serve no purpose in the workup of this patient. Adolescents with chronic anovulation will typically respond well to outpatient therapy, most commonly oral contraceptives. If the patient is hemodynamically unstable, cannot tolerate outpatient management, or is symptomatic from anemia, a brief hospitalization with high dose estrogen may be necessary. In this patient, since she is clinically stable, outpatient treatment with combined oral contraceptives is the most appropriate therapy. It is reasonable to prescribe an OCP taper to try to stop the acute bleeding. There are many ways to do this taper, but one option is to recommend one tablet three times a day for 3 days, one tablet twice a day for 3 days, and then on to one tablet per day. Admission for treatment is not necessary since she is clinically and hemodynamically stable.
What is the most appropriate next step in management?
A 32-year-old P0 morbidly obese diabetic woman presents to your office with a chief complaint of prolonged vaginal bleeding. Her periods were regular, monthly, and light until 2 years ago. At that time, she started having periods every 3 to 6 months. Her last normal period was 5 months ago. She started having vaginal bleeding again 3 weeks ago. It started as light bleeding, but over the last week, she has been bleeding heavily and passing large clots. On pelvic examination, the external genitalia is normal. The vagina is filled with blood and large clots. A large clot is seen protruding through the cervix. On bimanual examination, the uterus is at the upper limit of normal size, and the ovaries feel normal. Her urine pregnancy test is negative.
Which of the following is the most likely cause of her abnormal uterine bleeding (AUB)?
This patient presents an example of chronic anovulation in an older woman. She gives a classic history of changing from regular, monthly periods to irregular, infrequent episodes of vaginal bleeding. Patients with chronic anovulation often have underlying medical problems such as diabetes, thyroid problems, or PCOS. A patient with uterine fibroids may have heavy periods, but the regularity of the periods is usually not affected unless the patient has underlying ovulatory dysfunction. A cervical polyp would typically be seen on physical examination and, like uterine fibroids, would not affect the timing of menstruation. Patients with cervical polyps often complain of bleeding in between periods, sometimes provoked by intercourse. Since the patient’s pregnancy test is negative, she cannot have an incomplete abortion. Patients with coagulation defects typically have problems with heavy periods from the time of menarche.
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