Review Note

A 26-year-old GOP0 comes to your office with a chief complaint of being too hairy. She reports that her menses started at age 13 and have always been very irregular. She has menses every 2 to 6 months. She also complains of acne and is currently seeing a dermatologist for the skin condition. She denies any medical problems. Her only surgery was an appendectomy at age 8. 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 is sparse hair 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?

• Idiopathic hirsutism
• Polycystic ovarian syndrome
• Late-onset congenital adrenal
• hyperplasia Sertoli-Leydig cell
• tumor of the ovary
• Adrenal tumor
  

Polycystic ovarian syndrome (PCOS) is the most common cause of androgen excess and hirsutism. Women with this syndrome often have irregular menstrual cycles. 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 and tend to be unilateral and reach a size of 7 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. Women with idiopathic hirsutism have greater activity of 5a-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 owing to an increase in adrenal androgen production caused by a deficiency in 21-hydroxylase.

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