A 19-year-old woman is evaluated for irregular menstrual cycles since menarche at 12 years of age, increasing amount of coarse facial hair, and acne. Symptoms have worsened since she stopped playing high school sports and subsequently gained weight. She is most concerned about the hair growth and acne. Medical history is otherwise unremarkable, and she takes no medications.
On physical examination, vital signs are normal. BMI is 31. She has coarse terminal hair on the upper lip and chin, acne on the face and back, and non-discolored striae on the abdomen. There is no galactorrhea and no other evidence of virilization such as deepening of the voice, clitoromegaly, or male pattern balding.
Laboratory studies show a total testosterone level of 73 ng/dL (2.5 nmol/L), a dehydroepiandrosterone sulfate level of 1.8 µg/mL (4.9 µmol/L), and a hemoglobin A1c of 5.4%. Other laboratory results are normal. Serum pregnancy test is negative.
In addition to exercise and weight loss, which of the following is the most appropriate next step in management?
A. Combined oral contraceptive therapy
C. Pelvic ultrasound
MKSAP Answer and Critique
The correct answer is A. Combined oral contraceptive therapy. This content is available to MKSAP 18 subscribers as Question 22 in the Endocrinology and Metabolism section. More information about MKSAP is available online.
This patient has ovulatory dysfunction with clinical and biochemical evidence of hyperandrogenism. While this is suggestive of polycystic ovary syndrome, this is a diagnosis of exclusion. The prolonged clinical course and absence of the more concerning findings of virilization also support the diagnosis of polycystic ovary syndrome. Given that this patient is most concerned about hirsutism and acne, oral contraceptive therapy is the first-line therapeutic agent. Oral contraceptive therapy suppresses gonadotropin secretion and resultant ovarian androgen production. Additionally, the estrogen component increases sex hormone-binding globulin resulting in less androgen bioavailability. Oral contraceptives that contain 30 to 35 µg of ethinyl estradiol appear to be more effective in managing hirsutism than formulations containing less ethinyl estradiol. Furthermore, oral contraceptive therapy reduces new terminal hair growth, improves acne, and regulates menses to prevent endometrial hyperplasia.
Metformin minimally effects hirsutism and is not recommended for this indication. In patients with polycystic ovary syndrome, metformin could be considered for off-label treatment of prediabetes or treatment of type 2 diabetes, in addition to lifestyle modification.
Pelvic ultrasound and adrenal CT should be performed to exclude an ovarian or adrenal neoplasm if the serum total testosterone level is greater than 150 ng/dL (5.2 nmol/L), and adrenal CT is necessary to exclude an adrenal cortisol-secreting and/or androgen-secreting neoplasm if the plasma dehydroepiandrosterone sulfate (DHEAS) level is greater than 7.0 μg/mL (18.9 µmol/L). Pelvic ultrasound and adrenal CT are not indicated in this patient as her testosterone and DHEAS levels are not elevated to the degree that ovarian tumor is a consideration.
While spironolactone can reduce the growth of terminal hair, it is used as an add-on treatment to oral contraceptive therapy. This antiandrogen medication may disrupt organogenesis in a male fetus; thus, concomitant reliable contraception is mandated when initiating this treatment.
- Oral contraceptive agents are first-line pharmacologic therapy for hirsutism, acne, and menstrual dysfunction unless fertility is desired in a patient with polycystic ovary syndrome.