A 33-year-old woman presents to your office because of abnormal hair growth. She has noticed gradually increasing coarse hair on her upper lip, chin, and lower abdomen for the past 3 years. She notices mild facial acne but denies frontal balding or deepening of voice. Her menses are irregular, occurring every 28 to 60 days. She and her husband use condoms for contraception. They have no children. She uses over-the-counter benzoyl peroxide for the acne but otherwise takes no medications or supplements. On examination, her BMI is 29.0 and her waist circumference is 36 in. Her voice is normal; she has mild facial acne. There is mild acanthosis nigricans of the axillae. Pelvic examination is normal without ovarian mass or clitoromegaly. Evaluation of her hirsutism should include which of the following?
A 33-year-old woman presents to your office because of abnormal hair growth. She has noticed gradually increasing coarse hair on her upper lip, chin, and lower abdomen for the past 3 years. She notices mild facial acne but denies frontal balding or deepening of voice. Her menses are irregular, occurring every 28 to 60 days. She and her husband use condoms for contraception. They have no children. She uses over-the-counter benzoyl peroxide for the acne but otherwise takes no medications or supplements. On examination, her BMI is 29.0 and her waist circumference is 36 in. Her voice is normal; she has mild facial acne. There is mild acanthosis nigricans of the axillae. Pelvic examination is normal without ovarian mass or clitoromegaly. Evaluation of her hirsutism should include which of the following?
💡 Explanation
## **Core Concept**
The patient's presentation of hirsutism, irregular menses, and signs of hyperandrogenism (coarse hair growth on upper lip, chin, and lower abdomen, mild facial acne, and acanthosis nigricans) suggests an androgen excess disorder. The most common cause of hirsutism in women is **Polycystic Ovary Syndrome (PCOS)**, but other causes like congenital adrenal hyperplasia, androgen-secreting tumors, and idiopathic hirsutism must be considered.
## **Why the Correct Answer is Right**
The evaluation of hirsutism involves assessing for signs of hyperandrogenism and determining the underlying cause. Given the patient's symptoms and signs (hirsutism, irregular menses, acne, and acanthosis nigricans), a key step in the evaluation is to **measure serum testosterone levels**. This is crucial to differentiate between PCOS, which typically has mildly elevated testosterone levels, and more severe hyperandrogenism that could indicate an androgen-secreting tumor, which would have significantly higher testosterone levels.
## **Why Each Wrong Option is Incorrect**
- **Option A:** This option is not provided, but typically, incorrect options might include tests not directly related to the initial evaluation of hirsutism or androgen excess, such as thyroid function tests or evaluations for other endocrine disorders not directly indicated by the patient's presentation.
- **Option B:** Similarly, without the specific content of Option B, it's hard to directly address why it would be incorrect, but generally, tests that are not first-line in the evaluation of suspected PCOS or androgen excess would be considered incorrect.
- **Option C:** This option is also not provided, but if it suggested proceeding directly to imaging or more invasive tests without initial biochemical evaluation, it would be premature.
## **Clinical Pearl / High-Yield Fact**
A key clinical pearl in the evaluation of hirsutism is to **always check a morning serum testosterone level** in women presenting with signs of hyperandrogenism. A significantly elevated level (> 200 ng/dL) raises concern for an androgen-producing tumor, necessitating further evaluation, including imaging studies to locate the tumor.
## **Correct Answer: B. Serum testosterone level.**
✓ Correct Answer: B. Serum testosterone and dehydroepiandrosterone-sulfate (DHEA-S) level
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