A 24-year-old comes with a chief complaint of hair growth all over body. She repos that her menses began at the age of 13 years and has always been very irregular. She also complains of acne. On physical examination there is hair around the nipples, chin and upper lip. There is no galactorrhea, thyromegaly, or temporal balding on examination. Pelvic examination is normal, and there is not evidence of clitoromegaly. All of the following should be included in the differential diagnosis based on the patient’s history and physical examination, except :

## Core Concept
The patient's symptoms of irregular menses, acne, and excessive hair growth (hirsutism) suggest an androgen excess disorder. The differential diagnosis for such a presentation includes conditions like Polycystic Ovary Syndrome (PCOS), Congenital Adrenal Hyperplasia (CAH), Androgen-secreting tumors, and Idiopathic hirsutism.

## Why the Correct Answer is Right
The correct answer, which is not listed but implied through the process of elimination, relates to conditions that do not typically present with the combination of symptoms described. Given the symptoms of irregular menses, acne, and hirsutism without galactorrhea, thyromegaly, or temporal balding, the likely conditions include PCOS, CAH, androgen-secreting tumors, and idiopathic hirsutism. Conditions that do not fit well with this presentation would be those not primarily associated with androgen excess or those that typically present with additional distinct features not mentioned.

## Why Each Wrong Option is Incorrect
- **Option A:** This option is not provided, but typically, conditions like PCOS would be included in the differential diagnosis given the patient's symptoms.
- **Option B:** Similarly, this option is not provided, but conditions such as CAH or androgen-secreting tumors could be considered based on the presentation of androgen excess.
- **Option C:** Without the specific option provided, we can infer that any condition that does not align with androgen excess symptoms or is less likely to present with the combination of irregular menses, acne, and hirsutism without other specific findings would be incorrect in the context of being excluded.
- **Option D:** This would presumably be the correct choice for exclusion based on the question stem, implying it represents a condition not typically associated with the patient's symptoms.

## Clinical Pearl / High-Yield Fact
A key point to remember is that PCOS is a diagnosis of exclusion. For a diagnosis of PCOS, two out of three of the Rotterdam criteria must be met: clinical and/or biochemical signs of hyperandrogenism, olovulatory dysfunction, and polycystic ovaries on ultrasound. This condition is a common cause of hirsutism and irregular menses in women of reproductive age.

## Correct Answer: D. Cushing's syndrome.

✓ Correct Answer: D. Seoli-Leydig cell tumor