15 Year Old Girl with Hirsutism


Question

Here I send my question about the girl with hirsutism once more, now with the units of the laboratory tests. . She is 15-years old.Her problem is hirsutism. She has a beard, hair on chest, back and lower abdomen and limbs. She has developed and grown up normally, menarche at age of 13. Last menstrual periods 7 months ago. With dydrogesterone 10 mg for 10 days, one day uternal bleedinq. No family history of hirsutism. Hirsutism started two years ago. Height 160 cm, weight, 58 kg. No signs of Cushing syndrome. Blood pressure normal. On abdominal ultrasound scan, uterus and ovaries normal. Here are her laboratory test results: Prolaktin 55.76 ng/ml ( 3.26-29.12 ng/ml) TSH 2,1 mU/l T4 1,37 pmol/l Testosterone 4.2 nmol/l (0.3-1.4 nmol/l) DHEAS 418 mikrog/dl (39-288 mikrog/dl) 17-Hydroksiprogesteron 0.3 ng/ml ( 0.3-1 ng/ml) There are Prolactin, testosteron and DHEAS elevated. 17-hydroksi progesterone was normal so it not CAH? Is this PCOS? What do you advice? Thank you for your help! Dr. Heli Efendi

Response

The case you describe has features both typical for and atypical of PCOS. The following are consistent with PCOS: peripubertal onset, vaginal bleeding upon challenge with progestin, and elevation of testosterone level. The one feature that raises concern for another diagnosis (CAH has been excluded, Cushing’s seems unlikely) is the magnitude of the elevation of the testosterone level and the fact that she may have some evidence of virilization (does she have clitoromegaly or temporal balding? Any changes in muscle bulk?). This raises concern for the relatively rare conditions of hyperthecosis or ovarian neoplasm. The ultrasound findings are reassuring in this regard, but may not be definitive. The elevated prolactin level can be seen in PCOS and is thought to be due to a combination of increased GnRH pulse frequency and/or the effects of estrone to sensitize the lactotropes to the GnRH stimulus. In short, you may wish to consider more detailed imaging of the ovaries with CT or MRI. If these are negative, I would feel comfortable with the diagnosis of PCOS.

Treatment is most likely to involve an oral contraceptive with or without the addition of an antiandrogen. Here we would use Yasmin (an OCP that contains drosperinone). If cyproterone acetate (Diane) is available, this would be another good choice. I hope that this provides you with some useful suggestions. David Ehrmann, M.D.,The University of Chicago