Hirsutism, Hyperandrogenism, PCOS, Amenorrhea

Question 1

a progestin withdrawal test does what

Answer 1

induces mentrual bleeding in pts with amenorrhea if there’s not enough estrogen to prime the endometrium. They are given medoxyprogestrone for 5-10 days.

Question 2

causes of hirsutism in women

Answer 2

PCOS

idiopathic hirsutism

non classic 21 hydroxylase deficiency

androgen secreting ovarian tumor,

ovarian hyperthecosis

Cushings syndrome

Question 3

features of PCOS

and labs

Answer 3

oligomenorrhea,

hyperandrogenism,

obesity associated with DM2,

dyslipidemia,

obesity

and HTN

LABS: total testosterone will not be <150 or and DHEA-S is <1000

Question 4

features of idiopathic hirsutism

Answer 4

normal menstruation normal serum androgens

Question 5

non classic 21 hydroxylase deficiency clinical features

Answer 5

similar to PCOS elevated serum 17 hydroxyprogesterone

Question 6

androgen secreting ovarian tumors and ovarian hyperthecosis clinical features

Answer 6

more common in post menopausal women and rapidly progressive hirsutism with virilization very high serum androgens

seen in women >30 years

see total testosterone >150-200 DHEA-S level >2000

Question 7

Cushing’s syndrome

Answer 7

obesity (see face, neck, trunk abdomen) increased libido, virilization, irregular menses

Question 8

hirsutism should be differentiated from

Answer 8

hypertrichosis - increased growth of light unpigmented hair in nonsexual areas that can be due to systemic conditions like hypothyroidism, medications (phenytoin).

Can see increased facial hair that is seen in certain ethnicities (Hispanic) which can be normal variant.

Question 9

All women with hirsutism should get these labs:

Answer 9

serum total testosterone level to evalute underlying androgen disorder.

• may need 17 hydroxyprogesterone level depending if women has virilization and irregular menses.

Question 10

when do we get a pelvic ultrasound in the evaluation of hirsutism in women?

Answer 10

Very high testosterone >150 should get pelvic ultrasound to rule out androgen secreting ovarian tumor.

Question 11

hirsutism is

Answer 11

excess terminal hair growth in androgen dependent areas

(chin upper lip, upper abdomen, chest and back)

Question 12

causes of hirsutism in women are:

Answer 12

PCOS idiopathic hirsutism non classic 21 hydroxylase deficiency androgen secreting ovarian tumor, ovarian hypothecosis Cushing’s syndrome

Question 13

clinical features of PCOS?

Answer 13

oligomenorrhea,

hyperandrogenism,

obesity associated with DM2, HLD, and HTN

Question 14

clinical features of idiopathic hirsutism?

Answer 14

normal menstruation normal serum androgens see body hair

Question 15

clinical features of nonclassical 21 hydroxylase deficiency

Answer 15

similar to PCOS elevated serum 17 hydroxyprogesterone

Question 16

clinical features of androgen secreting ovarian tumor, ovarian hyperthecosis

Answer 16

more common in post menopausal women rapidly progressive hirsutism with virilization very high serum androgens

Question 17

clinical features of cushings dx

Answer 17

obesity (usually of the face, neck, trunk and abdomen) increased libido, virilization irregular menses

Question 18

virilization in women where is it seen?

Answer 18

frontal balding, voice deepening and clitoromegaly seen in androgen producing tumors of ovary or adrenal and non classical (late onset) congenital adrenal hyperplasia (CAH)

Question 19

triad of obesity, oligomenorrhea, hirsutism: think:

Answer 19

PCOS but other causes of hirsutisim and virilization should be ruled out by getting LH, FSH and prolactin and 17 hydroxyprogesterone level (to rule out androgen producing tumor or congenital adrenal hyperplasia)

Question 20

non classical (late onset) congenital adrenal hyperplasia (CAH) presentation

Answer 20

see deficiency in 21 hydroxylase enzyme deficiency. Pts have androgen excess with premature pubarche, acne, accelerated bone age, hirsuitism, mentrual irregularities in childhood and early adulthood. Usually no cortisol deficiency (unlike classic early onset CAH).

Question 21

who gets non classical (late onset) congenital adrenal hyperplasia (CAH)

Answer 21

Seen in younger pts teens and early adulthood Commonly seen in Ashkenazi Jewish, Italian, Slavic and hispanic pts.

Question 22

diagnosis of non classical (late onset) congenital adrenal hyperplasia (CAH)

Answer 22

elevated 17 hydroxyprogesterone basal levels >200 and confirmed by significant increase in 17 hydroxyprogesterone to >1000 after high dose ACTH (250 ug) administration

Question 23

when do we suspect androgen secreting tumors and what do we order to screen for it?

Answer 23

androgen secreting tumors are post menopausal women who get them will see elevated Testosterone level get a pelvic ultrasound.

Question 24

androgen excess, oligoovulation or anovulation obesity polycystic ovaries on U/S

Answer 24

clinical features of PCOS

Question 25

female pt with irregular menses to anovulation, who has acne, male patterned baldness, and mustasche hair, and is obese, should suspect:

Answer 25

PCOS - not rapid onset of androgenic hirsutism so don’t think of androgen secreting tumor.

Rather PCOS is a diagnosis of exclusion.

Question 26

pathophysiology behind PCOS is

Answer 26

See GnRH pulses and so see more LH being made which decreases FSH production. See excess LH and not enough FSH which results in excessive ovarian androgen production and ovulatory dysfunction. High androgens causes hirsutism. Also see insulin resistance which also increases estrogen production and prevents ovulation.

Labs: total testosterone will be elevated but <150. DHEAS will be elevated. LH:FSH 2:1 or imbalanced.

When treating PCOS, OCPs decrease free or bioavailable testosterone levels (via increased sex hormone binding globulin) and suppresses LH secretion resulting in reduced ovarian testosterone production

Question 27

what other medical conditions are often seen with PCOS

Answer 27

metabolic syndrome (diabetes, HTN)

OSA

NASH

Endometrial hyperplasia and cancer

Question 28

Treatment options for PCOS

for hirsutism

for anovulation

Answer 28

weight loss (First line)

OCP’s for menstrual regulation progestins for endometrial protection and will help with hirsutism (can take up to 6 months)

metformin can help with induction of ovulation (NOT used for treating hirsutism)

clomiphene citrate for ovulation induction

If no improvement in hirsutism with OCPs and it’s been >6 months, can try spironolactone.

Treatment goal is to improve hyperandrogenism symptoms, prevent associated comorbidities, and attempt ovulation induction in women who want to get pregnant.

Question 29

What is the minimum criteria to diagnose PCOS empirically (Rotterdam criteria)

Answer 29

irregular or absent ovulation (irregular menses, anovulation)

hyperandrogenism

—clinical based on signs of hirsuitism (acne or hirsutism)

—biochemical (elevated testosterone levels) of hyperandrogenism

Polycystic ovaries on ultrasound or in surgery

only need 2/3 to say they have PCOS

Question 30

what is seen on physical exam with these pts PCOS?

Answer 30

see abdominal striae

metabolic syndrome

hirsutism

Question 31

management of PCOS involves

Answer 31

improving hirsutism restoring reproductive function managing comorbidities

Question 32

what is the preferred treatment for oligomenorrhea and hirsutism in pts who do not want pregnancy and have PCOS

Answer 32

OCPs

OCPs i_ncrease sex binding protein levels_ and results decreased free androgen levels They also reduce circulating LH levels and this decreases ovarian androgen production.

Question 33

If pt with PCOS can’t take OCP what to offer next for treatment

Answer 33

Spironolactone

Question 34

if pt with PCOS is on OCP and they don’t have an improvement what to do next?

Answer 34

if 6 weeks passes and no improvement in symptoms give spironolactone

Question 35

what are features that would point to a androgen secreting tumor?

Answer 35

someone who has rapidly progressive hyperandrogenism with marked virilization and see clitoromegaly, voice deepening

Question 36

what to order for a suspected androgen secreting tumor?

Answer 36

dehydroepiandrosterone sulfate or DHEA-S >150 but >700 ug/dl is highly suggestive. Note: PCOS pts may have modestly elevated DHEA-S level

Question 37

infertility evaluation should be started after 6 months of unprotected intercourse for a woman who is

Answer 37

woman >35 yrs

Question 38

infertility evaluation be started after 1 yr of unprotected intercourse in woman

Answer 38

<35 yrs

Question 39

mid luteal phase serum progesterone level obtained 1 week before menses will show

Answer 39

progesterone >3 is evidence of recent ovulation

Question 40

Turner’s syndrome

Answer 40

loss of all an X so it’s 45 XO.

diagnosed after 12 years and present with primary amenorrhea and gonadal dysgenesis.

See short stature, neck webbing, hearing loss, aortic coarctation and bicuspid aortic valve.

Question 41

diagnosis of Turner’s syndrome

Answer 41

karotype analysis.

Question 42

functional hypothalamic amenorrhea (FHA) is what

Answer 42

this is secondary amenorrhea due to relative caloric deficiency (excessive exercise, weight loss, decreased intake) or stress lack of hypothalamic response results in low FSH level this causes lack of estrogen deficiency and so see thin endometrium and see lack of withdrawal bleeding during medroxyprogesterone actate challenge

Question 43

long term complications of functional hypothalamic amenorrhea (FHA)

Answer 43

stress fractures early onset osteoporosis secondary to low bone density

Question 44

Treatment of functional hypothalamic amenorrhea (FHA)

Answer 44

lifestyle changes increased caloric intake and decreased exercise stress reduction and weight gain normalization of estrogen will improve bone density combined OCPs is second line if pts are unwilling to or unable to make lifestyle changes.

Question 45

evaluation of secondary amenorrhea

Answer 45

Follow the chart.

Question 46

what to order for someone who develops rapid onset hirsutism and develops irregular menses. See total testosterone >150.

Answer 46

Needs U/S of ovaries to look for androgen secreting tumor.

Question 47

What is a longterm complication of PCOS?

Answer 47

increased risk for endometrial cancer

but no routine endometrial thickness not recommended.

Question 48

can we use progestin releasing IUD for long term contraception for women with PCOS?

Answer 48

yes. It provides good endometrial protection. IUDs that don’t have estrogen can’t suppress ovarian testosterone and won’t treat the hirsutism.

Question 49

how long does it take before women see a difference in PCOS therapy while on OCPs?

Answer 49

can take up to 6 months to see a difference and improvement in hair growth. if fails to reduce needs to get spironolactone therapy.

metformin is no longer a treatment for hirsutism. only can be used for concurrent DM2 and possibly for ovulation induction.

Question 50

what cancer are PCOS pts at highest risk for?

Answer 50

high risk for endometrial cancer but no screening needed unless they have symptoms

only person who is asymptomatic that needs endometrial cancer screening is Lynch syndrome.

Question 51

Emergency contraception

Answer 51

Question 52

PCOS pt who is 36 and has vaginal bleeding and spotting after sex should get:

Answer 52

need to get endometrial cancer screening if >35 yrs with endometrial biopsy if having symptoms

they are at greater risk for endometrial cancer

no screening if no symptoms.

Question 53

Treatment of hyperanderogenism

Answer 53

mechanical hair removal (threading depilatories, elctrolysis laser, may be adequate for cosmesis in women with idiopathic hirsutism.

1st line pharmacology is: hirsutism is combined hormonal estrogen-progestin oral OCPS and agents that suppress gonadotropin secretion and ovarian androgen production and increase SHBG (sex hormone binding globulin) levels.

Spironolactone can be added and need to add contraception to prevent male fetuses from getting teratogenesis.

Topical eflornithine is also used for unwanted hair growth.