Case History: 27 year old female was referred to endocrine clinic with complaints of excess hirsutism over face, chin and neck accompanied with oligomenorrhea and acne for three years. The hirsutism was worsening gradually and she had to shave or wax her facial hair on daily basis. She was born at full term and had menarche at 12 to 13 years of age with regular periods. She had no symptoms of galactorrhea, headache, visual problems or recent weight gain. There was no family history of diabetes but her elder sister had mild PCOS. Examination revealed BMI of 24.4, marked hirsutism over face, chin and neck but no features of virilization, Cushing’s syndrome or acromegaly.
Investigations: Serum testosterone 7.6 nmol/l. LH 9.1 IU/l, FSH 5.9 IU/l, Estradiol <92 pmol/l, SHBG 16 mmol/l. Serum Prolactin, 17-OH Progesterone, Androstenedione and DHAS levels normal. HbA1c 6.0%, TSH 0.82 mu/l, mildly deranged lipid profile with triglycerides 3.4 nmol/l. Electrolytes, renal, liver and bone biochemistry normal. Trans vaginal ultrasound revealed bilateral multiple small peripheral follicles, up to 20 seen, with a central echogenic stroma. right ovarian volume 14 ml and left ovarian volume 12 ml. MRI scan of abdomen and pelvis did not reveal any focal adrenal lesion or free fluid in abdomen. An ovarian suppression test using GnRH analogues was performed to establish ovarian origin of androgens but unfortunately proper protocol was not followed to look for suppression of androgens following GnRH. However, results were appropriate with adequate rise in estradiol levels with LH and FSH levels.
Treatment An Follow Up: A diagnosis of PCOS was made and she was started on metformin and COCP(Yasmin) which made her cycles regular but had little effect on hirsutism. She was also given a trial of topical eflornithine cream with little effect. Subsequently spironolactone was started as hirsutism was her main concern and she did not have any active plans to conceive in near future. She was advised to avoid pregnancy for six months after stopping spironolactone. On subsequent follow ups, her serum testosterone decreased to 1.1 nmol/l, SHBG increased to 12 mol/l and her shaving frequency reduced considerably.
Conclusion: In diagnosing PCOS, other causes of androgen excess, such as non classical CAH and Cushing’s disease, should always be excluded. Severe hyperandrogenism of recent onset should always lead to exclusion of androgen secreting tumors of ovarian or adrenal origin.