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Endocrine Abstracts (2023) 91 WG4 | DOI: 10.1530/endoabs.91.WG4

The Hillingdon Hospital, London, United Kingdom

A 45-year-old female presented with secondary amenorrhea. Since menarche, her period has been irregular, which she initially managed with oral pills, which were discontinued in 2009. Subsequently, she does have complete secondary amenorrhoea. She has hirsutism at the age of 20. Which was initially well controlled with oral contraceptive pills but has been getting worse over the years. Ferriman-Gallwey’s score was high. She also stated that her weight had been steadily increasing over the years. Her weight was 105 kg when she first visited the clinic in 2018, and it is now 112.7 kg, with a BMI of more than 40. She has schizophrenia, and she is on Risperidone and Mirtazapine, which prompted her to gain more weight. She has no family history of note, particularly no history of diabetes. She has a clinically high BMI of more than 40, and her BP 130/80. She does have extensive hirsutism, and the Ferriman-Gallwey score was 31. She also does have acanthosis nigricans and multiple skin tags around her face, but no classical cushingoid and not virilised. She had investigations that revealed extremely high levels of testosterone was 13 nmol/l, normal DHEA, and marginally raised androstenedione making the ovarian source more likely. She had an overnight dexamethasone suppression test, the cortisol level was supressed and the testosterone level was still high, suggesting a possible ovarian source of testosterone. She also underwent an MRI and US scans of the ovaries, both of which revealed polycystic ovaries. Other than that, no other sinister pathology was noted. Additionally, the CT adrenals were normal. We did start her on a trial of Zoladex GnRH agonist injection due to the risk of thrombosis. She was referred to the weight management team. She also referred for ovarian venous sampling to determine the source of the testosterone. Subsequently ,she may require an oophorectomy. She is quite keen to take this route.Conclusion- PCOS is a common disorder of young women and can rarely have extreme presentation.- This patient’s case was unusual in that the presenting symptoms of severe hirsutism, and significantly elevated androgens raised concern for a non-PCOS pathology- Approach to such patients involves suppression testing with Dexamethasone to differentiate between adrenal and ovarian sources.- Dexamethasone suppression test was in favour of ovarian source, and MRI imaging excluded ovarian and adrenal tumour- Certain imaging may not reveal smaller masses, and ovarian/adrenal vein sampling may be needed.

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