Woman with Hirsutism and Menstrual Disorders: Case Study and Evaluation
A 45-year-old woman presented with hirsutism, menstrual irregularities, skin darkening, weight gain, hair loss, and other symptoms. Past medical history includes amenorrhea and hypertension. Physical examination revealed characteristic features. Detailed evaluation and management are discussed in this case study.
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Presentation Transcript
PRESENT ILLNESS a 45-year-old woman with chief complaint of hirsutism and menstural disorders came to clinic . She had secondary oligoamenorrhea from 6 years ago, at first she had oligomenorrha and then it stopped for 1/5 years. she started treatment with LD from 4 years ago and the mensturations were regular until 8 months ago, that she had menometrorrhagia . she stopped using LD for one month and then started again until 3 months ago that stopped and didn t have mensturation after that. She mentioned hirsutism from two years ago that progressed specialy in chin.
She also complained about skin darkening specially in axilla and neck , weight gain(30 Kg during 2 years), hair loss(temporal) and acne. She mentioned increased libido , but no deepening of voice and change in breast size. She didn t have galactorrhea , easy bruising, headache or visual impairment. and at 98/8/26 she admitted for more evaluation.
PAST HISTORY Mensturation age was 15 years old G1 : 14 y ago/ 2months/ missed abortion G2: 13y/ girl/ term / cs lack of delivery She didn t have infertility She had normal breast feeding
PAST MEDICAL HISTORY Amenorrhea ( from 6y ago) Hypertension ( from 2y ago) MNG (?) Thyroid scan 96 : MNG Left thyroid lobe cold nodule FNA : neg for malignancy
DRUG HISTORY Tab Sprinolacton 100mg daily (from 2y ago) Tab metformin 500mg BD ( 2 y ago) Tab LD (from 4y ago) Tab Levothyroxine 0.1 daily ( from 2y ago) Tab Propranolol 10 daily ( from 2y ago) Tab Triamterene H daily (from 2y ago)
PAST SURGICAL HISTORY & FAMILY HISTORY c/s 13 y ago No significant point in family history
PHYSICAL EXAM GA: young woman with male & course feature, she is not ill & toxic. BP:110/80 PR:75 RR:18 T:37 BMI:39 H&N: bi temporal alopecia + moon face - dorsocervical fat pad - supraclavicular fat LAP- increased muscular mass in shoulder gridle facial plethora - Thyroid : normal size & consistency , no detectable nodule Skin: acanthosis nigricans in neck , axilla, groin acne on arms and upper back
Chest : lung & heart ausculation is normal breast atrophy breast discharge - Abdomen : no tenderness or guarding, no organomegaly , fatty, no central obesity purple striae - Genitalia: clitoromegaly + sagittal diameter: 15mm * transverse diameter: 10mm clitoral index : 150 mm Ext: normal force edema- proximal muscles weakness -
Ferriman Gallwey score : 16 upper lip :1 chin:3 chest : 3 abd:1 pelvis:2 arm:1 thigh:2 upper back:2 lower back: 1
PROBLEM LIST A 45 years old woman Menstrual disorders ( oligomenorrhea then amenorrhea) from 6y ago Progressive Hirsutism from 2y ago Weight gain Hair loss Skin darkening neck , axilla , groin Acne on arms and back Clitoromegaly
98/6/31 unit normal WBC 19/2 1000/ UL 4/3-11 HB 13/9 g/dl 11/2-16 PLT 399 1000/ul 150-450 FBS 118 mg/dl <100 HbA1C 6/3 % <6/5 AST 16 U/L 0-40 ALT 17 U/L 0-40 ALP 171 U/L 70 - 310 CHOL 198 mg/dl <200 TG 208 mg/dl <150 HDL 48 mg/dl >35 LDL 108 mg/dl <110 Ca 9/4 mg/dl 8/5 10/5 p 4/1 mg/dl 2/6 - 5
98/ 6 /31 unit normal Testostrone > 15 ng/ml 0.05- 0.73 Free testos 35 pg/ml 0-3 17 OH Prog 1/1 ng/ml 0.2- 4.5 DHEAS 73/1 micro/dl 58.7- 227 BHCG 1/1 mIu/ml <5 TSH 0/65 mIu/ml 0.3 - 5 Anti TPO 7/7 IU/ml 1-16 FSH <0/25 mIu/ml 3.5 9.2 LH < 0/2 mIu/ml 1.9 9.2 Cortisol 8am (ODST) 4/08 micg/dl 5.49 28.7
SPIRAL ABDOMINOPELVIC CT WITH & W/O IV CONTRAST 98/6/31 ( pars medical imaging center) Uterus has diffusely large size about 120 * 75 * 88mm both sides ureters middle to distal segments are relatively distended. Right ovary has large size 44*33mm. Left ovary is unremarkable. No other pathologic findings.
98 / 7 /9 unit normal Testostrone >15 ng/ml 0.05 0.73 Estradiol 118 pg/ml 10 - 122 DHEAS 40.2 mic/dl 58.7 - 227 Cortisol (LD) 1.1 Micg/dl 4.5 - 24 UFC/24 112 Micg/24 50-190 BUN 21 mg/dl 4.6 23.2 Cr 1.4 mg/dl 0.6 1.1
THYROID SONOGRAPHY & TVS 98 / 8/ 27
PELVIC MRI 98/8/29
98/8/28 WBC HB PLT BUN Cr Na K AST ALT LDH AFP BHCG CA125 TSH prolactin Testostrone DHEADS unit normal 12.2 12.9 334 24 1.2 137 4.3 25 30 491 5 <2 13 0.54 39.4 > 12 2.3 1000/ UL g/dl 1000/ UL mg/ dl mg/dl mg/dl mg/dl U/L U/L U/L ng/ml iu/ml iu/ml miciu/ml ng/ml ng/ml mg/ml 0.2 8.5 0.5 - 10 <35 0.35-5.3 5.5 - 26 0.2 0.95 0.03-3
SURGERY TAH + BSO Surgery done at 98/9/5 Frozen section done for 3 cm mass in left ovary and 2 cm mass in right ovary , that showed sertoli leydig cell tumor ( benign ) The patient was discharged , testosterone one week after surgery (98/9/11) was 0.16 ng/mL.
