Hyperandrogenism

• PCOS:
  • Diff: Gradual onset, mild hyperandrogenism, LH:FSH > 2:1, bilateral cystic ovaries on US.
• Non-classical CAH:
  • Diff: Gradual onset, ↑ baseline/stimulated 17-OHP, normal DHEAS, standard ovarian US.
• Sertoli-Leydig Cell Tumor:
  • Diff: Rapid onset of severe virilization, extremely high testosterone (>150 ng/dL), unilateral ovarian mass on US. c
    • Functional endocrine tumors, can leads to rapid systemic changes in weeks to months
• Adrenal Tumor (Adenoma/Carcinoma):
  • Diff: Rapid onset of virilization, extremely high DHEAS (>700 mcg/dL), adrenal mass on CT.
• Cushing Syndrome:
  • Diff: Presence of striae, buffalo hump, central obesity, dx via 24-hr urine free cortisol or low-dose dexamethasone suppression test.

Diagnosis

• Initial/Screening Labs:
  • Total & Free Testosterone: Elev in PCOS (mild, <150 ng/dL); Markedly elev in Sertoli-Leydig tumor (>150 ng/dL).
  • DHEAS: Mildly elev in PCOS; Markedly elev in adrenal tumors (>700 mcg/dL).
  • 17-hydroxyprogesterone (17-OHP): Screen for non-classical CAH (21-hydroxylase deficiency).
• Imaging:
  • Pelvic Ultrasound: Initial test for PCOS (“string of pearls”/follicles) or ovarian masses.
  • CT/MRI Abdomen/Pelvis: Indicated if adrenal source suspected (markedly elevated DHEAS).
• Confirmatory Tests:
  • ACTH stimulation test: Confirms non-classical CAH if baseline 17-OHP is borderline.
  • Biopsy/Surgical pathology: For suspected ovarian or adrenal neoplasms.