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Severe Hirsutism in a Patient with Dysmennorhea: An Unusual
Presentation of Polycystic Ovarian Syndrome
Davis, BW, MS, MPH ; Weiner-Smith, J, MD.
Central Maine Medical Center Clinical Campus, Lewiston, ME.
Introduction: Menstrual irregularity and hirsutism, or unwanted hair growth, are
concerns that frequently lead women to seek medical care. Physiologically, the
presence of the two in tandem can suggest significant hormone imbalances and
must be investigated for underlying pathology such as neoplasm or
endocrinopathy. Polycystic ovarian syndrome (PCOS) is the cause of hirsutism
in 75-80% of all cases, and normally presents with findings of obesity, insulin
resistance, hyperlipidemia, and a lack of virilization in addition to hirsutism and
multiple ovarian cysts. This case explores a hirsute patient diagnosed with
PCOS despite absence of these symptoms, and demonstrates the complexity of
expression of polycystic ovarian syndrome.
Case Discussion: The patient is a twenty-one year old woman who was referred
to the gynecologist from her primary care physician after complaining of
oligomennorhea. She reported beginning her menses at sixteen years of age
and experiencing somewhat regular menses from age eighteen to twenty. Over
the past year, she became concerned by the increasing irregularity of her
menstrual cycles and reported that she did not menstruate for two consecutive
months with only “light spotting” in the month prior to her gynecological visit.
During the interview the patient’s significant facial hirsutism and somewhat
masculine facial structure and body habitus were readily apparent. On physical
exam, the patient was noted to have extensive male pattern hair growth of the
face, chest, abdomen, genitalia, legs, and back for a modified Ferriman-Gallway
hirsutism score between 23-30 out of a potential 36. Her breasts were consistent
with Tanner stage II and cliteromegaly was present. A full work-up for hirsutism
showed appropriate DHEA sulfate (171 ug/dL) and 17-OH progesterone (130
ug/dL) levels for a female of her age, with an elevated free serum testosterone of
94 ng/dL. A CT scan of her abdomen and pelvis was unremarkable except for
one large cyst, a smaller potential cyst, and multiple ovarian follicles. Despite
significant hirsutism and a complaint of oligommenorhea, the patient’s DHEA
sulfate, 17-OH progesterone, and free testosterone levels were reassuring
suggesting against neoplasm, cushing’s syndrome, 21-hydroxylase deficiency, or
all other known hirsute conditions. She therefore met the criteria for polycystic
ovary syndrome (PCOS) as established by the American Endocrine Society.
Discussion: The patient was started on an estrogen-progestin oral
contraceptive. Many women with PCOS respond to an oral contraceptive in that it
reduces hirsutism, normalizes their menses, and offers the added benefit of
reduced endometrial hyperplasia and risk of neoplasm.