Journal of Clinical Outcomes Management. 2016 May;23(5)
References
The patient’s detailed diet history included eating 3 meals daily and snacks in-between meals. The patient was consuming sweet beverages regularly. There was minimal intake fruits and vegetables. The portion sizes for each meal were large. The patient had minimal physical activity and screen time was more than 2 hours daily.
Family history is significant for obesity and type 2 diabetes in her mother and maternal grandmother and is negative for PCOS.
Physical Examination
Vital signs were within normal limits. She was 5 ft 6 in tall and weighed 242 lb, with a body mass index (BMI) of 40 (99th percentile; Z-score 2.41). Physical examination showed coarse hair extending from the sideburns to the chin as well as from pubis symphysis to navel with evidence of hair removal. She had acanthosis nigricans on her neck, mild acne, and evidence of central obesity with pink striae marks on the abdomen. She was Tanner stage 5 for breast and pubic hair and there was no evidence of virilization (clitoral hypertrophy, deepening of the voice, severe hirsutism, male pattern baldness, and masculine habitus). Other physical examination findings were within normal limits.
What physical findings in this patient are suggestive of clinical hyperandrogenemia?
Physiologic irregular menstruation is a well known phenomenon in adolescent girls and is generally due to anovulatory cycles [9–12]. Menstrual cycles shorter than 19 days or longer than 90 days at any stage after menarche are considered abnormal. The menstrual irregularity that is commonly seen within the first 2–3 years after the first menarche can last up to 5 years [5]. However, the majority of girls establish 20- to 45-day cycles within the first 2 years [13].
Androgen excess, defined by the presence of clinical and/or biochemical hyperandrogenemia, should be considered in any adolescent girl who is 2 to 3 years’ post-menarche and presenting with irregular menstrual periods, coarse terminal hair in a male distribution pattern (hirsutism), or moderate to severe inflammatory acne. Hirsutism is androgen dependent [14–16] and must be distinguished from hypertrichosis, which is generalized excessive vellus hair growth present all over the body. Clinical hyperandrogenemia, which includes hirsutism, acne vulgaris, as well as androgenetic alopecia, is well correlated with elevated androgen levels; however, the severity of hirsutism does not correlate well with circulating androgen levels [17,18]. Mild hirsutism is often not associated with hyperandrogenemia in otherwise asymptomatic individuals,but it may be a sign of hyperandrogenemia in adolescents when associated with other features of PCOS, ie, menstrual irregularity [14–16, 19–22]. Defining hirsutism in early adolescence may be difficult since the sexual hair may still be developing, and laboratory evaluation should be considered (see below), especially in an overweight/obese adolescent girl presenting with oligomenorrhea. Ethnic variation due to decreased skin sensitivity to androgens can result in minimal hirsutism despite elevated plasma androgen levels and must be considered among certain Asian women. Women with PCOS from China, Japan, Thailand, and East and Southeast Asian countries tend to have low scores on hirsutism rating scales even with elevated plasma androgens levels [16,23].
