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A 37-year-old female presents to your clinic with a long-standing history of abnormal menstrual cycles, often occurring irregularly more than 40 days apart. She has ongoing struggles with weight gain, acne, and facial hair growth. She states that she is not currently sexually active. Her last Papanicolaou smear 2 years ago was normal. Her vital signs and a physical examination are unremarkable other than a BMI of 36 kg/m2. An office urine pregnancy test is negative. Laboratory evaluation reveals a hemoglobin A1c of 6.2%, and normal TSH, prolactin, and 17-hydroxyprogesterone levels.

Which one of the following is required to confirm the most likely diagnosis?

 

A. No additional evaluation
B. A serum C-peptide test
C. A dexamethasone suppression test
D. Ultrasonography of the pelvis
E. CT of the abdomen and pelvis

ANSWER: A

This patient has signs and symptoms consistent with polycystic ovary syndrome (PCOS). The Rotterdam 2003 criteria are the most widely used diagnostic criteria for PCOS, endorsed by multiple national and international professional societies. These criteria require the presence of two out of the following three features: oligomenorrhea, hyperandrogenism, and the presence of polycystic ovaries on ultrasonography. When the first two of these criteria are clearly met, ultrasonography to establish the presence of polycystic ovaries is not required. Therefore, a diagnosis is already warranted for this patient and additional evaluation is not needed. When patients require imaging, pelvic ultrasonography is the preferred modality rather than CT. While this patient has evidence of insulin resistance, as is common for patients with PCOS, a C-peptide test is not indicated. Dexamethasone suppression testing is not indicated because this patient does not have any other clinical signs and symptoms that would be consistent with Cushing syndrome.

Ref: Williams T, Mortada R, Porter S: Diagnosis and treatment of polycystic ovary syndrome. Am Fam Physician 2016;94(2):106-113.

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