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Recent onset hirsutism, acne, fatigue
Hi, hopefully someone can give me some advice.
I'm a 24yo female, non-smoker, non-drinker, no meds, no history of any medical problem.
Six months ago I started getting acne for the first time in my life, quickly gained 15lbs, and I started losing scalp hair by the handful but growing dark thick hair where I'd never had any before (upper lip, chin, thighs, buttocks, upper and lower abdomen, periareolar, upper arms, shoulders, back). At the same time my periods suddenly became irregular, 45-65 days apart and only lasting one day (before they were always a clockwork 29-days, lasting 5-6 days).
For the last 3 months (in addition to the acne and hair growth worsening) I've had no appetite and have been so tired that I need at least 10-12 hours of sleep just to function. Because the fatigue started affecting my job performance I had to cut my hours, and also cut back significantly on my daily jogging -- yet somehow I've since lost those 15lbs (current weight 135lbs, 5'5" tall), my muscles are bulging, and my resting pulse has dropped from 58 to 45. I constantly have dark circles around my eyes, a red face, oily skin/scalp, brittle hair, slow healing, sweaty hands; I've been having bouts of dizziness and chills, and dull intermittent right-sided lower abdominal (ovarian?) pain.
I went to a GP who based on my symptoms (no exam, not even a BP) ordered blood work (CBC, electrolytes, kidney and liver panels, TSH, LH, FSH, cortisol). All were apparently normal except my 8AM serum cortisol which was high at 700 (lab range 120-620), repeated it 3 weeks later and it was 480 (although I was working the midnight-to-8AM shift then, so I don't know if that might have affected it). Had a pelvic ultrasound which showed a cyst on my right ovary (which I was told was completely normal) otherwise the results were unremarkable. My doctor's telling me that I'm perfectly healthy -- my thyroid's fine and he doesn't think I have polycystic ovary syndrome based on my ultrasound and normal LH-to-FSH ratio, but offered birth control pills to regulate my cycle (I declined, instead requesting a gyn referral, but it'll be several weeks if not months until I can get an appointment).
So if it's not thyroid or PCOS what else could it be? From what I've read, my symptoms seem to suggest high androgen levels, so do I need those tested? My doc doesn't seem inclined to run any more tests or do any sort of exam, he practically pushed me out the door last time I saw him, telling me that I'm fine. But I find it hard to believe that all of this is normal, especially coming on and progressing so quickly. Any ideas?
Thanks,
Kay
Answer:
Recent onset hirsutism, acne, fatigue
You are correct that your symptoms are suggestive of polycystic ovary syndrome (PCOS). However, there are various other disorders that may produce similar symptoms. The symptoms suggest elevated androgen levels, which can be caused by a disorder either in the pituitary-ovarian or the pituitary-adrenal axis. These are hormonal (endocrinological) pathways that control the secretion of androgenic hormones and other hormones that could cause such symptoms. Also, Cushing's syndrome (adrenal) and hyperprolactinemia (pituitary) may cause some similar symptoms.
As always, a thorough history and physical examination by a physician is absolutely necessary. A pelvic examination should be done also, preferably by a gynecologist. These lay the groundwork for the evaluation. An endocrinologist and gynecologist should be consulted. The endocrinologist may then order laboratory or radiological examinations, which may include a dexamethasone suppression test, dihydroepiandrosterone sulfate (DHEAS), androstenedione, free testosterone, and a variety of specific hormone and hormone-binding protein lab tests which are ordered as needed. Some basic labwork it seems has already been done, and these may need to be expanded. Transvaginal ultrasound is needed if PCOS is suspected. If an adrenal tumor is suspected, CT or MRI needs to be done.
The above is the general scheme for the evaluation of elevated androgen levels. I cannot say whether this is the cause of your symptoms, and what examinations should be done in your case - your own doctors will need to determine that. Good luck!
Answer:
Recent onset hirsutism, acne, fatigue
This is a bit belated, but THANK YOU so much for your reply Dr. Joshua!! Your information was very helpful, and allowed me to do a lot of focused reading & research while waiting for my referral.
Just as an update, I did finally get in to see a gynecologist. After a complete history / physical exam and extensive blood work, by exclusion it appears that I do indeed have PCOS.
My day-3 LH, FSH, LH:FSH ratio, prolactin, progesterone, and estradiol were all normal. 17-OHP was normal, ruling out late-onset CAH. Neither my free testosterone nor DHEAS level was high enough to indicate a tumor, which the gyn seemed particularly concerned about given the signs of virilization and sudden onset oligomenorrhea & hirsutism (one was upper-limit normal, the other was marginally elevated). Serum cortisols were again elevated, but since I don't have striae, bruising or obesity, and a low-normal BP, Cushing's isn't suspected. On pelvic exam and repeat transabdominal ultrasound my ovaries were normal size, without the typical polycystic appearance (but again no transvaginal ultrasound since it's counter-indicated, ie. virginal).
So the gyn thinks it's an atypical presentation of PCOS, but wants repeat hormone levels in 4-6 months just to make sure nothings changed. Was started on bcp to regulate my cycle, prevent cyst formation, and hopefully help the acne/hirsutism... although I think I'm gonna see my GP to discuss whether an antiandrogen or additional acne treatment would be beneficial (6 months of salicylic acid hasn't helped), and also ask about being tested for insulin resistance (random glucose was normal, but I haven't had a fasting glucose, insulin, or GTT). In the mean time, I'm making diet and exercise my priority, and trying to wait out these bcp side effects (I can live with the nausea and breast tenderness, but the eye pressure / visual disturbances and abdominal cramps are really getting to me).
Anyway, thanks again Dr. Joshua, for your guidance and for so generously sharing your expertise with us!!
Answer:
Recent onset hirsutism, acne, fatigue
You are very welcome, Kay, and thanks for writing back. Hang in there with the drug side effects, hopefully they will become more bearable over time.