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CASE STUDY
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Cushings syndrome in women with polycystic ovaries and hyperandrogenism
P Gerry Fegan, Derek D Sandeman, Nils Krone, Deborah Bosman, Peter J Wood, Paul M Stewart and Neil A Hanley*
SUMMARY
Vanderbilt Continuing Medical Education online
This article offers the opportunity to earn one Category 1
credit toward the AMA Physicians Recognition Award.
Background A 41-year-old woman presented to an endocrinology gynecology clinic having been diagnosed 7 years earlier with polycystic ovarian syndrome on account of hirsutism, subfertility, greasy skin, acne and multiple ovarian cysts. Ovulation induction had led to a successful pregnancy. Subfertility recurred, however, and persisted alongside a new diagnosis of hypertension and progressive weight gain. Upon examination, the patient was hypertensive with facial plethora, rounded facies and violaceous abdominal striae.
Investigations Low-dose dexamethasone test, bedtime salivary and 24-h urinary free cortisol estimations, CT scan of the abdomen, and serum hormone and gonadotropin analyses.
Diagnosis Cushings syndrome due to a right adrenocortical adenoma. Management The patient underwent laparoscopic right
adrenalectomy, which led to resolution of all symptoms, signs and
biochemical abnormalities.
KEYWORDS cortisol, Cushings syndrome, polycystic ovarian syndrome
THE CASEA 41-year-old woman presented at an endocrinologygynecology clinic. Seven years previously she had tbeen investigated at another hospital for primary infertility of 5 years standing, associated with secondary amenorrhea for the preceding 6 months, oily skin, acne and facial hirsutism. At the time, laparoscopy and dye infusion had demonstrated multiple, small ovarian cysts with patent oviducts. A diagnosis of polycystic ovarian syndrome (PCOS) was made. Attempts at ovulation induction were then undertaken with 50 mg clomifene citrate on days 26 of the menstrual cycle, following which she conceived aged 35 years and carried a successful pregnancy to term, giving birth to a healthy baby girl.
Subfertility was again problematic and led to the patients referral for in vitro fertilization, one cycle of which was unsuccessful. At this time, the patients BMI was 26 kg/m2 and investigations revealed serum total testosterone levels of 2.6 nmol/l (75 ng/dl; normal range 0.52.6 nmol/l [1475 ng/dl]) and serum estradiol levels of 47 pmol/l (13 pg/ml; normal range 100500 pmol/l [27136 pg/ml] early follicular phase; 3001,250 pmol/l [82 341 pg/ml] luteal phase). The patients serum androstenedione, dehydroepiandrosterone sulfate and gonadotropin levels were normal....