ANSWER 45
This patient has hirsutism and secondary amenorrhoea due to polycystic ovaries(Stein–
Leventhal syndrome). This is a complex disorder characterized by excessive androgen pro-
duction by the ovaries and/or adrenal cortex which interferes with ovarian follicular ripening.
Patients are usually obese with the adipose tissue converting androgens to oestrogens,
leading to high LH levels stimulated by positive feedback of oestrogens on the pituitary,
and low FSH levels due to negative feedback. The low FSH level means that ovarian folli-
cles do not mature normally. A large number of follicles develop abnormally leading to
enlarged ovaries.
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- Constitutional
- Drugs, e.g. ciclosporin, minoxidil
- Cushing’s syndrome
- Congenital adrenal hyperplasia
- Androgen-secreting tumours
- Hypothyroidism
Differential diagnoses of hirsutismPatients with androgenic tumours usually have a shorter history, signs of virilism such as clit-
oral hypertrophy and very high testosterone levels. This woman had an ovarian ultrasound
(Fig. 45.1) which showed polycystic ovaries. A laparoscopic biopsy confirmed the diagnosis.
Hirsutism can be treated by combined oestrogen/progestogen oral contraception (to induce
sex hormone-binding globulin and thus mop up excess unbound testosterone) and by the
anti-androgen, cyproterone acetate. Ovulation can be induced with clomifene or pulsatile
gondotrophin-releasing hormone (GnRH) therapy. Dietary advice should be given to reduce
obesity which otherwise helps maintain the condition. She will need social and psychological
support to return to her studies and social life.