From the Research
The next step in managing this 43-year-old woman should be to evaluate for an adrenal tumor, specifically an androgen-secreting adrenal adenoma, as the elevated androstenedione level of 199 coupled with suppressed ACTH suggests autonomous adrenal androgen production. I recommend ordering an adrenal CT scan with contrast to visualize the adrenal glands. The patient's difficulty controlling blood sugar and weight can be explained by the autonomous adrenal androgen production, which is supported by the study 1 that found a strong negative association between serum androstenedione and insulin sensitivity. If an adrenal tumor is identified, referral to an endocrinologist and possibly an endocrine surgeon would be appropriate for consideration of surgical removal. While awaiting these results, optimizing her current diabetes management with metformin (which may help with both insulin resistance and androgen excess) at 1000mg twice daily would be beneficial, as suggested by the study 2 that found metformin to be effective in improving insulin sensitivity. Additionally, addressing her depression with either an SSRI like sertraline (starting at 50mg daily) or referral to mental health services is important, as depression can both result from and exacerbate metabolic disorders. The normal DST, normal cortisol, and normal imaging studies have ruled out Cushing's syndrome and polycystic ovary syndrome, while normal metanephrines exclude pheochromocytoma, making an androgen-secreting adrenal tumor the most likely diagnosis requiring further investigation, as supported by the study 3 that found adrenal androgen excess to be a common feature in patients with polycystic ovary syndrome. Some studies, such as 4 and 5, provide additional insights into the pathophysiology and treatment of hyperandrogenism, but the most recent and relevant study 1 guides the recommendation for evaluating and managing this patient's condition.