Differential Diagnosis

The patient's symptoms and laboratory results suggest a complex endocrine disorder. Here's a differential diagnosis, categorized for clarity:

• Single most likely diagnosis
  • Polycystic Ovary Syndrome (PCOS): High LH and total T levels, along with normal TSH and free T, are consistent with PCOS. The condition often presents with hormonal imbalances, pain, and fatigue, which can be exacerbated by physical activity.
• Other Likely diagnoses
  • Congenital Adrenal Hyperplasia (CAH): Although less common, CAH can cause elevated androgen levels, leading to similar symptoms. The normal free T level might not entirely rule out this condition, as it can be influenced by SHBG.
  • Thyroid Resistance: Despite a normal TSH, thyroid resistance could lead to elevated SHBG and total T. However, this diagnosis would typically require additional thyroid function tests to confirm.
  • Idiopathic Hyperandrogenism: This condition involves elevated androgen levels without a clear underlying cause, which could fit the patient's profile.
• Do Not Miss
  • Adrenal Tumor or Cancer: Although rare, an adrenal tumor could cause significant hormonal imbalances, including elevated androgens. Missing this diagnosis could have severe consequences, making it crucial to consider and rule out with imaging studies if necessary.
  • Pituitary Adenoma: A pituitary adenoma, especially one secreting LH, could explain the patient's high LH levels. This condition requires prompt diagnosis and treatment to prevent further complications.
• Rare diagnoses
  • 17,20-Desmolase Deficiency: A rare genetic disorder affecting steroid synthesis, leading to an imbalance in sex hormones. This condition would be unusual but could explain some of the patient's symptoms and laboratory findings.
  • Aromatase Deficiency: Another rare genetic disorder that affects the conversion of androgens to estrogens, potentially leading to elevated androgen levels and symptoms like those described.