From the Guidelines
The patient's worsening PCOS symptoms, particularly voice deepening despite oral contraceptive therapy, suggest an androgen-secreting ovarian tumor, and the ultrasound ordered is the correct next step to evaluate for an ovarian tumor, particularly an androgen-producing tumor such as a Sertoli-Leydig cell tumor, which can cause rapid onset of virilization. This suspicion is appropriate given her previously stable PCOS that has suddenly changed character with new virilizing symptoms (voice deepening) that weren't present during her initial PCOS diagnosis. The patient's acanthosis nigricans (velvety pigmented plaques) indicates insulin resistance, common in PCOS but not directly related to the new concerning symptoms, as noted in studies such as 1.
The sudden change in symptom pattern despite previously effective treatment is the key clinical feature suggesting progression beyond typical PCOS to a possible androgen-secreting neoplasm. Additional appropriate workup would include measuring serum total testosterone, free testosterone, DHEAS, and androstenedione levels to assess for markedly elevated androgens that would support the tumor diagnosis, as suggested by guidelines and studies on PCOS management, including 1 and 1.
Some key points to consider in the management of PCOS include:
- The association between obesity and PCOS is complex and bidirectional, with obesity exacerbating PCOS clinical features, as noted in 1
- Weight loss is recommended as part of management in individuals with PCOS with higher body mass index (BMI), with weight reduction shown to improve reproductive and metabolic consequences of PCOS, as discussed in 1
- Pharmacotherapy, including anti-obesity agents such as glucagon-like peptide 1 receptor agonists (GLP-1 RAs), may be considered as an adjunct to lifestyle approaches to optimize weight loss success and efficacy in obesity, as reviewed in 1 and 1
- The patient's BMI of 33 kg/m2 indicates obesity, which is a common comorbidity in PCOS and contributes to insulin resistance and other metabolic complications, highlighting the need for a comprehensive management plan that addresses both PCOS and obesity, as discussed in 1 and 1.
If the ultrasound identifies an ovarian mass, surgical intervention would likely be necessary. The patient's clinical presentation and the need for a thorough evaluation and management plan are consistent with the principles outlined in recent studies and guidelines on PCOS, including 1 and 1.
From the Research
Patient Presentation
The patient is a 26-year-old woman with a history of polycystic ovary syndrome (PCOS) diagnosed 6 years ago. She presents with worsening symptoms, including irregular menstrual bleeding despite taking daily combined estrogen/progestin oral contraceptives as directed. She has noticed deepening of her voice but no changes in hair growth, weight gain, or galactorrhea.
Clinical Findings
- Blood pressure: 132/84 mm Hg
- Pulse: 78/min
- BMI: 33 kg/m2
- Velvety, pigmented plaques on the back of the neck and axilla
- Coarse hairs on the upper lip and chin
- Multiple small comedones on the forehead
Treatment Options
- First-line intervention for menstrual irregularities in PCOS should entail dietary and lifestyle modifications for overweight or obese women 2
- Combination low-dose hormonal contraception is the most effective and first-line choice for regulating menstrual cycles in women not seeking fertility 2
- Metformin is an appropriate medical option to improve ovulation rates for women who cannot take combined hormone contraception or are attempting conception 2
- Drospirenone, a relatively new progestin, has shown benefit in the PCOS population when used in conjunction with ethinyl estradiol 3
Effects of Treatment
- Ethinyl estradiol-drospirenone alone or in combination with metformin improves clinical and biochemical hyperandrogenism in lean PCOS women 4
- Metformin addition to ethinyl estradiol-drospirenone significantly decreases waist circumference, fasting insulin, and HOMA-IR 4
- Combination treatment with metformin and oral contraceptive pills may decrease cardiovascular disease risk in women with PCOS by improving elastic properties of the aorta 5