Exclusion of Specific Disorders

Approximately 6% of androgen excess patients suffer from a specific disorder, including classic and nonclassic 21-hydroxylase deficiencies, the HAIR-AN syndrome, or an ASN, among others (12). In patients clinically suspected of having an ASN, a computed tomography or magnetic resonance imaging scan of the adrenals and transvaginal ovarian ultrasonography should be obtained to assess for adrenal or ovarian masses, respectively. Importantly, measurement of a basal 17-hydroxyprogesterone serum level should be obtained in the follicular phase of the menstrual cycle, preferably in the morning, to exclude 21-hydroxylase-deficient NCAH (39). In patients suspected of having Cushing's syndrome, it will also include a 24-hour urinary free cortisol level or a cortisol level following an overnight dexamethasone (1.0 mg at 11 pm) test. If the HAIR-AN syndrome is suspected, a basal or preferably a glucose-stimulated insulin level should be obtained. Growth hormone levels should be obtained in patients suffering from acromegaly. In patients with a blind vaginal pouch and/or abnormality of the external genitalia, male pseudohermaphroditism or XY gonadal dysgenesis should be considered and a karyotype should be obtained.

As already mentioned, in eumenorrheic women with other hyperandrogenic features, a day 22-24 P4 level, preferably in two consecutive cycles, should be obtained. In patients demonstrating ovula-tory dysfunction, thyroid-stimulating hormone and prolactin levels may also be obtained to exclude thyroid dysfunction and hyperprolactinemia, respectively. The prevalence of these two latter abnormalities among women with hyperandrogenic features is less than 2% (12).

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