Endo Case Challenge: Amenorrhea for Months, Mood Swings, Weight Gain in a 38-Year-Old Woman

Benjamin Scott Harris, MD, MPH; Thomas Michael Price, MD


September 13, 2022

Physical Examination and Workup

Upon physical examination, the patient appears normally developed and well nourished. She is in no acute distress. Her heart rate is 92 beats/min, and her blood pressure is 142/98 mm Hg. She is afebrile. She has no evidence of lid lag, stare, or exophthalmos. Her thyroid is normal in size and texture. Her lungs are clear to auscultation. The heart examination reveals regular rate and rhythm, with normal S1 and S2. Her abdomen is soft and nontender and shows no striae. The pelvic examination is deferred.

Laboratory studies reveal these values:

  • Anti-müllerian hormone: 0.064 ng/mL (reference range, 1.0-3.0 ng/mL)

  • Day 3 follicle-stimulating hormone (FSH): 8.4 mIU/mL (reference range, 1.37-9.9 mIU/mL [follicular phase])

  • Day 3 estradiol: 48 pg/mL (reference range, 25-75 pg/mL)

  • Thyroid-stimulating hormone: 2.34 µIU/mL (reference range, 2-10 μU/mL)

  • Prolactin: 11.69 ng/mL (reference range, 3-27 ng/mL [adult female])

  • Total testosterone: < 7 ng/dL (reference range, 15-40 ng/dL [women])

  • Dehydroepiandrosterone sulfate (DHEA-S): 2 µg/dL (reference range, 45-270 µg/dL [women aged 30-39 years])

Owing to an abnormally low DHEA-S level, additional testing is performed, including:

  • Adrenocorticotropic hormone (ACTH): 3 pg/mL (reference range, 9-52 pg/mL)

  • Cortisol (PM): 12 µg/dL (reference range, 3-13 µg/dL)

  • Cortisol (AM): 12.1 µg/dL (reference range, 5-23 µg/dL)

  • 24-hour free cortisol: 74 µg/24 h (reference range, 4-40 µg/24 h)

  • Aldosterone: 8.1 ng/dL (reference range, < 10 ng/dL)

  • Renin activity, plasma: 0.6 ng/mL/h (reference range, 0.6-4.3 ng/mL/h)

  • Metanephrines, plasma: < 10 pg/mL (reference range, 12-60 pg/mL)

Other laboratory values are:

  • White blood cell count: 8700 cells/µL, with 62% neutrophils (reference range, 4500-11,000 cells/µL, with 40%-70% neutrophils)

  • Hemoglobin: 13.8 g/dL (reference range, 12.1-15.1 g/dL)

  • Platelet count: 310,000 cells/µL (reference range, 150,000-450,000 cells/µL)

  • Sodium: 136 mmol/L (reference range, 134-145 mmol/L)

  • Potassium: 3.3 mmol/L (reference range, 3.5-5.1 mmol/L)

  • Chloride: 101 mmol/L (reference range, 96-106 mmol/L)

  • Blood urea nitrogen: 10 mg/dL (reference range, 7-20 mg/dL)

  • Creatinine: 0.7 mg/dL (reference range, 0.6-1.1 mg/dL)

  • Alkaline phosphatase: 42 U/L (reference range, 40-150 U/L)

  • Alanine aminotransferase: 15 U/L (reference range, 19-25 U/L)

  • Aspartate aminotransferase: 22 U/L (reference range, 9-32 U/L)

  • Total bilirubin: 0.7 mg/dL (reference range, 0.1-1.2 mg/dL)

CT of the abdomen and pelvis shows a large left adrenal mass measuring up to 4.9 × 2.9 cm, which is compatible with a lipid-rich adenoma.


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