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


Measurement of DHEA-S and testosterone is common in women with infertility, and evidence of ovulatory dysfunction is based on menstrual cycle irregularity. Testing is performed mainly to detect elevated androgen levels, which would suggest a diagnosis of polycystic ovary syndrome (PCOS), the most common cause of ovulatory dysfunction. Unexpectedly, this patient had a very low DHEA-S level, which suggests adrenal androgen suppression. Further testing showed this suppression to be due to a low ACTH level from hypercortisolism secondary to an adrenal tumor.

PCOS can be diagnosed using the Rotterdam criteria (two of three are required):

  • Oligoovulation/anovulation

  • Hyperandrogenism (clinical or laboratory evidence)

  • Polycystic ovaries

Although this patient had anovulation, she did not have evidence of hyperandrogenism. In fact, she had low adrenal androgen levels. Ultrasonography was not performed for evaluation of polycystic ovary morphology.

Ovarian insufficiency was unlikely in this patient. Although she had secondary amenorrhea, she did not yet meet the clinical criteria for menopause (absence of menses for 12 months). Moreover, she did not demonstrate additional symptoms of estrogen deficiency, such as hot flushes, night sweats, and atrophic symptoms, which further lowered this suspicion. Lastly, her FSH levels were < 10 mIU/mL in the presence of a normal estradiol level, which demonstrated normal ovarian function.


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