A 32 year old female presents to the GP surgery with concerns about excessive hair growth on her face and chest. She reports that for the past year, her periods have become increasingly unpredictable. While she used to have a fairly regular 28-day cycle, she now experiences menstruation at varying intervals, ranging from 24 to 55 days. She denies any significant changes to her lifestyle.

On examination, the presence of terminal hair growth in male-pattern distribution is noted.

Which of the following additional symptoms is most likely to be seen?

Options:
explanation: Although the combination of hirsutism and irregular menstrual periods is suggestive of a hormonal disorder, it is less likely to be associated with weight loss. This combination of symptoms is suggestive of polycystic ovary syndrome (PCOS). Instead, weight gain or difficulty losing weight is a more common finding in PCOS due to insulin resistance. Elevated androgens such as testosterone that are seen in PCOS can disrupt oestrogen levels and contribute to central fat distribution, resulting in abdominal obesity.
name: Weight loss
label: e
answer: no
explanation: Galactorrhoea is the spontaneous flow of milk from the breast unrelated to childbirth or nursing. It can be a symptom of certain hormonal disorders but is not typically associated with the combination of hirsutism and irregular menstrual periods. Galactorrhoea is more commonly linked to hyperprolactinaemia (elevated levels of the hormone prolactin) and can result from various causes, such as a pituitary tumour. This vignette is more suggestive of polycystic ovary syndrome (PCOS).
name: Galactorrhoea
label: c
answer: no
explanation: Hot flashes are typically linked to fluctuations in oestrogen levels that occur during the perimenopausal and menopausal periods. Although the patient has increasingly irregular periods, menopause is not seen with hirsutism. Furthermore, her young age makes menopause unlikely, as menopause normally occurs between the ages of 45 to 55. This vignette is more suggestive of polycystic ovary syndrome (PCOS).
name: Hot flashes
label: d
answer: no
explanation: This is the correct answer. Polycystic ovary syndrome (PCOS) can be diagnosed if at least two of the following criteria are met:

* Polycystic ovaries (>12 cysts seen on imaging or ovarian volume >10 cubic cm)
* Oligo-/anovulation
* Clinical or biochemical features of hyperandrogenism

In this case, two criteria are met: oligoovulation (irregular periods) and features of hyperandrogenism (hirsutism). Acanthosis nigricans can also be seen in PCOS. It refers to the thickening and coarsening of the skin, commonly observed in the armpits and elbows, and is characterised by a velvety texture. This skin condition is associated with insulin resistance. Insulin resistance causes the pancreas to increase the production of insulin, which stimulates the release of androgens including testosterone from the ovaries and adrenal gland. This further contributes to hyperandrogenism in PCOS.
name: Acanthosis nigricans
label: a
answer: yes
explanation: Easy bruising is a common feature in Cushing's syndrome or disease, characterised by excess cortisol. Irregular menstrual periods can occur in Cushing's syndrome, but they are often not the primary symptom. Increased ACTH stimulation on the zona reticularis can cause excessive androgen secretion, thus hirsutism is also possible, but again should not be the primary symptom in Cushing's syndrome or disease. In addition, the lack of other cushingoid signs make Cushing's syndrome or disease unlikely. This vignette is more suggestive of polycystic ovary syndrome (PCOS).
name: Easy bruising
label: b
answer: no

Correct answer: a