The detection of clinical
hyperandrogenism in women presenting with
infertility requires detailed hormonal investigations using the decisional plan suggested here. Initial studies including measurement of plasma
androgen, gonadotrophic
hormones and
prolactin levels, may be sufficient to reveal an adrenal origin or pure ovarian origin. Non-
tumor androgenic
hypercorticism is seen classically in late-presenting
enzyme deficits, but also in other situations: excessive adrenarche,
hyperprolactinemia,
obesity, chronic stress. The immediate Synacthene test can then eliminate diagnostic uncertainties if it leads to the discovery of appearances of 21- or 11-hydroxylase or 3 beta-ol
dehydrogenase blocks. Intense virilisation in a woman with a
testosterone level above 2 ng/
ml (7 nM/l) should lead to suspicion of an
androgen-secreting
tumor of the ovary or adrenal. CT scan of the abdomen and true pelvis is essential here since it may reveal the presence of an adrenal or ovarian mass. If no morphological abnormality is shown by this investigation, an endocrine lesion of a small ovary should be strongly suspected, the demonstration of which requires
isotope techniques and/or catheterisation of the ovarian veins. Two situations also exist which are responsible for severe
hyperandrogenism but less alarming in terms of their course and significance: certain homozygous forms of
21-hydroxylase deficit diagnosed late and ovarian hyperthecosis. It may happen that these hormonal investigations do not suffice alone to determine the precise origin of
hyperandrogenism and its cause. The
dexamethasone adrenal suppression test is useful in the diagnosis of type II micropolycystic dystrophy, in order to define the essentially ovarian, adrenal or mixed origin of
hyperandrogenism.