Barbara is presented to the family physician for evaluation of irregular menses. Her periods have always been irregular - coming once in every 6 months - since menarche occurred at the age of 14. Her bleeding is often heavy, passing large clots and has a lot of cramps. She also complains about strong appearance of facial, abdomen and arm hair. She denies any changes to her voice or muscles. Her medical history is otherwise insignificant.

On examination:

• Height: 170 cm, Weight: 92.5 Kg, BMI: 32
• BP: 135/85 mmHg, Heart Rate: 82 /min, Respiratory rate: 16 /min, Temperature: 37.0⁰C,
• Excessive hair growth on face, abdomen, and arms. Acne vulgaris on her face and both shoulders.

What is the correct hormonal axis to primarily regulate the menstrual cycle?

Which of the following hormones are produced by the ovaries and responsible for the menstrual cycle? (select all that apply)

Barbara’s laboratory investigation showed:

• Blood analysis:
  • CBC:
    • RBCs: 4.0 x 10¹²/L, Hemoglobin: 135.5 g/L, Hematocrit: 0.38
    • MCV: 87 fL, MCH: 31pg, RDW: 12.1%, Reticulocytes: 1.2%, ESR: 8 mm/hour
    • WBC: 9.5 x 10⁹/L, (Neutrophils: 5.0 x 10⁹/L, Lymphocytes: 3.4 x 10⁹/L, Basophils: 0.08 x 10⁹/L, Eosinophils: 0.31 x 10⁹/L, Monocytes: 0.7 x 10⁹/L)
    • Platelet counts: 277 x 10⁹/L
  • Na: 142 mmol/L, K: 4.2 mmol/L, Cl: 102 mmol/L, Ca (total): 2.4 mmol/L, Ca (ionized): 1.13 mmol/L
  • Glucose: 8.6 mmol/L, HbA1C: 7.3%, BUN: 6.2 mmol/L, Creatinine: 82.3 µmol/L, Uric acid: 322 mmol/L
  • Triglycerides: 3.8 mmol/L, Cholesterol: 9.2 mmol/L, HDL: 2.8 mmol/L, LDL: 6.7 mmol/L
  • Bilirubin: 12 mmol/L, Albumin: 42 g / L,
  • Insulin: 286 pmol/L, Glucose/Insulin ratio: 3.7
  • Cortisol (8 am): 517 nmol/L
  • Testosterone: 7.2 nmol/L, Dehydroepiandrosterone- sulfate (DHEA-S): 15.3 µmol/L
  • Prolactin: 20 mcg/L, FSH: 5.9 IU/L, LH: 17.8 IU/L, LH/FSH: 3:1
  • Estradiol: 202 pmol/L
  • CA 19-9: 32 kU/L, CA 125: 25 kU/L, β-hCG: 2 mlU/mL

• Urinalysis:
  • Color: yellow, pH: 6.6, Specific gravity: 1017, Osmolarity : 594 mOsm/kg; Glucose, Ketones, Albumin, Bilirubin: negative, WBCs and RBCs: 0 and 2/HPF, Squamous epithelial cells: 1-2/HPF, Bacteria, Crystals, Casts: negative. Yeast: +

How do you interpret the testosterone and DHEA-S levels?

Have a look at the laboratory results again:

• Blood analysis:
  • CBC:
    • RBCs: 4.0 x 10¹²/L, Hemoglobin: 135.5 g/L, Hematocrit: 0.38
    • MCV: 87 fL, MCH: 31pg, RDW: 12.1%, Reticulocytes: 1.2%, ESR: 8 mm/hour
    • WBC: 9.5 x 10⁹/L, (Neutrophils: 5.0 x 10⁹/L, Lymphocytes: 3.4 x 10⁹/L, Basophils: 0.08 x 10⁹/L, Eosinophils: 0.31 x 10⁹/L, Monocytes: 0.7 x 10⁹/L)
    • Platelet counts: 277 x 10⁹/L
  • Na: 142 mmol/L, K: 4.2 mmol/L, Cl: 102 mmol/L, Ca (total): 2.4 mmol/L, Ca (ionized): 1.13 mmol/L
  • Glucose: 8.6 mmol/L, HbA1C: 7.3%, BUN: 6.2 mmol/L, Creatinine: 82.3 µmol/L, Uric acid: 322 mmol/L
  • Triglycerides: 3.8 mmol/L, Cholesterol: 9.2 mmol/L, HDL: 2.8 mmol/L, LDL: 6.7 mmol/L
  • Bilirubin: 12 mmol/L, Albumin: 42 g / L,
  • Insulin: 286 pmol/L, Glucose/Insulin ratio: 3.7
  • Cortisol (8 am): 517 nmol/L
  • Testosterone: 7.2 nmol/L, Dehydroepiandrosterone- sulfate (DHEA-S): 15.3 µmol/L
  • Prolactin: 20 mcg/L, FSH: 5.9 IU/L, LH: 17.8 IU/L, LH/FSH: 3:1
  • Estradiol: 202 pmol/L
  • CA 19-9: 32 kU/L, CA 125: 25 kU/L, β-hCG: 2 mlU/mL

What other laboratory values are elevated? (select all that apply)