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EVALUATION OF PATIENTS WITH POTENTIAL HYPERANDROGENISM
Hirsutism, acne, alopecia, menstrual
dysfunction, oligomenorrhea, or polycystic
ovaries?
Yes
Clinical signs
of
virilization?
Clinical signs of
Cushing’s Sx?
Yes
Evaluate for an
ASN
Yes
No
Yes
No
 P4 level day 22-24
 Total & free T,
DHEAS, TSH, Prl,
17-HP
No
≥4 ng/mL
<4 ng/mL
 Total & free T,
DHEAS, 17-HP
 Total & free T,
DHEAS; TV-US
of ovaries &
CT/MRI of
adrenals
Mass detected,
or repeated
total T >200
ng/dL or
DHEAS >6000
ng/mL
‘Regular’ periods?
Clinical signs of
Acanthosis
Nigricans?
Yes
No
No
 24-hr urine
free F, or am F
after 1 mg
DEX h.s.
No
mass
 24-hr
free F, or
am F
Evaluate for
Cushing’s Sx
 oGTT for
INS & GLU
Nl
Peak INS
>300
IU/mL,
and normal
GLU
Evaluate for
HAIRAN Sx
Repeated
TSH or Prl
elevated
Peak INS
<300
IU/mL
 Total, free T,
or DHEAS, or
hirsutism;
normal TSH &
Prl
17-HP >200
ng/dL
 ACTH
test
17-HP
<1000 ng/dL
 Total, free T,
or DHEAS,
and hirsutism
or polycystic
ovaries; Nl 17HP
Nl
Hirsute?
17-HP
>1000 ng/dL
Yes
Evaluate for
thyroid or
pituitary
disorder
PCOS
NCAH
Atypical or
ovulatory
PCOS
IH
No
No hyperandrogenism
Abbreviations: ACTH, adrenocorticotropic hormone; ASN, androgen secreting neoplasm; DEX, dexamethasone; DHEAS, dehydroepiandrosterone sulfate; F, cortisol; GLU, glucose;
HAIRAN, hyperandrogenism insulin resistance acanthosis nigricans; 17-HP, 17-hydroxyprogesterone; IH, idiopathic hirsutism; INS, insulin; NCAH, non-classic adrenal hyperplasia;
Nl, normal; oGTT, oral glucose tolerance test; P4, progesterone; PCOS, polycystic ovary syndrome; Prl, prolactin; Sx, syndrome; T, testosterone; TSH, thyroid stimulating hormone;
TV-US, transvaginal ultrasound.
Conversion factors: To convert DHEAS from ng/mL to mol/L, multiply by 0.002714; to convert INS from IU/mL to pmol/L, multiply by 6; to convert 17-HP from ng/dL to nmol/L,
multiply by 0.03; to convert P4 from ng/mL to nmol/L, multiply by 3.18; to convert total T from ng/dL to nmol/L, multiply by 0.03467.