Endocrinology Q 22

A 19-year-old woman is evaluated for irregular menstrual cycles since menarche at 12 years of age, increasing amount of coarse facial hair, and acne. Symptoms have worsened since she stopped playing high school sports and subsequently gained weight. She is most concerned about the hair growth and acne. Medical history is otherwise unremarkable, and she takes no medications.

On physical examination, vital signs are normal. BMI is 31. She has coarse terminal hair on the upper lip and chin, acne on the face and back, and non-discolored striae on the abdomen. There is no galactorrhea and no other evidence of virilization such as deepening of the voice, clitoromegaly, or male pattern balding.

Laboratory studies show a total testosterone level of 73 ng/dL (2.5 nmol/L), dehydroepiandrosterone sulfate level of 1.8 µg/mL (4.9 µmol/L), and hemoglobin A1c of 5.4%. Other laboratory results are normal. Serum pregnancy test is negative.

In addition to exercise and weight loss, which of the following is the most appropriate next step in management?

A Combined oral contraceptive therapy

B Metformin

C Pelvic ultrasound

D Spironolactone

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