On certain days my Tampa office turns into a shelter of sorts for those who are lost without a diagnosis, and when I first saw Debbie a year ago she appeared to be the most stranded of all. A 49-year-old mother of four, she looked tired, like a pelican stuck on top of a pole in the gulf, uncertain as to whether she could ever fly home.
Debbie was anxious and desperate for answers. She had a growth on her face that had been there for a year; she told me that it “itches and bleeds.”
I performed a routine biopsy and found she had a basal cell skin cancer. When the lab report came back I also found that my initial biopsy had removed all of the cancer and that the margins were clear. I was as pleased as Debbie that no more work seemed necessary.
But on her second visit, I realized that our optimism had been misplaced. It quickly became apparent that she had a plethora of other conditions that needed to be woven together into a coherent diagnosis.
“I’ve been losing my hair,” she said, indicating the top of her scalp. “And lately I feel like my legs are getting thinner but I’m getting thicker in the center.”
“You’ve gained weight?”
“I’ve put on about 40 pounds, and it feels like it’s all right here in my gut,” she said, pointing.
I reviewed her medical and social background. She had a history of gallbladder and ovarian cyst surgery, smoked a pack of cigarettes every three days, and said she was not an alcohol abuser. In her records I saw she had suffered from depression.
“How are you doing now?” I asked regarding that part of her life.
“It’s gotten worse,” she said. “I tried Prozac and it seemed to help for a while, but now it just doesn’t. And I get agitated a lot.”
“More than in the past?” I asked.
“A lot more,” she admitted.
In fact, her depression had been quite severe at times, twice requiring hospitalization.
“What else?” I asked.
“While I’m losing hair up here,” she said, patting the top of her head, “I’ve got hair everywhere else—just like a man. And I’m only getting my period every three months or so.”
On examination, I saw that she did have hair loss at the top of her scalp and excessive hair growth elsewhere. There was puffiness on her upper chest above the clavicles. I also noticed that she had some bruising on the skin of her arms. She wasn’t taking steroids, which can bring on bruising, and her skin was not abnormally thin. I ordered some blood tests, including a reading of testosterone levels, and scheduled a follow-up visit for two weeks later.
In women, hair on the chin, upper lip, or arms and legs can create an appearance of old age or masculinization and can be quite psychologically disturbing. Hirsutism is the medical term for such excess hair in places where it should grow only on adult men. It is usually caused by an increased sensitivity to or increased production of hormones called androgens (testosterone and its metabolites). A disorder known as hyperandrogenism—increased levels of male hormone production in women—affects up to 10 percent of all women and commonly brings on irregular menstrual cycles.
At her next appointment, Debbie appeared even more agitated. I checked her testosterone results, which proved to be elevated. A number of causes for this needed to be considered. One common condition that leads to hyperandrogenism is polycystic ovary syndrome (PCOS). One in 10 women has PCOS, a condition that causes cysts to grow in their ovaries. Along with high levels of androgens, it can create irregularities in the menstrual cycle and trigger excessive hair growth.
Tumors of the adrenal cortex can also bring on these symptoms. Identifying a tumor and distinguishing which kind of tumor it might be—benign (an adenoma) or malignant—requires specialized scanning techniques and hormone investigations. Debbie’s abnormal blood test results, with her overproduction of hormones, indicated the need to do more imaging studies. So I ordered an abdominal CT scan and told the radiologist to get back to me with her findings as soon as she could.