mrfreddy
Sun, Nov-16-03, 18:25
Hey LISA SANDERS, M.D., ever heard of a low carb diet? If I ever heard of a case that calls for it, it's this poor woman's.
http://www.nytimes.com/2003/11/16/magazine/16DIAGNOSIS.html?pagewanted=print&position=
Male Pattern Baldness, Irregular Periods, Dark Skin Patches
By LISA SANDERS, M.D.
1. Symptoms
''Doctor, I think I look like a man.'' The young woman sat on the examining table. She stared at the ground as she spoke, then looked up, her eyes shiny with tears that didn't spill. ''Really, doctor, I know I look like a man, and I don't understand why.''
She was a young woman with dark curly hair and a pleasant but clearly masculine face and bearing. I'd noticed -- anyone would have -- but I'd been hesitant to bring it up. Somehow, it felt too awkward in our first appointments. I was comfortable asking her intimate details -- was she involved in a sexual relationship? Did she use drugs? Had she ever been the target of abuse? Yet to raise a topic as potentially painful as her appearance felt too intimate -- as if I needed to get to know her better. But it was time to approach the topic, and I was grateful she had brought it up.
She explained that she had always been tall and on the heavy side. But in the past few years, she'd put on a lot of weight, though she wasn't sure why. And while she had never gone in for dresses or makeup, she had never been mistaken for a man until the past year. She quit a receptionist job after only a few weeks because so many people called her ''Mr.'' Then, not long ago, while standing in line at the grocery store, a little girl asked her if she was a man or a woman. The child's mother apologized. ''But it didn't make me feel any better,'' she said. ''I just want whatever it is that's happening to me to stop.'' She roughly brushed away the escaping tears.
I listened to her story and paged through her chart once again. She had high blood pressure and diabetes, both diagnosed recently and moderately well controlled. She was 27; she smoked a little, but she didn't drink or use drugs. These days, she worked at a factory and lived with her parents. Her periods were irregular -- infrequent, but heavy and uncomfortable. She wasn't sexually active right now, and she had never been pregnant.
2. Investigation
I studied her carefully to see if I could pinpoint what gave her such a manly appearance. First, there was her size; she was nearly six feet tall, and her head seemed enormous. At 400 pounds, she was obese as well. Her shoulders were broad and muscular, and her hands and feet were big. Although she was soft-spoken, her voice was quite deep for a woman.
During a physical exam, I noted that her hair, which was cut in short, glossy ringlets, was thinning above her temples and at the top of her forehead in what is frequently referred to as ''male pattern baldness.'' Her skin was smooth and free of blemishes, though she had faint scars from what looked to be some serious teenage acne. Above her lip and on her cheeks, thick hair was clearly visible.
At the base of her neck extending toward her shoulders, her olive skin was darkened, as if that area alone had been exposed to the sun. That patch was thickened and had a velvety texture; so was the skin under her arms. This finding, called ''acanthosis nigricans,'' is common in overweight patients. It is most often associated with high levels of circulating insulin, though it has other causes: drugs, including birth-control pills and niacin, as well as some unusual cancers. The rest of her exam was pretty normal. Her breasts were small but fully developed. A pelvic exam was also normal.
It was clear to me that she had some hormonal abnormality. Did she have too much of one of the male hormones in her system? All women have some of them, but there are tumors that can produce an excess of testosterone or other androgens; they are rare, but their effects can be devastating. Too much growth hormone, caused by a tumor, could explain her height and the size of her hands and feet. In addition, a small percentage of women are born with a problem in the chemical machinery that produces and regulates the hormones necessary for sexual development. This abnormality, called congenital adrenal hyperplasia, is often obvious from birth but in some cases will not become apparent until young adulthood. A thyroid hormone deficiency could also have resulted in weight gain and a deepened voice.
All of her symptoms could also be related to high levels of insulin. Physicians are only beginning to recognize some of the side effects from exposure to chronically high insulin. At this point, I know of two syndromes in the medical literature. Both identify the same three key features seen through the perspective of different specialities: the development of male characteristics like facial hair, acanthosis nigricans and menstrual irregularities. Endocrinologists dubbed this polycystic ovary syndrome, while internists call it HAIR-AN syndrome. Either would fit my patient.
Finally, if she were taking some sort of supplement or drugs containing anabolic steroids, the drugs taken by athletes to help them build bigger muscles, she might develop some of the other male qualities: a deep voice, hair loss and increased body hair.
3. Resolution
The patient vehemently denied ever using steroids: ''No way!'' I sent her to the lab to get blood taken and asked her to bring in an old photograph to see if any obvious physical changes had occurred. If her problem had been a growth-hormone-producing tumor, characteristic alterations in the bones and features would be obvious in photos taken years apart. She returned a week later with an old picture. Other than the weight gain, I could see no real difference between her face then and now. Certainly she didn't show the changes you might expect with an excess of growth hormone.
Surprisingly, her hormone levels were pretty normal. Her estrogen was a little low, but it was hard to believe that this could be the sole cause of her masculine appearance. Her insulin level, on the other hand, was sky-high: more than five times the normal level.
Could all this really be due to her chronically high insulin? She fit both polycystic ovary syndrome and HAIR-AN syndrome -- but there was no definitive test that could confirm the diagnosis. I decided to start treating her, and if she improved -- if her periods became regular -- I would have proved the diagnosis through its response to therapy.
The kind of high insulin levels my patient had occur when the body becomes resistant to the effect of that hormone. In other words, she needed a lot of insulin in her system to get its most important job done -- helping cells take up sugar from the bloodstream. Treatment is then based on techniques to improve the body's response to insulin: daily exercise helps; weight loss helps. I also started her on a new diabetes medicine that can improve insulin sensitivity. I also decided to send her to an endocrinologist -- just in case I had missed anything. I explained all this to her and asked her if she understood what I had told her. She asked a few quick questions, then got ready to leave. On her way out, she turned. ''Why me?'' she asked. ''How come, in a country of fat people, I've got to get the kind of fat that makes me look like a man? Don't really seem fair, does it?''
I saw her a few weeks later. Her periods are regular again, and she has lost some weight. While her insulin resistance could be solely responsible for her masculine appearance, I needed to be sure. In medical school and beyond, the goal is a single, elegant diagnosis. But our patients' diseases don't always cooperate. She has an appointment to see an endocrinologist at an academic medical center later this year.
Lisa Sanders is an internist and is on the faculty at the Yale University School of Medicine. Her book ''The Perfect Fit Diet'' will be published in January by Rodale.
http://www.nytimes.com/2003/11/16/magazine/16DIAGNOSIS.html?pagewanted=print&position=
Male Pattern Baldness, Irregular Periods, Dark Skin Patches
By LISA SANDERS, M.D.
1. Symptoms
''Doctor, I think I look like a man.'' The young woman sat on the examining table. She stared at the ground as she spoke, then looked up, her eyes shiny with tears that didn't spill. ''Really, doctor, I know I look like a man, and I don't understand why.''
She was a young woman with dark curly hair and a pleasant but clearly masculine face and bearing. I'd noticed -- anyone would have -- but I'd been hesitant to bring it up. Somehow, it felt too awkward in our first appointments. I was comfortable asking her intimate details -- was she involved in a sexual relationship? Did she use drugs? Had she ever been the target of abuse? Yet to raise a topic as potentially painful as her appearance felt too intimate -- as if I needed to get to know her better. But it was time to approach the topic, and I was grateful she had brought it up.
She explained that she had always been tall and on the heavy side. But in the past few years, she'd put on a lot of weight, though she wasn't sure why. And while she had never gone in for dresses or makeup, she had never been mistaken for a man until the past year. She quit a receptionist job after only a few weeks because so many people called her ''Mr.'' Then, not long ago, while standing in line at the grocery store, a little girl asked her if she was a man or a woman. The child's mother apologized. ''But it didn't make me feel any better,'' she said. ''I just want whatever it is that's happening to me to stop.'' She roughly brushed away the escaping tears.
I listened to her story and paged through her chart once again. She had high blood pressure and diabetes, both diagnosed recently and moderately well controlled. She was 27; she smoked a little, but she didn't drink or use drugs. These days, she worked at a factory and lived with her parents. Her periods were irregular -- infrequent, but heavy and uncomfortable. She wasn't sexually active right now, and she had never been pregnant.
2. Investigation
I studied her carefully to see if I could pinpoint what gave her such a manly appearance. First, there was her size; she was nearly six feet tall, and her head seemed enormous. At 400 pounds, she was obese as well. Her shoulders were broad and muscular, and her hands and feet were big. Although she was soft-spoken, her voice was quite deep for a woman.
During a physical exam, I noted that her hair, which was cut in short, glossy ringlets, was thinning above her temples and at the top of her forehead in what is frequently referred to as ''male pattern baldness.'' Her skin was smooth and free of blemishes, though she had faint scars from what looked to be some serious teenage acne. Above her lip and on her cheeks, thick hair was clearly visible.
At the base of her neck extending toward her shoulders, her olive skin was darkened, as if that area alone had been exposed to the sun. That patch was thickened and had a velvety texture; so was the skin under her arms. This finding, called ''acanthosis nigricans,'' is common in overweight patients. It is most often associated with high levels of circulating insulin, though it has other causes: drugs, including birth-control pills and niacin, as well as some unusual cancers. The rest of her exam was pretty normal. Her breasts were small but fully developed. A pelvic exam was also normal.
It was clear to me that she had some hormonal abnormality. Did she have too much of one of the male hormones in her system? All women have some of them, but there are tumors that can produce an excess of testosterone or other androgens; they are rare, but their effects can be devastating. Too much growth hormone, caused by a tumor, could explain her height and the size of her hands and feet. In addition, a small percentage of women are born with a problem in the chemical machinery that produces and regulates the hormones necessary for sexual development. This abnormality, called congenital adrenal hyperplasia, is often obvious from birth but in some cases will not become apparent until young adulthood. A thyroid hormone deficiency could also have resulted in weight gain and a deepened voice.
All of her symptoms could also be related to high levels of insulin. Physicians are only beginning to recognize some of the side effects from exposure to chronically high insulin. At this point, I know of two syndromes in the medical literature. Both identify the same three key features seen through the perspective of different specialities: the development of male characteristics like facial hair, acanthosis nigricans and menstrual irregularities. Endocrinologists dubbed this polycystic ovary syndrome, while internists call it HAIR-AN syndrome. Either would fit my patient.
Finally, if she were taking some sort of supplement or drugs containing anabolic steroids, the drugs taken by athletes to help them build bigger muscles, she might develop some of the other male qualities: a deep voice, hair loss and increased body hair.
3. Resolution
The patient vehemently denied ever using steroids: ''No way!'' I sent her to the lab to get blood taken and asked her to bring in an old photograph to see if any obvious physical changes had occurred. If her problem had been a growth-hormone-producing tumor, characteristic alterations in the bones and features would be obvious in photos taken years apart. She returned a week later with an old picture. Other than the weight gain, I could see no real difference between her face then and now. Certainly she didn't show the changes you might expect with an excess of growth hormone.
Surprisingly, her hormone levels were pretty normal. Her estrogen was a little low, but it was hard to believe that this could be the sole cause of her masculine appearance. Her insulin level, on the other hand, was sky-high: more than five times the normal level.
Could all this really be due to her chronically high insulin? She fit both polycystic ovary syndrome and HAIR-AN syndrome -- but there was no definitive test that could confirm the diagnosis. I decided to start treating her, and if she improved -- if her periods became regular -- I would have proved the diagnosis through its response to therapy.
The kind of high insulin levels my patient had occur when the body becomes resistant to the effect of that hormone. In other words, she needed a lot of insulin in her system to get its most important job done -- helping cells take up sugar from the bloodstream. Treatment is then based on techniques to improve the body's response to insulin: daily exercise helps; weight loss helps. I also started her on a new diabetes medicine that can improve insulin sensitivity. I also decided to send her to an endocrinologist -- just in case I had missed anything. I explained all this to her and asked her if she understood what I had told her. She asked a few quick questions, then got ready to leave. On her way out, she turned. ''Why me?'' she asked. ''How come, in a country of fat people, I've got to get the kind of fat that makes me look like a man? Don't really seem fair, does it?''
I saw her a few weeks later. Her periods are regular again, and she has lost some weight. While her insulin resistance could be solely responsible for her masculine appearance, I needed to be sure. In medical school and beyond, the goal is a single, elegant diagnosis. But our patients' diseases don't always cooperate. She has an appointment to see an endocrinologist at an academic medical center later this year.
Lisa Sanders is an internist and is on the faculty at the Yale University School of Medicine. Her book ''The Perfect Fit Diet'' will be published in January by Rodale.