Effect of dexamethasone and clomiphene citrate on peripheral steroid levels and ovarian function in a hirsute amenorrheic patient.

A 22-year-old infertile woman with amenorrhea and mild hirsutism failed to experience uterine bleeding following withdrawal of progestin therapy and failed to ovulate or menstruate following treatment with clomiphene citrate in doses up to 200 mg/day for 5 days. Clomiphene citrate, 200 mg/day, plus 10,000 IU of human chorionic gonadotropin given on day 13 also failed to induce either ovulation or menses. Serum androgen levels were: cortisol, 186 ng/ml; dehydroepiandrosterone sulfate, 6400 ng/ml; dehydroepiandrosterone, 17.92 ng/ml; androstenedione, 4.68 ng/ml; testosterone, 1.28 ng/ml; and dihydrotestosterone, 0.75 ng/ml. Upper limits of normal values for these androgens in our laboratory are, respectively: 140, 2500, 8.0, 2.3, 0.5, and 0.35 ng/ml. The dexamethasone (Dex) suppression test indicated predominantly an adrenal source of the hyperandrogenism. Except for androstenedione the levels of all androgens measured returned to normal following treatment with 0.5 mg of Dex/day. Four months of this treatment had a beneficial effect on the hirsutism but failed to induce ovulation or menses. Clomiphene citrate, 100 mg/day for 5 days, given concurrently with Dex therapy resulted in ovulation and conception. Adrenal androgen excess has been postulated to be a cause of ovarian dysfunction. Our data support this postulate.