A young girl suddenly grew a beard. This is what was happening in her ovaries. KT is a seventeen year old girl presenting to the emergency room with nocturnal somnambulation, sleep apnea, and rapid onset hirsutism. She tells the admitting nurse that she had gained 50 pounds (22.7 kg) over the last 3 months and was in emotional distress as she suddenly grew thick facial hair overnight. You see, KT was an adopted American girl. Her birth mother was uneducated, homeless, and diabetic. But her adoptive parents offered a happy childhood full of opportunity. About 6 years ago when KT was 11, her parents noticed that she was gaining more weight than the other kids. "She's just a growing girl," they thought. The following year at age 12, KT experienced Menarche, or her first period the event was very normal for a girl that age, but subsequent menstrual cycles became irregular, erratic. "Just some growing pains," her parents thought. Earlier in the year KT's siblings noticed that she was sleep walking. Episodes would involve her going into the refrigerator and eating large amounts of food. At first they thought she was joking but then quickly realized that she couldn't recall any of the nighttime engorgement. Visibly, KT was unhealthy. At physical examination, she presented with Acanthosis Nigricans Acantha in ancient Greek referring to spines or in this case, the Stratum Spinosum layer of the skin. Osis meaning disease of, and Nigricans referring to a blackening. Her skin had velvety gray patches below her neck and axilla. Indicating insulin resistance and type 2 diabetes. Similarly, she had elevated serum aminotransferase Serum referring to the amber colored liquid that separates out when blood coagulates and aminotransferase being an important liver enzyme. Elevations of this in a teenager with diagnostic exclusion of both hepatitis and Wilson's disease, which is a genetic disorder leading to the accumulation of copper in the body indicates that KT has nonalcoholic fatty liver disease All of this was combined with class 3 obesity as she was 5 foot 4 inches (163cm) tall and weighed 306 pounds (139kg), as well as a self reported menstruation count of 2 in the past year. The physical problems of KT are obvious, but the underlying causes are not. Sleep apnea was first observed at age 13. The disturbances in sleep that she suffered over the years began to negatively impact her life, as psychiatric evaluation found her to suffer from mild depression and low motivation Adolescent sleep derangements are detrimental as the brain is still developing and growing at this age. Recent overnight polysomnographs show worsening intermitent oxygen desaturation indicating airway obstruction and sleep disruption consistent with a sudden weight gain of 50 pounds (22.7kg) over 3 months, but something's wrong. Did she gain 50 pounds (22.7kg) in 3 months because of disturbances in her sleep patterns or did she develop disturbances in her sleep patterns because she gained 50 pounds (22.7kg) in 3 months? A blood test reveals that "KT's" serum total testosterone level is 120 nanograms per deciliter. Two times the upper limit of normal in a woman and just under half the lower limit of normal for an adult man We can conclude here that she's suffering from Hyperandrogenemia. Hyper meaning high Androgen referring to male hormones mainly testosterone and emia meaning presence in blood. High male hormone presence in blood. But KT is a girl. If male hormones are made by male parts but KT is a girl and has female parts then where are those male hormones coming from? How is it possible that she has high male hormone presence in blood? Well, there's a bit of basic human physiology to be known here. Men and women produce both testosterone and estrogen. It's the concentration that makes the distinction. Men have 10 to 20 times more testosterone in their body than women and women have more estrogen than men Estrogen refers to a grouping of hormones, the most common being, estradiol. In humans, testosterone is an obligate intermediate in the biosynthesis of estradiol meaning that if the body's making estrogen then it has done so in part because it has made testosterone. In some sense, testosterone is made first and because it promotes the production of estrogen women must produce testosterone, but men produce estrogen really only because of testosterone. These hormones determine physical masculine and feminine characteristics. A beard is normal for a 30 year old man, but abnormal for a 17 year old girl, meaning in KT's case, it's a serious sign of an underlying endocrinopathy: a disease centered on hormones. Androgens affect ventilatory control and increase visceral fat so obstructive sleep apnea like in KT's case is typically more common in in boys after puberty when testosterone levels are high but it's also common for women who have an ovary syndrome meaning that KT's weight gain and sleep disturbances are not caused by one another, but are caused by her hyperandrogenemia. In normal functioning women 25% of all testosterone produced is from the ovaries. Another 50% is created through peripheral conversion of androstenedione the precursor hormone of both estrogen and testosterone which is produced by the ovaries. Peripheral, meaning that the conversion happens in the liver, skin, and fat tissue. The idea of a precursor hormone is important to note because it indicates that both testosterone and estrogen are formed from this same common pathway deriving from cholesterol. Estrogen is produced downstream meaning that testosterone, for the most part, comes first and women have to make testosterone. Disturbing the equilibrium of this state such as adding more testosterone through anabolic steroid abuse increases estrogen presence in blood causing male athlete steroid abusers to have gynecomastia without the use of anti-aromatase. Inside the ovaries excess testosterone will signal a stop to androstenedione production, so that less testosterone and estrogen are released into the blood. This negative feedback explains why hormones fluctuate from day to day and from week to week but if KT's testosterone levels are high then why is her body producing more of it? Negative feedback is supposed to suppress production when levels are high, right? Well, let's go back to the source of testosterone production in women. The ovaries account for only 25% of all androgen produced in the body and remember that 50% comes from the peripheral conversion of androstenedione in the liver, skin, and fat tissue. Because KT is 17, she's still in puberty so maybe her liver will get a little bigger, but that's not likely and she also has nonalcoholic fatty liver disease so its probably not going to make more testosterone But how about her skin? Well, she's gaining weight faster than her skin can expand explaining her lower abdominal striae, so she's not really growing more skin right now so that's not a possible source of more testosterone. But how about the fat tissue? KT just gained 50 pounds (22.7kg) over the last 3 months and with confirmation that she's type 2 diabetic then by definition it means she has hyperinsulinemia high insulin presence in blood and insulin is a powerful stimulus for the fat tissue to produce more testosterone through peripheral conversion of androstenedione. Hyperinsulinemia also increases ovarian steroidogenesis too, meaning that the weight that she gained perpetuated her hyperandrogenism, caused her irregular menstruation leading to anovulation and provided a condition sufficient for her to grow coarse facial hair and increase her chances of infertility and endometrial cancer into adulthood. Pelvic ultrasound finds that KT has bilateral sclerocystic ovaries. Slcero meaning hardened. Cystic referring to cyst which is an abnormal sac containing fluid and bilateral meaning on both sides her ovaries are covered with numerous hardened cysts. Multiple follicles fail to ovulate, so they accumulate in number and this morphology confirms that KT has Polycystic Ovary Syndrome (PCOS). The abnormal steroidogenesis fed into her obesity, sleep disturbance, and amenorrhea. Subsequently, the obesity encouraged her hormone imbalance by feeding forward into the mechanism of testosterone production and gave her erratic menstrual cycles, anovulation and hirsutism. Polycystic Ovary Syndrome is the most common endocrinopathy documented in women all around the world and its first report in human history goes back to Hippocrates who wrote in 400 B.C. about "women whose menstruation is less than 3 days with a masculine appearance yet they are not concerned about bearing children nor do they become pregnant." The Romans centuries later in 100 A.D. noted that there was a natural absence of menstruation in persons whose bodies are of masculine type and those women who are rather robust like mannish and sterile women. Modern understanding of PCOS dates back to just 1935 where 7 women presented with amenorrhea, hirsutism, obesity, and polycystic ovaries by 1970, reasoning determined that excess testosterone through an inappropriate secretion of gonadotropin hormones was the main culprit and in 1986 a cohort of 19 people who transitioned from female to male in this lifetime were treated with exogenous testosterone and 17 of them developed enlarged polycystic ovaries. By 1990 the diagnostic criteria was developed which enabled women with the syndrome of anovulation, hyperandrogenism, and polycystic ovaries to be recognized and treated through classification and diagnosis. PCOS is a syndrome meaning that it's a group of symptoms that generally occur together. The keyword being generally. Polycystic ovaries can be found in women who aren't obese, but still have hyperandrogenemia. Some others may be obese, have anovulation and are hirsute but don't have actual polycystic ovaries and diagnostic criteria would still qualify but not confirm them with PCOS. This means that diagnosis in adolescents like KT should be taken with care. Teenage girls can typically have times of anovulation. This is a time when menstruation is irregular and erratic, which means increased testosterone levels leading to temporary development of acne, hirsutism, and weight gain. But because this is transient in occurrence and can be common, a diagnosis of PCOS cannot be made solely on those grounds. Confirmation of a diagnosis of PCOS in an adolescent girl cannot be had without further evaluation because it's typically a diagnosis of exclusion, meaning many other hyperandrogenic disorders need to be ruled out first. The adrenal glands, which make adrenaline and sit on top of the kidneys, makes the remaining 25% of testosterone in women so the adolescent female patient may have congenital adrenal hyperplasia, a genetically linked overgrowth of the adrenal glands which can overproduce androgens. Ovarian tumors can grow at adolescence and they too can secrete inappropriate amounts of testosterone. Thyroid disorders, insulin resistance, Cushing's disease, and even acromegaly, which is an excess of growth hormone caused by pituitary tumor that can take 10 to 15 years to diagnose all have symptoms that can mimic polycystic ovary syndrome and they should be ruled out before diagnosis can be confirmed. For KT, metformin is initiated for her diabetes with a regimen of exercise beginning at 30 minutes for 3 days a week with a personal trainer. Her sleep apnea is treated with a mask and positive pressure, but as up to 20% of patients are typically noncompliant with the treatment it was used with limited success. If she has excess testosterone in her blood the preferred treatment modality for her PCOS is estrogen combined with progestin. Combination oral contraceptives will promote menstrual regularity and by equilibrium reduce ovarian testosterone production thus reducing hirsutism and acne. Metformin will suppress liver glucose production reducing its presence in blood thereby reducing insulin presence and mitigate ovarian steroidogenesis, while modestly slowing peripheral conversion of androstenedione to testosterone. Physician follow-up is needed with combination oral contraceptives as they are associated with a four-fold increase in incidence of venous thromboembolism which are large blood clots that can develop silently and once large enough can break off dislodge into the lungs and cause a pulmonary embolism and sudden death. Ethinyl estradiol dosages can increase the risk of stroke and heart attack by up to two-fold without proper monitoring. The benefits of this treatment though outweigh its risks. We are trading a decrease in chance of infertility, decreasing risk of endometrial cancer, and alleviation of hirsutism and androgenic presentation with increased risk of cardiovascular adverse events. KT is a patient that my colleague saw in the Illinois Medical District in March of 2009 Most of these case reports in video are patients that I or my colleagues have seen and while it's impossible for me to know the entire backstory for each patient the videos are written, recorded and edited solely by me and fact checked by my colleagues all across the United States who practice and research in the topic of each case. Videomaking or cinematography and storywriting are things that I've learned on my own and Skillshare helped me learn those basics and they also helped sponsor this video. Skillshare is an online learning community with 20,000 classes from business to leadership and design. I try to learn something new every day and apply those principle to my funtime hobby like making videos and Skillshare helps me do that. The annual subscription to Skillshare is less than 10 dollars a month and the first 500 people to sign up at the link in the description will get their first 2 months free, risk free. With adherence to treatment, strong family support, and a caring medical team KT was able to make a recovery. Was she able to have children later in life? Well, thats a part of the story she's still writing. Thank you so much for watching, take care of yourself and be well.
Great series of videos, I really appreciate them being posted.
Please tell me his name
Really appreciate the effort this guy goes through to make these types of video's. Awesomely informative even for people not medically trained.
Also finally someone who explains the meaning of the words you hear so frequently making this allot more accessible.
TLAADW: (Too Long And Annoying Don't Watch) Polycystic Ovary Syndrome
Set of symptoms due to elevated male hormones (androgens) in females.
The medical cause of POCS is uncertain.
I have this aswell.. it sucks..
I read that title and knew this was chubbyemu. I love that guy.
Suddenly? holy shit!
Looks like Reddit's love for this guy has ended.