Late-onset Congenital Adrenal Hyperplasia or Early-onset Polycystic Ovarian Syndrome: A Clinical Dilemma

Aim: To differentiate nonclassical congenital adrenal hyperplasia (NCCAH) from polycystic ovarian syndrome (PCOS) in a 13-year-old girl. Introduction: Hirsutism and virilization are effects of hyperandrogenism by ovaries and adrenal glands. It has a marked psychological and social impact affecting the quality of life. About 75% of premenarchal girls have hyperandrogenism due to PCOS but late-onset CAH cannot be ruled out, and this leaves the clinician in a quandary regarding the diagnosis and management. Case report: A 131⁄2-year-old girl presented with excessive facial hair, hoarseness of voice, and darkening of elbow pits since past 2 months, which was increasing in severity. The patient had not yet attained menarche but had pubarche 1 year earlier. Examination revealed presence of acanthosis, underdeveloped breasts, and clitoromegaly >3 cm. Levels of 17-hydroxyprogesterone were normal but higher levels were reported poststimulation. Fasting insulin levels were also high. Appropriate treatment was started, which led to improvement in patient’s symptoms. Conclusion: There is significant overlapping between PCOS and NCCAH, which warrants accurate diagnosis based on hormonal analysis to institute early and appropriate therapy. Clinical significance: Early therapy can prevent infertility and androgenic complications later in life.