A 14-year-old White female presents to her pediatrician for her annual exam. Her mother states that the patient has experienced irregular periods for the past 8 months. Age at menarche was 12.

A physical exam reveals accumulation of adipose tissue around the neck and abdomen. The patient's breathing is slightly labored and there appears to be some facial hair on the upper lip and on the sides of the face near her neck. Systemic assessments are normal, except for her blood pressure, which is 130/80 mm Hg. Closer examination reveals genital and pubic hair development are Tanner stage 5. The patient's height is 5 ft 2 in and her weight is 155 lb, which places her in the 96th percentile for her age.

Further questioning reveals that except for gym class and regular daily activity, the patient does not participate in any exercise or sports programs. She swam competitively but stopped a year and a half ago because of bullying from her peers. Her diet is the standard American diet, with some sweets and processed/fast foods. In the past 3 years, the patient has lost all four of her grandparents, two of whom lived close by and with whom she spent part of each day. The patient's mother has expressed concern because she has noticed the effect of the patient's weight gain on her mood and confidence.