An occult cause of hirsutism
NM O'Mullane1, A Watson2 & B Bannerjee3
A 64 year-old woman was referred because of male pattern baldness and hirsutism. There were no virilizing or Cushingoid features and no abnormalities on gynaecological assessment.
Investigations: Testosterone 7.4 nmol/L [0-2.4], FSH 81.0 iu/L, LH 38.3 iu/L, 17 Alpha hydroxyprogesterone 11.0 nmol/L [0-10], Free androgen index 21.1 [0-7.5], DHEA sulphate 1.9 micromol/L [2.2-10.0], urine free cortisol less than 150 nmol/24 hrs. Chest x-ray normal, abdominal and pelvic ultrasound and CT scan of abdomen showed multiple uterine fibroids and endometrial thickening. Ovaries and adrenals were normal.
Oral hydrocortisone was commenced because of the possibility of the adult onset adrenogenital syndrome. The testosterone level suppressed to 1.5 nmol/L, but there was no clinical improvement in the hirsutism.
Selective inferior vena caval blood sampling of testosterone showed a level of 7.6 in the right ovarian vein. Total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. There was no macroscopic abnormality of the ovaries. Histology showed a right ovarian hilus cell tumour [crystal positive]. Hydrocortisone was discontinued. Subsequent outpatient testosterone level was undetectable and there was a lessening of the hirsutism and baldness.
This case illustrates the difficulty in diagnosis of a small and potent ovarian tumour and also suppressibility of the testosterone production with hydrocortisone.