Postmenopausal hyperandrogenism of ovarian origin: diagnostic and therapeutic difficulties
K Ashawesh, B Jose, DH Redford & DM Barton
Background: Rapidly progressive hirsuitism or virilization raises the suspicion of an androgen-secreting tumour. Adrenal tumours are usually ruled out by hormonal testing and imaging studies. Small virilizing ovarian tumours may not be detectable by imaging studies.
Case 1: A 66 year-old woman presented with 4 year history of hirsutism and virilization. She had a history of longstanding uterine bleeding secondary to fibroids. Investigations revealed raised serum total testosterone, 5.6 nmol/L (N: 0.03.4 nmol/l), with sex hormone binding globulin (SHBG), dehydroepiandrosterone- sulfate (DHEAS), 17-hydroxyprogesterone (17 OHP), androstenedione and overnight dexamethazone suppression test (ODST) being within the reference ranges. CT abdomen and pelvis was unremarkable except for uterine fibroids. In view of the uterine bleeding, she underwent hysterectomy with bilateral oopherectomy. Histological examination showed benign uterine leiomyomata and bilateral ovarian fibrothecoma. Postoperative testosterone levels returned to normal (<0.1 nmol/l).
Case 2: A 61 year-old woman presented with hirsutism and male-pattern baldness developing over a two year period. Forty years previously, she underwent total abdominal hysterectomy and left oopherectomy. Initial endocrine testing revealed elevated serum total testosterone, 12.8 nmol/l with normal SHBG, DHEAS, androstenedione, 17 OHP and ODST. CT abdomen and pelvis was unremarkable. A laparoscopic right ophorectomy was performed and a17 mm Leydig cell tumour of hilus cell type was detected on histologic examination. 2 months later, she had a regression of hirsutism and her serum testosterone returned to normal.
Comment: Androgen-secreting ovarian tumours may represent a diagnostic and therapeutic challenge. In post menopausal women with progressive hirsutism or virilization, it may be reasonable to consider bilateral oopherectomy in the setting of normal adrenal and ovarian imaging and biochemical evidence of ovarian source of the hyperandrogenism. This approach avoids unnecessary investigations and delays in definitive management. Laparoscopy may be useful in the diagnosis and treatment of selected cases.