Ovarian hyperthecosis is a rare cause of androgenic alopecia in postmenopausal women. The physiological levels of androgens, secreted by ovarian stromal cells, are greatly increased with hyperplastic or neoplastic transformation leading to possible clinical consequences.
We report a case of a 56-year-old woman with type 2 diabetes presenting with hirsuitism and a history of male pattern hair loss over a two year period. Biochemistry showed elevated levels of testosterone 9.7 nmol/l (range: 0.22.9 nmol/l), extracted testosterone 8.5 nmol/l (range: 0.52.5 nmol/l) and androstenedione 13.1 nmol/l (range: 1.712.9 nmol/l) whilst gonadotropins, oestradiol, cortisol, prolactin and thyroid hormones were within the appropriate reference range. These hormone levels together with a non-suppression of testosterone during low dose dexamethasone suppression test raised the possibility that the elevated testosterone was of ovarian origin. A transvaginal ultrasound revealed bilateral solid adnexal masses, likely to be ovarian in nature, although no normal ovarian tissue was identified.
Based on the above investigations a working diagnosis of hyperandrogenism of ovarian origin was made at multidisciplinary team meeting and after discussing the treatment options with the patient a bilateral oophorectomy was carried out. The left ovary measured 50×30×25 mm and the right ovary 60×30×20 mm and the resulting histology revealed significant bilateral ovarian hyperthecosis. In our patient, surgical therapy had an excellent result. An alternative treatment option for ovarian hyperthecosis, as reported in various case reports, is GnRH agonist therapy.
A month following surgery the testosterone levels were normalized (between 0.2 and 0.4 nmol/l) and the patient reported a clear regression of both hirsuitism and hair loss. However, surprisingly her glycaemic control deteriorated significantly after surgery (pre-surgery HbA1c: 7.4%, post-surgery HbA1c: 9.5%) and this was contrary to expectations as studies suggested that the patient could have anticipated an improvement. At present, we can offer no satisfactory explanation of this last observation.