A 73-year-old woman developed androgenic alopecia and progressive hair growth on the chest, back and abdomen over the course of 34 years. Menarche was at age 16. She had irregular menstrual periods subsequently but gave birth to three children. She reached menopause at age 40. No history of weight loss or sweating was reported. At presentation, we saw a 73-year-old lady with pronounced hirsutism (FerrimanGallway-score 24/36). No virilizing signs of the external genitalia were present but there was impressive androgenic alopecia. BMI was 31.5 kg/m2, blood pressure was 160/85 mmHg, pulse was 68 bpm and regular. The abdomen was soft; there were no masses palpable except for an incisional hernia. Hormonal evaluation of hyperandrogenism revealed elevation of total testosterone level to the neoplastic range. DHEA-S, androstendione, 17-OH-progesterone and a 24 h urine collection for cortisol were normal. Transvaginal ultrasound of the ovaries was normal and abdomino-pelvic CT-scan showed no tumorous lesions of the adrenal glands and ovaries. Careful re-evaluation of the CT-scan indicated that the ovaries appeared to be too large in relation to age. We postulated excess ovarian production of testosterone and performed bilateral ovarectomy. The histopathological examination of the ovaries showed stromal hyperthecosis. The postoperative testosterone-level normalized, hirsutism and androgenic alopecia improved on follow-up.
Ovarian hyperthecosis with hyperandrogenism is a rare cause of hirsutism and virilization in postmenopausal women and is difficult to diagnose as it may elude imaging studies. It should be included in the differential diagnosis in postmenopausal women with recent-onset of androgen excess. Careful intraoperative examination of even normal-appearing ovaries is imperative, particularly if no other cause of marked androgen excess is found.