Introduction: Ovarian hyperthecosis is a rare cause of severe hyperandrogenism. Unlike PCOS, it is also described in postmenopausal women.
We report the case of a 67-year-old obese (BMI=37.5 kg/m2) and dyslipidemic woman, gravid 5 para 3, menopause at 49, with poor controlled type 2 diabetes mellitus (HbA1c=10%). She was in treatment with insulin for the last 12 years, currently on 168 U/24 h (1.71 U/kg)- indicating severe insulin resistance, complicated with stage III diabetic nephropathy, hypertension, ischemic heart disease with history of coronary artery bypass surgery and class III NYHA heart failure. She was admitted for severe hirsutism and balding, symptoms that developed progressively in the last 2 years. Physical examination revealed androgenic rash, male type alopecia, severe facial and thoracic hirsutism, deepening of the voice, acanthosis nigricans, mild ankle edema, dyspnea at minimal effort, BP=130/80 mmHg, HR=74/min. Biochemical profile: erythrocytosis (Hb=16.6 g/dl), renal failure (creatinine =2.9 mg/dl, BUN=159 mg/dl), hyperglycemia (Glyc=240 mg/dl), dyslipidemia (triglycerides=435 mg/dl). Basal total testosterone level was high (2.74 ng/ml), with normal plasma cortisol (15.7 μg/dl), and DHEAS (32.5 μg/ml). Mullerian inhibiting substance was in the fertile female range (1.27 ng/ml), β-hCG and CA125 were normal. A two days low dose dexamethasone suppression test indicated normal suppression of the adrenal axis (plasma cortisol=1.26 μg/dl), with no significant reduction (<40%) of the total testosterone (1.85 ng/ml), reflecting autonomous androgen secretion of ovarian source. Transvaginal ultrasound examination showed enlarged uterus (57/46 mm) and ovaries (left ovary 30/26 mm, right ovary 29/30 mm) for age. The patient was transferred to the gynecological department where total hysterectomy with bilateral anexectomy was performed. Two weeks after surgery the insulin requirement dropped by 39% (102 U/24). Total testosterone was under the detectable range of the laboratory.
Conclusion: Etiologic treatment of hyperandrogenism in cases of insulin-treated type 2 diabetes mellitus can lower the insulin resistance.
30 Apr - 04 May 2011
European Society of Endocrinology