Background: Multiple diagnostic modalities may be needed to establish the source of excessive androgen production in women. The detection of testosterone-producing ovarian tumors by imaging techniques can be difficult because of their in same cases small size and radiological structure.
Case report: We describe a 55-year-old postmenopausal woman presenting with progressive severe virilization (Ferriman Gallwey-Score: 2326), increased hair growth, male pattern baldness and deepening of the voice. Measurements of circulating hormones demonstrated severe hyperandrogenism with a markedly elevated total testosterone concentration of 775 ng/dl (reference 2.940.8 ng/dl) and elevated levels of androstendione and suppressed gonadotropines. Cortisol levels went down, but total testosterone inhibition did not occur after suppression test with dexamethasone. In addition, red blood count, hemoglobin and hematocrit values were elevated. An extensive pre-operative diagnostic work up was performed, including transvaginal ultrasound, abdomenthorax computed tomography, abdomenpelvic magnetic resonance imaging, as well endoscopic ultrasound, but all failed to localize an androgen-secreting tumor. Therefore, a selective venous catheterization and hormonal sampling (SVCHS) of the ovarian und adrenal veins were performed. The total testosterone concentration was significantly higher in the samples taken from the right ovarian vein (>1500 ng/ml; right:left ratio 2.8; and reference <1.44). An exploratory laparoscopic right saplingo-oophrectomy was performed and gave evidence of a right ovarian tumor. Immunohistochemical examinations revealed a stromal luteoma of the ovary. The patients postoperative testosterone levels declined rapidly to normal levels.
Conclusion: Bilateral selective venous sampling from ovarial and adrenal veins can be valuable for the localization of small androgen-producing tumors and enable an operative cure, especially when imaging offers confounding results.