Endocrine Abstracts

Introduction: Polycystic ovarian syndrome (PCOS) is a common cause of hyperandrogenism in women of reproductive age but rarely causes very high testosterone levels and frank virilisation which is associated with ovarian or adrenal tumours. We present a rare case of progressively increasing testosterone levels causing virilisation from a histologically confirmed right polycystic ovary. Complete cure was achieved by right salpingo-oophrectomy.

Case: A 32 year old lady diagnosed with PCOS four years previously, presented with worsening extensive hair growth forcing her to shave daily, receding thinning hair line, deepened voice with male stature and amenorrhoea of 8 years duration despite Metformin and spironolactone therapy and weight loss. On examination she had a BMI of 36, and Ferriman-Gallwey score of 30 with evidence of virilisation. Testosterone was 12 nmol/l (0 – 2.8) from 5.6 nmol/l at the time of diagnosis of PCOS with marginally raised androstenedione level 13.5 nmol/l (up to 12.9). LH, FSH, oestradiol, DHEAS, 17-hydroxyprogesterone and CA125 levels as well as MRI adrenals were all normal. She was under surveillance for a 3×4 cm right dermoid cyst and she then underwent a right salpingo-oophrectomy. Histology showed ovarian follicular cysts and no malignancy. Testosterone levels 3 days and 6 weeks postoperatively were <0.6 and 1.4 nmol/l respectively and she continues to notice marked improvement in her symptoms.

Discussion: PCOS, the commonest cause of ovarian hyperandrogenism has moderately elevated testosterone levels. The presence of virilization is rare in PCOS and warrants consideration of solid ovarian malignancies such as teratomas. The unusual features of this case were; firstly the degree of virilisation was greater than expected for PCOS raising suspicion of an underlying ovarian malignancy which was the presumed dermoid cyst. Secondly, the slowly progressive nature of her symptoms leading up to virilisation is unusual. Lastly her imaging was of a unilateral cystic ovary not bilateral.