Introduction: Hirsutism affects 10% of the female population caused by hyperandrogenism of benign aetiologies or androgen-secreting tumours. Tumorous causes of hyperandrogenism include androgen producing ovarian or adrenal tumours. Leydig cell tumours are rare ovarian testosterone producing tumours that comprise 0.1% of total ovarian tumours. It is rare in postmenopausal women and present with features of hyperandrogenaemia or hyperestrogenemia.
Case: We present the case of a 58-year-old post-menopausal woman with a 6-month history of virilisation characterized by rapidly progressive hirsutism, alopecia, and deepening of her voice. The diagnostic evaluation showed elevated testosterone (11.6 nmol/l) with normal dehydroepiandrosterone sulphate (DHEAS). CT abdomen, MR pelvis and a transvaginal ultrasound revealed normal ovarian morphology and left adrenal nodule (8 mm). This created the diagnostic dilemma with suspicion of adrenal tumour producing hyperandrogenaemia, as isolated testosterone producing adrenal tumours has been described in the literature. However, the postmenopausal status of our patient, normal DHEAS levels, the decision was made to do bilateral oophorectomy in the first step that showed well defined un-encapsulated ovarian Leydig cell tumour. Repeat testosterone 2 weeks post op showed normal testosterone levels (0.3 nmol/l) with significant improvement of wellbeing and the pitch of her voice, confirmed the diagnosis of ovarian Leydig cell tumour as the cause of her virilism with co-existing adrenal incidentaloma.
Conclusion: In the case of equivocal radiological investigations and a biochemical picture of ovarian hyperandrogenaemia, it is reasonable to proceed with oophorectomy for post-menopausal women or women not desiring future fertility. For those wanting to preserve fertility, precise aetiology needs to be worked out by selective venous sampling, measuring other hormonal hypersecretion and measuring androgen suppression by dexamethasone.