We describe a 39-year-old lady who was managed as polycystic ovarian syndrome for nearly six years with an initial testosterone level of 5 nmol/l (01.8 nmol/l). She underwent laparoscopic ovarian drilling surgery followed by two unsuccessful IVF cycles for primary infertility. Deranged liver function and subsequent diagnosis of non-alcoholic fatty liver disease halted third trial of IVF. At that time, pelvic ultrasound demonstrated five follicles in both ovaries. In addition, a 2.3 cm×1.9 cm well vascularised echogenic mass in the right ovary was detected. CA 125 was within the normal range. GP referred to Endocrinology clinic for excessive hair growth, hyperandrogenemia and menstrual irregularities. Upon review, whole body hirsutism, masculinisation and breasts atrophy were the predominant manifestation. The patient faced relationship crisis as she was described to be converting to male phenotype by her relatives. Abdominal examination revealed a palpable right-sided mass. Hormonal assessment showed high testosterone 21.2 nmol/l (01.8 nmol/l), 17-hydroxyprogesterone 29.9 nmol/l (05 nmol/l), Androstenedione 1.8 nmol/l (1.012.9 nmol/l). Urinary steroid profile and LDDST excluded adrenal cause of high androgen; therefore imaging studies were arranged for further evaluation. MRI pelvis and transvaginal US supported clinical suspicion of SertoliLeydig cell tumour. Consequently, laparoscopic right salpingoopherectomy was performed with histological confirmation of the tumour of low Ki 67< 1%. Post surgery, hirsutism improved, menstrual cycles recommenced regularly with complete normalisation of testosterone 0.7 nmol/l.
Conclusion: This lady was treated for PCOS for years prior to endocrinology referral. Initially, She with severe physical and psychological consequences. Other less common causes of very high androgens should be sought in patients with non-classial presentation. SertoliLeydig cell tumour is a rare malignancy accounting for less than 0.5% of ovarian neoplasms. In one-third of the cases, there are hypervirilisation symptoms.