Introduction: New-onset hyperandrogenism is rare in postmenopausal women and is usually associated with causes such as ovarian hyperthecosis, androgen-secreting tumor or medication. Patients with hyperandrogenism and breast cancer need a special attention when choosing the treatment.
Case history: A 46-year old woman diagnosed with hormone receptor-positive breast cancer at 37 years old, for which she underwent surgery, chemotherapy, radiotherapy and hormonal therapy, until the age of 41, when she had adnexectomy; she presented for hair loss with significant vertex alopecia and upper lip hirsutism developed in 1 year. At the clinical exam she was mildly hypertensive (120/90 mmHg).
Investigations: Hormonal evaluation revealed: postmenopausal levels of serum gonadotroph hormones and estradiol, normal basal and stimulated cortisol, normal basal ACTH and 17 hydroxyprogesterone and hyperandrogenism: mildly elevated DHEAS: 591 mcg/dl (N<282.9), testosterone: 64.17 ng/dl (551), low SHBG: 18 nmol/l (26110) and low 11-deoxicorticosterone: <2 ng/dl (215). Other androgens were normal. CT scan showed bilateral adrenal hyperplasia, no ovarian tissue was visible.
Results and treatment: The patient had a suboptimal clinical response at spironolactone and cyproterone acetate. She also received 2 more years of aromatase inhibitor (AI), with the aim of reducing the impact of hyperandrogenism upon the breast. Dexamethasone (DXM) 0.25 mg in the evening normalized DHEAS levels and significantly improved the hair growth. The patient had not developed metastases until the age of 49, but mild osteopenia occurred.
Discussion: With aging, there usually is a dramatic decrease in adrenal androgens, principally dehydroepiandrosterone and its sulfate (DHEA-S), from their peak in early adulthood. Antioestrogens treatment for breast cancer may mildly increase the androgens levels, even in postmenopausal women; in our patient with overt adrenal hyperandrogenism and alopecia, persistant after AI withdrawal, only DXM was efficacious. However, it has been reported that glucocorticoid treatment increases the risk for metastases in patients already having breast cancer. Moreover, glucocorticoid treatment and the lack of the oestrogens due to AI treatment predispose to osteoporosis. In this case, the most important aspect is to prevent a breast cancer recurrence. Therefore, after a succesful course of DXM, a maintenance treatment with an androgen receptor blocker was proposed, associated with calcium and vitamin D. The addition of an aromatase inhibitor may be considered.