Case History: Hyperandrogenism is a relatively common clinical problem. However, severe hyperandrogenism causing virilisation is rare. A 22-year-old lady with no significant past medical history, presented with oligomenorrhoea, hirsutism and male pattern hair loss over last 3 years duration. She has no acne or change in voice or clitoromegaly. She was also noted to be having high BP on clinic visit and grade 1 acanthosis nigricans.
Investigations: Her total testosterone was elevated to 5.9 nmol/l with elevated free testosterone index of 28.9 and low SHBG at 18nmol/l, normal FSH, LH and oestradiol (152 pmol/l) level. She was sub clinically hypothyroid with TSH was raised to 6.67 m U/lwith normal free T4 and free T3. The 17-hydroxypogesterone was normal (3.2 nmol/l) with normal prolactin. Trans abdominal ultrasound pelvis was normal, MRI /Pelvis revealed enlarged ovaries with thickening of the ovarian stroma and multiple small peripheral follicles. The appearances were suggestive of PCOS. This excluded any suspicious adnexal mass. CT/adrenal was normal with no evidence of soft tissue enhancement. Her HbA1C was 39 mmol/mol.
Treatment: We discussed lifestyle modification ensuring stable weight and avoiding weight gain. She was prescribed metformin to maximum tolerable dose and the combined oral contraceptive pill. We considered spironolactone at some stage in the future. We also considered BP monitoring and low salt diet to help with hypertension
Discussion: Ovarian hyperthecosis or ovarian stromal hyperplasia is a non-neoplastic functional disorder resulting from the presence of luteinized thecal cells within a hyperplastic ovarian stroma. The condition is more common in postmenopausal women than in those of reproductive age and leads to substantial clinical and laboratory alterations, principally androgenetic alopecia, progressive hirsutism, and elevated testosterone levels. Investigation should include clinical evaluation, laboratory tests, and imaging tests to differentiate between the principal diagnostic hypotheses. The gold standard for diagnosis is histopathology of the ovarian tissue which is not often possible in young women. Medical treatment with GnRH analogue and combined oral contraceptive pills usually has an excellent clinical and biochemical response resulting in suppression of testosterone levels. Treatment with long term GnRH analogue has its own side effects, worsening metabolic abnormalities. PCOS per se is closely linked to metabolic disorders such as obesity and insulin resistance which were seen in our patient too. This case highlights a rare presentation of ovarian hyperthecosis in a young woman with severe hyperandrogenism mimicking a virilising neoplasm.