Endocrine Abstracts

Background: Hyperandrogenism in women presents with diverse clinical manifestations, ranging from mild hirsutism to overt virilization. Establishing the underlying cause is crucial, but diagnostic challenges arise when hormonal levels fluctuate, and imaging is inconclusive. This case highlights the complexity of evaluating unexplained hyperandrogenism in a middle-aged woman.

Case Presentation: A 48-year-old woman was referred to the endocrine clinic with a one-year history of worsening hirsutism and mild virilization, on a six-year background of these virilization symptoms. Current medications included hormone replacement therapy with estradiol and progesterone, taken for the past four years, and a prior short course of Testogel replacement for six to eight months in 2022. On physical examination, she weighed 68.2 kg with a BMI of 24.2 kg/m². She had androgenic alopecia, clitoromegaly, and voice deepening.

Investigations: The hormonal profile showed elevated serum testosterone at 4.8 nmol/l (reference range 0–1.8). Gonadotropin levels were within the normal range (LH 5.6 IU/l [4-14] , FSH 7.6 IU/l [3-13]). DHEAS, androstenedione, 17-hydroxyprogesterone, and prolactin levels were all normal. Cortisol appropriately suppressed to 26 nmol/l following an overnight dexamethasone suppression test. Interestingly, her testosterone levels were not consistently elevated; they peaked at 9 nmol/l in 2024 but later normalized spontaneously to 1.2 nmol/l in 2025. A 24-hour urinary steroid profile has been requested and is currently pending. Imaging investigations, including transvaginal ultrasound, pelvic MRI, and dedicated adrenal MRI, were unremarkable, with no evidence of ovarian or adrenal pathology.

Management and outcome: Given the normalization of testosterone without intervention and the absence of identifiable ovarian or adrenal tumors, a conservative management approach was adopted. The plan was to continue close follow-up with serial hormonal monitoring and reassessment should androgen levels rise again.

Conclusion: This case highlights the diagnostic challenge of fluctuating hyperandrogenism in women. A transient elevation of testosterone with spontaneous normalization suggests either prior exogenous exposure or intermittent endogenous androgen secretion. In the absence of persistent biochemical or imaging abnormalities, continued surveillance with serial hormonal monitoring represents the most appropriate management approach.