Category: Reproductive Endocrinology
Hyperandrogenism is uncommon in post-menopausal women. Causes include neoplastic and non-neoplastic conditions of ovaries or adrenal glands. We report a case of a post-menopausal woman with testosterone levels in the male range, caused by ovarian hyperthecosis.
Case: A 70-year old female presented with 1-year history of worsening frontotemporal alopecia, hirsutism and elevated testosterone. She reported history of irregular periods during premenopausal years and 30 lbs weight gain over 3 years. There was no history of deepening of voice, clitoromegaly, muscle weakness or steroid use.
Physical examination revealed frontotemporal baldness, terminal hair growth on upper lip, chin, jawline, upper chest and lower abdomen. Hormonal workup showed total testosterone level 208 (12-36 ng/dl), free testosterone 36.4 (0.3-5 pg/ml), LH 20.6 mIU/ml and FSH 33 mIU/ml (within postmenopausal range), DHEAS 47 (9- 246 mcg/dl), androstenedione 77 (30-200 ng/dl), 17-OH progesterone 138 (< 51 ng/dl), night time salivary cortisol < 50 ng/dl. Transvaginal ultrasound and CT abdomen pelvis revealed prominent ovaries for a postmenopausal patient without a definite mass. Endometrial hyperplasia was noted and proven benign on biopsy. No adrenal abnormalities were found. She underwent bilateral oophorectomy. Pathology finding showed bilateral ovarian hyperthecosis. Her testosterone level normalized to 32 ng/dl at 1 month after oophorectomy with significant improvement of hirsutism and alopecia.
Results : N/A
Virilization in postmenopausal women with testosterone level above 150 ng/dL suggests androgen-secreting neoplasm. Ovarian hyperthecosis is a benign condition characterized by overproduction of androgen from stromal cells associated with endometrial hyperplasia and increased risk of endometrial cancer. Ovarian size may be within normal range for a premenopausal but not for a postmenopausal woman. Bilateral oophorectomy is the treatment of choice for these post-menopausal women.
Among androgen secreting neoplasms, ovarian tumors are more frequent than adrenal tumors. Onset and progression of virilization are clues for differentiating benign from malignant causes. Establishing the cause of hyperandrogenism in women with virilization requires the proper use of imaging techniques. CT or MRI are the most effective tools for visualizing the adrenals and transvaginal ultrasound examination is the image of choice for the ovaries. Nevertheless, if suspicion for an androgen producing tumor is high, surgery is indicated even with negative imaging.
Resident Physician, Internal Medicine
University of North Dakota
Fargo, North Dakota
Completed MBBS from Government Kilpauk Medical College, Chennai, India in 2014. Currently PGY-2 , Department of Internal Medicine at the University of North Dakota School of Medicine.