Endocrine Abstracts

A 73 years old female presented in 2005 with 8 year history of face and body hirsutism. Examination confirmed hirsutism but there were no other masculinization features. Her initial investigations revealed a high testosterone of 13 nmol/l, normal androstenedione, DHEA-S and 17 hydroxy progesterone. CT and U/S of pelvis and abdomen, showed normal adrenals, ovaries and a large calcified uterine fibroid. Urinary steroid metabolites ruled out adrenal testosterone source and exogenous testosterone intake. Selective sampling of ovarian and adrenal veins showed high testosterone from the left ovarian vein. Laparoscopic bilateral oopherectomy performed in July 2006 revealed normal ovarian histology. Hyperandrogenaemia persisted after surgery (testosterone 16 nmol/l). Symptom control was achieved using cyproterone acetate at doses of 25–50 mg o.d. which also lowered her testosterone (4.0 nmol/l).

Further tests to identify the source of testosterone production were planned; F-18 fluorodeoxyglucose–positron emission tomography (FDG PET scan) revealed high uptake in the uterus corresponding to the uterine fibroid which raised the suspicion of uterine cancer. Repeating the selective venous sampling this time showed high testosterone from the common iliac veins which raised the possibility of testosterone-secreting uterine pathology. Open abdominal hysterectomy was done and histopathology confirmed the presence of uterine fibroid with no other features. The persistently elevated testosterone continued to be managed symptomatically with cyproterone acetate.

In summary this is an unusual case of postmenopausal hyperandrogenaemia which remains unsolved as to the source of the raised testosterone despite the intensive and thorough investigations.