Endocrine Abstracts

Introduction: After menopause, an abrupt drop in estrogen levels happens, while ovary androgens secretion declines gradually with aging. This relative hyperandrogenism may lead to the development of hyperandrogenic symptoms. However, the development of marked hirsutism and/or symptoms/signs of virilization, make necessary a detailed study in order to rule out tumorous cause (from adrenal glands or ovaries).

Case report: 58 years old woman with progressive appearance of abundant terminal hairs in face, decrease in scalp hair and deepening of the voice during the last 5 years, worse in the last year. Medical history: smoker, no treatments. Menarche at age 13, regular periods. 4 pregnancies, 1 abortion. Hysterectomy at age 43 due to uterine fibroids. Physical examination: BMI 24.9 kg/m², blood pressure 140/80 mmHg; severe hirsutism (Ferriman-Gallwey scale: 32), male type balding, clitoromegaly and centripetal fat distribution without other signs of hypercortisolism. Laboratory evaluation: hematocrit 48.5%, TSH 2.7 μUI/ml (0.35–3.7), FSH 64 μUI/ml (>30), LH 22 μUI/ml (>14), prolactin 5.5 ng/ml (<25), estradiol 26 pg/ml (0–32.2), progesterone 0.7 ng/ml (<1), 17-hydroxyprogesterone 0.89 ng/ml (0.23–1.36), DHEA-S 57.9 μg/dl (80–560), androstenedione 0.83 ng/ml (0.6–3.5), testosterone 6.54 ng/ml (0.14–0.76), serum cortisol levels (after 1 mg overnight dexamethasone) 1.07 μg/dl (<1.8). With these findings, we suspected tumorous cause. However, abdominal MRI, adrenal CT scan, and gynecologic ultrasonography did not show any tumor. After excluding adrenal gland mass, due to the high levels of testosterone, the most reasonable diagnosis was an ovarian tumor eluding detection with imaging so, given the difficulty of performing an ovarian and adrenal venous sampling, Decapeptyl (a GnRH analogue) was prescribed to the patient. GnRH analogues have been shown to normalize testosterone levels in patients with ovarian hyperandrogenism. After Decapeptyl therapy, testosterone levels become normal (testosterone 0.14 ng/ml, FSH 9.33 μUI/ml, LH <0.07 μUI/ml) and we observe an evident clinical improvement, supporting ovarian origin. Therefore, oophorectomy was performed. Histopathology: 4 mm primitive rests in the hilus of right ovary, expecting determination of androgen receptor. Current laboratory evaluation: testosterone 0.16 ng/m, FSH 57 μUI/ml, LH 41 μUI/ml.

Conclusion: Despite it is usual to find hyperandrogenic symptoms after menopause, the development of severe hyperandrogenism or virilization should makes us rule out an organic cause, including tumoral origin. If imaging is inconclusive, GnRH analogues would be an effective treatment for ovarian virilization in postmenopausal women.