Endocrine Abstracts

A 61 year-old woman presented with a two year history of facial hirsutism and frontal balding. She did not report voice change or acne. Menarche was at age 14 with regular menses until a hysterectomy (with ovarian preservation) for menorrhagia aged 29. She had a past medical history of T2DM and gastric bypass surgery. She was not on androgenic medication. Examination revealed clinical hyperandrogenism with androgenic alopecia and hirsutism (FG score 20) but no cliteromegaly. There were no clinical features of Cushings or other endocrine disease. Secondary sexual characteristics and remaining examination were normal. Blood tests revealed marked biochemical hyperandrogenism; testosterone 4.7 nmol/l(0–2), androstenedione 1.6 nmol/l(0–9), DHEAS 0.8 umol/l(0.4–4.7), oestrogen <70 pmol/l with gonadotrophins in the postmenopausal range. Prolactin, AFP, and hCG were normal. Testosterone was non-suppressible on LDDST. MRI adrenals and US ovaries were unremarkable with normal-size ovaries. She was initially diagnosed with ovarian hyperthecosis and commenced on monthly LHRH-analogue therapy. However on LHRH-analogue therapy, her testosterone levels, although now lower were still raised (2.3–3.8 nmol/l). Given the rapidity of the hirsutism, the normal-sized ovaries on US, and the failure to suppress adequately with LHRH-analogues, the diagnosis was questioned. Subsequent MRI offered superior resolution for ovarian pathology and revealed a 1 cm left ovarian mass. She subsequently underwent laparoscopic bilateral salpingo-oophorectomy and the histopathology identified an ovarian Leydig cell tumour. Six months post-surgery her testosterone remains undetectable off LHRH-analogues, with gradual improvement of her hirsutism and stabilisation of her alopecia. Leydig cell tumours make up <0.5% of ovarian tumours with over a third presenting with overt clinical hyperandrogenism. This case also demonstrates the need to question a previous diagnosis (ovarian hyperthecosis) when features are inconsistent, and to determine appropriate management based on the entire clinical picture and not imaging alone.