Endocrine Abstracts

A 48 years old lady with BMI of 46kg/m² was postmenopausal since age 45. Due to abdominal discomfort she had an abdominal CT, which incidentally identified bilateral adrenal adenoma (9 mm on right, 18 mm on left, with fat content). This resulted in Endocrinology referral and a history of gradually worsening hirsuitism was uncovered. Her hyperandrogenism was confirmed biochemically with markedly elevated testosterone at 6.5 nmol/l (0.0–1.8), leading to a search for adrenal and ovarian source. However, her adrenal androgens were normal: Androstenedione 3.3 nmol/l (0.9–4.8), DHEAS 0.9 μmol/l (0.7–7.8), and 17-OH progesterone 3.4 nmol/l (0.0–5.0). FSH and LH were of post-menopausal levels. Thyroid function test, ACTH, 9am Cortisol, prolactin and CA125 were normal. Her body habitus limited ultrasound and MRI-abdomen-pelvis was performed. Again, adenomatous adrenals with signal-drop were identified. Interestingly, the ovaries were reported to have normal appearance with small follicles. A delineation between adrenal and ovarian aetiology was unclear at this stage while patient preference and body habitus limited the option for specific venous sampling. An overnight dexamethasone suppression test had led to cortisol suppression to 38 nmol/l excluding Cushing’s syndrome, while testosterone remained non-suppressed at 5.8 nmol/l, suggesting an ovarian androgen source. Following this, a trial of GnRH analogue (subcutaneous Leuprorelin 3.75 mg monthly) had led to suppression and normalisation of testosterone (0.6 nmol/l) after 2 months, consistent with ovarian hyperandrogenism. However, she found GnRH analogue intolerable due to flushing, precluding its adoption as long-term therapeutic measure. Laparoscopic bilateral oophorectomy then resulted in persistent normalisation of post-op testosterone level (0.6 nmol/L at 2 month), further affirming the ovarian source. Contrary to the MRI findings, her ovaries were found to be significantly large (17 and 23 cm³) for a postmenopausal lady, who typically has mean ovarian volume of 1.3–3.7 cm³. Therefore, a diagnosis of hyperthecosis was entertained.