Endocrine Abstracts

Introduction: Hirsutism is the presence of excess hair growth in females as a result of increased androgen production and/or increased skin sensitivity to androgens. In a postmenopausal female presenting with hirsutism, a high level of clinical suspicion, a detailed history and physical examination, substantiated by focused biochemical and morphological confirmation is necessary.

History: The authors present a case of a female with a longstanding history of recurrent hirsutism that had worsened over a short number of weeks. A 61-year-old, post-menopausal lady, with a past medical history of PCOS, was referred to the endocrine outpatients with a two-year history of hirsutism and markedly elevated serum testosterone. Accompanying symptoms included increased libido, weight gain, baldness, generalised pruritus and deepening of the voice.

Investigations: On examination the patient was normotensive, with central adiposity and male pattern baldness. A hormone profile revealed a markedly elevated serum testosterone of 18.3 nmol/L, androstenedione of 5.3 ng/mL (0.35–2.49 ng/mL) and a free androgen index 67% (<6.6%). Cortisol, prolactin, growth hormone and thyroid function tests were normal. A CT scan of the abdomen and pelvis carried out two years previously had shown a 12×15mm left ovarian cyst and normal adrenal glands. A recent ultrasound of the uterus and ovaries was performed by the referring gynaecologists, but failed to show any pathology (including the previously reported left ovarian cyst). An MRI was later performed and confirmed the presence of a 17mm left ovarian mass.

Results: The patient underwent a total abdominal hysterectomy with salpingo-oophorectomy. Histology confirmed the presence of a Leydig cell tumour, confined to the left ovary, with no malignant features. The tumour was deemed to have an excellent prognosis.

Discussion: Hyperandrogenism after menopause is a rare condition that needs careful evaluation in order to avoid misdiagnosis. This is a case of relapsing hirsutism initially due to PCOS and later due to an ovarian secreting, androgenic tumour. Whilst DHEAS levels are usually raised in adrenal tumours, androstenedione levels are usually raised in ovarian tumours. On the other hand, 17-hydroxyprogesterone (17-OHP) may be raised with both adrenal and extra-adrenal tumours. This can help guide to the possible source of androgen excess and hence direct further imaging. Ovarian and adrenal vein sampling may be used to determine the source of hyperandrogenism with variable success.