Endocrine Abstracts

Androgen excess in post-menopausal women usually results from ovarian or adrenal pathology. Identifying pathology is significant as many ovarian tumors can be malignant in nature. We report a case of granulosa cell tumor which presented with virilizing signs. A 66-year-old postmenopausal lady presented with temporal hair loss and weight gain. She had to drop out of her church choir as she had a change in her voice. She was concerned about her facial hair growth which was significantly affecting her social life. She had no known comorbidities and her past medical and family histories were noncontributory. She was on over the counter herb-based nutritional supplements. On examination, she appeared muscular, had temporal recession of hair, had a deep low-pitched voice. Modified Ferriman – Gallwey score was 3/36; involved mainly face. Biochemical evaluation revealed FSH – 44 mIU/ml, LH- 14.71 mIU/ml, Total testosterone – 530.3 ng/dl, Free testosterone – 14.43 ng/dl, bioavailable testosterone – 368 ng/dl, SHBG – 17 nmol/l, DHEA-S – 329.03 ng/ml, androstenedione – 1.72 ng/ml, TSH – 3.06 mIU/l. Renal and liver functions were normal. Ovaries and adrenals were normal on abdominal MRI; there were multiple uterine fibroids. A re-evaluation after a month of discontinuing the nutritional supplements revealed persistently high testosterone of 517 ng/dl, free testosterone – 10.9 ng/dl, bioavailable testosterone – 279 ng/dl, and a free androgen index of 59.2%. 8 am cortisol was 6 mg/dl. GnRH suppression with GnRH analogue was conducted. A reduced level of testosterone (150 ng/dl) post GnRH suppression suggested an ovarian source of testosterone. She was suggested to undergo bilateral salpingo-oophorectomy along with hysterectomy. Pathologists were requested for careful inspection of ovaries. Histopathology revealed granulosa cell tumor of the ovary measuring 1.2 cm × 1 cm with no significant nuclear atypia along with uterine leiomyoma and adenomyosis. The tumor was limited to one ovary. On follow-up, after a month, her voice improved and there was a decrease in hair-fall and change in body habitus. Androgen secreting tumors form about 1% of all ovarian tumors. Granulosa cell tumors belong to sex cord-stromal tumors. Generally, they secrete estrogen but rarely may secrete androgens. Due to the malignant behavior of the tumors, early diagnosis plays an important role.