Endocrine Abstracts

Background: Hyperandrogenism is infrequent in menopause, being the most common cause benign pathologies. However, it can also be produced by an ovarian or adrenal tumour. Correct diagnosis and location can be challenging because small lesions may not be visible with modern imaging studies. We report a case of ovarian stromal hyperplasia where selective venous catheterization and hormonal sampling were performed to find the origin of excessive androgen production.

Case report: A 74-year-old woman was referred to our hospital with high serum testosterone level and hirsutism. Her medical history included obesity (IMC 34 kg/m²), type 2 diabetes, dyslipidaemia and OSAS. Her symptoms had begun five years previously with 8 kg weight gain, frontal alopecia and hirsutism on her chest, arms and abdomen. Ferriman-Gallwey scored 21. Laboratory examination revealed severe hyperandrogenism with a total testosterone of 2.27 ng/ml (normal range 0.03-0.41 ng/ml) and free testosterone of 5.1 pg/ml (normal range 0-3.7 ng/ml). Dehydroepiandrosterone sulfate, androstenedione, 17-hydroxyprogesterone, prolactin, IGF-1 and thyroid hormones were all within normal range. Urinary free cortisol was normal in two determinations. An overnight 1 mg dexamethasone suppression test showed normal suppression of serum cortisol. Transvaginal ultrasonography showed that both ovaries were of normal size with no detectable masses. Adrenal computed tomography did not detect enlargement or tumour formation in either adrenal gland. Pelvic magnetic resonance did not show any remarkable findings. An ovarian androgen production was suspected. Selective vein catheterization and hormonal sampling from both ovarian and adrenal veins were performed before and after stimulation with 250 mg ACTH_1-24. Serum testosterone levels from left and right ovarian vein were remarkably higher than in the other veins, 387 ng/dl and 52.80 ng/dl respectively. Right ovarian vein sampling was uncertain because of anatomic difficulties. Owing to the fact the patient was menopausal, she underwent a laparoscopic bilateral oophorectomy. Final pathology demonstrated ovarian stromal hyperplasia. Postoperatively, her total testosterone levels decreased to 0.10 ng/ml. Four months after the surgery there was a clear improvement in hirsutism and frontal alopecia.

Conclsion: Selective ovarian and adrenal venous sampling is useful to localize the androgen producing source when imaging technique findings are inconclusive. In our case, an ovarian origin was confirmed. Due to the fact that the patient was menopausal and the right ovarian vein sampling was uncertain, a bilateral oophorectomy was preferred. However, selective venous sampling is especially important in women on reproductive age to avoid bilateral oophorectomy.