Endocrine Abstracts

Introduction: Hyperandrogenism is a relatively common medical condition, however severe post-menopausal hyperandrogenism should raise suspicion of a malignant etiology and prompt clinical evaluation. Furthermore, androgen excess has also been associated with severely decreased quality of life. As such, identification of its cause and adequate treatment should not be delayed.

Case Report: We report a case of a 66-year-old woman, who had a 5-year history of worsening hirsutism - particularly on the face, neck, chest, back, and abdomen (Ferriman-Gallwey score = 15) – without signs of virilization. She had been taking prednisolone 5 mg for the last 7 years due to hemolytic anemia. She also had a prior medical history of diabetes, hypercholesterolemia and hysterectomy with right oophorectomy. On examination she had central obesity, with a BMI of 38 Kg/m2, facial plethora and buffalo-hump, and male pattern hair loss. Laboratory tests showed a total testosterone of 253 ng/dl (2.9-40.8), delta-4-androstenedione 1.7 ng/ml (0.3-3.3), dehydroepiandrosterone sulfate 16.3 (9.4-246), follicular stimulating hormone (FSH) 48.1 IU/l, luteinizing hormone (LH) 30.1 IU/l and a serum estradiol 45.0 pg/ml. A CT scan of the abdomen did not show adrenal lesions. Transvaginal pelvic ultrasound did not identify the left ovary, hence a pelvic MRI was performed which showed a solid mass with 18mm in the left ovary. A GnRH stimulation test was performed - one month following the administration of triptorelin (3 mg) total testosterone levels decreased to 25 ng/dl, LH to 0.87 IU/l and FSH to 6.03 IU/l. Given the previous surgical history and medical comorbidities with a significantly increased operatory risk, the surgical team decided against surgery and the patient was initiated on oral anti-androgenic medication - cyproterone 50 mg daily. Two months after starting therapy there was a remarkable clinical improvement, with significant regression of alopecia and decrease of the terminal hair on the chest, back and abdomen. A biochemical response was also achieved, with total testosterone levels decreasing to 33 ng/dl. No side effects were reported.

Conclusions: A detailed clinical history, physical examination and directed laboratory and imaging exams are essential to identify the cause of post-menopausal hyperandrogenism. Treatment should be promptly started, ideally aimed at the primary cause. However, especially in case of benign etiologies and/or unacceptable surgical risk, anti-androgenic medications can be an alternative. This case illustrates that when surgery is not feasible, hyperandrogenism control is still achievable using anti-androgenic therapy.