Endocrine Abstracts

Background: Hyperandrogenism in postmenopausal women is extremely rare and requires exclusion of malignancy.

Case reports: 1. A 65-year-old woman was referred to our Department of Endocrinology for appearance of hirsutism and alopecia for about 2 years. Abdomen-pelvis CT scan showed a 2-cm lesion (45 HU) at the left adrenal gland, confirmed by MRI scan, without loss of signal intensity in opposed-phase sequences. In addition, in the right ovary, a 3-cm lesion with progressive enhancement was found, suspected for malignancy. Hormone assays detected increased levels of adrenal and ovarian androgens (DHEAS 107.7 μg/dl, Delta 4-Androstenedione 401 ng/dl, Testosterone, Te, 5.97 nmol/l), Estradiol (40 pg/ml) and Urinary Free Cortisol (298 mg/24h) with normal to low values of ACTH (14.5 pg/ml) and inappropriately normal for age LH values. She therefore performed a 18F-FDG PET scan, which showed uptake in the left adrenal (SUVmax 6.5) and a focal and inhomogeneous distribution of the tracer in the right ovary (SUVmax 4.1). She then underwent left adrenalectomy, with normalization of adrenal androgen levels but persistence of elevated Te levels post-surgery (8.69 nmol/l). She therefore performed bilateral oophorectomy, with subsequent normalization of Te levels (1.19 nmol/l). Histological examination showed left adrenal adenoma and steroid cell tumor of the right ovary.

2. A 73-year-old woman was referred for clinical hyperandrogenism (alopecia and hirsutism for about 20 years, with worsening in the last 4 years) with increased Te levels (5.5 nmol/l). She performed adrenal-pelvis MRI scan, which found two lesions in both adrenal glands (9 mm in the right and 13 mm in the left), referable to adrenal cortical nodular hyperplasia. In addition, both ovaries were enlarged, but free from lesions. Basal hormone assessment showed a marked increase in serum Te (6.58 nmol/l), 17-OH-Progesterone (2.4 ng/ml) and gonadotropin levels (FSH 76.22 mUI/ml, LH 24.99 mUI/ml). A normal short Synacthen test for 17-OH-Progesterone excluded congenital adrenal hyperplasia, while a prolonged Dexamethasone test for androgens failed to suppress Te levels. Ovarian hyperthecosis was hypothesized. The patient was, thus, addressed for bilateral oophorectomy.

Conclusions: The coexistence of adrenal and ovarian androgen-secreting lesion, although rare, is a possibility and a challenge for the endocrinologist in the differential diagnosis of hyperandrogenism.