Endocrine Abstracts

Background and aim: Ovarian hyperandrogenism is a known cause of post-menopausal hirsutism and virilisation, more frequently of a benign nature (e.g. ovarian hyperthecosis, Leydig cell hyperplasia). Bilateral salpingo-oophorectomy delivers both definitive diagnostic and therapeutic results. However, after excluding the presence of a suspicious ovarian mass, the use of GnRH analogues (GnRH-a) offers a valuable therapeutic alternative with cases reporting a sustained response in time, besides suggesting an ovarian origin of the hyperandrogenism by their suppressive action on gonadotropins.

Cases presentation: Two post-menopausal women (aged 73 and 74 years) presenting with progressive hirsutism and alopecia were referred to our unit for further evaluation. They both showed high testosterone (T) levels (1.71 and 0.80 ng/ml, respectively), not adequately suppressed after low-dose dexamethasone suppression test (48-h 2 mg/d) and dosable oestradiol (E2) levels. All other steroidal hormones were in the normal range. The second patient underwent videodermatoscopy, showing an increase of hair diameter variability >20%, some empty follicles, peripilar depressions and some small short regrowing hair. No ovarian or adrenal findings suspicious for malignancy were found at the abdominal CT scan and pelvic US. The pituitary MRI scan was within the normal range. We started both patients on a 3-month treatment with GnRH-a (triptorelin 3.75 mg im injection every 28 days) to confirm the presumed ovarian origin of T overproduction and to achieve both clinical and biochemical regression of their hyperandrogenic condition.

Results: We re-evaluated both patients one month after the first GnRH-a injection, three months after the last injection and then every 4-6 months, up to 2.5 years after the treatment initiation for the first patient. Both patients showed suppression of gonadotropins and E2 levels and reduction in T levels to within the normal range one month after the first injection (<0.1 and 0.46 ng/ml, respectively). Gonadotropin levels then progressively rose up to a post-menopausal range after finishing the treatment, while E2 levels remained suppressed and T levels remained within a normal range (0.19 and 0.54 ng/ml, respectively). Both patients reported clinical improvement for both hirsutism and alopecia. Videodermatoscopy re-evaluation confirmed a marked trichoscopical improvement.

Conclusions: GnRH-a is a valid choice for the treatment of post-menopausal hyperandrogenism of presumed benign ovarian origin, as an alternative to surgery. It has shown a sustained clinical and biochemical response up to 6 months in both patients and up to 2.5 years for one patient.