Endocrine Abstracts

Background: Most women with androgen excess have polycystic ovary syndrome (PCOS); however, rarer pathology is considered in a severe phenotype such as ovarian or adrenal androgen-producing tumours. Simultaneous adrenal and ovarian vein sampling is rarely performed to aid the localisation of the androgen excess source. We report four cases that underwent this procedure.

Case descriptions: Case 1: A 27-year-old presented with infertility, long history of menstrual disturbance and hirsutism. Testosterone was 36.5nmol/l without suppression after 96hr dexamethasone or GnRH superagonist. MRI showed left ovarian 2.0cm lesion. Venous sampling showed left ovarian testosterone 710nmol/l. Histology after left oophorectomy confirmed Leydig-cell tumour and testosterone normalised.

Case 2: A 47-year-old presented with 12-months of hirsutism and testosterone 17.4nmol/l without suppression after 96hr of dexamethasone or GnRH superagonist. Cross-sectional imaging showed no tumours. Venous sampling showed left ovarian testosterone >80nmol/l. Histology after bilateral oophorectomy confirmed Leydig-cell tumour and testosterone normalised.

Case 3: A 64-year-old presented with 15-years of virilisation and testosterone 17.4nmol/l without suppression after 96hr of dexamethasone. Imaging showed bilateral adrenal adenomas (right 2.6cm, left 1.0cm) and normal ovaries. Venous sampling showed right adrenal testosterone 48.9nmol/l. She then developed acute valvular heart failure which precluded surgery.

Case 4: A 24-year-old presented with hirsutism and menstrual disturbance since menarche. High testosterone 4.9nmol/l, DHEAS 15.8 mol/l, and androstenedione 18.8nmol/l triggered adrenal CT which showed 1.0cm right-sided adenoma. Transvaginal ultrasound showed PCO. 96hr dexamethasone suppression test showed no testosterone suppression, DHEAS suppression 11.6µmol/l to 3.2µmol/l, and androstenedione 19.1nmol/l to 13.0nmol/l. Venous sampling showed right and left ovarian testosterone 10.9nmol/l and 14.6nmol/l, respectively. The working diagnosis was PCOS with adrenal hyperandrogenism and incidental adrenal adenoma.

Conclusion: Adrenal and ovarian vein sampling has a role in selected challenging cases of androgen excess in women to localise the source. However, the procedure is non-standardised and requires careful interpretation.