Endocrine Abstracts

Introduction: In post-menopausal women, the differential diagnosis of hirsutism caused by testosterone excess includes ovarian and adrenal sources. Bilateral ovarian hyperthecosis is a common cause of testosterone excess in post-menopausal women and the diagnosis is confirmed by histopathological examination of the ovaries. Adrenal tumors causing testosterone excess is exceedingly rare. In fact, most causes of hirsutism secondary to adrenal tumors is due to dehydroepiandrosterone sulfate (DHEAS) and androstenedione excess. Further, the median tumor size of an adrenal cortical carcinoma (ACC) is 10 cm. We present a case of a post-menopausal women with ACC of 1.2 cm with testosterone excess.

Case report: A 60-year-old female presented to the clinic in October 2023 with a two-year history of isolated hirsutism. In September 2022 patient had investigations showing an elevated serum testosterone (172 ng/dl), a normal dehydroepiandrosterone sulfate (DHEAS) of 68 mg/dl, and a normal androstenedione 78 ng/dl. Her local endocrinologist recommended bilateral oophorectomy. Surprisingly, after the oophorectomy, her testosterone levels did not drop (testosterone 138 ng/dl). Pathology of the ovaries were normal. Computed Tomography (CT) of abdomen done showed 1.2 cm right adrenal nodule with unenhanced density of 20 Hounsfield units (HU) and a normal left adrenal. Contrast washout characteristics showed an absolute washout of 61.6% and relative washout of 51.7%. Subsequently, the identified source of testosterone production was suspected to be associated with the adrenal mass. The patient was treated with a right laparoscopic adrenalectomy. Post-operatively, testosterone concentrations dropped. Ultimately, the pathology had features of low-grade ACC which included 6 mitotic figures/50 high power fields (HPFs), Ki-67: 5.13%.

Conclusions: We describe a patient with a testosterone-secreting adrenal mass with findings consistent with a low-grade ACC. The workup of a post-menopausal women with hyperandrogenism includes androgen secreting ovarian or adrenal tumors, Cushing’s syndrome or iatrogenesis. The adrenal cortex produces the androgens: DHEAS, androstenedione, and a small amount of testosterone. When only the testosterone level is elevated, it typically indicates an ovarian source. Therefore, isolated elevation of testosterone is rarely due to an adrenal source. Further, most cases of testosterone producing adrenal masses are benign. Moreover, the median size of an ACC is usually 10 cm. Therefore, finding an ACC of 1.2 cm that exclusively secretes testosterone is very rare. This highlights the importance of considering adrenal sources of isolated testosterone secretion.