Endocrine Abstracts

Background: New onset postmenopausal hyperandrogenism (PMH) is rare and is a diagnostic and therapeutic challenge.

Clinical Case: AB, a 69-year woman, had 14-years of hirsutism and 1-year of male-pattern balding. Androgen profile was high: testosterone (T) 4.9nmol/L, androstenedione (A) 3.7nmol/L, 17OHP 2.3nmol/L. DHEAS and pre- and post-1 mg ONDST cortisol was normal. Adrenals and ovaries on CT were unremarkable, hence benign ovarian source assumed. She declined surgery, leuprolin and finasteride. Spironolactone was trialled but discontinued due to nephrotoxicity. Symptoms are currently controlled by topical minoxidil. CD, a 46-year woman, had 1-year of hirsutism, clitoromegaly, mood changes and bilateral labial hypertrophy. Androgen profile was high (T 2.0nmol/L; A 4.8nmol/L; 17OHP 6.9nmol/L); a normal SST excluded NCCAH. DHEAS was normal. TVUS showed normal ovaries; MRI showed unremarkable ovaries and adrenals. Benign ovarian source was assumed. Leuprolin caused T suppression (1.1nmol/L after 5 months), hence laparoscopic BSO was done; ovarian histology was normal with few cystic follicles. 2 months later, A reduced (3.2nmol/L) and symptoms improved. WX, a 58-year woman, had 4-years of hirsutism and male-pattern balding. Pre- and post-ONDST androgen profile was high (T 12.4nmol/L, A 5.4nmol/L, 17OHP 2.8nmol/L) with no suppression (T 11.3nmol/L, A 4.4nmol/L, 17OHP 2.7nmol/L). ACTH, pre- and post-ONDST cortisol, DHEAS, 24h-urinary steroids and CA125 were normal. CT showed unremarkable adrenals and ovaries. Benign ovarian source was assumed. Leuprolin improved biochemistry (T <0.5nmol/L, A 1.4nmol/L after 3 months) and symptoms. WX awaits bilateral oophorectomy. YZ, a 56-year woman, had 9-months of hirsutism, hair loss and mild clitoromegaly. Pre- and post-ONDST androgen profile was high (T 4.9nmol/L, A 3.7nmol/L, 17OHP 2.3nmol/L) with no suppression (T 4.0nmol/L, A 2.0nmol/L, 17OHP 2.1nmol/L). Prolactin, DHEAS and 24h urinary steroids were normal. No adrenal/ovarian tumour was found on CT; pelvic USS showed normal postmenopausal ovaries (volume right 4.6ml, left 2.7ml, n<6ml) and some small fibroids. Benign ovarian source was assumed. Leuprolin improved biochemistry and symptoms (T <0.5nmol/L after 3 months). Laparoscopic BSO was done; histology showed ovarian hyperthecosis. Androgens normalised after 8 months with symptom improvements (T 0.6nmol/L, A 2.7nmol/L).

Conclusion: We propose an algorithm to standardise initial workup of PMH and highlight that: 1) PMH has significant phenotypic variability; 2) DHEAS and pre- and post-1 mg ONDST androgen profile may differentiate ovarian/adrenal sources; 3) consider combined ovarian and adrenal imaging regardless of malignancy risk; and 4) localising source and excluding malignancy can inform management.

Acknowledgement: We are grateful to Dr Marie Freel for providing advice.