Endocrine Abstracts

Introduction: Hyperandrogenism causing virilisation in postmenopausal females is rare. It is caused by abnormal ovarian or adrenal androgen production, but establishing the source of androgen excess can be challenging. Testosterone levels >5 nmol/l can be associated with virilization (Hirschberg, 2022).

Case: A 75-year-old post-menopausal woman, with a 3-year history of androgenic alopecia (Ludwig scale 3/3) and hirsutism (Ferrimen Gallwey Score 32/36) was investigated. She had known, but previously unexplained, polycythaemia (Hgb 17.6 g/dl). Laboratory testing showed extremely elevated Testosterone (30.6 nmol/l, RR 0.4-1.4), moderately elevated Androstenedione (4.29 nmol/l, RR 0.5-2.8) but normal DHEAS levels (1.1umol/l, RR 0.3-4.2). Estradiol (321 pmol/l), LH and FSH levels (both <1 IU/l, <1 IU/l) were inappropriate for her post-menopausal status. There was no evidence of congenital adrenal hyperplasia (17 OHP 1.36 nmol/l) or Cushing’s syndrome (cortisol level post dexamethasone administration 36 nmol/l). MRI revealed bilateral mildly enlarged ovaries with multiple small follicles and a thickened endometrium. Adrenal imaging was normal. GnRH was not administered given already suppressed gonadotropins. Hysterectomy and bilateral salpingo-oophorectomy were performed. The left ovary contained a well circumscribed, non-capsulated tumour which expressed inhibin, Calretinin and Melan-A, indicating a steroid cell tumour. Two months following surgery, biochemistry showed undetectable Testosterone (<0.4 nmol/l). Estradiol (<92 nmol/l), LH (19 IU/l) and FSH (28 IU/l) were physiological for age and polycythaemia had resolved (Hgb 15.8 g/dl). At 6 months postoperatively, her hirsutism and alopecia were persistent, but improved (Ferrimen Gallwey Score 17/36, Ludwig scale 2/3).

Conclusion: This case offers insight into the workup of post-menopausal virilisation, which is rare and always requires further investigation. This patient presented with extreme biochemical hyperandrogenism and virilisation due to an ovarian tumour, and exhibited resolution of endocrine abnormalities and polycythaemia following successful surgery. Her case also highlights the importance of checking a testosterone level in females with unexplained polycythaemia.

Reference: 1. Hirschberg, A.L. (2022) ‘Approach to investigation of hyperandrogenism in a postmenopausal woman’, The Journal of Clinical Endocrinology & Metabolism, 108(5), pp. 1243–1253. doi:10.1210/clinem/dgac673.