Bilateral Ovarian Leydig Cell Tumors in a Postmenopausal Woman Causing Hirsutism and Virilization

Abstract

Objective To evaluate a rare case of a postmenopausal woman with hirsutism and virilization due to Leydig cell tumors (LCTs) of both ovaries. Methods In this challenging case, the diagnostic studies included the detection of total/free testosterone, hemoglobin, and estradiol levels; adrenal computed tomography; and pelvic magnetic resonance imaging. Results A 61-year-old woman presented for the evaluation of hirsutism. Physical examination revealed normal vital signs and evidence of virilization. The baseline laboratory findings were hemoglobin level of 16.2 g/dL (reference, 12.0-15.5 g/dL), total testosterone level of 803 ng/dL (reference, 3-41 ng/dL), and free testosterone level of 20.2 pg/mL (reference, 0.0-4.2 pg/mL). Pelvic magnetic resonance imaging showed bilateral homogeneous ovarian enhancement. Based on the magnetic resonance imaging findings and clinical presentation, the patient was diagnosed with ovarian hyperthecosis and underwent laparoscopic bilateral oophorectomy. Pathology confirmed LCTs in both ovaries. Six months later, testosterone levels normalized, with significant improvement in hirsutism and virilization. Conclusion Clinicians should be aware of androgen-secreting tumors, including rare bilateral LCTs in postmenopausal women presenting with progressing hirsutism and virilization. Marked hyperandrogenemia with total testosterone level of >150 ng/dL (5.2 nmol/L) or serum dehydroepiandrosterone sulfate level of >700 μg/dL (21.7 mmol/L) is typically found. It should be recognized that diffuse stromal Leydig cell hyperplasia and small LCTs may be missed on imaging, and in some cases only pathology can confirm the result.

Leydig cell hyperplasia as a cause of virilization in a postmenopausal woman: A case report

“…Serum total testosterone is the primary measure of androgen production and values above 150 ng/dL are suggestive of an androgen-secreting tumor, although lower levels should not detain evaluation in a woman with rapidly progressive symptoms [ 8 ]. In postmenopausal women, levels above 100 ng/dL should raise suspicion.…”

“…Androgen-secreting tumors are usually of ovarian and rarely of adrenal origin. Such tumors that derive from the ovaries represent mainly sex cord-stromal tumors and can usually be depicted with transvaginal US, although very small Leydig cell tumors and hyperplastic foci, as in the present case, cannot be visualized [ 8 , 12 ]. Ovarian causes of androgen overproduction also include endocrine abnormalities, such as PCOS, stromal hyperthecosis and hyperandrogenism, insulin resistance and acanthosis nigricans (HAIR-AN) syndrome.…”

The Leydig Steroid Cell Tumor in a Postmenopausal Woman with Clinical and Biochemical Hyperandrogenism: A Case Report

“…In the clinical case, we described a histological picture of Leydig cell hyperplasia in the second (left) ovary with an unpredictable prognosis of the disease. The type of surgery (bilateral oophorectomy) used in this study is explained by the previously described probability of hyperplasia and LCT in the contralateral ovary [ 27 , 28 , 29 , 30 , 31 ].…”