Diabetes in a Bearded Woman

Abstract

A 61-year-old woman with no past medical history was admitted with nonketotic hyperosmolar state that was complicated by seizures. At presentation, her serum glucose was 800 mg/dL with negative ketones. Glycosylated hemoglobin (HbA1c) was 14.1%. The patient was started on intravenous insulin and fluids. Serum insulin levels were not measured since the patient was already started on an insulin drip. She was also noted to have virilization. She had normal menarche, regular menses until menopause, and had delivered 4 children without any difficulty. Virilization developed gradually over 2 years, and the patient had been shaving daily for the past 1 year. There was no prior history of diabetes mellitus. Her weight was 176 pounds, with a height of 66 inches (body mass index of 28 kg/m 2 ). Physical examination showed temporal recessions, balding vertex, and a full beard ( Figure 1A through C). There was terminal hair on the chest, abdomen, and extremities ( Figure 1D and E). Clitoromegaly was present; however, her voice was normal. Acanthosis nigricans was absent, and there were no stigmata of Cushing syndrome. Serum total testosterone was 525 ng/dL (49-102), free testosterone measured 101 pg/mL (1.0-8.5), and bioavailable testosterone was 190 ng/dL (3-29). The rest of the work-up showed dehydroepiandrosterone measuring 314 g/dL (130-980), luteinizing hormone measuring 32.6 mIU/mL (14.4-62.2), follicle-stimulating hormone measuring 53.1 mIU/mL (25-160), and 24-hour urine free Cortisol of 20 g/d (Ͻ50). Pelvic examination was normal.

Pregnancy Luteomas

“…The coexistence of luteomas with such conditions as polycystic ovarian syndrome and diabetes has been well established (7,19,20). Recurrence of luteomas is rare (7); however, there have been at least 5 reports of recurrent virilization in subsequent pregnancies (18).…”

“…Four case reports exemplify the following difference: a 61-year-old diabetic who had virilization and difficulty with insulin resistance and poor glycemic control (20); a 65-year-old with endometrial adenocarcinoma who was found to have an adnexal mass during surgery defined as a "stromal luteoma" (28); a 63-year-old Japanese woman with a stromal luteoma, nodular hyperthecosis, and atypical endometrial hyperplasia (26); and a 65-year-old with postmenopausal bleeding secondary to endometrial hyperplasia (29). These presentations demonstrate an association between endometrial hyperplasia and stromal luteomas.…”