Ovarian Stromal Hyperthecosis and Hyperandrogenemia Refractory to Hormonal Suppression

Abstract

been menopausal since age 53 and for approximately 1 year, had noted undesired increased libido and hirsutism. Although she was not sexually active with her husband, she experienced frequent and unprovoked spontaneous orgasms. She also reported hair growth on her arms, shoulders, chin and upper lip as well as recession of her hairline and thinning of hair on her scalp. The patient's medical history was remarkable for recently diagnosed subclinical hyperthyroidism, osteoporosis, obesity, as well as Meniere's disease, hypertension and chronic obstructive pulmonary disease. She also had a long-standing history of type 2 diabetes mellitus on oral hypoglycemics with a baseline hemoglobin A1C value of 6.2%. Her obstetrical history was significant for 2 terms, uncomplicated vaginal deliveries. Her gynecologic history included late onset of menarche at the age of 16 and a history of life-long oligomenorrhea. Other than a twenty-pack year smoking history, she reported no other significant medical comorbidities.On evaluation, the patient was noted to have normal vital signs with a body mass index of 36.6 kg/m 2 . She appeared hirsute with facial and lower abdominal hair growth as well as male pattern alopecia. She also exhibited cervicodorsal protuberance ("buffalo hump") and clitoromegaly, above the upper limit for her age. Laboratory assessment demonstrated elevated free (12.0 pg/mL) and total (115 ng/dL) testosterone, but normal 17-hydroxyprogesterone (39 ng/dL), dehydroepiandrosterone (57 mcg/dL), and its sulfate (36 mcg/dL). Prolactin (10.6 ng/mL), estradiol (18 pg/mL), luteinizing hormone (43.1 mIU/mL) and follicular stimulating hormone (48.5 mIU/mL) were all within normal limits for a postmenopausal woman. Thyroid stimulating hormone levels were very low (< 0.005 uU/mL), and the patient was started on methimazole for hyperthyroidism. Additional laboratory values,such as glucose tolerance testing and insulin levels, were unavailable. The patient's workup included a transvaginal ultrasound demonstrating a uterus measuring 3.7 × 6.4 × 4.7 cm, with right ovary measuring 1.74 × 2.27 × 2.42 cm and her left ovary measuring 1.89 × 2.26 × 2.24 cm. Given the increased ovarian volume for a postmenopausal woman (normal postmenopausal average volume of

How hairfall saved the patient from cancer twice – A postmenopausal patient with synchronous endometrial and endocervical carcinomas presenting with endocrine symptoms

“…Aetiology is not completely known. 2 Management of hyperthecosis is usually bilateral salpingo-oophorectomy. 3 But fortunately, on referral of the case to gynaecology, two malignancies in their early stage could be diagnosed.…”

“…1 The differential diagnosis of hyperandrogenemia includes pituitary, ovarian and adrenal sources of androgen production. 2 Among the ovarian causes in postmenopausal women, ovarian virilizing tumours and hyperthecosis of the ovarian stroma are most common. 3 Stromal hyperthecosis occurs in one third of postmenopausal patients usually as an incidental finding.…”

“…Peripheral aromatization of androgen can lead to elevated estrogen levels, which can result in endometrial overgrowth including endometrial carcinoma. 2 Endometrial carcinoma is also seen most commonly amongst post-menopausal women, usually presenting with postmenopausal bleeding. 4 Another neoplasm that can present with bleeding and has similar morphology in the uterus is endocervical carcinoma which can sometimes be picked up by cervical smear screening.…”

“…Peripheral aromatization of androgen can lead to elevated estrogen levels, which can result in endometrial overgrowth including endometrial carcinoma. 2…”

Imaging features of intra-abdominal and intra-pelvic causes of hirsutism

“…7 ). Rarely, this entity can manifest as bilateral ovarian masses which are isointense to uterine myometrium on T1- and T2-weighted images [ 19 , 21 ].

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