Dr Madeleine Haygarth1
1Royal Perth Hospital, WA, Australia
A 60-year-old post-menopausal female presented with a 4-week history of androgenic alopecia and 10kg weight loss. She later developed acne and voice hoarseness with clitoromegaly noted on clinical examination. There was no hirsutism. Initial serum testosterone level was 11 nmol/L (<2) with elevated androstenedione and mildly elevated dehydroepiandrosterone sulfate (DHEAS). Initial imaging with abdominal CT and pelvic ultrasonography did not identify a lesion. An MRI eventually detected a large 6cm left adnexal cystic lesion. Laparoscopic bilateral salpingo-oophorectomy was performed with histology confirming a Leydig cell tumour. The androgen profile improved day 1 post-surgery with normalisation of testosterone level to 0.8 nmol/L.
New-onset hyperandrogenism is rare in postmenopausal women. If rapid-onset virilization or higher androgen levels (testosterone >5 nmol/L) are present, an underlying ovarian or adrenal androgen-secreting tumour should be considered. The latter can usually be differentiated by concurrently raised DHEAS with tumours identified on adrenal imaging. However, pure testosterone-secreting adrenal adenomas with normal DHEAS have been described, and conversely some ovarian tumours have been associated with raised DHEAS. Ovarian androgen-secreting tumours are commonly benign and not considered hereditary. They can be difficult to localise on imaging, and as occurred in this case negative scans do not necessarily rule-out the diagnosis.
First year Endocrinology trainee at Royal Perth Hospital.