D K Sennik (ST4 Diabetes & Endocrinology), A Tailor (Consultant Gynae-Oncologist), P Bearn (Consultant Colo-rectal Surgeon), M Pradhan (Consultant Histopathologist), SS Naqvi (Consultant in Diabetes and Endocrinology), Ashford and St Peters Hospital.
We present the case of a 43 year old lady who presented with signs of virilisation, including hirsutism, acne and deepening of her voice developing over the last 8 months. Past medical history included two caesarean sections and a hysterectomy for fibroids which had been complicated by haemorrhage and required subsequent laparotomy. She also had a history of hypertension and was a carrier for fragile X syndrome. Examination revealed hirsutism, with facial hairs present on her chin and cliteromegaly. Examination of the abdomen and pelvis was normal.
Biochemical tests demonstrated markedly elevated androgen levels (testosterone 42.8 nmol/l, SHBG 17 nmol/l, free testosterone index 251.8). Her androstendione was 22.6 nmol/l, 17-alpha hydroxyprogesterone 28.7 nmol/l with a normal DHA Sulphate of 2.9 μmol/l. An overnight dexamethasone suppression test showed adequate suppression (cortisol 23). An oral glucose tolerance test was consistent with diabetes mellitus. Ca 125 tumour marker level was normal (7 KU/L).
Radiological investigations including ultrasound of the pelvis (transvaginal) and computed tomography (CT) of the abdomen was normal. Magnetic resonance imaging (MRI) scan of the pelvis demonstrated an abnormal looking right ovary containing a 3.3 x 2.7cm mass. There was a second complex cystic mass arising low in the pelvis and extending through the right sciatic notch which was felt to be benign.
Laparoscopy demonstrated multiple adhesions. The right ovary, although normal in appearance, was adherent to small bowel and the pelvic side wall. Right salpingo-oophorectomy and left oophorectomy was performed. The complex cystic mass was examined under anaesthetic and felt to be benign
The histology of the right ovary was confirmed as luteinizing thecoma. Post-operatively androgen levels dropped (testosterone 1.8 nmol/l, SHBG 14 nmol/l, free testosterone index 12.9, androstendione 2.8 nmol/l five weeks post operatively) and the patient had dramatic improvement in her symptoms.