Hyperandrogenism in post – menopausal women- a case report
Jayamalathy Mannar Mannan, Gideon Mlawa and Panos Theofanoyiannis
Background: Hyperthecosis is defined as the development of luteinized theca cells in the ovarian stroma and as a result of this there is excessive production of androgens and presentation with hirsutism and other androgen excess signs and symptoms. It affects post-menopausal women.
We present a case of 70-yr-old postmenopausal woman with gradual and worsening thinning of the scalp hair at temples and increased dark hair growth over limbs, back and abdomen (Fig. 1). She also complained of deepening of voice and mood changes. Examination revealed severe hirsutism: Ferriman-Gallwey score of 28(normal, ≤7), lower voice and androgenic type alopecia. Endocrine investigations showed raised testosterone at 24.0nmol/L (< 1.7), raised free androgen index 48.0(0.1-5.0), oestradiol 279pmol/L (postmenopausal, <44-145), LH 17.3u/L (postmenopausal, >8), FSH 9.5u/L (postmenopausal, >25). Radiological investigations showed bilateral adrenal adenomas but no ovarian enlargement, which was further confirmed by trans-vaginal ultrasound of the ovaries. Screening for the adrenal origin of hyperandrogenism was negative, with 17-OH progesterone of 6 nmol/L (1-10nmol/L), DHEAS 1.8nmol/L (0.5-5.6nmol/L), overnight dexamethasone test cortisol <50nmol/L. Following the injection of 3.75mg im Leuprorelin and subsequent weekly measurement of testosterone, LH, FSH showed marked reduction in levels along with improved symptoms.
The origin of hyperandrogenism is presumed from the ovaries and ovarian hyperthecosis is the likely diagnosis as the patient had much worse hirsute features along with testosterone level >5.2nmol/L , raised LH,FSH and normal DHEAS. This was further confirmed by the GnRH agonist test as it suppressed the ovarian testosterone production (baseline, 24nmol/L Vs. post GnRH at 3 weeks, <0.4nmol/L). She was referred to gynaecologist for further management of bilateral oophorectomy and a histological diagnosis.
Hyperthecosis is common in postmenopausal women, and the testosterone level is markedly elevated in these individuals in contrast to that of polycystic ovarian syndrome .Hirsutism and insulin resistance are therefore more severe in hyperthecosis.
Ovarian hyperthecosis is a cause of post-menopausal hyperandrogenism and should be considered as a differential diagnosis in post-menopausal women showing severe hirsutism features.