Because of the recurrence of her symptoms, the patient underwent surgical excision of her ovary. After the surgery, her testosterone levels decreased to normal postmenopausal levels. Healio News Endocrinology Hormone Therapy. Issue: November By Stephanie L. Read next. November 01, Receive an email when new articles are posted on. Please provide your email address to receive an email when new articles are posted on. You've successfully added to your alerts. You will receive an email when new content is published.
Click Here to Manage Email Alerts. We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice slackinc. Back to Healio. Most of CAH cases are diagnosed and treated at a much younger age [ 14 ]. High testosterone levels such as our cases can be seen in simple virilizing or salt losing forms of CAH; however, these forms of CAH are associated with adrenal insufficiency and high ACTH, both of which the patient did not have.
The prevalence of hirsutism in women with NCAH increases with age and the degree of hyperandrogenism may worsen in postmenopausal women [ 15 ]. In reproductive her menscycles are regular along reproductive age. There was no adrenal hyperplasia or nodular lesion in abdomen CT and 17 OH progesterone levels were normal range. For these reasons NCAH was excluded.
In contrast to CS secondary to adrenal carcinomas, signs of hyperandrogenism are usually mild in women with the adrenocorticotropin- ACTH- dependent CS and are virtually absent in women with adrenal adenomas [ 17 ].
When hirsutism is more severe and accompanied by symptoms or signs of virilization, ovarian hyperthecosis, adrenals, or the ovarian tumors should be excluded [ 6 , 18 ]. The main nontumoral cause of postmenopausal ovarian biochemical hyperandrogenism seems to be ovarian hyperthecosis [ 19 ].
Hyperthecosis is a severe form of PCOS and results from an overproduction of androgens in the ovarian stromal cells [ 20 ]. Women typically present with slowly progressive acne and hirsutism e.
Patients with hyperthecosis typically have normal serum dehydroepiandrosterone sulfate DHEA sulfate concentrations [ 22 , 23 ].
Ultrasonography in women with hyperthecosis usually shows a bilateral increase in ovarian stroma and the ovaries appear more solid [ 24 ].
Similarly MRI findings in ovarian hyperthecosis include symmetric bilateral ovarian enlargement [ 25 ]. Serious hyperandrogenemia, virilization symptoms, and normal DHEAS levels suggested hyperthecosis in our case but in pelvic MRI showed atrophic ovaries. Adrenal androgen-secreting tumors are rare but highly suggestive of malignancy.
These tumors are easily identified on imaging techniques. Patients with adrenal androgen-secreting tumors typically have elevated serum dehydroepiandrosterone sulfate DHEA sulfate concentrations [ 27 ]. Androgen-producing ovarian tumors include lipoid, Leydig cell, granulosa-theca cell, and Sertoli-stromal cell tumors. Ovarian androgen-secreting tumors are not easily identified in imaging techniques.
Their ultrasonographic aspect depends on tumor type and ultrasonography studies for Sertoli-Leydig, steroid cell tumors, and thecomas have been reported negative in postmenopausal women [ 30 — 33 ]. Rapidly progressive virilization symptoms and very high testosterone levels suggested tumoral causes. Negativity of ovarian imaging does not exclude ovarian malignancy. Ovarian sampling, bilateral oophorectomy, or GnRH analogue treatment is suggested in these cases.
We detected serious decrease in control testosterone levels. This condition, before further investigation, was suggested exogenous androgen exposed. Testosterone levels were decreased gradually every other day.
Iatrogenic or self-administration of androgenic drugs and supplements can induce symptoms and signs of hyperandrogenism via an increase in circulating androgen levels or an intrinsic androgenic activity of the drug. Drugs most commonly responsible include androgens, anabolic steroids, and antiepileptics [ 35 ]. Several case reports show that topical androgens may result in clinical syndromes of hyperandrogenism in exposed children and women [ 36 ].
In conclusion, iatrogenic causes of hyperandrogenemia should be kept in mind in differential diagnosis of hyperandrogenemia. The authors declare that there is no conflict of interests regarding the publication of this paper. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Article of the Year Award: Outstanding research contributions of , as selected by our Chief Editors. Read the winning articles. Journal overview. Academic Editor: Hidetoshi Ikeda. Received 11 Nov Accepted 05 Dec If these have not helped after 6 months, your GP may refer you to a specialist.
They may recommend other medicines to control your hormone levels. There are treatments that can get rid of unwanted hair for longer than the things you can do at home. But they're not usually permanent. Make sure you research these treatments before trying them. Of note, the moderate increase in serum androgen levels found in our patient further indicates that the search for the source of androgen excess in cases of virilization should not be oriented by the severity of hyperandrogenemia.
In women with severe hyperandrogenemia, the low-dose dexamethasone suppression test has been proposed to distinguish androgenic ovarian and adrenal tumors from non-neoplastic causes of hyperandrogenism 15 , 16 because both adrenal and ovarian tumors would fail to suppress androgen levels after glucocorticoid administration Similarly, suppression of hyperandrogenemia in response to long-acting GnRH agonists in postmenopausal women would be suggestive of ovarian hyperandrogenism However, utilization of adrenal and gonadal stimulation and suppression are considered unreliable for determining a source of androgens 14 , and long-term follow-up of most women presenting with androgen levels greater than the above-mentioned cutoff values fails to reveal any androgen-secreting tumor Establishing the cause of hyperandrogenism in women with virilization actually requires the proper use of imaging techniques with the aim of localizing the rare possibility of an androgen-secreting tumor one in every patients presenting with hyperandrogenic signs Computed tomography or magnetic resonance scans are the most effective techniques for visualizing the adrenals, and transvaginal ultrasound examination is the technique of choice for the imaging of the ovaries These techniques detect most adrenal and ovarian androgen-secreting tumors 14 , yet some ovarian androgen-secreting tumors are very small and may be missed even by transvaginal ultrasound.
Positive imaging findings must always be interpreted carefully while taking into account the clinical context of the patient, and the finding of a small adrenal mass in our patient serves as an example. Among androgen-secreting neoplasms, ovarian tumors are much more frequent compared with adrenal tumors. After menopause, ovarian causes of hirsutism and virilization are more frequent compared with adrenal disorders and include androgen-secreting neoplasms and benign disorders such as ovarian stromal hyperplasia and hyperthecosis 7 , Adrenal androgen-secreting neoplasms are usually large and aggressive carcinomas that present also with Cushing's syndrome and have a very rapid progression and almost invariably a fatal outcome These carcinomas are more frequent in young children and adults 40 to 50 yr old Moreover, adrenal tumors frequently present with increased DHEAS levels, which were normal in our patient.
Of note, incidentally discovered adrenal masses have been recently reported in women with virilization of ovarian origin 24 , The results of combined adrenal and ovarian venous sampling suggested the ovaries as the more likely source of androgen excess in our patient. Bilateral laparoscopic salpingo-oophorectomy and histological examination confirmed bilateral ovarian hyperthecosis, and the patient was spared an unnecessary adrenalectomy.
Her increased androgen concentrations rapidly returned to the normal range, further confirming the diagnosis. Finally, Fig. In women with a chronic history of mild or moderate hyperandrogenic symptoms before menopause, in the absence of virilization and defeminization and especially if accompanied by menstrual disturbances and infertility, aggravation of a preexisting condition such as polycystic ovary syndrome or nonclassic congenital adrenal hyperplasia must be suspected, and conservative management is warranted.
In contrast, when symptoms clearly develop after menopause, hyperandrogenism is severe, progression is rapid, and virilization or defeminization are present, adrenal and ovarian imaging must be conducted immediately.
The presence of a large or irregular adrenal mass in computed tomography or magnetic resonance scans, especially if there is evidence of hypercortisolism, is highly suggestive of an adrenal carcinoma, and adrenalectomy must be performed to confirm the diagnosis.
If transvaginal ultrasound examination shows an ovarian tumor, oophorectomy must be conducted. Hence, this procedure must be conducted in experienced hands and reserved for patients in whom uncertainty remains because imaging techniques show no tumor, imaging findings are inconclusive, or a small adrenal tumor suggestive of an adenoma is found.
Algorithm for the diagnosis and management of postmenopausal hyperandrogenism. In summary, diagnosis of hyperandrogenism in postmenopausal women is a difficult challenge. Imaging techniques do not always reveal the source of androgen excess and may even be misleading. Although technically difficult, combined adrenal and ovarian venous sampling may be required to confirm the source of androgen excess before the most appropriate surgical approach is decided. J Clin Endocrinol Metab 92 : — Google Scholar.
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Philadelphia : Wolters Kluwer Health. Google Preview. Hum Reprod 24 : — Am J Obstet Gynecol : — Nagamani M Ovarian hyperthecosis.
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