Hyperandrogenism in menopause: a case report and literature review

Abstract

Hyperandrogenism is an uncommon diagnosis in postmenopausal women. In this case, we report on a 69-year-old postmenopausal woman who presented with several months of worsening hirsutism of the face, neck, and chin, which was confirmed on examination. Laboratory testing revealed markedly elevated testosterone levels and typical post-menopausal gonadotropin levels. Transvaginal ultrasonography and pelvic and abdominal magnetic resonance imaging (MRI) failed to reveal an ovarian or adrenal abnormality. The patient was a poor surgical candidate and was counseled to start on gonadotropin releasing hormone (GnRH) agonist therapy. Administration of leuprolide resulted in a dramatic decline in testosterone levels. The patient reported significant “hot flashes”, difficulty sleeping, anxiety, and depression secondary to treatment, and patient discontinued leuprolide therapy 3 months after initiation. To our knowledge, this is the first case that describes a woman being treated with a GnRH agonist for hyperandrogenism subsequently discontinuing GnRH agonist treatment due to significant side-effects. This case also highlights the difficulty of prescribing appropriate but off-label use of expensive medications not covered by insurance in a senior population of limited income.

Hormonal Effects on Hair Follicles

“…It is suspected that the cessation of ovarian estrogen production and complex interactions with other hormones, growth factors, and cytokines contribute to alterations in hair growth characteristics [ 63 , 71 ]. Estrogen levels decrease abruptly after menopause, while androgen secretion declines gradually with ageing and is maintained until the later stages of life [ 72 ]. After menopause, the increase in luteinizing hormone (LH) maintains the ovarian androgen production.…”

Postmenopausal virilization secondary to a large ovarian cystadenoma with stromal hyperthecosis

“…In rare circumstances, such as seen here, these tumors may be a source of androgen secretion, a phenomenon more commonly occurring in adolescent and pregnant women 8 . Accessory sources of androgen production should also be considered, most notably the adrenal glands 9 which, in this case, were negative for abnormalities on CT and MRI. Our patient, as a postmenopausal individual, therefore represents a truly rare and unique presentation with only 4 previously existing reported cases to the best of our knowledge 5‐7,10 .…”

Hyperandrogenism in a Postmenopausal Woman Secondary to Testosterone Secreting Ovarian Stromal Tumor with Acoustic Schwannoma

“…Later on, bilateral laparoscopic salpingo-oophorectomy and excisional biopsy revealed left stromal luteoma, bilateral stromal hyperthecosis and right paratubular cysts. Various case studies are available where ultrasound scan, CT scan, MRI imaging failed to detect androgen-producing ovarian tumors [8, 9]. Therefore, detection, localization and removal of androgen-secreting tumors are of significant importance.…”

“…In our case, elevated testosterone, hirsutism, virilization, prediabetes and hyperlipidemia favour ovarian hyperthecosis, which was confirmed on biopsy. Dolinko and Ginsburg presented a similar case of a 69-year-old woman where they failed to locate the elevated androgen source and the patient was treated with leuprolide [9]. They did not perform oophorectomy due to the poor condition of the patient.…”