Clinical Judgement Trumps Imaging Studies in the Work-up of Ovarian Hyperthecosis

Severe post-menopausal hyper-androgenism often requires a work-up for possible tumorous and non-tumorous causes of the ovaries and adrenal glands. There is minimal guidance regarding the extent of required work-up and the imaging modality of choice. Hence, clinical judgment is especially important in such cases. Herein, we present a case of severe post-menopausal hyperandrogenism of suspected ovarian source but with non-visualized ovaries on transvaginal ultrasound.

Case Description:

A 74-year-old female presented to clinic with slowly progressive deepening of the voice, hirsutism and hyper-sexuality manifesting as a new infatuation with erotic novels. She denied a history of menstrual irregularities or similar symptoms during her reproductive years. On review of system, she reported enlargement of her clitoris and progressive hair thinning. Physical exam revealed elevated blood pressure (BP 156/75) and body mass Index (31.3 kg/m2), deep voice, hair loss in male pattern distribution, shaved terminal hair shafts on her chin, and evident chest hair (Ferriman-Gallwey Score 3). Laboratory investigations revealed normal thyroid function tests, normal hemoglobin a1c, normal comprehensive metabolic panel, morning cortisol within the reference range, elevated total and free testosterone (3 times the upper limit of normal) and a normal Dehydroepiandrosterone-Sulfate. The patient underwent transvaginal ultrasound but neither ovary could be visualized. Given high clinical suspicion for Ovarian Hyperthecosis, the patient underwent bilateral salpingo-oophorectomy. Pathology showed bilateral ovarian stromal hyperthecosis and ovaries measuring 3.6 cm and 3.0 cm in greatest dimension for the right and left ovaries, respectively. Six weeks post-operatively, her testosterone level normalized and her symptoms improved.

Discussion:

An isolated testosterone elevation in a post-menopausal female raises suspicion for an ovarian source. Severe post-menopausal hyper-androgenism from ovarian sources can be seen in secretory tumors as well as ovarian hyperthecosis. Transvaginal ultrasound is limited in the evaluation of Ovarian Hyperthecosis as illustrated in our case, but can assist in ruling out tumorous causes. More advanced imaging studies, such as magnetic resonance imaging, may reveal ovarian enlargement. However, Ovarian Hyperthecosis is a histo-pathological diagnosis that requires a high degree of clinical suspicion in the post-menopausal population.