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Luque-Ramírez M, Nattero-Chávez L, Rodríguez-Rubio Corona C, Ortiz-Flores AE, García-Cano AM, Rosillo Coronado M, Pérez Mies B, Ruz Caracuel I, Escobar-Morreale HF. Postmenopausal onset of androgen excess: a diagnostic and therapeutic algorithm based on extensive clinical experience. J Endocrinol Invest 2024; 47:2007-2020. [PMID: 38349517 PMCID: PMC11266381 DOI: 10.1007/s40618-023-02297-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/28/2023] [Indexed: 07/25/2024]
Abstract
PURPOSE Postmenopausal hyperandrogenism is a rare condition that requires identifying those women bearing a life-threatening tumor. We aimed to study diagnostic work-up and management of postmenopausal androgen excess, proposing an algorithm for clinical decision supporting. METHODS We conducted an observational cross-sectional study and longitudinal follow-up including 51 consecutive menopausal patients reported for hyperandrogenism between 2003 and 2023 to our clinics. We assessed diagnostic testing accuracy and performance by receiver operating characteristic curves, their respective areas under the curve (AUCROC), and 95% confidence intervals (95%CI), for distinguishing between benign and malignant conditions, and androgen excess source. RESULTS Most commonly, postmenopausal hyperandrogenism derived from benign conditions such as ovarian hyperthecosis (n = 9). However, four (8%) patients had borderline/malignant tumors arising at the ovaries (n = 3) or adrenals (n = 1). These latter were more likely to develop virilization than those with benign disorders [specificity(95%CI)]: 0.87 (0.69; 0.92)]. Circulating total testosterone [AUCROC(95%CI): 0.899 (0.795; 1.000)] and estradiol [AUCROC(95%CI): 0.912 (0.812; 1.000)] concentrations showed good performances for discriminating between both conditions. Transvaginal-ultrasonography found two out of three potentially malignant ovarian neoplasms, and another was apparent on a pelvic computed tomography scan. An adrenal computed tomography scan also located an androgen-secreting carcinoma. CONCLUSIONS Clinical or biochemical features of an aggressive androgen-secreting tumor should lead to urgently obtaining a targeted imaging. At first, an abdominal-pelvic CT scan represents the best choice to perceive adrenal malignancy, and may identify aggressive ovarian tumors. When warning signs are lacking, a calm and orderly work-up allows properly addressing the diagnostic challenge of postmenopausal hyperandrogenism.
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Affiliation(s)
- M Luque-Ramírez
- Diabetes, Obesity, and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) & Universidad de Alcalá, Centro de Investigación Biomédica en RED (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain.
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo, KM 9.1, 28034, Madrid, Spain.
| | - L Nattero-Chávez
- Diabetes, Obesity, and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) & Universidad de Alcalá, Centro de Investigación Biomédica en RED (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo, KM 9.1, 28034, Madrid, Spain
| | | | - A E Ortiz-Flores
- Diabetes, Obesity, and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) & Universidad de Alcalá, Centro de Investigación Biomédica en RED (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain
- Department of Internal Medicine, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
| | - A M García-Cano
- Department of Biochemistry, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - M Rosillo Coronado
- Department of Biochemistry, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - B Pérez Mies
- Department of Pathology, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERONC, Madrid, Spain
| | - I Ruz Caracuel
- Department of Pathology, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERONC, Madrid, Spain
| | - H F Escobar-Morreale
- Diabetes, Obesity, and Human Reproduction Research Group, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) & Universidad de Alcalá, Centro de Investigación Biomédica en RED (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo, KM 9.1, 28034, Madrid, Spain
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Salim M, Dasaraju S, Erickson B, Khalifa M, Burmeister LA. Postmenopausal Hyperandrogenism Associated With Synchronous Ovarian Brenner Tumor, Bilateral Leydig Cell Tumor, and Adrenal Mass. Cureus 2024; 16:e55334. [PMID: 38559537 PMCID: PMC10981901 DOI: 10.7759/cureus.55334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Hyperandrogenism in postmenopausal females may arise from either ovarian or adrenal sources and can pose a challenging diagnostic dilemma. We present the case of a 66-year-old female with postmenopausal hyperandrogenism with virilization, adrenal incidentaloma, and concurrent finding of two extremely rare ovarian tumors, including bilateral Leydig cell tumor and Brenner tumor. Laboratory tests showed elevated testosterone and androstenedione and normal dehydroepiandrosterone sulfate (DHEAS). Response to 1 mg overnight dexamethasone suppression test demonstrated persistently elevated testosterone and incomplete suppression of androstenedione. Computed tomography (CT) scan showed a left adrenal nodule and an unremarkable appearance of the ovaries. The pelvic ultrasound did not show an ovarian tumor on the right ovary, and the left ovary was not seen. Adrenal and ovarian vein sampling suggested the ovaries as the source of the testosterone. Given the ovarian vein sampling results, a multidisciplinary discussion between endocrinology and gynecologic oncology concluded that bilateral salpingo-oophorectomy (BSO) was the next best step for diagnosis and management. Laparoscopic BSO was performed. Histopathology showed bilateral Leydig cell tumors and a left ovarian Brenner tumor. At one-year postoperative follow-up, alopecia improved, and testosterone level normalized. This case highlights the importance of diagnostic pathways and interdisciplinary collaboration in managing rare clinical scenarios of hyperandrogenism in postmenopausal females. As in our case, surgeons may be hesitant to remove normal-appearing ovaries. While the three presented tumor types in this case arise from distinct tissues and exhibit different histological characteristics, the presence of such a unique triad prompts consideration of potential unifying pathogenic mechanisms.
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Affiliation(s)
- Michael Salim
- Endocrinology, Diabetes, and Metabolism, University of Minnesota School of Medicine, Minneapolis, USA
| | - Sandhyarani Dasaraju
- Laboratory Medicine and Pathology, University of Minnesota School of Medicine, Minneapolis, USA
| | - Britt Erickson
- Gynecologic Oncology, University of Minnesota School of Medicine, Minneapolis, USA
| | - Mahmoud Khalifa
- Laboratory Medicine and Pathology, University of Minnesota School of Medicine, Minneapolis, USA
| | - Lynn A Burmeister
- Endocrinology, Diabetes, and Metabolism, University of Minnesota School of Medicine, Minneapolis, USA
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The Leydig Steroid Cell Tumor in a Postmenopausal Woman with Clinical and Biochemical Hyperandrogenism: A Case Report. Metabolites 2022; 12:metabo12070620. [PMID: 35888744 PMCID: PMC9320079 DOI: 10.3390/metabo12070620] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 02/05/2023] Open
Abstract
Leydig cell tumors (LCTs) refer to tumors of the stroma of the genital strand, which are found mainly in postmenopausal women. The diagnosis of LCTs in postmenopausal women is associated with specific difficulties and is based on the identification of hyperandrogenism with clinical manifestations of virilization, which has an erased picture in postmenopausal women. LCTs require differential diagnosis with other causes of hyperandrogenism. We present the clinical case of a 55-year-old Russian postmenopausal patient with LCTs of the right ovary, significantly increased levels of androgens, and rapidly progressive clinical signs of hyperandrogenism. The patient underwent laparoscopic bilateral salpingo-oophorectomy, and the androgen indices reached average values by the first and third month after surgery. This case demonstrates that LCTs are often benign with a good prognosis and normalization of the clinical and laboratory manifestations of hyperandrogenism after surgical treatment. The type of surgery performed (bilateral salpingo-oophorectomy rather than unilateral) is recommended as the treatment of choice for LCTs in postmenopausal patients.
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Pinto AM, Martins MB, Oliveira N, Oliveira M. Ovarian steroid cell tumour inducing virilisation in a postmenopausal woman. BMJ Case Rep 2022; 15:e249907. [PMID: 35444026 PMCID: PMC9021769 DOI: 10.1136/bcr-2022-249907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 02/05/2023] Open
Abstract
Hyperandrogenism with virilisation de novo in postmenopausal women is exceedingly rare, with aetiology oscillating between ovarian tumours, adrenal tumours, ovarian hyperthecosis and, less frequently, Cushing's syndrome. We report a case of a postmenopausal woman in her late 60s, referred from her primary healthcare physician to a gynaecology appointment due to hirsutism and vasomotor symptoms. At physical examination, clitoromegaly was also identified. Blood tests revealed severe hyperandrogenemia, with total testosterone above 200 ng/dL, but transvaginal ultrasound and abdominal CT were unremarkable. Three months later, abdominal CT was repeated, revealing a moderate heterogeneous enhancement with 18 mm on the left ovary, which was confirmed by transvaginal ultrasound. Total laparoscopic hysterectomy with bilateral adnexectomy was performed. Histopathological examination reported an ovarian steroid cell tumour not otherwise specified on the left ovary and bilateral ovarian hyperthecosis. Two months later, the patient had normal total testosterone and the hirsutism complaints were completely absent.
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Affiliation(s)
- Ana Marta Pinto
- Obstetrics and Gynaecology, Centro Hospitalar do Baixo Vouga EPE, Aveiro, Portugal
| | - Maria Boia Martins
- Obstetrics and Gynaecology, Centro Hospitalar do Baixo Vouga EPE, Aveiro, Portugal
| | - Nuno Oliveira
- Obstetrics and Gynaecology, Centro Hospitalar do Baixo Vouga EPE, Aveiro, Portugal
| | - Mário Oliveira
- Obstetrics and Gynaecology, Centro Hospitalar do Baixo Vouga EPE, Aveiro, Portugal
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Rajamani K, Moore RG, Stanard SM, Astapova O. Testosterone-secreting Endometrioid Ovarian Carcinoma Presenting with Hyperandrogenism. AACE Clin Case Rep 2022; 8:135-138. [PMID: 35602879 PMCID: PMC9123561 DOI: 10.1016/j.aace.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/11/2022] [Accepted: 01/19/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Richard G. Moore
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, New York
| | - Sheena M. Stanard
- Rochester Regional Health, 100 Kings Highway South, Rochester, New York
| | - Olga Astapova
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, New York
- Address correspondence to Dr Olga Astapova, Division of Endocrinology, Diabetes, and Metabolism, University of Rochester Medical Center, 601 Elmwood Ave, Box 693, Rochester, NY 14642.
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