Long-term suppression of testosterone after treatment with a gonadotropin-releasing hormone agonist in a woman with a presumed testosterone secreting ovarian tumor

From diagnosis to treatment of androgen-secreting ovarian tumors: a practical approach

About 5% of all ovarian tumors develop some form of hormonal activity. Only 1% of ovarian tumors will secrete androgens causing clinical hyperandrogenism. Most androgen-secreting neoplasms (ASN) derive from sex cord or stroma cells of the ovary and may affect both premenopausal and postmenopausal women. Typically, a patient will present reporting symptoms of rapidly increasing hyperandrogenization such as: hirsutism, acne, frontal/male pattern balding, and in severe cases even virilization. Sertoli-Leydig Cell Tumors are the most frequent ASN and constitute about 0.5% of all ovarian neoplasms. Typically affecting women under 30 years of age, these tumors are usually unilateral and benign. They are also the most common tumor in postmenopausal women suffering with hyperandrogenism. Other tumors originating from the sex-cord stroma are also known to develop in this population, but the incidence of these is much lower. Approaching suspected hyperandrogenemia and its related symptoms in a clinical setting can be a significant diagnostic challenge. When evaluating a patient for hyperandrogenism, it is important to assess the severity of symptoms but most of all it is critical to assess the time of onset and dynamics of symptom progression. Diagnostic tools including laboratory tests and imaging studies should also be engaged. When deriving a differential diagnosis for androgen-secreting ovarian tumors, adrenal gland tumors should be considered as well as typical endocrine pathologies including polycystic ovary syndrome, congenital adrenal hyperplasia, Cushing's disease, and acromegaly. Treatment options for an androgen-secreting ovarian tumors is mainly surgical, but in exceptional cases can involve pharmacotherapy alone.

High concentrations of LH cause virilization in a postmenopausal woman

Some testosterone-producing adrenal tumors can be successfully treated with long-acting GnRH analogs and adrenal venous sampling can be useful to detect rare ectopic sex steroid-producing tumors or confirm bilateral adrenal androgen hyperproduction in female hyperandrogenism.

Hyperandrogenism in menopause: a case report and literature review

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.

Gonadotropin-releasing hormone agonist treatment in postmenopausal women with hyperandrogenism of ovarian origin

CONTEXT

The most frequent cause of virilization in postmenopausal women is excessive androgen production of ovarian origin. Bilateral oophorectomy is usually performed, even in cases of benign tumors or hyperthecosis. This is the first report of a case series of long-term GnRH-agonist treatment of hyperandrogenism in postmenopausal women.

OBJECTIVE

We present three women with postmenopausal hyperandrogenism of ovarian origin who were treated with GnRH agonists.

PATIENTS

We describe three cases of postmenopausal women with virilization and hyperandrogenism of presumed ovarian origin, all with slight enlargement of the ovaries but without visualization of a tumor, who had long-term treatment with GnRH agonists. No histological diagnosis was available, and therefore all patients received careful follow-up, including periodic testing of androgen levels and ovarian imaging by computed tomography scans. The three patients responded in different ways to treatment with GnRH agonists.

CONCLUSIONS

Long-term GnRH agonist treatment is an acceptable choice for treatment of postmenopausal hyperandrogenism in patients where ovarian origin of androgen excess is ascertained, and especially in those patients who have an increased risk for surgery due to comorbidities or who are unwilling to undergo bilateral oophorectomy.

Ovarian thecoma with androgenic manifestations in a postmenopausal woman

A 50-year-old woman, who presented with progressive androgenization, central obesity and severe hypertension, was initially suspected to have an adrenal virilizing tumor. Her serum testosterone level was in the male range (9.3-11.6 ng/ml) and was not suppressed with dexamethasone. Although no pathological abdominal or pelvic mass was detected, total hysterectomy and bilateral salpingo-oophorectomy was performed. Histopathological examination revealed a theca-cell tumor of the right ovary. Postoperatively the testosterone level returned to normal and the patient had regression of virilism. Our case illustrates that a virilizing ovarian tumor can be small and elude imaging studies, but may be detected by means of well-considered clinical management.

Diagnosis and localization of testosterone-producing ovarian tumors: imaging or biochemical evaluation

OBJECTIVE

In the testosterone-secreting ovarian tumor (TSOT), the role of whole-body positron emission tomography (WBPET) with (fluorine-18)-2-deoxyglucose scanning (FDG) and/or [(11)C]acetate is unclear, although it presents a rationale that these functional tumors would be more active and have increased use of glucose and oxygen consumption than normal tissues.

CASE

A 52-year-old woman had a history of steroid cell tumors of the right ovary (IIA) and she received staging surgery including total hysterectomy, salpingo-oophorectomy, and lymph node sampling. Reelevated serum levels of T (5.24 ng/ml) were noted 52 months later. The patient received serial preoperative examinations including WBPET with FDG and acetate, ultrasound, computerized tomography (CT), and magnetic resonance imaging (MRI) to evaluate her recurrence. A suspicious mass on the liver was found on ultrasound, CT, and MRI. The ultrasound-guided biopsy was performed three times, and each of them failed to provide any pathological confirmation. Functional imaging studies showed an abnormal uptake in WBPET using [(11)C]acetate but were negative using FDG. Because of the size of the tumor, the patient's hesitatancy toward an operation, and good previous response to gonadotropin-releasing hormone (GnRH) agonist treatment, the patient received a six-cycle GnRH agonist treatment. Serum T levels returned to normal limits after administration of the first dose of GnRH agonist. At follow-up, serum hormone levels were all within the normal ranges consistent with menopause, but the size of the metastatic tumor was constant. The tumor was then completely excised pathologically proven to be a metastatic TSOT.

CONCLUSIONS

Recurrent TSOT might be successfully detected using WBPET with [(11)C]acetate. In addition, GnRH agonist could be tried in patients with TSOT if initial responses were excellent and surgical intervention could not be performed.

Ectopic and abnormal hormone receptors in adrenal Cushing's syndrome

The mechanism by which cortisol is produced in adrenal Cushing's syndrome, when ACTH is suppressed, was previously unknown and was referred to as being "autonomous." More recently, several investigators have shown that some cortisol and other steroid-producing adrenal tumors or hyperplasias are under the control of ectopic (or aberrant, illicit, inappropriate) membrane hormone receptors. These include ectopic receptors for gastric inhibitory polypeptide (GIP), beta-adrenergic agonists, or LH/hCG; a similar outcome can result from altered activity of eutopic receptors, such as those for vasopressin (V1-AVPR), serotonin (5-HT4), or possibly leptin. The presence of aberrant receptors places adrenal cells under stimulation by a trophic factor not negatively regulated by glucocorticoids, leading to increased steroidogenesis and possibly to the proliferative phenotype. The molecular mechanisms responsible for the abnormal expression and function of membrane hormone receptors are still largely unknown. Identification of the presence of these illicit receptors can eventually lead to new pharmacological therapies as alternatives to adrenalectomy, now demonstrated by the long-term control of ectopic P-AR- and LH/hCGR-dependent Cushing's syndrome by propanolol and leuprolide acetate. Further studies will potentially identify a larger diversity of hormone receptors capable of coupling to G proteins, adenylyl cyclase, and steroidogenesis in functional adrenal tumors and probably in other endocrine and nonendocrine tumors.

Long-term remission of ovarian hyperandrogenism after short-term treatment with a gonadotropin-releasing hormone agonist

OBJECTIVE

To assess the long-term effects of GnRH agonist (GnRH-a) therapy in a patient with benign ovarian hyperandrogenism.

DESIGN

Case report.

SETTING

University Hospital endocrine outpatient's clinic.

PATIENT(S)

A 55-year-old postmenopausal woman with hirsutism and virilization of ovarian origin.

INTERVENTION(S)

Treatment with a course of GnRH-a (triptorelin 3.75 mg IM every 28 days for 4 months). Follow-up for 3 years.

MAIN OUTCOME MEASURE(S)

Serum gonadotropin and androgen levels, clinical assessment using the Ferriman-Gallwey score, and assessment of ovarian morphology by ultrasonography.

RESULT(S)

Administration of triptorelin resulted in suppression of serum testosterone and gonadotropin values and relief of the hyperandrogenic symptoms. Upon discontinuation of treatment, the patient's serum gonadotropin levels returned to the postmenopausal range, but the testosterone levels remained normal and the patient was asymptomatic for an observation period of 3 years.

CONCLUSION(S)

This case is the first example of long-term remission of ovarian hyperandrogenism in a postmenopausal woman, after short-term treatment with GnRH-a. This supports the view that GnRH-a therapy could be used, even in short courses, for the long-term suppression of benign ovarian hyperandrogenism.

Managing a patient with presumed testosterone-secreting ovarian tumor

We report the case of a 70-year-old woman who was presumed to have right ovarian testosterone-secreting tumor and was treated with long-acting gonadotropin-releasing hormone agonist therapy plus add-back hormone replacement therapy. The patient presented with various medical problems including hypertension, intracranial hemorrhage, myocardial infarction, unstable angina pectoris, and poor control of diabetic mellitus and had exhibited rapid symptoms of androgen excess such as progressive hirsutism and bilateral temporal balding for half a year. Tumor survey was negative except for an elevated testosterone level. Renal vein catheterization successfully detected a right ovarian androgen-secreting tumor. Because the patient was deemed medically unable to tolerate surgery, she received an alternative treatment consisting of 6 months of gonadotropin-releasing hormone-agonist (GnRH-a) and add-back hormone replacement therapy (HRT). Serum testosterone levels returned to normal limits after administration of the first dose of GnRH-a. A follow-up tumor survey was negative. The patient has been alive and free of disease for 8 months after six doses of GnRH-a. We conclude that this strategy might be used as urgent therapy in a medically compromised patient with presumed ovarian androgen-secreting tumor.