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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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Postmenopausal Hyperandrogenism due to Ovarian Hyperthecosis. Case Rep Obstet Gynecol 2023; 2023:2783464. [PMID: 36743832 PMCID: PMC9897934 DOI: 10.1155/2023/2783464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/18/2022] [Accepted: 12/24/2022] [Indexed: 02/07/2023] Open
Abstract
Ovarian hyperthecosis or ovarian stromal hyperplasia is a non-neoplastic functional disorder resulting from the presence of luteinized thecal cells within a hyperplastic ovarian stroma. The condition is more common in postmenopausal women than in those of reproductive age and leads to substantial clinical and laboratory alterations, principally androgenetic alopecia, progressive hirsutism, and elevated testosterone levels. Investigation should include clinical evaluation, laboratory tests, and imaging tests to differentiate between the principal diagnostic hypotheses. The gold standard for diagnosis is histopathology of the ovarian tissue. The present case report describes a woman being followed up as an outpatient at the Santa Casa de Misericórdia Hospital in Vitória, Brazil. The objective in publishing this case report is to add to available data on ovarian hyperthecosis, thus contributing towards improving timely diagnosis and treatment. Early diagnosis and treatment would ensure better quality of life for patients with this condition and better physical and mental health. Moreover, these data should be useful both for the medical community and for future research into this disease.
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Liao Z, Gao Y, Zhao Y, Wang Z, Wang X, Zhou J, Zhang Y. Pure androgen-secreting adrenal tumor (PASAT): A rare case report of bilateral PASATs and a systematic review. Front Endocrinol (Lausanne) 2023; 14:1138114. [PMID: 37033242 PMCID: PMC10075358 DOI: 10.3389/fendo.2023.1138114] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/01/2023] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND Adult pure androgen-secreting adrenal tumors (PASATs) are extremely rare, and their characteristics are largely unknown. METHODS A rare case of adult bilateral PASATs was reported, and a systematic literature review of adult PASATs was conducted to summarize the characteristics of PASATs. RESULTS In total, 48 studies, including 40 case reports and 8 articles, were identified in this review. Analysis based on data of 42 patients (including current case and 41 patients from 40 case reports) showed that average age was 40.48 ± 15.80 years (range of 18-76). The incidence of adult PASAT peaked at 21-30 years old, while that of malignant PASAT peaked at 41-50 years old. Most PASAT patients were female (40/42, 95.23%), and hirsutism was the most common symptom (37/39, 94.87%). Testosterone (T) was the most commonly elevated androgen (36/42, 85.71%), and 26 of 32 tested patients presented increased dehydroepiandrosterone sulfate (DS) levels. In malignancy cases, disease duration was significantly decreased (1.96 vs. 4.51 years, P=0.025), and tumor diameter was significantly increased (8.9 vs. 4.9 cm, p=0.011). Moreover, the androgen levels, namely, T/upper normal range limit (UNRL) (11.94 vs. 4.943, P=0.770) and DS/UNRL (16.5 vs. 5.28, P=0.625), were higher in patients with malignancy. In total, 5 out of 7 patients showed an increase in DS or T in the human chorionic gonadotropin (HCG) stimulation test. Overall, 41 out of 42 patients (including current case) underwent adrenal surgery, and recurrence, metastasis, or death was reported in 5 out of 11 malignant patients even with adjuvant or rescue mitotane chemotherapy. CONCLUSION Adult PASAT, which is predominant in women, is characterized by virilism and menstrual dysfunction, especially hirsutism. Elevated T and DS may contribute to the diagnosis of adult PASAT, and HCG stimulation test might also be of help in diagnosis. Patients with malignant PASAT have a shorter disease duration, larger tumor sizes and relatively higher androgen levels. Surgery is recommended for all local PASATs, and Malignancy of PASAT should be fully considered due to the high risk of malignancy, poor prognosis and limited effective approaches.
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Affiliation(s)
- Zhangcheng Liao
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuting Gao
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yang Zhao
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhan Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xu Wang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jiaquan Zhou
- Department of Urology, Hainan General Hospital, Haikou, China
| | - Yushi Zhang
- Department of Urology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Yushi Zhang,
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Hirschberg AL. Approach to Investigation of Hyperandrogenism in a Postmenopausal Woman. J Clin Endocrinol Metab 2022; 108:1243-1253. [PMID: 36409990 PMCID: PMC10099172 DOI: 10.1210/clinem/dgac673] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 11/23/2022]
Abstract
Postmenopausal hyperandrogenism is a condition caused by relative or absolute androgen excess originating from the ovaries and/or the adrenal glands. Hirsutism, i.e., increased terminal hair growth in androgen-dependent areas of the body, is considered the most effective measure of hyperandrogenism in women. Other symptoms can be acne and androgenic alopecia or the development of virilization including clitoromegaly. Postmenopausal hyperandrogenism may also be associated with metabolic disorders like abdominal obesity, insulin resistance and type 2 diabetes. Mild hyperandrogenic symptoms can be due to relative androgen excess associated with menopausal transition or polycystic ovary syndrome, which is likely the most common cause of postmenopausal hyperandrogenism. Virilizing symptoms, on the other hand, can be caused by ovarian hyperthecosis or an androgen-producing ovarian or adrenal tumor that may be potentially malignant. Determination of serum testosterone, preferably by tandem mass spectrometry, is the first step in the endocrine evaluation providing important information on the degree of androgen excess. Testosterone > 5 nmol/L is associated with virilization and requires prompt investigation to rule out an androgen-producing tumor in first instance. To localize the source of androgen excess, imaging techniques are used like transvaginal ultrasound or magnetic resonance imaging (MRI) for the ovaries and computed tomography (CT) and MRI for the adrenals. Bilateral oophorectomy or surgical removal of an adrenal tumor is the main curative treatment and will ultimately lead to a histopathological diagnosis. Mild to moderate symptoms of androgen excess are treated with anti-androgen therapy or specific endocrine therapy depending on diagnosis. This review summarizes the most relevant causes of hyperandrogenism in postmenopausal women and suggests principles for clinical investigation and treatment.
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Affiliation(s)
- Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet and Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
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5
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Sarfati J, Moraillon-Bougerolle M, Christin-Maitre S. [Hyperandrogenism after menopause: Ovarian or adrenal origin?]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:675-681. [PMID: 35609786 DOI: 10.1016/j.gofs.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/20/2022] [Accepted: 05/01/2022] [Indexed: 06/15/2023]
Abstract
Postmenopausal hyperandrogenism is an androgen excess originating from either the adrenals and/or the ovaries. Clinically, symptoms can be moderate (increase in terminal hair growth, acnea) or severe with signs of virilization (alopecia, clitoridomegaly). In either setting, physicians need to exclude relatively rare but potentially life-threatening underlying tumorous causes, such as adrenal androgen-secreting tumors. The objectives of this review are to evaluate which hormonal measurements (T, delta 4 androstenedione, 17 OH progesterone, SDHEA, FSH, LH) and/or imaging (pelvic ultrasound, MRI or adrenal CT-scan) could be useful identifying the origin of the androgen excess. Our review illustrates that the rate of progression of hirsutism and/or alopecia, and serum testosterone levels are in favor of tumors. Pelvic MRI and adrenal CT-scan are useful tools for identifying the different causes of androgen excess.
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Affiliation(s)
- J Sarfati
- Service d'endocrinologie, hôpital Saint-Antoine, 184, rue du faubourg Saint-Antoine, 75012 Paris, France.
| | - M Moraillon-Bougerolle
- Service de gynécologie, centre hospitalier Montluçon Neris-les-Bains, 18, avenue du 8 Mai 1945, 03100 Montluçon, France
| | - S Christin-Maitre
- Service d'endocrinologie, hôpital Saint-Antoine, 184, rue du faubourg Saint-Antoine, 75012 Paris, France; Sorbonne Université, Paris, France
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6
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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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7
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Shwana S, Shrikrishnapalasuriyar N, Yin W, Vij M, Kalhan A. An Occult Leydig Cell Tumour in a Postmenopausal Woman Presenting with Alopecia and Hirsutism: A Case Report. TOUCHREVIEWS IN ENDOCRINOLOGY 2022; 17:75-78. [PMID: 35118450 DOI: 10.17925/ee.2021.17.1.75] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/14/2020] [Indexed: 01/15/2023]
Abstract
Progressive hirsutism and moderate to severe male-pattern balding in women requires exclusion of an adrenal or ovarian tumour, especially in the presence of significantly elevated androgen levels. We present the case of a 68-year-old woman who was referred to an endocrinology clinic with insidious onset excessive facial hair growth and loss of scalp hair. Her testosterone levels were significantly elevated at 13 nmol/L (normal range: 0.1-1.4 nmol/L), although dehydroepiandrosterone sulphate and 17-hydroxyprogesterone levels were normal, suggestive of an ovarian source of androgens. Repeated radiologic investigations, including pelvic ultrasound, and abdominal and pelvic computed tomography, could not identify the obvious source of androgens. Based on strong clinical suspicion of an ovarian tumour, she underwent an elective salpingo-oophorectomy, which detected an occult Leydig cell tumour on histopathological analysis. Post-operatively, her hyperandrogenic features significantly improved and testosterone levels normalized.
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Affiliation(s)
| | | | - Win Yin
- Royal Glamorgan Hospital, Llantrisant, Wales, UK
| | | | - Atul Kalhan
- Royal Glamorgan Hospital, Llantrisant, Wales, UK
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8
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Esquivel-Zuniga MR, Kirschner CK, McCartney CR, Burt Solorzano CM. Non-PCOS Hyperandrogenic Disorders in Adolescents. Semin Reprod Med 2022; 40:42-52. [PMID: 35052005 DOI: 10.1055/s-0041-1742259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Hyperandrogenism-clinical features resulting from increased androgen production and/or action-is not uncommon in peripubertal girls. Hyperandrogenism affects 3 to 20% of adolescent girls and often is associated with hyperandrogenemia. In prepubertal girls, the most common etiologies of androgen excess are premature adrenarche (60%) and congenital adrenal hyperplasia (CAH; 4%). In pubertal girls, polycystic ovary syndrome (PCOS; 20-40%) and CAH (14%) are the most common diagnoses related to androgen excess. Androgen-secreting ovarian or adrenal tumors are rare (0.2%). Early pubic hair, acne, and/or hirsutism are the most common clinical manifestations, but signs of overt virilization in adolescent girls-rapid progression of pubic hair or hirsutism, clitoromegaly, voice deepening, severe cystic acne, growth acceleration, increased muscle mass, and bone age advancement past height age-should prompt detailed evaluation. This article addresses the clinical manifestations of and management considerations for non-PCOS-related hyperandrogenism in adolescent girls. We propose an algorithm to aid diagnostic evaluation of androgen excess in this specific patient population.
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Affiliation(s)
- M Rebeca Esquivel-Zuniga
- Division of Endocrinology and Metabolism, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Cassandra K Kirschner
- Department of Pediatrics, University of Virginia Health System, Charlottesville, Virginia
| | - Christopher R McCartney
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia.,Center for Research in Reproduction, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Christine M Burt Solorzano
- Division of Endocrinology and Metabolism, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia.,Center for Research in Reproduction, University of Virginia School of Medicine, Charlottesville, Virginia
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9
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Zou M, Chen R, Wang Y, He Y, Wang Y, Dong Y, Li J. Clinical and ultrasound characteristics of virilizing ovarian tumors in pre- and postmenopausal patients: a single tertiary center experience. Orphanet J Rare Dis 2021; 16:426. [PMID: 34641931 PMCID: PMC8513290 DOI: 10.1186/s13023-021-02057-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/30/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND A virilizing ovarian tumor (VOT) is a rare cause of hyperandrogenism in pre- and postmenopausal women. Although transvaginal ultrasound is considered as the first-line imaging method for ovarian tumors, it is examiner-dependent. We aimed to summarize the clinical and ultrasound manifestations of VOTs to help establish the diagnosis with emphasis on those causing diagnostic difficulty. METHOD We retrospectively identified 31 patients with VOTs who underwent surgery at Peking Union Medical College Hospital. RESULTS Patients with VOTs were predominantly premenopausal. All patients showed androgenic manifestations with serum testosterone levels elevated to varying degrees. The tumor size of VOTs was significantly correlated with age (P < 0.001). The VOTs in the postmenopausal group were significantly smaller than those in the premenopausal group (median 1.8 cm [range, 1.3-4.8 cm] vs 4.5 cm [range, 0.7-11.9 cm]; P = 0.018). Twenty-seven out of 31 VOTs were successfully identified by ultrasound. On ultrasound, VOTs are mostly solid and hypoechoic masses with enhanced vascularity. Four VOTs (0.7-1.5 cm) were radiologically negative, and they were the smallest among all patients. CONCLUSION Patients with VOTs showed androgenic manifestations with varying degrees of hyperandrogenemia. Older patients tend to have smaller VOTs. Ultrasound is an effective method for the detection of VOTs. Some VOTs can be very small and difficult to visualize radiologically, especially in postmenopausal patients. Examiners must remain vigilant about very small VOTs on the basis of endocrine symptoms.
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Affiliation(s)
- Mi Zou
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Rong Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
| | - Yahong Wang
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yonglan He
- Department of Radiology, Peking Union Medical College Hospital, Beijing, China
| | - Ying Wang
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yifan Dong
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jianchu Li
- Department of Ultrasound, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
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10
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Tng EL, Tan JMM. Dexamethasone suppression test versus selective ovarian and adrenal vein catheterization in identifying virilizing tumors in postmenopausal hyperandrogenism - a systematic review and meta-analysis. Gynecol Endocrinol 2021; 37:600-608. [PMID: 33660585 DOI: 10.1080/09513590.2021.1897099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE The diagnostic accuracy of tests in identifying virilizing tumors in postmenopausal hyperandrogenism is limited. This systematic review compares the dexamethasone suppression test against selective ovarian and adrenal vein sampling of androgens in distinguishing neoplastic from non-neoplastic causes of postmenopausal hyperandrogenism. METHODS Diagnostic test accuracy studies on these index tests in postmenopausal women were selected based on pre-established criteria. The true positive, false positive, false negative, and true negative values were extracted and meta-analysis was conducted using the hierarchical summary receiver operator characteristics curve method. RESULTS The summary sensitivity of the dexamethasone suppression test is 100% (95% CI 0-100%) and that for selective venous sampling is 100% (95% CI 0-100%). The summary specificity of the dexamethasone suppression test is 89.2% (95% CI 85.3-92.2%) and that for selective venous sampling is 100% (95% CI 0.3-100%). CONCLUSION There is limited evidence for the use of dexamethasone suppression test or selective venous sampling in identifying virilizing tumors in postmenopausal hyperandrogenism.
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Affiliation(s)
- Eng-Loon Tng
- Department of Medicine, Ng Teng Fong General Hospital, Singapore
| | - Jeanne May-May Tan
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Hospital, Singapore
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11
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Abstract
Postmenopausal hyperandrogenism is a state of relative or absolute androgen excess originating from the adrenal glands and/or ovaries clinically manifested by the presence of terminal hair in androgen-dependent areas of the body, and other manifestations of hyperandrogenism such as acne and alopecia or the development of virilization. In such circumstances, physicians must exclude the possibility of rare but serious androgen-producing tumors of the adrenal glands or ovaries. Worsening of undiagnosed hyperandrogenic disorders such as polycystic ovary syndrome, congenital adrenal hyperplasia, ovarian hyperthecosis, Cushing syndrome and iatrogenic hyperandrogenism should be considered for differential diagnosis. Elevated serum testosterone not only causes virilizing effects, but also will lead to hypercholesterolemia, insulin resistance, hypertension and cardiac disease. An ovarian androgen-secreting tumor, which is diagnosed in 1-3 of 1000 patients presenting with hirsutism, comprises less than 0.5% of all ovarian tumors. Adrenal tumors, including non-malignant adenomas and malignant carcinomas, are less common than ovarian tumors but cause postmenopausal virilization. Measurement of serum testosterone, sex hormone-binding globulin, dehydroepiandrosterone sulfate, androstenedione and inhibin B is necessary in postmenopausal women with the complaints and signs of hyperandrogenism. Some tests to discard Cushing syndrome should also be done. After an etiological source of androgen hypersecretion has been suspected, we recommend performing magnetic resonance imaging of the adrenal glands or ovaries. Medical management with gonadotropin-releasing hormone agonist/analogues or antagonists has been reported for women who are either unfit for surgery or in whom the source of elevated testosterone is unidentified.
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Affiliation(s)
- T Yoldemir
- Department of Obstetrics and Gynaecology, Marmara University Hospital, Istanbul, Turkey
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12
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Mendonça F, Souto S, Magalhães D, Portugal R, Coelho AR, Fernandes AS, Falcão V, Tavares S, Portugal I, Beires J, Carvalho D. Hyperandrogenism, oligomenorrhea, and erythrocytosis caused by an ovarian Leydig cell tumor: A case report. Clin Case Rep 2021; 9:e04001. [PMID: 34026130 PMCID: PMC8117810 DOI: 10.1002/ccr3.4001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/09/2020] [Accepted: 01/02/2021] [Indexed: 12/31/2022] Open
Abstract
Leydig cell tumors are rare ovarian neoplasms. Affected individuals typically present with amenorrhea/oligomenorrhea and rapidly progressive features of virilization. Erythrocytosis can also occur as a result of high testosterone levels.
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Affiliation(s)
- Fernando Mendonça
- Serviço de Endocrinologia Diabetes e Metabolismo Centro Hospitalar e Universitário de S. João Porto Portugal.,Faculdade de Medicina da Universidade do Porto Porto Portugal.,i3S - Instituto de Investigação e Inovação em Saúde Universidade do Porto Porto Portugal
| | - Selma Souto
- Serviço de Endocrinologia Diabetes e Metabolismo Centro Hospitalar e Universitário de S. João Porto Portugal.,Faculdade de Medicina da Universidade do Porto Porto Portugal.,i3S - Instituto de Investigação e Inovação em Saúde Universidade do Porto Porto Portugal
| | | | - Raquel Portugal
- Serviço de Anatomia Patológica Centro Hospitalar e Universitário de S. João Porto Portugal
| | - Ana Rita Coelho
- Serviço de Anatomia Patológica Centro Hospitalar e Universitário de S. João Porto Portugal
| | - Ana Sofia Fernandes
- Serviço de Ginecologia Centro Hospitalar e Universitário de S. João Porto Portugal
| | - Vera Falcão
- Serviço de Ginecologia Centro Hospitalar e Universitário de S. João Porto Portugal
| | - Sara Tavares
- Serviço de Ginecologia Centro Hospitalar e Universitário de S. João Porto Portugal
| | - Inês Portugal
- Serviço de Radiologia Centro Hospitalar e Universitário de S. João Porto Portugal
| | - Jorge Beires
- Serviço de Ginecologia Centro Hospitalar e Universitário de S. João Porto Portugal
| | - Davide Carvalho
- Serviço de Endocrinologia Diabetes e Metabolismo Centro Hospitalar e Universitário de S. João Porto Portugal.,Faculdade de Medicina da Universidade do Porto Porto Portugal.,i3S - Instituto de Investigação e Inovação em Saúde Universidade do Porto Porto Portugal
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13
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Ferrinho C, Silva E, Oliveira M, Sequeira Duarte J. Ovarian Leydig cell tumor and postmenopausal hirsutism with signs of virilisation. BMJ Case Rep 2021; 14:14/3/e240937. [PMID: 33731391 PMCID: PMC7978078 DOI: 10.1136/bcr-2020-240937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
A 71-year-old woman was referred to the endocrinology clinic to investigate postmenopausal hirsutism with 10 years of evolution. She had history of regular menses and menopause with 50 years old. Physical examination showed a male pattern facies, deepening of the voice, androgenic alopecia and hirsutism with a score of 23 according to the modified Ferriman-Gallwey scale. Testosterone and androstenedione were increased. Transvaginal ultrasound, abdominal and pelvic CT showed uterine fibroids with no pathological findings in the adrenals or ovaries. Since she had postmenopausal vaginal bleeding, uterine fibroids and suspicion of an ovarian source for her hyperandrogenism, total hysterectomy and bilateral oophorectomy were performed. Histopathological diagnosis was a Leydig cell tumour located in left ovary and endometrial carcinoma. Improvement of hirsutism was started to notice 1 month after the surgery and she was referred to the oncology clinic for adjuvant treatment.
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Affiliation(s)
- Cátia Ferrinho
- Endocrinology, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Egas Moniz, Lisboa, Portugal
| | - Eugénia Silva
- Endocrinology, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Egas Moniz, Lisboa, Portugal
| | - Manuela Oliveira
- Endocrinology, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Egas Moniz, Lisboa, Portugal
| | - João Sequeira Duarte
- Endocrinology, Centro Hospitalar de Lisboa Ocidental EPE Hospital de Egas Moniz, Lisboa, Portugal
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14
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Abstract
Evidence of clinical and/or biochemical androgen excess poses a unique differential in postmenopausal women. Some signs and symptoms of postmenopausal hyperandrogenism can be normal and attributed to the natural aging process. However, the causes of androgen excess in this group include both nontumorous and tumorous causes. Treatment of androgen excess may improve both quality of life and long-term metabolic outcomes.
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Affiliation(s)
- Adnin Zaman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, 12801 East 17th Avenue, MS 8106, Aurora, CO 80045, USA.
| | - Micol S Rothman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, 12801 East 17th Avenue, MS 8106, Aurora, CO 80045, USA
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15
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Driano JE, Creo AL, Kumar S, Chattha AJ, Lteif AN. Ovarian Steroid Cell Tumor Masquerading as Steroid-Unresponsive Congenital Adrenal Hyperplasia. AACE Clin Case Rep 2021; 7:261-263. [PMID: 34307849 PMCID: PMC8282522 DOI: 10.1016/j.aace.2021.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 11/25/2022] Open
Abstract
Objective Ovarian neoplasms in children are rare. The objective of this report is to emphasize the importance of considering those neoplasms in the differential diagnosis of hyperandrogenism even with negative diagnostic imaging. Methods We report the case of a 12-year-old girl who presented with virilization and elevated 17 hydroxyprogesterone (17-OHP) and who was subsequently diagnosed with an ovarian neoplasm. Results The patient was initially seen for hirsutism and deepening of the voice. Elevated 17-OHP, androstenedione, and testosterone prompted the initial diagnosis of nonclassic congenital adrenal hyperplasia due to 21-hydroxylase deficiency, but those levels failed to suppress on corticosteroid therapy. Ultrasound, computed tomography scan, and magnetic resonance imaging of the abdomen and pelvis were normal. Genetic testing for congenital adrenal hyperplasia was negative. Bilateral selective adrenal and ovarian venous sampling confirmed the ovarian origin of her hyperandrogenism. A unilateral salpingo-oophorectomy revealed a steroid cell tumor. Postoperatively there was normalization of testosterone and 17-OHP. Conclusion This report highlights the utility of selective adrenal and ovarian sampling when suspecting a primary androgen-secreting neoplasm, even in the setting of elevated 17-OHP levels and negative imaging studies, as early diagnosis can prevent manifestation of irreversible symptoms of virilization
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Affiliation(s)
- Jane E Driano
- Creighton University School of Medicine, Omaha, Nebraska
| | - Ana L Creo
- Division of Pediatric Endocrinology and Metabolism
| | - Seema Kumar
- Division of Pediatric Endocrinology and Metabolism
| | - Asma J Chattha
- Division of Pediatric Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Aida N Lteif
- Division of Pediatric Endocrinology and Metabolism
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16
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Tng EL, Tan JMM. Gonadotropin-Releasing Hormone Analogue Stimulation Test Versus Venous Sampling in Postmenopausal Hyperandrogenism. J Endocr Soc 2021; 5:bvaa172. [PMID: 33324863 PMCID: PMC7724751 DOI: 10.1210/jendso/bvaa172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Indexed: 11/19/2022] Open
Abstract
Postmenopausal hyperandrogenism can be due to excessive androgen secretion from adrenal or ovarian virilizing tumors or nonneoplastic conditions. The etiology of postmenopausal hyperandrogenism can be difficult to discern because of limited accuracy of current diagnostic tests. This systematic review compares the diagnostic accuracy of the gonadotropin-releasing hormone (GnRH) analogue stimulation test against selective ovarian and adrenal vein sampling of androgens in distinguishing neoplastic from nonneoplastic causes of postmenopausal hyperandrogenism. Diagnostic test accuracy studies on these index tests in postmenopausal women were selected based on preestablished criteria. The true positive, false positive, false negative, and true negative values were extracted and meta-analysis was conducted using the hierarchical summary receiver operator characteristics curve method. The summary sensitivity of the GnRH analogue stimulation test is 10% (95% confidence interval [CI], 1.1%-46.7%) and that for selective venous sampling is 100% (95% CI, 0%-100%). Both tests have 100% specificity. There is limited evidence for the use of either test in identifying virilizing tumors in postmenopausal hyperandrogenism.
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Affiliation(s)
- Eng-Loon Tng
- Department of Medicine, Ng Teng Fong General Hospital, Singapore
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17
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Shwana S, Shrikrishnapalasuriyar N, Yin W, Vij M, Kalhan A. An Occult Leydig Cell Tumour in a Postmenopausal Woman Presenting with Alopecia and Hirsutism: A Case Report. EUROPEAN ENDOCRINOLOGY 2021. [DOI: 10.17925/ee.2021.1.1.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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18
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J Orrego J, A Chorny J. Aldosterone- and cortisol-cosecreting adrenal adenoma, ovarian hyperthecosis and breast cancer. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200121. [PMID: 33434176 PMCID: PMC7576653 DOI: 10.1530/edm-20-0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 08/09/2020] [Accepted: 08/25/2020] [Indexed: 11/25/2022] Open
Abstract
SUMMARY We describe a 56-year-old postmenopausal woman with hypertension, hypokalemia and severe alopecia who was found to have a 4.5-cm lipid-poor left adrenal mass on CT scan performed to evaluate her chronic right-sided abdominal pain. Hormonal studies revealed unequivocal evidence of primary aldosteronism and subclinical hypercortisolemia of adrenal origin. Although a laparoscopic left adrenalectomy rendered her normotensive, normokalemic and adrenal insufficient for 2.5 years, her alopecia did not improve and she later presented with facial hyperpigmentation acne, worsening hirsutism, clitoromegaly, and an estrogen receptor-positive breast cancer. Further testing demonstrated markedly elevated serum androstenedione and total and free testosterone and persistently undetectable DHEAS levels. As biochemical and radiologic studies ruled out primary adrenal malignancy and obvious ovarian neoplasms, a bilateral salpingo-oophorectomy was undertaken, which revealed bilateral ovarian hyperthecosis. This case highlights how the clinical manifestations associated with hyperaldosteronism and hypercortisolemia masqueraded the hyperandrogenic findings. It was only when her severe alopecia failed to improve after the resolution of hypercortisolism, hyperandrogenic manifestations worsened despite adrenal insufficiency and an estrogen receptor-positive breast cancer was found, did it becomes apparent that her symptoms were due to ovarian hyperthecosis. LEARNING POINTS As cortisol cosecretion appears to be highly prevalent in patients with primary aldosteronism, the term 'Connshing' syndrome has been suggested. The associated subclinical hypercortisolemia could be the driver for the increased metabolic alterations seen in patients with Conn syndrome. The identification of these dual secretors before adrenal venous sampling could alert the clinician about possible equivocal test results. The identification of these dual secretors before unilateral adrenalectomy could avoid unexpected postoperative adrenal crises. Hyperfunctioning adrenal and ovarian lesions can coexist, and the clinical manifestations associated with hypercortisolemia can masquerade the hyperandrogenic findings.
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Affiliation(s)
- John J Orrego
- Departments of Endocrinology and Metabolism, Kaiser Foundation Health Plan of Colorado, Denver, Colorado, USA
| | - Joseph A Chorny
- Pathology, Kaiser Foundation Health Plan of Colorado, Denver, Colorado, USA
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19
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Sehemby M, Bansal P, Sarathi V, Kolhe A, Kothari K, Jadhav-Ramteke S, Lila AR, Bandgar T, Shah NS. Virilising ovarian tumors: a single-center experience. Endocr Connect 2018; 7:1362-1369. [PMID: 30400027 PMCID: PMC6280592 DOI: 10.1530/ec-18-0360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/30/2018] [Indexed: 11/08/2022]
Abstract
Literature on virilising ovarian tumors (VOTs) is limited to case reports and series reporting single pathological type. We have analyzed the clinical, hormonal, radiological, histological, management and outcome data of VOT. This retrospective study was conducted at a tertiary health care center from Western India. Consecutive patients with VOT presenting to our endocrine center between 2002 and 2017 were included. Our study included 13 patients of VOT. Out of 13 patients, two were postmenopausal. All patients in the reproductive age group had secondary amenorrhea except one who presented with primary amenorrhea. Modified F and G score (mFG) at presentation was 24 ± 4.3 and all patients had severe hirsutism (mFG ≥15). Change in voice (n = 11) and clitoromegaly (n = 7) were the other most common virilising symptoms. Duration of symptoms varied from 4 to 48 months. Median serum total testosterone level at presentation was 5.6 ng/mL with severe hyperandrogenemia (serum testosterone ≥2 ng/mL) but unsuppressed gonadotropins in all patients. Transabdominal ultrasonography (TAS) detected VOT in all except one. Ten patients underwent unilateral salpingo-oophorectomy whereas three patients (peri- or postmenopausal) underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Seven patients had Sertoli Leydig cell tumor, three had steroid cell tumor and two had Leydig cell tumor and one had miscellaneous sex cord stromal tumor. All patients had normalization of serum testosterone after tumor excision. In conclusion, VOTs present with severe hyperandrogenism and hyperandrogenemia. Sertoli Leydig cell tumor is the most common histological subtype. Surgery is the treatment of choice with good surgical outcome.
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Affiliation(s)
- Manjeetkaur Sehemby
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
| | - Prachi Bansal
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
| | - Vijaya Sarathi
- Department of Endocrinology, Narayana Medical College, Nellore, Andhra Pradesh, India
| | - Ashwini Kolhe
- Department of Pathology, Seth GS Medical college and KEM Hospital, Parel, Mumbai, India
| | - Kanchan Kothari
- Department of Pathology, Seth GS Medical college and KEM Hospital, Parel, Mumbai, India
| | - Swati Jadhav-Ramteke
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
| | - Anurag R Lila
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
- Correspondence should be addressed to T Bandgar:
| | - Nalini S Shah
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
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20
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Sharma A, Kapoor E, Singh RJ, Chang AY, Erickson D. Diagnostic Thresholds for Androgen-Producing Tumors or Pathologic Hyperandrogenism in Women by Use of Total Testosterone Concentrations Measured by Liquid Chromatography-Tandem Mass Spectrometry. Clin Chem 2018; 64:1636-1645. [DOI: 10.1373/clinchem.2018.290825] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 07/16/2018] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Previously defined thresholds for total testosterone (TT) concentrations to screen for androgen-producing tumors (APTs) have used RIA, which can be less accurate in women. We aimed to define diagnostic thresholds to screen for APTs or postmenopausal pathologic hyperandrogenism using TT concentrations measured by Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS).
METHODS
We performed a retrospective cohort study on all women with TT ≥3.5 nmol/L and all postmenopausal women presenting with hyperandrogenism between 2004 and 2014 at the Mayo Clinic in Rochester, MN.
RESULTS
Of the 369 women with TT ≥3.5 nmol/L, 89 were included and subdivided into 3 groups based on their clinical diagnosis [21 (24%), APT; 16 (18%), postmenopausal pathologic hyperandrogenism; 52 (58%), polycystic ovary syndrome]. The source of the APT was more frequently ovarian (81%, n = 17) than adrenal (19%, n = 4). The diagnostic threshold using ROC analysis for TT to identify APT in women with severe biochemical hyperandrogenemia was ≥5.1 nmol/L (sensitivity, 90%; specificity, 81%). In a second analysis of a cohort of postmenopausal women only presenting with symptoms or signs of hyperandrogenism, median TT was significantly higher in the postmenopausal pathologic hyperandrogenism group (APT and ovarian hyperthecosis) vs the idiopathic hyperandrogenism group (4.9 vs 0.8 nmol/L; P < 0.01). In postmenopausal women, the diagnostic threshold for pathologic hyperandrogenism was TT ≥2.2 nmol/L (sensitivity, 100%; specificity, 86%).
CONCLUSIONS
The diagnostic threshold for TT concentration as measured by LC-MS/MS to identify APT in women with biochemical severe hyperandrogenemia was TT ≥5.1 nmol/L. In postmenopausal women, the diagnostic threshold for pathologic hyperandrogenism was lower (TT ≥2.2 nmol/L).
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Affiliation(s)
- Anu Sharma
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester MN
| | - Ekta Kapoor
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester MN
| | - Ravinder J Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester MN
| | - Alice Y Chang
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester MN
| | - Dana Erickson
- Division of Endocrinology, Diabetes and Nutrition, Mayo Clinic, Rochester MN
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21
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Bienenfeld A, Azarchi S, Lo Sicco K, Marchbein S, Shapiro J, Nagler AR. Androgens in women: Androgen-mediated skin disease and patient evaluation. J Am Acad Dermatol 2018; 80:1497-1506. [PMID: 30312644 DOI: 10.1016/j.jaad.2018.08.062] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/16/2018] [Accepted: 08/22/2018] [Indexed: 12/20/2022]
Abstract
Androgens are produced throughout the body in steroid-producing organs, such as the adrenal glands and ovaries, and in other tissues, like the skin. Several androgens are found normally in women, including dehydroepiandrosterone, dehydroepiandrosterone-sulfate, testosterone, dihydrotestosterone, and androstenedione. These androgens are essential in the development of several common cutaneous conditions in women, including acne, hirsutism, and female pattern hair loss (FPHL)-androgen-mediated cutaneous disorders (AMCDs). However, the role of androgens in the pathophysiology of these diseases is complicated and incompletely understood. In the first article in this Continuing Medical Education series, we discuss the role of the skin in androgen production and the impact of androgens on the skin in women. Specifically, we review the necessary but insufficient role that androgens play in the development of acne, hirsutism, and FPHL in women. Dermatologists face the challenge of differentiating physiologic from pathologic presentations of AMCDs in women. There are currently no dermatology guidelines outlining the indications for endocrinologic evaluation in women presenting with acne, hirsutism, or FPHL. We review the available evidence regarding when to consider an endocrinologic workup in women presenting with AMCDs, including the appropriate type and timing of testing.
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Affiliation(s)
- Amanda Bienenfeld
- New York University School of Medicine, New York University School of Medicine, New York, New York
| | - Sarah Azarchi
- New York University School of Medicine, New York University School of Medicine, New York, New York
| | - Kristen Lo Sicco
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
| | - Shari Marchbein
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
| | - Jerry Shapiro
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
| | - Arielle R Nagler
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York.
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22
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Chen M, Zhou W, Zhang Z, Zou Y, Li C. An ovarian Leydig cell tumor of ultrasound negative in a postmenopausal woman with hirsutism and hyperandrogenism: A case report. Medicine (Baltimore) 2018. [PMID: 29517680 PMCID: PMC5882447 DOI: 10.1097/md.0000000000010093] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
RATIONALE The incidence of severe hyperandrogenism associated with masculinity in women is very low. While rare and difficult to diagnose, androgen secreting tumors should be suspected in women with hyperandrogenism and hirsutism, especially in the postmenopausal population. Herein we present one case of ovarian Leydig cell tumor (LCT) with markedly elevated serum testosterone levels and frank hirsutism. PATIENT CONCERNS A 60-year-old woman, presented with increased hair growth and androgenic alopecia and the hormonal laboratory examination showed that she had elevated serum testosterone level and normal dehydroepiandrosterone sulfate (DHEAS), androstenedione, 17- hydroxyprogesterone, cortisol and thyroid stimulating hormone (TSH). DIAGNOSES The diagnosis of possible testosterone secreting tumor was performed when pelvic computed tomography (CT) and magnetic resonance image (MRI) showed a right adnexal mass of 15mm×16mm indicative of sex cord- stromal tumors. INTERVENTIONS The patient received laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy. OUTCOMES After operation, testosterone got back to the normal level and clinical symptoms subsided. LESSONS It is common that postmenopausal androgen excess is a state of relative or absolute androgen excess originating from the adrenal gland and/or ovaries. In either case, doctors need to assess such patients and exclude relatively rare potential causes of tumors. Any woman who has hirsutism or frank evidence of markedly increased testosterone should exclude this kind of possibility of androgen producing tumors. It is possible to determine the origin of androgen hypersecretion with the severity of symptoms, the extent of androgen excess, and the relevant imaging studies. Since LCT are rare ovarian sex-cord stromal tumors, it can be beneficial for diagnosis with careful research of patient history of the defeminization followed by virilization, and a CT and MRI image.
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Affiliation(s)
- Min Chen
- Department of Endocrinology, the First Affiliated Hospital, College of Medicine, Zhejiang University
| | - Weibin Zhou
- Department of Endocrinology, the First Affiliated Hospital, College of Medicine, Zhejiang University
| | - Zhe Zhang
- Department of Endocrinology, the First Affiliated Hospital, College of Medicine, Zhejiang University
| | - Yuting Zou
- Department of Endocrinology, the Second Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Chengjiang Li
- Department of Endocrinology, the First Affiliated Hospital, College of Medicine, Zhejiang University
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23
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Mamoojee Y, Ganguri M, Taylor N, Quinton R. Clinical Case Seminar: Postmenopausal androgen excess-challenges in diagnostic work-up and management of ovarian thecosis. Clin Endocrinol (Oxf) 2018; 88:13-20. [PMID: 28980338 DOI: 10.1111/cen.13492] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 09/19/2017] [Accepted: 09/29/2017] [Indexed: 02/06/2023]
Abstract
Postmenopausal hyperandrogenism can be tumour- or non-tumour-related, with pathology residing either in the ovary or adrenal gland(s). The tempo of investigation is determined by the clinical severity of hyperandrogenism (presence/absence of actual virilisation) and degree of serum testosterone elevation. When clinical or biochemical hyperandrogenism is severe, rapidly developing, or associated with hypercortisolism, screening for adrenocortical or ovarian carcinoma with cross-sectional imaging should be prioritised over detailed biochemical evaluation. Adrenal hyperandrogenism is readily characterised, both biochemically and radiologically. By contrast, even a combination of high-resolution imaging with laboratory evaluation, including dynamic endocrine testing, often cannot distinguish between ovarian hyperthecosis (OH) and virilising ovarian tumour (VOT); a definitive diagnosis usually emerging only after histological examination of excised ovaries. VOTs are typically below the resolution-limit of current imaging modalities and exhibit suppression of gonadotropin-dependent androgen secretion with GnRH-analogue therapy. Thus, for well-characterised ovarian hyperandrogenism, laparoscopic bilateral salpingo-oophorectomy may serve both as a diagnostic and therapeutic procedure. Nevertheless, women unable or unwilling to undergo ovarian surgery can be reassured that malignant VOTs are exceedingly rare and that long-term medical therapy with oral antiandrogens or GnRH-analogues is safe and well-tolerated. OH is strongly associated with insulin-resistance, with hyperinsulinaemia acting synergistically with raised gonadotropin levels to stimulate thecal cell hyperplasia and androgen secretion by the postmenopausal ovary, which lacks granulosa cell aromatase activity and thus cannot convert testosterone to 17 beta estradiol. Thus, features of metabolic syndrome may indicate OH, and significant reductions in androgens can thereby potentially be achieved with lifestyle measures and/or insulin-sensitising drugs.
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Affiliation(s)
- Yaasir Mamoojee
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals, Newcastle Upon Tyne, UK
| | - Murali Ganguri
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals, Newcastle Upon Tyne, UK
| | - Norman Taylor
- Steroid Laboratory, Kings College Hospital, London, UK
| | - Richard Quinton
- Department of Endocrinology, Newcastle-upon-Tyne Hospitals, Newcastle Upon Tyne, UK
- Institute of Genetic Medicine, University of Newcastle-upon-Tyne, Newcastle Upon Tyne, UK
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24
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Yance VRV, Marcondes JAM, Rocha MP, Barcellos CRG, Dantas WS, Avila AFA, Baroni RH, Carvalho FM, Hayashida SAY, Mendonca BB, Domenice S. Discriminating between virilizing ovary tumors and ovary hyperthecosis in postmenopausal women: clinical data, hormonal profiles and image studies. Eur J Endocrinol 2017; 177:93-102. [PMID: 28432270 DOI: 10.1530/eje-17-0111] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 03/31/2017] [Accepted: 04/21/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND The presence of virilizing signs associated with high serum androgen levels in postmenopausal women is rare. Virilizing ovarian tumors (VOTs) and ovarian stromal hyperthecosis (OH) are the most common etiologies in virilized postmenopausal women. The differential diagnosis between these two conditions is often difficult. OBJECTIVE To evaluate the contribution of clinical features, hormonal profiles and radiological studies to the differential diagnosis of VOT and OH. DESIGN A retrospective study. SETTING A tertiary center. MAIN OUTCOME MEASURES Clinical data, hormonal status (T, E2, LH and FSH), pelvic images (transvaginal sonography and MRI) and anatomopathology were reviewed. PATIENTS Thirty-four postmenopausal women with a diagnosis of VOT (13 women) and OH (21 women) were evaluated retrospectively. RESULTS Clinical signs of hyperandrogenism were more prevalent in the VOT group than the OH group. Although the VOT group showed higher T and E2 levels and lower gonadotropin levels than the OH group, a great overlap occurred among the hormone levels. A pelvic MRI provided an accurate differentiation of these two conditions. CONCLUSION In this group of patients, the main features contributing to the differential diagnosis of VOT and OH were serum levels of testosterone and gonadotropins and the presence of an ovarian nodule identified on the MRI. Although the association of clinical, hormonal and radiological features contributes to the differential diagnosis of these two conditions, histopathological analysis remains the gold standard for the diagnosis of ovarian hyperandrogenism in postmenopausal women.
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Affiliation(s)
- V R V Yance
- Unidade de Endocrinologia do DesenvolvimentoLaboratório de Hormônios e Genética Molecular LIM42, Disciplina de Endocrinologia
| | - J A M Marcondes
- Unidade de Endocrinologia do DesenvolvimentoLaboratório de Hormônios e Genética Molecular LIM42, Disciplina de Endocrinologia
| | - M P Rocha
- Unidade de Endocrinologia do DesenvolvimentoLaboratório de Hormônios e Genética Molecular LIM42, Disciplina de Endocrinologia
| | - C R G Barcellos
- Unidade de Endocrinologia do DesenvolvimentoLaboratório de Hormônios e Genética Molecular LIM42, Disciplina de Endocrinologia
| | - W S Dantas
- Unidade de Endocrinologia do DesenvolvimentoLaboratório de Hormônios e Genética Molecular LIM42, Disciplina de Endocrinologia
| | - A F A Avila
- Instituto de Radiologia do Hospital das Clínicas
| | - R H Baroni
- Instituto de Radiologia do Hospital das Clínicas
| | | | - S A Y Hayashida
- Departamento de Ginecologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSP, Brasil
| | - B B Mendonca
- Unidade de Endocrinologia do DesenvolvimentoLaboratório de Hormônios e Genética Molecular LIM42, Disciplina de Endocrinologia
| | - S Domenice
- Unidade de Endocrinologia do DesenvolvimentoLaboratório de Hormônios e Genética Molecular LIM42, Disciplina de Endocrinologia
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25
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Carré J, Grunenwald S, Vezzosi D, Mazerolles C, Bennet A, Meduri G, Caron P. Virilizing oncocytic adrenocortical carcinoma: clinical and immunohistochemical studies. Gynecol Endocrinol 2016; 32:662-666. [PMID: 26954035 DOI: 10.3109/09513590.2016.1149811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
CONTEXT Oncocytic tumors of the adrenal cortex are rare, mostly nonfunctioning and benign. SETTING Report virilizing oncocytic adrenocortical carcinoma in a 50-year-old woman. PATIENT She presented a recent and progressive virilization syndrome, associated with high blood pressure. Hormonal evaluation showed elevated serum testosterone and delta-4-androstenedione levels, normal urinary free cortisol level and incomplete suppression of cortisol at the 1 mg dexamethasone suppression test. CT scan of the abdomen revealed a 35 mm left adrenal mass. INTERVENTION The patient underwent a left adrenalectomy, and the histological study showed a 3 cm oncocytic adrenocortical carcinoma with signs of malignancy. RESULTS Immunohistochemical study revealed that tumor cells expressed the steroidogenic enzymes involved into androgen synthesis (3βHSD and P450c17α), P450 aromatase and luteinizing hormone (LH) receptors. Post-operatively, signs of virilization improved rapidly, serum testosterone and delta-4-androstenedione levels returned to normal, as did the dexamethasone suppression test. During follow-up CT-scan and 18-FDG PET/CT showed a right ovary mass, corresponding to a follicular cyst associated with hyperthecosis. The patient is alive with no recurrence 48 months after adrenal surgery. CONCLUSION Oncocytic adrenocortical carcinomas, although extremely rare, should be considered in women with a virilization syndrome. In this woman immunohistochimical studies revealed the presence of steroidogenic enzymes involved into androgen synthesis and aromatization, and LH receptors could be implicated in this pathology.
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Affiliation(s)
- Julie Carré
- a Department of Endocrinology and Metabolic Diseases , Pôle Cardio-Vasculaire Et Métabolique, CHU Larrey , Toulouse , France
| | - Solange Grunenwald
- a Department of Endocrinology and Metabolic Diseases , Pôle Cardio-Vasculaire Et Métabolique, CHU Larrey , Toulouse , France
| | - Delphine Vezzosi
- a Department of Endocrinology and Metabolic Diseases , Pôle Cardio-Vasculaire Et Métabolique, CHU Larrey , Toulouse , France
| | | | - Antoine Bennet
- a Department of Endocrinology and Metabolic Diseases , Pôle Cardio-Vasculaire Et Métabolique, CHU Larrey , Toulouse , France
| | | | - Philippe Caron
- a Department of Endocrinology and Metabolic Diseases , Pôle Cardio-Vasculaire Et Métabolique, CHU Larrey , Toulouse , France
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Noninvasive test for the diagnosis of ovarian hormone-secreting-neoplasm in postmenopausal women. Gynecol Oncol Rep 2016; 15:12-5. [PMID: 26937480 PMCID: PMC4750012 DOI: 10.1016/j.gore.2015.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/04/2015] [Accepted: 06/07/2015] [Indexed: 12/03/2022] Open
Abstract
Context The diagnosis of ovarian hormone-secreting neoplasm in postmenopausal women is currently based on imaging modalities and selective venography. However, these diagnostic tests are not always accurate. In order to improve and simplify the diagnosis, we propose a noninvasive hormonal test. Objective To report our experience using noninvasive hormonal test for the diagnosis of ovarian hormone producing tumor in two postmenopausal women. Design and intervention Evaluation of androgen and estradiol serum levels following 1. Adrenal hormonal depression, 2. ovarian hormonal depression and 3. ovarian hormonal stimulation. Setting Tertiary care medical center. Main outcome measures Changes in androgen and estradiol levels. Results In the first case, total testosterone, free androgen index and estradiol serum levels decreased following ovarian depression by GnRH-antagonist (6.9 nmol/L, 67 nmol/L and < 70 pmol/L, respectively) and subsequently increased after ovarian stimulation with LH (11.5 nmol/L, 117 nmol/L and 176 pmol/L, respectively). Histological evaluation revealed steroid cell tumor in one ovary. In the second case, estradiol serum levels decreased following ovarian depression by GnRH-antagonist (73 pmol/L) and subsequently increased following ovarian stimulation with FSH (118 pmol/L). Histological evaluation revealed granulosa cell tumor in one ovary. Conclusions To our knowledge, these are the first cases of ovarian hormone-producing tumors in postmenopausal women diagnosed by noninvasive hormonal test. The proposed test can be considered in postmenopausal women suspected of having androgen and/or estrogen producing tumors. A noninvasive test for diagnosing postmenopausal hormone-producing ovarian tumors Hormonal levels following adrenal depression, ovarian depression and stimulation Changes in hormone levels indicate the presence of ovarian producing tumors.
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Mendoza-Mathison LC, Rabasa MF, González C, Pérez A. Postmenopausal Hyperandrogenism in a Patient With an Adrenal Adenoma: How Should We Approach It? AACE Clin Case Rep 2016. [DOI: 10.4158/ep15776.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
Postmenopausal hyperandrogenism is a state of relative or absolute androgen excess originating from either the adrenals and/or the ovaries, clinically manifested as the appearance and/or increase in terminal hair growth or the development of symptoms/signs of virilization. In either settings, physicians need to evaluate such patients and exclude the presence of the relatively rare but potentially life-threatening underlying tumorous causes, particularly adrenal androgen-secreting tumors. It has been suggested that the rapidity of onset along with severity of symptom and the degree of androgen excess followed by relevant imaging studies may suffice to identify the source of excessive androgen secretion. However, up to date, there is no consensus regarding specific clinical and hormonal indices and/or imaging modalities required for diagnostic certainty. This is particularly relevant as the aging population is increasing and more cases of postmenopausal women with clinical/biochemical evidence of hyperandrogenism may become apparent. Furthermore, the long-term sequels of nontumorous hyperandrogenism in postmenopausal women in respect to cardiovascular morbidity and mortality still remain unsettled. This review delineates the etiology and pathophysiology of relative and absolute androgen excess in postmenopausal women. Also, it attempts to unravel distinctive clinical features along with specific hormonal cut-off levels and/or appropriate imaging modalities for the facilitation of the differential diagnosis and the identification of potential long-term sequels.
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Affiliation(s)
- Marios C Markopoulos
- Endocrinology and Metabolism UnitAretaieion University Hospital, Vasilisis Sofias 76, 11528 Athens, GreeceDepartment of BiochemistryDepartment of PathophysiologyLaikon Hospital, National University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Evanthia Kassi
- Endocrinology and Metabolism UnitAretaieion University Hospital, Vasilisis Sofias 76, 11528 Athens, GreeceDepartment of BiochemistryDepartment of PathophysiologyLaikon Hospital, National University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Krystallenia I Alexandraki
- Endocrinology and Metabolism UnitAretaieion University Hospital, Vasilisis Sofias 76, 11528 Athens, GreeceDepartment of BiochemistryDepartment of PathophysiologyLaikon Hospital, National University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - George Mastorakos
- Endocrinology and Metabolism UnitAretaieion University Hospital, Vasilisis Sofias 76, 11528 Athens, GreeceDepartment of BiochemistryDepartment of PathophysiologyLaikon Hospital, National University of Athens, Mikras Asias 75, 11527 Athens, Greece
| | - Gregory Kaltsas
- Endocrinology and Metabolism UnitAretaieion University Hospital, Vasilisis Sofias 76, 11528 Athens, GreeceDepartment of BiochemistryDepartment of PathophysiologyLaikon Hospital, National University of Athens, Mikras Asias 75, 11527 Athens, Greece
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Glintborg D, Altinok ML, Petersen KR, Ravn P. Total testosterone levels are often more than three times elevated in patients with androgen-secreting tumours. BMJ Case Rep 2015; 2015:bcr-2014-204797. [PMID: 25616651 DOI: 10.1136/bcr-2014-204797] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Hirsutism is present in up to 25% reproductive aged women and is most often caused by polycystic ovary syndrome. Less than 5% of patients with hirsutism are diagnosed with rare endocrine diseases including ovarian or adrenal androgen-producing tumours, but these tumours may be malignant and need surgery. Terminal hair growth on lip and chin gradually increases after menopause, which complicates distinction from normal physiological variation. Precise testosterone assays have just recently become available in the daily clinic. We present three women diagnosed with testosterone-producing tumours. Gold standard techniques were used to measure testosterone levels. All tumours originated from the ovaries. Based on the present cases and the existing literature, we suggest that androgen-producing tumours should be suspected in patients with rapid progression of hyperandrogen symptoms, particularly when total testosterone levels are above three times the upper reference limit.
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Affiliation(s)
- Dorte Glintborg
- Department of Endocrinology, Odense University Hospital, Odense C, Denmark
| | - Magda L Altinok
- Department of Endocrinology, Odense University Hospital, Odense C, Denmark
| | - Kresten R Petersen
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense C, Denmark
| | - Pernille Ravn
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense C, Denmark
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Peigné M, Villers-Capelle A, Robin G, Dewailly D. [Hyperandrogenism in women]. Presse Med 2013; 42:1487-99. [PMID: 24184282 DOI: 10.1016/j.lpm.2013.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 06/20/2013] [Accepted: 07/10/2013] [Indexed: 12/13/2022] Open
Abstract
Clinical signs of hyperandrogenism include hirsutism, acne and/or seborrhea, androgenic alopecia, menstrual disorders and at maximum virilization. Hirsutism is defined by the presence of a coarse and pigmented hair in male territory. In the Caucasian populations, a Ferriman Gallwey score ≥ 6 means hirsutism. Polycystic ovary syndrome is the most common cause of hyerandrogenism in women (70 % of cases) but must remain a diagnosis of exclusion. A neoplasm origin is suspected in case of recent onset of hyperandrogenism, which is rapidly progressive and with signs of virilization. The serum level of total testosterone and 17-hydroxyprogesterone and pelvic ultrasonography are the first line tests in case of clinical hyperandrogenism. Combined oral contraceptive pill can be the first line treatment in case of moderate hyperandrogenia, associated, if needed, with a specific acne treatment. Cyproterone acetate is the best-known and most effective antiandrogenic treatment. It decreases the hair density, speed of regrowth and pigmentation. It is indicated in severe hirsutism and must be combined with cosmetic cares.
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Affiliation(s)
- Maëliss Peigné
- Hôpital Jeanne de Flandre, département de gynécologie, service de gynécologie endocrinienne et de médecine de la reproduction, 59037 Lille cedex, France.
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Saraceno G, Barresi V, Trimarchi F, Cannavo S. Occult leydig cell tumour and androgen-receptor positive breast cancer in a woman with severe hyperandrogenism. J Ovarian Res 2013; 6:43. [PMID: 23816265 PMCID: PMC3703298 DOI: 10.1186/1757-2215-6-43] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 06/19/2013] [Indexed: 11/18/2022] Open
Abstract
Leydig cell tumours represent more than 75% of all testosterone-secreting ovarian masses. These benign tumours are frequently occult or very small, but cause dramatic virilization. Chronic hyperandrogenism can also induce systemic complications, which increase morbidity and mortality risk. One of the most obvious effects of increased testosterone levels is polycythemia, a complication which induces dermatologic, osteoarticular and gastrointestinal manifestations and is associated with increased thrombotic risk. However, scientific literature reports few data concerning etiopathogenesis and management of polycythemia in patients with Leydig cell tumours. Moreover, no data are available about the effect of androgen excess on other concomitant tumours expressing androgen receptors. In this paper we report for the first time the case of a woman, with previous infertility, dramatic virilisation and chronic erythrocytosis, who was affected by an occult Leydig cell tumour and an androgen receptor positive breast cancer. This association gives us the opportunity to discuss the role of the steroid receptor expression of breast cancer in the presence of circulating androgen excess. Moreover, we demonstrate for the first time that treatment with flutamide (anti-androgen drug) is able to normalize blood cell count and haematocrit, before of achieving the definitive cure of hyperandrogenism by oophorectomy.
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Affiliation(s)
- Giovanna Saraceno
- Department of Clinical and Experimental Medicine, Via Consolare Valeria, Messina, 98125, Italy.
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