Hyperandrogenism after menopause

The role of sex hormone binding globulin levels in the association of surgical and natural premature menopause with incident type 2 diabetes

OBJECTIVE

To examine associations of surgical and natural menopause before the age of 40 years with the risk of type 2 diabetes (T2D) in women.

METHODS

A total of 273,331 women from the United Kingdom were recruited between 2006 and 2010 in the UK Biobank (UKB) study, and 146,343 women aged 40 to 69 years who were postmenopausal at baseline were included in the analysis. Surgical menopause and natural premature menopause were defined as bilateral oophorectomy before the age of 40 and menopause before the age of 40 without oophorectomy, respectively. Multivariable Cox regression models were used to estimate the hazard ratios (HRs) and 95 % confidence intervals (CIs) for the association between premature menopause and the incidence of T2D.

RESULTS

During a median follow-up of 10.4 years, 47 women with surgical premature menopause, 244 women with natural premature menopause, and 4724 women without premature menopause developed T2D. Compared with women without premature menopause, both surgical premature menopause (adjusted HR = 1.46, 95 % CI: 1.09-1.95; P = 0.01) and natural premature menopause (adjusted HR = 1.20, 95 % CI: 1.06-1.37; P < 0.01) were associated with higher risks of incident T2D in the multivariable-adjusted models. Additionally, we observed a significant interaction between levels of sex hormone binding globulin (SHBG) (Pinteraction < 0.01) and the effects of premature menopause on incident T2D. The association between premature menopause and T2D risk appeared to be stronger in women with higher SHBG levels. Furthermore, a joint association was detected between premature menopause and the genetic risk score (GRS) of T2D, with a higher score indicating a higher risk of developingT2D. The highest risk of T2D was observed with higher T2D GRS and surgical premature menopause (adjusted HR = 2.61, 95 % CI: 1.65-4.12; P < 0.01).

CONCLUSIONS

Surgical menopause and natural menopause before the age of 40 years were associated with an increased risk of T2D among postmenopausal women. The findings also suggest potential interactions of premature menopause with SHBG levels, with the association appearing to be stronger in higher SHBG levels, as well as a joint association between menopause status and genetic risk factors on T2D incidence.

Postmenopausal onset of androgen excess: a diagnostic and therapeutic algorithm based on extensive clinical experience

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.

An updated clinico-investigative approach to diagnosis of cutaneous hyperandrogenism in relation to adult female acne, female pattern alopecia & hirsutism a primer for dermatologists

INTRODUCTION

Hyperandrogenism is a clinical state consequent to excess androgen production by the ovary, adrenals, or increased peripheral conversion of androgens. The varied manifestations of hyperandrogenism include seborrhea, acne, infertility, hirsutism, or overt virilization of which adult female acne, hirsutism, and female pattern hair loss are of clinical relevance to dermatologists.

AREAS COVERED

We limited our narrative review to literature published during period from 1 January 1985 to Dec 2022 and searched PubMed/MEDLINE, Web of Science (WOS), Scopus, and Embase databases with main search keywords were 'Hyperandrogenism,' 'Female,' 'Biochemical,' 'Dermatological', and 'Dermatology.' We detail the common etiological causes, nuances in interpretation of biochemical tests and imaging tools, followed by an algorithmic approach which can help avoid extensive tests and diagnose the common causes of hyperandrogenism.

EXPERT OPINION

Based on current data, total testosterone, sex hormone binding globulin, DHEAS, prolactin, free androgen index, and peripheral androgenic metabolites like 3-alpha diol and androsterone glucuronide are ideal tests though not all are required in all patients. Abnormalities in these biochemical investigations may require radiological examination for further clarification. Total testosterone levels can help delineate broadly the varied causes of hyperandrogenism. Serum AMH could be used for defining PCOM in adults.

Understanding of and clinical approach to cardiometabolic transition at the menopause

Cardiovascular disease (CVD) represents the leading cause of death and accounts for almost 50% of all deaths in women worldwide. The menopausal transition is associated with central body fat accumulation, a decrease in energy expenditure, weight gain, insulin resistance and a pro-atherogenic lipid profile. Moreover, menopause is independently associated with an adverse effect on functional and structural indices of subclinical atherosclerosis. Women with premature ovarian insufficiency have heightened CVD risk compared to women of natural age at menopause. Furthermore, women with severe menopausal symptoms may have a more adverse cardiometabolic profile than those without symptoms. We reviewed the latest evidence on the cardiovascular management of perimenopausal or postmenopausal women. Clinicians should aim for cardiovascular risk stratification, followed by dietary and lifestyle advice as required based on individual needs. The medical management of cardiometabolic risk factors at midlife should always be individualized, focusing on hypertension, diabetes and dyslipidemia. Menopausal hormone therapy, when prescribed for the management of bothersome menopausal symptoms or for the prevention of osteoporosis, has also a beneficial effect on cardiometabolic risk factors. This narrative review aims to summarize the cardiometabolic alternations occurring during the menopausal transition and to outline the appropriate prevention strategies to prevent future cardiovascular adverse outcomes.

Clinical management of androgen excess and defect in women

INTRODUCTION

Hyperandrogenism and hypoandrogenism are complex disorders involving multiple-organ systems. While androgen excess is a well-characterized condition, androgen deficiency still needs diagnostic criteria, as there are no specific cutoffs.

AREAS COVERED

We highlight the most recent findings on the role of androgens in female pathophysiology, investigating clinically relevant conditions of androgen insufficiency or excess throughout a woman's life, and their possible therapeutic management.

EXPERT OPINION

Combined oral contraceptives (COCs) should be considered as first-line therapy for the management of menstrual irregularity and/or clinical hyperandrogenism in adolescents with a clear diagnosis of polycystic ovary syndrome (PCOS). There are limited evidence-based data regarding specific types or doses of COCs for management of PCOS in women; however, the lowest effective estrogen dose should be considered for treatment. Despite evidence regarding safety, efficacy, and clinical use, testosterone therapy has not been approved for women by most regulatory agencies for treatment of hypoactive sexual desire disorder (HSDD). The long-term safety for treatments with testosterone is still to be evaluated, and this review highlights the need for more research in this area.

PCOS during the menopausal transition and after menopause: a systematic review and meta-analysis

BACKGROUND

Current knowledge about the consequences of PCOS during the late reproductive years and after menopause is limited.

OBJECTIVE AND RATIONALE

We performed a systematic review and meta-analysis of data on the pathophysiology, clinical manifestations, diagnosis, prognosis, and treatment of women ≥45 years of age-peri- or postmenopausal-with PCOS.

SEARCH METHODS

Studies published up to 15 April 2023, identified by Entrez-PubMed, EMBASE, and Scopus online facilities, were considered. We included cross-sectional or prospective studies that reported data from peri- or postmenopausal patients with PCOS and control women with a mean age ≥45 years. Three independent researchers performed data extraction. Meta-analyses of quantitative data used random-effects models because of the heterogeneity derived from differences in study design and criteria used to define PCOS, among other confounding factors. Sensitivity analyses restricted the meta-analyses to population-based studies, to studies including only patients diagnosed using the most widely accepted definitions of PCOS, only menopausal women or only women not submitted to ovarian surgery, and studies in which patients and controls presented with similar indexes of weight excess. Quality of evidence was assessed using the GRADE system.

OUTCOMES

The initial search identified 1400 articles, and another six were included from the reference lists of included articles; 476 duplicates were deleted. We excluded 868 articles for different reasons, leaving 37 valid studies for the qualitative synthesis, of which 28 studies-published in 41 articles-were considered for the quantitative synthesis and meta-analyses. Another nine studies were included only in the qualitative analyses. Compared with controls, peri- and postmenopausal patients with PCOS presented increased circulating total testosterone (standardized mean difference, SMD 0.78 (0.35, 1.22)), free androgen index (SMD 1.29 (0.89, 1.68)), and androstenedione (SMD 0.58 (0.23, 0.94)), whereas their sex hormone-binding globulin was reduced (SMD -0.60 (-0.76, -0.44)). Women with PCOS showed increased BMI (SMD 0.57 (0.32, 0.75)), waist circumference (SMD 0.64 (0.42, 0.86)), and waist-to-hip ratio (SMD 0.38 (0.14, 0.61)) together with increased homeostasis model assessment of insulin resistance (SMD 0.56 (0.27, 0.84)), fasting insulin (SMD 0.61 (0.38, 0.83)), fasting glucose (SMD 0.48 (0.29, 0.68)), and odds ratios (OR, 95% CI) for diabetes (OR 3.01 (1.91, 4.73)) compared to controls. Women with PCOS versus controls showed decreased HDL concentrations (SMD -0.32 (-0.46, -0.19)) and increased triglycerides (SMD 0.31 (0.16, 0.46)), even though total cholesterol and LDL concentrations, as well as the OR for dyslipidaemia, were similar to those of controls. The OR for having hypertension was increased in women with PCOS compared with controls (OR 1.79 (1.36, 2.36)). Albeit myocardial infarction (OR 2.51 (1.08, 5.81)) and stroke (OR 1.75 (1.03, 2.99)) were more prevalent in women with PCOS than controls, the ORs for cardiovascular disease as a whole, coronary artery disease as a whole, breast cancer and age at menopause, were similar in patients and controls. When restricting meta-analysis to studies in which women with PCOS and controls had a similar mean BMI, the only difference that retained statistical significance was a decrease in HDL-cholesterol concentration in the former and, in the two studies in which postmenopausal women with PCOS and controls had similar BMI, patients presented with increased serum androgen concentrations, suggesting that hyperandrogenism persists after menopause, regardless of obesity.

WIDER IMPLICATIONS

Hyperandrogenism appeared to persist during the late-reproductive years and after menopause in women with PCOS. Most cardiometabolic comorbidities were driven by the frequent coexistence of weight excess and PCOS, highlighting the importance of targeting obesity in this population. However, the significant heterogeneity among included studies, and the overall low quality of the evidence gathered here, precludes reaching definite conclusions on the issue. Hence, guidelines derived from adequately powered prospective studies are definitely needed for appropriate management of these women.

Ovarian Leydig Cell Tumor and Ovarian Hyperthecosis in a Postmenopausal Woman: A Case Report and Literature Review

Ovarian Leydig cell tumor is a rare type of ovarian steroid cell neoplasms, presenting in only 0.1% of all ovarian tumor cases, and is generally androgen-secreting and unilateral. Although they are often malignant non-spreading tumors, which have excellent prognosis, benign ovarian Leydig cell tumors with low-risk malignancy can be also detected. Ovarian hyperthecosis is a rare non-neoplastic disorder, in most cases bilateral. Ovarian tumors and ovarian hyperthecosis are one of the main causes of hyperandrogenism in postmenopausal women, a condition strongly associated with both hormonal and metabolic changes. Here, we report a 65-year-old patient with complaints of excessive body hairiness and alopecia. The laboratory investigation showed increased levels of serum testosterone and dehydroepiandrosterone sulfate (DHEA-S). Imaging, including transvaginal ultrasound and pelvic MRI revealed the presence of two masses in the ovaries. The patient underwent a laparoscopic bilateral salpingo-oophorectomy due to the ovarian tumors unknown etiology, and histopathological examination revealed a unilateral benign left ovarian Leydig cell tumor with bilateral ovarian stromal hyperplasia and ovarian hyperthecosis. Making differential diagnosis between ovarian tumors and ovarian hyperthecosis is difficult. Bilateral salpingo-oophorectomy is the treatment of choice in postmenopausal women with benign Leydig cell ovarian tumor, as well as ovarian hyperthecosis, as it offers both a cure and diagnostic confirmation.

Surgical treatment of post-menopausal ovarian hyperandrogenism improves glucometabolic profile alongside clinical hirsutism

Hyperandrogenism during menopause is often underestimated by clinicians and attributed to the natural aging process. Hyperandrogenism can be associated with some metabolic abnormalities linked together in a vicious circle by insulin resistance. We present the case of an elderly woman affected with type 2 diabetes and obesity who reported the occurrence of clinical hirsutism after physiological menopause at the age of 47 years. At presentation, physical examination and Ferriman-Gallwey score revealed a condition of moderate hirsutism, with markedly increased levels of plasma testosterone and delta-4-androstenedione, obesity (body mass index 31.9), and inadequate glycemic control (glycated hemoglobin 65 mmol/mol). The patient underwent a thorough differential diagnosis by a multidisciplinary team approach, including the various causes of hyperandrogenism during menopause. After choosing surgical option as the appropriate treatment, clinical resolution of hirsutism was observed alongside patient satisfaction and marked improvement of the glucometabolic profile.

Postmenopausal Hyperandrogenism due to Ovarian Hyperthecosis

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.

Approach to Investigation of Hyperandrogenism in a Postmenopausal Woman

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.

The influence of ESR1 polymorphisms on selected hormonal, metabolic and mineral balance markers in women with hyperandrogenism

Hyperandrogenism is the most common endocrine disorder in women, characterized by an imbalance in normal estrogen and androgen levels in the blood. Androgens influence bone mineral density, body mass composition, muscle mass, mental state, and the regulation of sexual function.. The aim of the study was to assess the effect of estrogen receptor α gene (ESR1) polymorphisms on selected markers of bone metabolism and hormonal parameters in women with hyperandrogenism. The study group included 80 young women with hyperandrogenism who underwent measurements of bone mineral density (BMD), and determination of hormonal and metabolic parameters. Enzyme immunoassays were used to measure leptin, sRANKL (soluble receptor activator of nuclear factor-kB ligand), osteoprotegerin and 25-OH vitamin D total levels. An analysis of ESR1 gene polymorphisms was performed using the real-time PCR method. A relationship was demonstrated between the concentration of free estradiol (FEI) and the concentration of 17-OH-progesterone, and the ESR1 gene polymorphisms: rs3020314 (p = 0.031, p = 0.026 respectively) and rs1884051 (p = 0.033, p = 0.026 respectively). In conclusion, the ESR gene polymorphisms may be associated with hormonal disturbances in the concentration of estrogens and androgens, in hyperandrogenism in young women which may indirectly affect bone mineral density. However, no statistically significant relationships between the studied polymorphisms and the selected parameters of mineral metabolism have been demonstrated..

Androgen-secreting adult granulosa cell tumor in a woman with polycystic ovary syndrome: a case report

Aim: To present the clinicopathologic findings of the second case of androgen-secreting adult granulosa cell tumor (AGCT) in a woman with polycystic ovary syndrome (PCOS) and discuss in the light of the literature. Methods: Description of a case and discussion of the literature. Results: A patient with oligomenorrhea, amenorrhea and hirsutism who was diagnosed as PCOS and treated by oral contraceptive for three years, then left ovarian solid and liquid mass was found and pathologically confirmed to be androgen-secreting AGCT after left oophorectomy. She got regular menstrual cycle and gave birth naturally, but clinical features of PCOS reappeared after breastfeeding. Conclusion: Androgen-secreting AGCT and PCOS have similar clinical features of hyperandrogenism, it is difficult to diagnose androgen-secreting AGCT when both diseases occur in the same patient. If the size of cystic mass in androgen-secreting AGCT is too small to differentiate from PCOM on imaging, pathological examination after surgery may be the only way to find the disease.

[Hyperandrogenism after menopause: Ovarian or adrenal origin?]

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.

Ovarian Hemangioma With Stromal Luteinization

Ovarian hemangiomas are generally asymptomatic. However, associated stromal luteinization, reported in some cases, may lead to the development of hyperandrogenic syndrome. We report the case of a 61-year-old female referred to the endocrinology outpatient clinic for hirsutism, hair loss, and deepening of the voice tone. The investigation showed high serum testosterone and normal dehydroepiandrosterone sulfate (DHEAS). Normal ovaries were observed in the initial transvaginal ultrasound, but an abdominal-pelvic nuclear magnetic resonance imaging (MRI) identified a solid mass in the right ovary. The patient underwent surgery, and pathological examination revealed a capillary-type ovarian hemangioma with stromal luteinization. After the surgery, clinical and analytical response was very favorable.

Non-alcoholic fatty liver disease through the female lifespan: the role of sex hormones

The prevalence of non-alcoholic fatty liver disease (NAFLD) differs between various stages of the female lifespan. The aim of this review is to summarize current evidence on the association of NAFLD and circulating sex hormones and to explore the pathogenesis of NAFLD within the context of (1) sex hormone changes during the reproductive, post-reproductive female life and beyond and (2) the in vitro and in vivo evidence on pharmacological modulation in women on menopausal hormone treatment (MHT) or endocrine therapy after breast cancer. The fluctuation in estrogen concentrations, the relative androgen excess, and the age-related reduction in sex hormone-binding globulin are related to increased NAFLD risk. Moreover, the peri-menopausal changes in body composition and insulin resistance might contribute to the increased NAFLD risk. Whether MHT prevents or improves NAFLD in this population remains an open question. Studies in women with breast cancer treated with tamoxifen or non-steroidal aromatase inhibitors point to their adverse effects on NAFLD development, although a more pronounced effect of tamoxifen is reported. Future studies focusing on the underlying pathogenesis should identify subgroups with the highest risk of NAFLD development and progression into more aggressive forms, as well as elucidate the role of hormone therapies, such as MHT.

Ovarian steroid cell tumour inducing virilisation in a postmenopausal woman

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.

A rare case of postmenopausal hyperandrogenism due to ovarian hyperthecosis and hilus cell hyperplasia

Postmenopausal hyperandrogenism is rare, and without consensus on specific investigative indices, diagnosis is challenging. A 77-year-old woman had a three-year history of hirsutism, male-pattern baldness and increased libido alongside elevated androstenedione, total testosterone and free androgen index levels. A magnetic resonance imaging (MRI) scan showed bilateral ovarian lesions, suggesting ovarian hyperthecosis. Histopathology obtained after a laparoscopic bilateral salpingo-oophorectomy confirmed ovarian hyperthecosis and hilus cell hyperplasia. We believe it's the first time they have been reported to occur in combination. The symptoms resolved within a month of surgery. This case highlights the difficulties of diagnosis alongside demonstrating the importance of management by a multidisciplinary team.

Depot Pure GnRH Antagonist for Long-term Treatment of Ovarian Hyperthecosis Monitored by Multisteroid LCMS Profiling

Ovarian hyperthecosis (OHT), severe hyperandrogenism after menopause in the absence of ovarian or adrenal tumors, is usually treated by surgical excision. We report a 58-year-old woman presenting with severe hyperandrogenism (serum testosterone 15.7-31.0 nmol/L, normal female <1.8 nmol/L) with menopausal gonadotropins and virilization but no adrenal or ovarian lesions. Multisteroid profiling by liquid chromatography mass spectrometry (LCMS) of adrenal and ovarian vein samples identified strong gradients in the left ovarian vein (10- to 30-fold vs peripheral blood in 17OHP₄, 17 hydroxyprogesterone, 17 hydroxypregnenolone, androstenedione, testosterone, dehydroepiandrosterone) but the right ovarian vein could not be cannulated with the same findings in a second ovarian vein cannulation. OHT diagnosis was confirmed by an injection of a depot pure gonadotropin-releasing hormone (GnRH) antagonist (80 mg Degarelix, Ferring) producing a rapid (<24 hour) and complete suppression of ovarian steroidogenesis as well as serum luteinizing hormone and follicle-stimulating hormone lasting at least 8 weeks, with reduction in virilization but injection site reaction and flushing and vaginal spotting ameliorated by an estradiol patch. Serum testosterone remained suppressed at 313 days after the first dose despite recovery of menopausal gonadotropins by day 278 days. This illustrates use of multisteroid LCMS profiling for confirmation of the OHT diagnosis by ovarian and adrenal vein sampling and monitoring of treatment by peripheral blood sampling. Injection of a depot pure GnRH antagonist produced rapid and long-term complete suppression of ovarian steroidogenesis maintained over 10 months. Hence a depot pure GnRH antagonist can not only rapidly confirm the OHT diagnosis but also induce long-term remission of severe hyperandrogenism without surgery.

Practical Approach to Hyperandrogenism in Women

The approach to hyperandrogenism in women varies depending on the woman's age and severity of symptoms. Once tumorous hyperandrogenism is excluded, the most common cause is PCOS. Hirsutism is the most common presenting symptom. The woman's concern about her symptoms plays an important role in the management of disease. Although measurement of testosterone is useful in identifying an underlying cause, care must be taken when interpreting the less accurate assays that are available commercially. Surgical resection is curative in tumorous etiologies, whereas medical management is the mainstay for non-tumorous causes.

Clinical and ultrasound characteristics of virilizing ovarian tumors in pre- and postmenopausal patients: a single tertiary center experience

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.

Effect of free androgen index on blood pressure variability and target organ damage in postmenopausal hypertensive women: findings from a cross-sectional study

OBJECTIVE

The present study investigated the effects of free androgen index (FAI) on ambulatory blood pressure (ABP) and target organ function in postmenopausal hypertensive women.

METHODS

A total of 285 postmenopausal hypertensive women (mean age 54.06 ± 3.61) were admitted to the Department of Hypertension of Lanzhou University Second Hospital between December 2018 and December 2020. According to the serum FAI level, the participants were divided into a low-FAI (<0.15) group, a medium-FAI (0.15-0.2) group, and a high-FAI (>0.2) group. The relationship of FAI with 24-hour ABP, left ventricular mass index (LVMI), and cardio-ankle vascular index (CAVI) was analyzed.

RESULTS

The LVMI, CAVI, 24-hour mean systolic blood pressure (SBP), 24-hour SBP coefficient of variation and 24-hour SBP standard deviation, 24-hour SBP average real variation (ARV), and 24-hour diastolic blood pressure (DBP) ARV in high-FAI group were significantly higher than those in low- and medium-FAI groups (P < 0.05). After adjusting for confounding factors, partial correlation analysis showed that FAI was positively correlated with LVMI (r = 0.728, P < 0.001), CAVI (left: r = 0.718, P < 0.001; right: r = 0.742, P < 0.001), 24-hour SBP ARV (r = 0.817, P < 0.001), and 24-hour DBP ARV (r = 0.747, P < 0.001). After adjusting for confounding factors, it was found that LVMI increased by 17.64 g/m2 for every 1 unit increase in FAI. CAVI also increased by 8.983 for every additional unit of FAI. In addition, the results also showed that LVMI and CAVI decreased respectively by 0.198 g/m2 and 0.009 for every 1 unit increase in sex hormone-binding globulin. Multivariable linear regression showed that FAI was an independent risk factor for 24-hour SBP ARV (OR: 20.416, 95% CI 8.143-32.688, P = 0.001) and 24-hour DBP ARV (OR: 16.539, 95% CI 0.472-32.607, P = 0.044). The results also showed that sex hormone-binding globulin was an independent factor of 24-hour SBP ARV (OR: -0.022, 95% CI -0.044 to 0.000, P = 0.048) and 24-hour DBP-ARV (OR: -0.018, 95% CI -0.029 to -0.008, P = 0.001).

CONCLUSION

Higher serum FAI levels in postmenopausal hypertensive women indicate abnormal BP regulation and more serious target organ damage. FAI is closely related to 24-hour SBP ARV and 24-hour DBP ARV in postmenopausal hypertensive women.

Dexamethasone suppression test versus selective ovarian and adrenal vein catheterization in identifying virilizing tumors in postmenopausal hyperandrogenism - a systematic review and meta-analysis

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.

Postmenopausal hyperandrogenism

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.

Nutraceuticals

Hair loss has a multifactorial etiology that includes internal and external triggers. These include poor diet and nutrition (extrinsic), as well as the natural aging process (intrinsic). Other external factors include pollution, hair products, hair styling, and ultraviolet exposure, which can cause free radical formation, oxidative stress, and microinflammation at the site of the hair follicles. Botanic substances have demonstrated antioxidant, anti-inflammatory, and immune-enhancing properties. Vitamins and minerals are needed when deficiencies are apparent or demonstrate efficacy at higher doses than normally found in one's diet. The safety and efficacy of oral nutraceuticals have been demonstrated in clinical trials.

Differential diagnosis of adipocytic differentiation in androgen-secreting mature ovarian teratoma with Leydig cell hyperplasia

Mature cystic teratomas (dermoid cysts) of the ovary are very rarely associated with androgen production. The source of androgens in these cysts may be tumours such as Sertoli-Leydig cell tumour or Leydig cell hyperplasia. In this study, we present a case of virilisation in a postmenopausal female patient, where Leydig cell hyperplasia in a mature cystic teratoma was found to be responsible for the production of testosterone. In addition, extensive areas of lipomatous differentiation were identified. These areas showed significant alterations in adipocytic morphology, and differential diagnoses such as spindle cell lipoma (SCL) and atypical lipomatous tumour (ALT) were excluded after additional workup. Adipose tissue is traditionally described as an energy reservoir, but recently it has become clear that adipose tissue is a complex endocrine organ with additional metabolic roles in whole body homeostasis. Exuberant proliferation of lipomatous tissue in this teratoma raises the possibility of a synergistic role of Leydig cells and adipocytes in the development of hyperandrogenism.

Prevalence of at-risk hyperandrogenism by age and race/ethnicity among females in the United States using NHANES III

OBJECTIVE

Hyperandrogenism in females leads to multiple endocrine and metabolic disorders including polycystic ovary syndrome (PCOS) that yields adverse health outcomes across all ages. We sought to estimate the prevalence of hyperandrogenemia and at-risk hyperandrogenism among the US females of different age groups, racial/ethnic, and metabolic characteristics.

MATERIALS AND METHODS

A retrospective population-based cross-sectional study of females 6 years or older having serum testosterone measures using the National Health and Nutrition Examination Surveys, 2013-2016 was conducted. Age-appropriate thresholds as per assay methods were used for evaluating high total testosterone, low sex hormone binding globulin (SHBG), and high free androgen index (FAI) levels. The weighted analysis was performed to estimate prevalence and 95 % confidence interval (CI).

RESULTS

The prevalence of at-risk hyperandrogenism was estimated as 19.8 % (95 %CI: 18.6 %, 21.2 %) in the overall sample, 11.8 % (95 %CI: 9.5 %, 14.5 %) in prepubertal, 20.5 % (95 %CI: 18.9 %, 22.2 %) in premenopausal, and 21.1 % (95 %CI: 18.7 %-23.7 %) in postmenopausal females with considerable heterogeneity by racial/ethnic and metabolic characteristics. In the entire sample, hyperandrogenemia was estimated as 10.4 % and 4.3 % using total testosterone and FAI respectively while 10.7 % cases had a low SHBG.

CONCLUSIONS

At-risk hyperandrogenism is equally prevalent in premenopausal and postmenopausal women with a considerable amount in prepubertal females and varied by racial/ethnic groups depending on specific ages. Regular screening of hyperandrogenism using SHBG and total testosterone measures among at-risk subjects for specific ages is critical for treating and preventing adverse consequences of abnormal hormonal parameters.

Ovarian Leydig cell tumor and postmenopausal hirsutism with signs of virilisation

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.

Postmenopausal Hyperandrogenism: Evaluation and Treatment Strategies

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.

Androgen Plays a Carcinogenic Role in EOC via the PI3K/AKT Signaling Pathway in an AR-Dependent Manner

Background: Epithelial ovarian cancer (EOC) is one of the most common gynecological cancers with the highest mortality rate. Studies indicate that androgens contribute to initiation or progression of EOC through poorly understood mechanisms, however, in the phase II clinical studies of antiandrogen therapy for EOC, neither flutamide nor bicalutamide showed good antitumor effects. Based on the contradictions, the purpose of this study was to explore the role of androgen receptor (AR) in the androgen pathogenesis of EOC and the possible mechanism, and further to find an indicator to screen the anti-androgen therapy sensitive cases. Methods: In this study, 70 EOC biopsies and 17 para-cancerous tissues with complete medical information were collected and analyzed. The expression of the androgen receptor (AR) was detected by immunohistochemistry. In addition, ovarian cancer cell lines were used for in vitro studies to further explore the role of androgen in cell proliferation and the possible mechanisms. Results: The results showed that the expression of AR in ovarian cancer tissues was significantly elevated compared to the para-cancerous tissues, particularly in low-grade EOC, and the presence of high AR expression often suggested a worse prognosis. The in vitro study indicated that testosterone promoted the proliferation of the AR-positive SKOV3 cell line, which could be blocked by flutamide, but not in the AR-negative A2780 cell line. Next, we showed that testosterone-promoted proliferation in SKOV3 cells was abolished after we knocked out the AR. The mechanism studies revealed that the p-AKT expression in the ovarian cancer tissue was increased compared to the para-cancerous tissues, following a pattern similar to the increase of AR expression. Furthermore, the deletion and overexpression of SKOV3 cells' ARs lead to corresponding changes in the p-AKT levels. In addition, the BEZ235, an inhibitor of the PI3K/AKT signaling pathway blocked the proliferative effect of testosterone in SKOV3 cells. Conclusion: We showed that testosterone was able to promote the proliferation of ovarian cancer cells through activating the PI3K/AKT signaling pathway in an AR dependent manner and AR may be a screening indicator for anti-androgen therapy sensitive cases of EOC.

Changes of androgens levels in menopausal women

Androgens play an important role in women’s health. They are responsible for the sexual well-being and for maintaining proper structure and function of genitourinary woman’s tract. In menopausal period a relative increase in androgens level is observed as a result of dramatic demise of estrogens and increase of sex hormone-binding globulin (SHBG). However, the response of target tissue depends on its ability to control androgens availability. In menopausal women the symptoms of both hyperandrogenemia and of androgens deficiency may be observed. Hyperandrogenemia may result in discrete symptoms, such as slight terminal facial hair grow, or worsening of scalp hair loss. Those symptoms should not be belittled in any of the cases, especially when their severity increases one should seek possible causes of postmenopausal hyperandrogenemia.

Ovarian and adrenal aging, leading to a progressive decline in androgen levels, may exert detrimental effects on the quality of life. During menopause, changes in activation of particular brain spheres are connected with low sex hormone concentration and correlate with loss of sexual arousability. Hypoactive sexual desire dysfunction (HSDD) may be the direct result of androgens deficiency in menopausal women. It is the only evidence-based indication for the use of testosterone in women. However, before treatment, other diseases must be excluded that might alternatively be the cause of HSDD.

Gonadotropin-Releasing Hormone Analogue Stimulation Test Versus Venous Sampling in Postmenopausal Hyperandrogenism

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.

Gonadal hormones and stroke risk: PCOS as a case study

It is well known that stroke incidence and outcome is sex-dependent and influenced by age and gonadal hormones. In post-menopausal and/or aged females, declining estrogen levels increases stroke risk. However, women who experience early menopause also have an increase in stroke risk. This suggests that, regardless of age, gonadal hormones regulate stroke risk and severity. This review discusses prolonged gonadal hormone dysfunction in a common female endocrine disorder known as polycystic ovarian syndrome, PCOS, and the associated increased risk of stroke due to resulting hyperandrogenism and metabolic comorbidities.

MULTILOCULAR PURE LEYDIG CELL TUMOR OF OVARY, FALLOPIAN TUBE, AND EXTRAOVARIAN SOFT TISSUE

Objective

Leydig cell tumors (LCTs) of the ovary may produce androgens and cause virilization. Although they are generally benign, these tumors are typically very small, making them hard to detect by imaging processes.

Methods

We report a case of a multilocular LCT involving the ovarian stroma, fallopian tube, and extra-ovarian soft tissue. It was diagnosed by catheter blood sampling of ovarian and adrenal venous blood.

Results

A 63-year-old female presented to the endocrinology department with progressive hirsutism and male pattern alopecia occurring within 1 year. Laboratory tests revealed high serum testosterone. Diagnosis of an androgen-producing tumor was considered, however computed tomography and magnetic resonance imaging scans did not show any conspicuous results. Gynecological examination showed slightly enlarged ovaries. Ovarian and adrenal venous blood sampling was performed via catheter for further diagnostics. The testosterone concentration from the right ovarian vein was highly elevated. The patient was admitted for surgery to the gynecological department and bilateral adnexectomy was performed. Microscopic examination showed a multilocular LCT of the right ovary which was located in the ovarian stroma, the fallopian tube, and the extraovarian soft tissue. Following the surgery, her hirsutism disappeared and serum testosterone decreased to normal levels.

Conclusion

LCTs typically present with postmenopausal virilization. Catheter blood sampling is a reliable method for diagnosis. Furthermore, follow up is essential as ovarian LCTs often have multilocular presentation.

Androgen Effects on the Adrenergic System of the Vascular, Airway, and Cardiac Myocytes and Their Relevance in Pathological Processes

INTRODUCTION

Androgen signaling comprises nongenomic and genomic pathways. Nongenomic actions are not related to the binding of the androgen receptor (AR) and occur rapidly. The genomic effects implicate the binding to a cytosolic AR, leading to protein synthesis. Both events are independent of each other. Genomic effects have been associated with different pathologies such as vascular ischemia, hypertension, asthma, and cardiovascular diseases. Catecholamines play a crucial role in regulating vascular smooth muscle (VSM), airway smooth muscle (ASM), and cardiac muscle (CM) function and tone.

OBJECTIVE

The aim of this review is an updated analysis of the role of androgens in the adrenergic system of vascular, airway, and cardiac myocytes. Body. Testosterone (T) favors vasoconstriction, and its concentration fluctuation during life stages can affect the vascular tone and might contribute to the development of hypertension. In the VSM, T increases α1-adrenergic receptors (α ₁-ARs) and decreases adenylyl cyclase expression, favoring high blood pressure and hypertension. Androgens have also been associated with asthma. During puberty, girls are more susceptible to present asthma symptoms than boys because of the increment in the plasmatic concentrations of T in young men. In the ASM, β ₂-ARs are responsible for the bronchodilator effect, and T augments the expression of β ₂-ARs evoking an increase in the relaxing response to salbutamol. The levels of T are also associated with an increment in atherosclerosis and cardiovascular risk. In the CM, activation of α _1A-ARs and β ₂-ARs increases the ionotropic activity, leading to the development of contraction, and T upregulates the expression of both receptors and improves the myocardial performance.

CONCLUSIONS

Androgens play an essential role in the adrenergic system of vascular, airway, and cardiac myocytes, favoring either a state of health or disease. While the use of androgens as a therapeutic tool for treating asthma symptoms or heart disease is proposed, the vascular system is warmly affected.

Menopausal Acne - Challenges And Solutions

Although acne is a disease predominant in adolescence, it is being increasingly observed in adult life, including the menopausal period. The etiology of menopausal acne is multifactorial, with hormonal imbalance being the major culprit. There is a relative increase of androgens in the menopausal female that leads to clinical hyperandrogenism manifesting as acne, hirsutism and androgenetic alopecia. Other endocrine disorders including thyroid abnormalities, hyperprolactinemia and insulin resistance also play a role. Genetics, stress, dietary changes, lack of sleep and exercise and other lifestyle changes are implicated as trigger factors. Most menopausal women with isolated few acne lesions have normoandrogenic serum levels and do not require extensive investigations. However, baseline investigations including total testosterone are useful. Patients must also be evaluated for associated comorbidities such as obesity, diabetes, hypertension and dyslipidemia. A detailed history can help to exclude polycystic ovarian syndrome, late-onset congenital adrenal hyperplasia or medications as a cause of acne. The evaluation of menopausal acne and the approach to treatment depend on the severity of acne and associated features. In patients with mild acne without virilization, prolonged topical therapy is the mainstay of treatment. Though combined oral contraceptives are effective, they are relatively contraindicated in the postmenopausal period. Spironolactone is the first choice of therapy in the subset of patients that require oral anti-androgen therapy. Procedural treatment can be useful as it can also help in the treatment of associated acne scars and concomitant skin aging. It is also important to focus on lifestyle changes such as reducing stress, controlling obesity, having a healthy diet, exercise and proper skin care routine to reduce acne. The focus of this article is on the clinical presentation and management challenges of menopausal acne, which represents a special subtype of acne.

Utilisation of gonadotrophin-releasing hormone (GnRH) analogue to differentiate ovarian from adrenal hyperandrogenism in postmenopausal women

Postmenopausal hyperandrogenism is a relatively rare diagnosis resulting from excess androgen production from the adrenals or ovaries. The exclusion of malignant causes is a priority. Laboratory tests and imaging are utilised to help differentiate the source of excess androgens. We report two cases of postmenopausal hyperandrogenism in women aged 75 and 67 years. Both cases presented with clinical features suggestive of hyperandrogenism which had developed gradually over the previous 2 years. Laboratory investigations confirmed a significant elevation in their serum testosterone levels. In both cases, imaging did not reveal any abnormality of the adrenals or ovaries. To help differentiate an adrenal vs ovarian source a single-dose GnRH analogue was given with measurement of testosterone and gonadotrophin levels pre and post. The reduction in gonadotrophins achieved by the GnRH analogue resulted in suppression of testosterone levels which suggested an ovarian source. Both patients proceeded to bilateral oophorectomy. Histology revealed a benign hilus cell tumour in one case and a benign Leydig cell tumour in the other.

Diagnostic Thresholds for Androgen-Producing Tumors or Pathologic Hyperandrogenism in Women by Use of Total Testosterone Concentrations Measured by Liquid Chromatography-Tandem Mass Spectrometry

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 &lt; 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).

Androgens in women: Androgen-mediated skin disease and patient evaluation

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.

Diagnostic Dilemma in Two Cases of Hyperandrogenism

Hirsutism is a common endocrine complaint affecting about 10 percent of women. It may be caused by multiple etiologies including adrenal and ovarian disorders. Usually, it is a result of a benign entity such as PCOs and idiopathic hirsutism. However, sometimes especially when it is severe and rapid in progression an androgen-secreting tumor should be excluded. Sertoli-Leydig cell tumors constitute fewer than 0.5 percent of ovarian tumors and it may be benign or malignant. In this article, we present two cases of hyperandrogenism caused by occult ovarian Leydig cell tumors. one of them was confounded by the presence of coincidental bilateral adrenal nodules that complicated the diagnostic process. Tumor dissection was curative in both cases and the diagnosis was confirmed by pathological and hormonal testing after surgery.

Polycystic ovary syndrome: definition, aetiology, diagnosis and treatment

Polycystic ovary syndrome (PCOS) is one of the most common endocrine and metabolic disorders in premenopausal women. Heterogeneous by nature, PCOS is defined by a combination of signs and symptoms of androgen excess and ovarian dysfunction in the absence of other specific diagnoses. The aetiology of this syndrome remains largely unknown, but mounting evidence suggests that PCOS might be a complex multigenic disorder with strong epigenetic and environmental influences, including diet and lifestyle factors. PCOS is frequently associated with abdominal adiposity, insulin resistance, obesity, metabolic disorders and cardiovascular risk factors. The diagnosis and treatment of PCOS are not complicated, requiring only the judicious application of a few well-standardized diagnostic methods and appropriate therapeutic approaches addressing hyperandrogenism, the consequences of ovarian dysfunction and the associated metabolic disorders. This article aims to provide a balanced review of the latest advances and current limitations in our knowledge about PCOS while also providing a few clear and simple principles, based on current evidence-based clinical guidelines, for the proper diagnosis and long-term clinical management of women with PCOS.

High Androgens in Postmenopausal Women and the Risk for Atherosclerosis and Cardiovascular Disease: The Rotterdam Study

CONTEXT

Polycystic ovary syndrome (PCOS) is closely linked to hyperandrogenism (HA). In PCOS, HA has been associated with metabolic disturbances that increase the risk for cardiovascular disease (CVD).

OBJECTIVE

To assess the association of high serum androgen levels, as a postmenopausal remnant of PCOS, with the prevalence of atherosclerosis and incidence of CVD in postmenopausal women.

DESIGN

The Rotterdam Study, a prospective population-based cohort study. Median follow-up was 11.36 years.

SETTING

General community.

PARTICIPANTS

A total of 2578 women aged >55 years. Exclusion criteria were missing informed consent or follow-up data, perimenopausal status, and menopause by surgical intervention or at an unnatural age (age <40 or >62).

INTERVENTION

None.

MAIN OUTCOMES AND MEASURES

Linear, logistic, and Cox regression models assessed the association of top quartiles (P75) of serum testosterone, free androgen index (FAI), dehydroepiandrosterone, and androstenedione and sex hormone-binding globulin with coronary artery calcium, carotid intima-media thickness (IMT), pulse wave velocity, peripheral artery disease, and incidence of coronary heart disease (CHD), stroke, and CVD.

RESULTS

Mean age (standard deviation) was 70.19 (8.71) years, and average time since menopause was 19.85 (9.94) years. Highest quartile FAI was associated with higher pulse wave velocity (β [95% confidence interval (CI)], 0.009 [0.000 to 0.018]). Highest quartile dehydroepiandrosterone [β (95% CI), -0.008 (-0.015 to -0.001)] and androstenedione [β (95% CI), -0.010 (-0.017 to -0.003)] levels were associated with a lower IMT. We found no association between high androgen levels and incident stroke, CHD, or CVD.

CONCLUSION

Postmenopausal high androgen levels were not associated with an elevated risk for CVD. Cardiovascular health in women with PCOS might be better than was anticipated.