1
|
Ni H, Schmidli R, Savkovic S, Strasser SI, Hetherington J, Desai R, Handelsman DJ. Depot Pure GnRH Antagonist for Long-term Treatment of Ovarian Hyperthecosis Monitored by Multisteroid LCMS Profiling. J Endocr Soc 2021; 5:bvab167. [PMID: 34877444 PMCID: PMC8645162 DOI: 10.1210/jendso/bvab167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Indexed: 11/19/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Huajing Ni
- Department of Andrology, Concord Hospital, Sydney, Australia
| | - Robert Schmidli
- Department of Endocrinology, Canberra Hospital, Canberra, Australia
| | - Sasha Savkovic
- Department of Andrology, Concord Hospital, Sydney, Australia
| | - Simone I Strasser
- AW Morrow Gastroenterology & Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
| | - Julie Hetherington
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Reena Desai
- ANZAC Research Institute, University of Sydney, Sydney, Australia
| | - David J Handelsman
- Department of Andrology, Concord Hospital, Sydney, Australia.,ANZAC Research Institute, University of Sydney, Sydney, Australia
| |
Collapse
|
2
|
Goyal A, Malhotra R, Kulshrestha V, Kachhawa G. Severe hyperandrogenism due to ovarian hyperthecosis in a young woman. BMJ Case Rep 2019; 12:e232783. [PMID: 31852694 PMCID: PMC6936414 DOI: 10.1136/bcr-2019-232783] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2019] [Indexed: 11/04/2022] Open
Abstract
Hyperandrogenism is a relatively common clinical problem. However, severe hyperandrogenism causing virilisation is rare. A 27-year-old woman presented with generalised hirsutism, clitoromegaly, breast atrophy and secondary amenorrhoea. She had serum testosterone levels elevated to the adult male range. Administration of gonadotropin-releasing hormone (GnRH) analogue resulted in >50% suppression of serum testosterone which was suggestive of luteinising hormone-dependent ovarian hyperandrogenism. Imaging studies of abdomen and pelvis were normal, and ovarian venous sampling failed to show a gradient between the two sides. A presumptive diagnosis of ovarian hyperthecosis was, therefore, considered. Medical treatment with GnRH analogue and combined oral contraceptive pills was initiated to which an excellent clinical and biochemical response was noted. This case highlights a rare presentation of ovarian hyperthecosis in a young woman with severe hyperandrogenism mimicking a virilising neoplasm.
Collapse
Affiliation(s)
- Alpesh Goyal
- Endocrinology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Rakhi Malhotra
- Endocrinology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Vidushi Kulshrestha
- Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Garima Kachhawa
- Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Röhrig T, Pihlajoki M, Ziegler R, Cochran RS, Schrade A, Schillebeeckx M, Mitra RD, Heikinheimo M, Wilson DB. Toying with fate: Redirecting the differentiation of adrenocortical progenitor cells into gonadal-like tissue. Mol Cell Endocrinol 2015; 408:165-77. [PMID: 25498963 PMCID: PMC4417465 DOI: 10.1016/j.mce.2014.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 11/30/2014] [Accepted: 12/01/2014] [Indexed: 01/07/2023]
Abstract
Cell fate decisions are integral to zonation and remodeling of the adrenal cortex. Animal models exhibiting ectopic differentiation of gonadal-like cells in the adrenal cortex can shed light on the molecular mechanisms regulating steroidogenic cell fate. In one such model, prepubertal gonadectomy (GDX) of mice triggers the formation of adrenocortical neoplasms that resemble luteinized ovarian stroma. Transcriptomic analysis and genome-wide DNA methylation mapping have identified genetic and epigenetic markers of GDX-induced adrenocortical neoplasia. Members of the GATA transcription factor family have emerged as key regulators of cell fate in this model. Expression of Gata4 is pivotal for the accumulation of gonadal-like cells in the adrenal glands of gonadectomized mice, whereas expression of Gata6 limits the spontaneous and GDX-induced differentiation of gonadal-like cells in the adrenal cortex. Additionally, Gata6 is essential for proper development of the adrenal X-zone, a layer analogous to the fetal zone of the human adrenal cortex. The relevance of these observations to developmental signaling pathways in the adrenal cortex, to other animal models of altered adrenocortical cell fate, and to human diseases is discussed.
Collapse
Affiliation(s)
- Theresa Röhrig
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA; Hochschule Mannheim - University of Applied Sciences, Mannheim 68163, Germany
| | - Marjut Pihlajoki
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA; Children's Hospital, University of Helsinki and Helsinki University Central Hospital, Helsinki 00290, Finland
| | - Ricarda Ziegler
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA; Hochschule Mannheim - University of Applied Sciences, Mannheim 68163, Germany
| | - Rebecca S Cochran
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA
| | - Anja Schrade
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA; Children's Hospital, University of Helsinki and Helsinki University Central Hospital, Helsinki 00290, Finland
| | - Maximiliaan Schillebeeckx
- Department of Genetics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA
| | - Robi D Mitra
- Department of Genetics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA
| | - Markku Heikinheimo
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA; Children's Hospital, University of Helsinki and Helsinki University Central Hospital, Helsinki 00290, Finland
| | - David B Wilson
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA; Department of Developmental Biology, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA.
| |
Collapse
|
6
|
Tutzer M, Winnykamien I, Davila Guardia J, Castelo-Branco C. Hyperandrogenism in post-menopausal women: a diagnosis challenge. Gynecol Endocrinol 2014; 30:23-5. [PMID: 24188447 DOI: 10.3109/09513590.2013.850661] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A 79-year-old woman, presented with increased hair growth in the chin and the upper lip but no in other androgen-dependent areas of her body. Hormonal evaluation showed markedly elevated serum testosterone level (>1.7 ng/ml) and normal DHEA-S, androstenedione, 17-hydroxyprogesterone, cortisol and TSH levels. The diagnosis of probable pure testosterone secreting tumor was made. Transvaginal ultrasound and magnetic resonance image revealed a 16 mm × 12 mm nodular formation indicative of an atypical adenoma in the left adrenal gland and a tube-shaped, fluid-filled, thin-walled image measuring 28 mm × 14 mm suggestive of a hydrosalpinx in the right ovary. Differential diagnosis between the coexistence of an androgen-producing ovarian tumor (occult) associated with a finding of an adrenal image (Incidentaloma) or an adrenal tumor secreting testosterone only was done. Since cortisol levels went down, but total testosterone inhibition did not occur after suppression with dexamethasone. An ovarian androgen secreting tumour was suspected and surgery was performed. Histological examination showed a Leydig cells hyperplasia. After the operation testosterone returned to normal with regression of clinical symptoms.
Collapse
|
7
|
Alterations in hair follicle dynamics in women. BIOMED RESEARCH INTERNATIONAL 2013; 2013:957432. [PMID: 24455742 PMCID: PMC3884776 DOI: 10.1155/2013/957432] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 12/14/2013] [Indexed: 12/26/2022]
Abstract
Endocrine changes supervening after parturition and menopause participate in the control of sebum production and hair growth modulation. The ensuing conditions include some peculiar aspects of hair loss (effluvium), alopecia, and facial hirsutism. The hair cycling is of major clinical relevance because most hair growth disorders result from disturbances in this chronobiological feature. Of note, any correlation between a biologic abnormality and hair cycling disturbance does not prove a relationship of causality. The proportion of postmenopausal women is rising in the overall population. Therefore, the prevalence of these hair follicle disturbances is globally on the rise. Current therapies aim at correcting the underlying hormonal imbalances, and at improving the overall cosmetic appearance. However, in absence of pathogenic diagnosis and causality criteria, chances are low that a treatment given by the whims of fate will adequately control hair effluvium. The risk and frequency of therapeutic inertia are further increased. When the hair loss is not controlled and/or compensated by growth of new hairs, several clinical aspects of alopecia inexorably develop. Currently, there is little evidence supporting any specific treatment for these endocrine hair disorders in post-partum and postmenopausal women. Current hair treatment strategies are symptomatic and nonspecific so current researchers aim at developing new, targeted methods.
Collapse
|
8
|
Damodaran S, Mahmood T, Nawroz I, Swaminathan K. Ovarian stromal hyperplasia and hyperthecosis: an unusual case of post-menopausal hirsutism. Eur J Obstet Gynecol Reprod Biol 2011; 158:114-5. [DOI: 10.1016/j.ejogrb.2011.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 02/21/2011] [Accepted: 04/25/2011] [Indexed: 11/29/2022]
|
9
|
Magnetic Resonance Imaging Appearance of Ovarian Stromal Hyperplasia and Ovarian Hyperthecosis. J Comput Assist Tomogr 2009; 33:912-6. [DOI: 10.1097/rct.0b013e3181a2ec0c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|