I would be grateful for you assistance regarding the following case: A 14-year-old female referred to me with the diagnosis of PCOs with high S.Testosterone of 6 nmol/l ( X3 ULN), high DHEA-S of 17 ( x2 ULN) and slightly raised s.PRL.Her Androstendione is slightly elevated with low SHBG and CT abdomen revealed a nodular Lt adrenal (the Rt looks normal ). I have ruled out cushings as well as late onset CAH.She has been on OCP with Aldactone for the last one year with no much improvement.worth. mentioning is the pelvic US which reveals multiple cysts mainly in the rt ovary. How should I proceed? where do this androgens come from? Ovaries or the Lt nodular adrenal?
Regards, Dr.Yahya Al Zaman, Salmaniya Medical Hospital, Kingdom of Bahrain
This case is highly suggestive of an adrenal androgen secreting tumor, and adenomas secreting androgens only are rare. Androgen secreting tumors in the adrenal gland, more commonly have been associated with carcinomas. Have you ruled out Conn's syndrome- does the patient have hypertension or electrolyte abnormalities. The levels of both testosterone and DHEAS are elevated above the range we normally see in PCOS. However these levels, in and of themselves, provide poor discrimination between a tumor and PCOS. Does the girl show any signs of virilization, i.e. voice changes and/or clitoromegaly, this would be highly suspicious for a tumor, and would prompt me to immediate surgery. The clearest way to make the diagnosis of a tumor would be selective adrenal vein sampling (both R and L) and measurement of androgens, there should be a pronounced gradient between right and left . If venous sampling is not available or there is virilization, then R adrenalectomy would appear indicated, given the abnormal CT findings. Your report however is vague. Is there a single discrete nodule or multiple nodules. How large are the nodules and how many are there? Large or multiple nodules would also lead me straight to surgery. .Dr Richard Legro