Masculinization and High Testosterone in a 63-year-old Woman


Question

I am an endocrinologist from India. I have an interesting case. I will be happy if you could help me in the management of this case. Case is a 63 year old female, who presented to us with history of hirsutism of 8 years duration and complaints of hair loss in the temperoparietal and frontal area (Male pattern baldness) of 2 years duration.Past issues in this case: 1.She undervent hysterectomy with Bilateral salphingo oopherectomy 8 yeras before (Indication not known). 2.Total thyroidectomy for MNG 1 year before. Now euthyroid on thyroxine replacement.(HPE: MNG, No evidence of malignancy) No history of drug intake or other co-morbidities.On examination she had Hirsutism(FG score>30), masculanizing features and voice change were present. She also had clitoromegaly. No evidence of cushings syndrome.

Investigations:

TSH-3.2mIU/l(0.3 to 4) on thyroxine 150mcg/day

RFT, LFT,Calcium, sodium, potassium-normal

Testosterone-6.14ng/ml

17 hydroxy progesterone-1.3ng/ml

DHEAS-259.2mcg/dl (normal: 80-390)

CT scan Abdomen: Adrenals normal. No abnormal pathology.

MRI of neck and chest to r/o germinoma was normal.

We had treated the patient with aldactone 100mg/day and finasteride � 5mg/day for 3 months and still her testosterone is 5.1ng/ml and not much of clinical improvement.The question of concern is: 1. What is the probable diagnosis and how do we proceed further? 2.How do we treat her? Dr.Kumaravel Amrita Institute of Medical Sciences, Cochin, India

Response

It is again difficult to address a specific problem in the absence of seeing a specific patient.All I can do is make some general comments.It would appear that the testosterone values are about 10 times the upper limit of the normal range for women. If this is the case, then a source must be identified. Generally speaking, testosterone is produced by ovarian androgen producing tumors (generally benign). These tumors can be quite small. Ovarian tissue can remain in the pelvis even if a BSO is produced. It would be reasonable to search for a source of androgen excess. IF there is a skilled interventional radiologist samples could be obtained from near the origins of the ovarian vessels and from other sites in the abdomen and measured for testosterone. This might help determine if surgery is warranted.It would not be unreasonable to determine if the testosterone is suppressible during a dexamethasone suppression test -- but this can occur with ovarian as opposed to adrenal lesions. Robert W. Rebar, M.D.