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 Table of Contents 
CASE REPORT
Year : 2016  |  Volume : 7  |  Issue : 4  |  Page : 189-192  

Postmenopausal hyperandrogenism of ovarian origin: A clinicopathologic study of five cases


Department of Obstetrics and Gynaecology, Academy of Medical Sciences, Pariyaram, Kannur, Kerala, India

Date of Web Publication14-Dec-2016

Correspondence Address:
S Ajith
Department of Obstetrics and Gynaecology, Academy of Medical Sciences, Pariyaram, Kannur - 670 503, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-7800.195699

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   Abstract 

In postmenopausal women presenting with virilization and elevated testosterone levels, laparoscopic salpingo-oophorectomy should be considered after exclusion of adrenal causes. A clinicopathological study was conducted among those women who presented with features of hyperandrogenism in our postmenopausal clinic over a period of 2 years. Relevant past medical and surgical histories were elicited. Basic hormonal evaluation and radiological imaging were done. Laparoscopic bilateral salpingo-oophorectomy was done. Six weeks postoperatively, serum testosterone was undetectable with significant clinical improvement. There was no recurrence of symptoms during the follow-up period of 2 years. Treatment of postmenopausal women with hyperandrogenism and virilization with laparoscopic bilateral salpingo-oophorectomy is effective if she has no pronounced ovarian enlargement or adrenal tumor on imaging. An extensive endocrine testing and a detailed search for metastatic disease may be unnecessary.

Keywords: Hyperandrogenism, laparoscopic, oophorectomy, ovarian, postmenopausal


How to cite this article:
Ajith S, Beena G, Mathew NM, Omana E K. Postmenopausal hyperandrogenism of ovarian origin: A clinicopathologic study of five cases. J Mid-life Health 2016;7:189-92

How to cite this URL:
Ajith S, Beena G, Mathew NM, Omana E K. Postmenopausal hyperandrogenism of ovarian origin: A clinicopathologic study of five cases. J Mid-life Health [serial online] 2016 [cited 2019 Dec 8];7:189-92. Available from: http://www.jmidlifehealth.org/text.asp?2016/7/4/189/195699


   Introduction Top


A hyperandrogenic phenotype has a detrimental effect on quality of life in postmenopausal patients as increased facial hair and loss of scalp hair may cause emotional and psychological distress. It is often related to ovarian stromal disorders. Androgen-secreting tumors account for <1% of all ovarian tumors and most of them are benign making bilateral salpingo-oophorectomy the procedure of choice. We present a clinicopathological study of five cases of postmenopausal hyperandrogenism reported in a tertiary care center in North Kerala, over a period of 2 years (2010-2012).


   Case Report Top


There were two cases of stromal luteoma, one case of Leydig cell tumor, one case of ovarian hyperthecosis, and one case of Sertoli-Leydig cell tumor (SLCT). All of them had rapid improvement of symptoms and normalization of androgen levels following surgery. None had recurrence during the follow-up period of 2 years.

A 70-year-old nulliparous woman presented with gradual onset of hyperandrogenism (Ferriman-Gallwey [FG] score 20) for 10 years [Figure 1] and [Figure 2]. Hormonal evaluation showed elevated testosterone (8 nmol/L) and normal dehydroepiandrosterone sulfate (DHEAS) (150 mcg/dL). Imaging studies showed normal adrenals and no clinical features of Cushing syndrome noted. Laparoscopic bilateral salpingo-oophorectomy was done. Intraoperatively, both ovaries were grossly looking normal. Histopathology showed polygonal cells with eosinophilic to foamy cytoplasm and dark-stained nuclei with mild pleomorphism suggesting steroid cell tumor - stromal luteoma type [Figure 3] and [Figure 4]. There was marked improvement in symptoms and hormone levels following surgery.
Figure 1: Clinical manifestations of hyperandrogenism irsuitism

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Figure 2: Low power microscopic view of stromal luteoma of ovary separated from normal ovarian tissue by fibrous septa

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Figure 3: High power microscopic view of stromal luteoma of ovary showing round to polygonal cells arranged in nests with central round nucleus and moderate to abundant clear to eosinophilic cytoplasm

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Figure 4: Clinical manifestations of hyperandrogenism lopecia

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A 63-year-old P3L3 woman presented with gradual onset of hyperandrogenism (FG score 18) for 5 years. Hormonal evaluation showed elevated testosterone (7.5 nmol/L) and normal DHEAS (123 mcg/dL). After ruling out adrenal cause for the pathology, laparoscopic bilateral salpingo-oophorectomy was done. Intraoperatively, left ovary was larger, whitish, and irregular. Cut section - grayish with brownish area 0.5 cm in diameter. Smaller right ovary had similar appearance. Histopathology suggested stromal luteoma.

A 68-year-old P3L2 woman presented with gradual onset virilization (FG score 14) for 3 years. Hormonal evaluation showed elevated testosterone (8.4 nmol/L) and normal DHEAS (84 mcg/dL). There were no features of Cushing syndrome and adrenal imaging was normal. Laparoscopic bilateral salpingo-oophorectomy was done. Intraoperatively, right ovary was comparatively larger. Histopathology showed cells with abundant granular eosinophilic cytoplasm, well-defined nuclear membrane, and patent nucleoli. Some cells showed pigmented lipochrome in their cytoplasm. There was no evidence of vascular invasion. Reinke crystals were identified suggesting Leydig cell tumor-hilar type.

A 65-year-old P2L2 woman presented with postmenopausal bleeding. She had hirsutism of gradual onset for 5 years. Hormonal evaluation showed elevated testosterone (9 nmol/L) and normal DHEAS (115 mcg/dL). There were no features of Cushing syndrome and adrenal imaging was normal. Hormonal evaluation showed elevated estradiol in addition. Endometrial evaluation showed proliferative endometrium. Laparoscopic bilateral salpingo-oophorectomy was done. Intraoperatively, both ovaries were enlarged and pearly white in color. Histopathology was suggestive of bilateral ovarian hyperthecosis. She was asymptomatic for a follow-up period of 2 years.

A 67-year-old P3L3 woman presented with rapidly progressing hirsutism for 2 years. Hormonal assay showed elevated DHEAS levels (635 mcg/dL) and normal testosterone levels (4 nmol/L). Magnetic resonance imaging showed a left adrenal mass for which left adrenalectomy was done which was unremarkable. There was persistence of hirsutism even after surgery. After 6 months, whole-body positron emission tomography-computed tomography revealed a suspicious enhancing lesion in the right ovary. Hysterectomy with bilateral salpingo-oophorectomy was done. Intraoperatively, the right ovary was of normal size with a central brown area of 7 mm. Histopathology suggested SLCT.


   Discussion Top


The management of hyperandrogenism in postmenopausal women is often quite challenging, especially for the source whether it is the ovary or the adrenal gland. Testosterone levels were elevated in all cases (reference values <2.6 nmol/L) and adrenal cause is ruled out by DHEAS levels (normal levels 15-150 mcg/L) and imaging studies. Surgical removal offers a confirmatory diagnosis and cure in such women.

Steroid cell tumors account for <0.1% of all ovarian tumors. They include (1) stromal luteoma, (2) steroid cell tumor, not otherwise specified (NOS), and (3) Leydig cell tumors. [1] Stromal luteomas constitute 20% of steroid cell tumors. It is usually benign. They originate from luteinized cells or their precursors or undifferentiated spindle cells of the ovarian stroma. [2] About 60% of cases present with estrogenic manifestations and only 12% cases are androgenic. [3] Some cases have been reported with estrogenic manifestations such as endometrial hyperplasia and well-differentiated endometrioid adenocarcinoma. [3] Stromal hyperthecosis has been found in association with stromal luteoma in the contralateral ovary in 90% of cases. [4] Leydig cell tumors are rare ovarian steroid cell neoplasms which include hilar and nonhilar type. [5] They present with progressive virilization by hyperproduction of testosterone. These are mostly benign and can be managed by oophorectomy. Steroid cell tumors, NOS are rare ovarian sex cord stromal tumors which are mostly benign but with malignant potential in premenopausal women.

SLCT or arrhenoblastoma is a rare ovarian tumor (0.1%-0.5%) in women of reproductive age and one-third are associated with androgen secretion. Some cases can benefit from adjuvant therapy with gonadotropin-releasing hormone analogs. [6] Recent studies have shown that many cases of SLCT of the ovary are caused by germline mutations in the DICER1 gene. These hereditary cases tend to belong to younger age group.

Ovarian hyperthecosis is a rare nonmalignant cause of postmenopausal hyperandrogenism. The differentiation of ovarian interstitial cells into steroidogenically active luteinized stromal cells lead to elevated serum testosterone levels. [7] There is associated hyperestrogenism. The hallmark of this syndrome is an increase in bilateral ovarian volume. [8] There will be associated hyperinsulinemia and insulin resistance in almost all cases. They are at risk of metabolic complications of hyperlipidemia and type 2 diabetes.


   Conclusion Top


Our cases illustrate that most cases of virilizing ovarian tumors in a postmenopausal woman are benign making bilateral salpingo-oophorectomy an appropriate cure. They can be small and elude imaging studies. Laparoscopic bilateral salpingo-oophorectomy may be regarded as the procedure of choice in a postmenopausal women with symptomatic hyperandrogenism, virilization, or both, who has no obvious ovarian or adrenal mass. [9],[10] This approach avoids unnecessary investigations and delays in definitive management. Since preoperative probability of malignancy is extremely remote, extensive imaging procedures for metastatic disease, and open laparotomy are unnecessary. Moreover, the availability of both ovaries for pathological examination allows detection of a rare malignancy and guides further therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Roth LM. Recent advances in the pathology and classification of ovarian sex cord-stromal tumors. Int J Gynecol Pathol 2006;25:199-215.  Back to cited text no. 1
    
2.
Scully RE. Stromal luteoma of the ovary. A distinctive type of lipoid-cell tumor. Cancer 1964;17:769-78.  Back to cited text no. 2
    
3.
Hayes MC, Scully RE. Stromal luteoma of the ovary: A clinicopathological analysis of 25 cases. Int J Gynecol Pathol 1987;6:313-21.  Back to cited text no. 3
    
4.
Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 24-1993. A 56-year-old woman with virilization. N Engl J Med 1993;328:1770-6.  Back to cited text no. 4
    
5.
Baiocchi G, Manci N, Angeletti G, Celleno R, Fratini D, Gilardi G. Pure Leydig cell tumour (hilus cell) of the ovary: A rare cause of virilization after menopause. Gynecol Obstet Invest 1997;44:141-4.  Back to cited text no. 5
    
6.
Chao HT, Wang PH, Lin HD. Gonadotropin-releasing hormone-agonist as a neoadjuvant therapy for Sertoli-Leydig cell tumors of the ovary. Int J Gynaecol Obstet 1999;66:189-90.  Back to cited text no. 6
    
7.
Krug E, Berga SL. Postmenopausal hyperthecosis: Functional dysregulation of androgenesis in climacteric ovary. Obstet Gynecol 2002;99(5 Pt 2):893-7.  Back to cited text no. 7
    
8.
Farber M, Madanes A, O'Briain DS, Millan VG, Turksoy RN, Rule AH. Asymmetric hyperthecosis ovarii. Obstet Gynecol 1981;57:521-5.  Back to cited text no. 8
    
9.
Silva PD, Sorensen ML, Reynertson R, Virata RL, Mahairas GH. Laparoscopic removal of virilizing hilar cell tumor in a postmenopausal patient. J Am Assoc Gynecol Laparosc 1997;4:499-502.  Back to cited text no. 9
    
10.
Hofland M, Cosyns S, De Sutter P, Bourgain C, Velkeniers B. Leydig cell hyperplasia and Leydig cell tumour in postmenopausal women: Report of two cases. Gynecol Endocrinol 2013;29:213-5.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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