A benign cause of hyperandrogenism in a postmenopausal woman

SUMMARY: Menopause is a relative hyperandrogenic state but the development of hirsutism or virilizing features should not be regarded as normal. We report the case of a 62-year-old woman with a 9-month history of progressive frontotemporal hair loss and hirsutism, particularly on her back, arms and forearms. Blood tests showed increased total testosterone of 5.20 nmol/L that remained elevated after an overnight dexamethasone suppression test. Free Androgen Index was 13.1 and DHEAS was repeatedly normal. Imaging examinations to study adrenals and ovaries were negative. The biochemical profile and the absence of imaging in favor of an adrenal tumor made us consider the ovarian origin as the most likely hypothesis. After informed consent, bilateral salpingectomy-oophorectomy and total hysterectomy were performed. Gross pathology revealed ovaries of increased volume and histology showed bilateral ovarian stromal hyperplasia. Testosterone levels normalized after surgery and hirsutism had completely subsided 8 months later. LEARNING POINTS: Menopause is a relative hyperandrogenic state. Hirsutism and/or virilizing features, in a postmenopausal woman, should raise the hypothesis of a malignant cause. In the absence of an identifiable ovarian or adrenal tumor, the ovarian origin remains the most likely. Peripheral aromatization of excess androgen may conduct to high levels of estrogen increasing the risk of endometrial cancer. Bilateral oophorectomy results in significant clinical improvement.