Management of postmenopausal virilization

Mild clinical signs of hyperandrogenism such as hirsutism may appear during the menopausal transition as part of the normal aging process, but the development of frank virilization suggests a specific source of androgen excess, including androgen-secreting tumors.

A 68-yr-old postmenopausal woman was referred because of a history of progressive development of hirsutism and frontal balding for the previous 8 yr, together with moderate hyperandrogenemia. Initial imaging procedures depicted a 2-cm solid nodule in the right adrenal gland and normal appearance of both ovaries. To confirm the source of androgen excess, we conducted simultaneous selective venous sampling of adrenals and ovaries. Sampling was consistent with an ovarian source. After bilateral laparoscopic salpingo-oophorectomy, the patient was diagnosed with bilateral ovarian hyperthecosis. Three weeks after surgery, her androgen levels had decreased to the normal female range.

Diagnosis of hyperandrogenism in postmenopausal women is challenging. Postmenopausal virilization may be associated with adrenal or ovarian androgen-secreting tumors or with benign conditions. A detailed clinical history is critical to differentiate the progressive development of virilization that characterizes benign causes from the rapid progression that characterizes malignant tumors. Imaging techniques do not always reveal the cause of hyperandrogenism and may even be misleading. Although technically difficult, combined adrenal and ovarian venous sampling may be required to confirm the source of androgen excess before the best surgical approach is determined.