Dual case insights shaping a new protocol for post-menopausal hirsutism

Hyperandrogenism in women typically presents with hirsutism and other virilizing features. When it presents with accelerated clinical features and/or high androgen levels (total testosterone > 5 nmol/L) (>145 ng/dL) (reference range, <2.4 nmol/L [SI: <70 ng/dL]), particularly in the post-menopausal state, an underlying ovarian or adrenal neoplasm should be considered. With ovarian pathology, androgen-secreting ovarian tumors and ovarian hyperthecosis are the key differential diagnoses. The recommended treatment for androgen-secreting ovarian tumors (ASOTs) is surgical removal. In contrast, ovarian hyperthecosis may be managed conservatively, provided an androgen-secreting malignant tumor has been excluded. Clarifying this diagnostic uncertainty is a challenge, and imaging and biochemical tests are not always diagnostic. There is additionally a need for better medical treatment in patients with benign ASOTs. We report two cases of female hyperandrogenism with a radiologically identified ovarian lesion, managed with a gonadotropin-releasing hormone (GnRH) antagonist, namely, degarelix. Degarelix was helpful for both diagnosis and treatment of symptoms. We highlight its potential role in diagnosis and medical management, particularly as an option for patients who are unwilling or unable to undergo immediate surgery. We also hypothesize that a fall in total testosterone following GnRH antagonist injection may indicate that an ovarian tumor is benign.