Hypersecretion of ovarian androgens may be gonadotrophin dependent many years after menopause

Hyperandrogenism in menopause: a case report and literature review

Hyperandrogenism is an uncommon diagnosis in postmenopausal women. In this case, we report on a 69-year-old postmenopausal woman who presented with several months of worsening hirsutism of the face, neck, and chin, which was confirmed on examination. Laboratory testing revealed markedly elevated testosterone levels and typical post-menopausal gonadotropin levels. Transvaginal ultrasonography and pelvic and abdominal magnetic resonance imaging (MRI) failed to reveal an ovarian or adrenal abnormality. The patient was a poor surgical candidate and was counseled to start on gonadotropin releasing hormone (GnRH) agonist therapy. Administration of leuprolide resulted in a dramatic decline in testosterone levels. The patient reported significant “hot flashes”, difficulty sleeping, anxiety, and depression secondary to treatment, and patient discontinued leuprolide therapy 3 months after initiation. To our knowledge, this is the first case that describes a woman being treated with a GnRH agonist for hyperandrogenism subsequently discontinuing GnRH agonist treatment due to significant side-effects. This case also highlights the difficulty of prescribing appropriate but off-label use of expensive medications not covered by insurance in a senior population of limited income.

An interesting cause of hyperandrogenemic hirsutism

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. We report a case of a 68-year-old woman with signs of virilization that had started 6 months before. Clinical analyses revealed high levels of serum testosterone for a postmenopausal woman. Pelvic MRI and abdomen CT showed no evidence of ovarian and adrenal tumor. Postmenopausal hyperandrogenism can be the result of numerous etiologies ranging from normal physiologic changes to ovarian or rarely adrenal tumors. Our patient was found to have iatrogenic hyperandrogenism. This condition is rarely reported cause of virilization.

Clinical implications of the detection of Y-chromosome mosaicism in Turner's syndrome: report of 3 cases

OBJECTIVE

To determine the clinical implications of the presence of a Y chromosome in Turner's syndrome patients with karyotype abnormalities.

DESIGN

To investigate the presence of Y-chromosome sequences in different tissue samples.

SETTING

Endocrinology outpatient clinic of a federal university in Brazil.

PATIENT(S)

Five Turner's syndrome patients with karyotype abnormalities such as marker chromosomes, additional material, or ring chromosomes.

INTERVENTION(S)

Peripheral blood, oral epithelial cells, and hair root samples were collected.

MAIN OUTCOME MEASURE(S)

The SRY gene and the DYZ3 repeat region were amplified by polymerase chain reaction followed by gel electrophoresis mobility of amplified genomic DNA, and ultraviolet visualization. Prophylactic gonadectomy was offered to the Y-positive patients.

RESULT(S)

The analysis of the different tissues revealed that three of the five patients studied presented Y-chromosome mosaicism. These three patients underwent prophylactic gonadectomy, and in one of them, the histopathologic study of the gonads disclosed hilus cell hyperplasia and stromal luteoma with contralateral nodular hyperthecosis.

CONCLUSION(S)

A systematic search for Y-chromosome mosaicism in Turner's syndrome patients is justified by the risk of developing gonadal tumors or androgen-producing lesions.

Turner's syndrome mosaicism 45X/47XXX: an interesting natural history

Mosaicism 45X/47XXX is a sporadic form of ovarian dysgenesis. Many of the cases previously described were characterized by a variable phenotype expression. We here report the case of a 33-yr-old woman with recent secondary amenorrhea, weight loss and breast regression. Her menarche had occurred at the age of 11 yr and 6 months and her menstrual cycles had been regular until the age of 28; then, oligomenorrhea and hypertricosis developed. A pelvic ultrasound showed enlarged polycystic-like ovaries and normal uterus. She was treated with ethynil-estradiol and cyproterone acetate for one year. At the age of 31 yr, she underwent a pelvic ultrasound--which revealed normal volume of the ovaries--and hormonal assays including FSH (69 UI/l), LH (113 UI/l), 17beta-estradiol (88 pg/ml), plasma androgens and cortisol levels within normal ranges. No organ-specific autoantibodies toward ovaries, steroid-producing cells or adrenals were found. At the age of 33 yr, there was ultrasound evidence of streak-like ovaries. The patient's height was 145 cm and her weight 45 kg. She had normal female external genitalia, abnormal upper-to-lower body segment ratio, webbed neck, low posterior hair line, cubitus valgus, short and asymmetrical 4th metacarpi, hallux with lateral deviation and moderate scoliosis. No increase in ovarian steroids were found after GnRH-analogue triptorelin (0,1 mg sc) administration. The karyotype analysis on peripheral blood lymphocytes showed a mosaic 45X (90% cells) and 47XXX (10% cells). Diagnostic pelviscopy confirmed streak gonads. Chronic lymphocytic thyroiditis was diagnosed but no cardiovascular or kidney abnormalities were found. A neuro-psychological evaluation revealed emotional and social immaturity, disorders in motorial coordination, visual-spatial organization, as well as reading difficulties and impaired complex phrase construction. The presence of several somatic features of Turner's syndrome, neuro-psychological disorders and an interesting natural history probably depended on the quantitative proportion of 45X to 47XXX cell-lines in different tissues and organs. Estrogen and progestin replacement therapy led to weight gain, re-appearance of secondary sexual characteristics and a mild improvement in mental equilibrium.