From diagnosis to treatment of androgen-secreting ovarian tumors: a practical approach

Society for Endocrinology Clinical Practice Guideline for the Evaluation of Androgen Excess in Women

CONTEXT

Androgen excess is common in women and refers to clinical or biochemical evidence of elevated androgenic steroids such as testosterone. It is associated with underlying polycystic ovary syndrome in the majority of cases. However severe androgen excess is less common and may indicate the presence of underlying adrenal or ovarian neoplasms, genetic disorders or severe insulin resistance syndromes. Currently there are few consensus guidelines to assist clinicians with a standardised management approach to the patient with severe androgen excess.

DESIGN

Clinical practice guideline.

METHODS

This guideline has been developed with expertise from colleagues in endocrinology, gynaecology, clinical biochemistry and nursing, and furthermore provides a unique patient perspective to guide clinicians.

RESULTS

The Society for Endocrinology commissioned this new guideline to collate multi-disciplinary guidance for clinical practitioners in the investigation of severe androgen excess. Recommendations have been made in the areas of clinical assessment, biochemical work up, dynamic testing and imaging, informed where possible by the best available evidence.

CONCLUSION

This guideline will provide guidance for clinicians in their approach to patients with severe androgen excess.

Diagnostic challenges of androgen secreting tumor by sclerosing stromal tumor: A case report

INTRODUCTION

Androgen-secreting tumors are rare ovarian or adrenal neoplasms associated with virilization symptoms such as hirsutism, deepening of the voice, and menstrual irregularities. These tumors present a diagnostic challenge due to overlapping features with conditions like polycystic ovary syndrome (PCOS) and congenital adrenal hyperplasia (CAH). Accurate diagnosis requires a combination of biochemical assays, imaging, and histopathological examination.

CASE PRESENTATION

An unmarried 22-year-old woman presented with two years of irregular menstruation and recent onset of virilization symptoms. Besides clinical assessment, transvaginal ultrasound revealed a solid right ovarian tumor, raising suspicion of an androgen-secreting neoplasm. Histopathological examination following surgical excision resulted features consistent with a sex cord-stromal tumor, specifically a Sertoli-Leydig cell tumor. Further analysis revealed pseudo lobular architecture and spindle-shaped stromal cells confirming the diagnosis of an androgen-secreting tumor.

CLINICAL DISCUSSION

This case highlights the diagnostic complexities of androgen-secreting ovarian tumors. The challenge lies in distinguishing them from conditions like PCOS, emphasizing the need for a multidisciplinary approach that includes clinical, biochemical, radiological, and pathological assessments. The tumor's histological features were key in making the final diagnosis.

CONCLUSION

This report emphasizes the importance of considering androgen-secreting ovarian tumors in young women with unexplained virilization and menstrual irregularities. A comprehensive diagnostic approach is essential for accurate identification and appropriate management, ensuring optimal patient outcomes.

Challenges in diagnosing ovarian sertoli-leydig cell tumors: A Peruvian case series

<b>Introduction</b>: The virilizing ovarian tumors represent less than 1% of ovarian tumors, with the most common being Sertoli-Leydig cell tumor (SLCT). This stufy is a case series.<br /> <b>Methods: </b>We present the diagnosis, treatment, and evolution of 2 Peruvian women who developed virilization.<br /> <b>Results</b>: Case 1 is a 27-year-old woman with a history of polycystic ovary syndrome (PCOS), whose usual treatment was combined oral contraceptives, which she discontinued in the last year; she presented with voice changes, increased muscular strength, and acne of 6 months duration. Physical examination revealed only clitoromegaly. Tests showed elevated total testosterone, normal dehydroepiandrosterone sulfate (DHEA-S), and transvaginal ultrasound with isoechoic image in frosted glass in the left ovary. Left salpingo-oophorectomy was performed, revealing SLCT. Case 2 is a 48-year-old woman with a history of PCOS since the age of 25, prediabetes, and dyslipidemia; she noticed progression of hirsutism, increased libido, deepened voice, alopecia, weight gain, and amenorrhea over the last 5 years. Physical examination revealed hirsutism, alopecia, and clitoromegaly. Tests showed markedly elevated total testosterone (1,080 ng/dl) and normal DHEA-S. Transvaginal ultrasound showed a larger right ovary, without tumor. Ovarian venous sampling showed lateralization towards the right ovary. Bilateral salpingo-oophorectomy plus hysterectomy was performed, revealing SLCT in the right ovary. In both post-surgery patients, there was normalization of androgens and clinical improvement.<br /> <b>Conclusion</b>s: SLCT s can occur at any age, with rapidly evolving hyperandrogenism and/or virilization symptoms, the cases described were of unusual presentation, which posed a diagnostic challenge.

Ovarian tumors in the pediatric population: An update

Research reveals that 1% of neoplasms in females under 17 years of age are ovarian neoplasms and though usually benign, malignant tumors may occur in the pediatric age group. This review considers various current concepts of these tumors including the epidemiology, risk factors, clinical presentations, diagnosis, differential diagnosis, and treatment options including the need to provide fertility-sparing surgery as well as their potential impacts on the psychological well-being of children and adolescents. We gathered data from the published articles ranging from studies, meta-analyses, retrospective studies, and reviews. We focused on the articles published in English between January 1, 2000, and August 31, 2023. Only a few articles published prior to 2000 were included for historical perspective.

Postmenopausal Hyperandrogenism Associated With Synchronous Ovarian Brenner Tumor, Bilateral Leydig Cell Tumor, and Adrenal Mass

Hyperandrogenism in postmenopausal females may arise from either ovarian or adrenal sources and can pose a challenging diagnostic dilemma. We present the case of a 66-year-old female with postmenopausal hyperandrogenism with virilization, adrenal incidentaloma, and concurrent finding of two extremely rare ovarian tumors, including bilateral Leydig cell tumor and Brenner tumor. Laboratory tests showed elevated testosterone and androstenedione and normal dehydroepiandrosterone sulfate (DHEAS). Response to 1 mg overnight dexamethasone suppression test demonstrated persistently elevated testosterone and incomplete suppression of androstenedione. Computed tomography (CT) scan showed a left adrenal nodule and an unremarkable appearance of the ovaries. The pelvic ultrasound did not show an ovarian tumor on the right ovary, and the left ovary was not seen. Adrenal and ovarian vein sampling suggested the ovaries as the source of the testosterone. Given the ovarian vein sampling results, a multidisciplinary discussion between endocrinology and gynecologic oncology concluded that bilateral salpingo-oophorectomy (BSO) was the next best step for diagnosis and management. Laparoscopic BSO was performed. Histopathology showed bilateral Leydig cell tumors and a left ovarian Brenner tumor. At one-year postoperative follow-up, alopecia improved, and testosterone level normalized. This case highlights the importance of diagnostic pathways and interdisciplinary collaboration in managing rare clinical scenarios of hyperandrogenism in postmenopausal females. As in our case, surgeons may be hesitant to remove normal-appearing ovaries. While the three presented tumor types in this case arise from distinct tissues and exhibit different histological characteristics, the presence of such a unique triad prompts consideration of potential unifying pathogenic mechanisms.

Clinical management of androgen excess and defect in women

INTRODUCTION

Hyperandrogenism and hypoandrogenism are complex disorders involving multiple-organ systems. While androgen excess is a well-characterized condition, androgen deficiency still needs diagnostic criteria, as there are no specific cutoffs.

AREAS COVERED

We highlight the most recent findings on the role of androgens in female pathophysiology, investigating clinically relevant conditions of androgen insufficiency or excess throughout a woman's life, and their possible therapeutic management.

EXPERT OPINION

Combined oral contraceptives (COCs) should be considered as first-line therapy for the management of menstrual irregularity and/or clinical hyperandrogenism in adolescents with a clear diagnosis of polycystic ovary syndrome (PCOS). There are limited evidence-based data regarding specific types or doses of COCs for management of PCOS in women; however, the lowest effective estrogen dose should be considered for treatment. Despite evidence regarding safety, efficacy, and clinical use, testosterone therapy has not been approved for women by most regulatory agencies for treatment of hypoactive sexual desire disorder (HSDD). The long-term safety for treatments with testosterone is still to be evaluated, and this review highlights the need for more research in this area.