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      Marked hyperandrogenicity in a 60-year-old woman


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          Markedly elevated androgen levels can lead to clinical virilization in females. Clinical features of virilization in a female patient, in association with biochemical hyperandrogenism, should prompt a search for an androgen-producing tumor, especially of ovarian or adrenal origin. We herein report the case of a 60-year-old woman of Pakistani origin who presented with the incidental finding of male pattern baldness and hirsutism. Her serum testosterone level was markedly elevated at 21 nmol/L (normal range: 0.4–1.7 nmol/L), while her DHEAS level was normal, indicating a likely ovarian source of her elevated testosterone. Subsequently, a CT abdomen-pelvis was performed, which revealed a bulky right ovary, confirmed on MRI of the pelvis as an enlarged right ovary, measuring 2.9 × 2.2 cm transaxially. A laparoscopic bilateral salpingo-oophorectomy was performed, and histopathological examination and immunohistochemistry confirmed the diagnosis of a Leydig cell tumor, a rare tumor accounting for 0.1% of ovarian tumors. Surgical resection led to normalization of testosterone levels.

          Learning points:
          • Hirsutism in postmenopausal women should trigger suspicion of androgen-secreting tumor

          • Extremely elevated testosterone level plus normal DHEAS level point toward ovarian source

          • Leydig cell tumor is extremely rare cause of hyperandrogenicity

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          Most cited references9

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          Clinical assessment of body hair growth in women.

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            Androgen production in women.

            To describe the sources, production rates, circulating concentrations, and regulatory mechanisms of the major androgen precursors and androgens in women. Review of the major published literature. Quantitatively, women secrete greater amounts of androgen than of estrogen. The major circulating steroids generally classified as androgens include dehydroepiandrosterone sulphate (DHEAS), dehydroepiandrosterone (DHEA), androstenedione (A), testosterone (T), and dihydrotestosterone in descending order of serum concentration, though only the latter two bind the androgen receptor. The other three steroids are better considered as pro-androgens. Dehydroepiandrosterone is primarily an adrenal product, regulated by adrenocorticotropic hormone (ACTH) and acting as a precursor for the peripheral synthesis of more potent androgens. Dehydroepiandrosterone is produced by both the ovary and adrenal, as well as being derived from circulating DHEAS. Androstenedione and testosterone are products of the ovary and the adrenal. Testosterone circulates both in its free form, and bound to protein including albumin and sex steroid hormone-binding globulin (SHBG), the levels of which are an important determinant of free testosterone concentration. The postmenopausal ovary is an androgen-secreting organ and the levels of testosterone are not directly influenced by the menopausal transition or the occurrence of menopause. Dihydrotestosterone (DHT) is primarily a peripheral product of testosterone metabolism. Severe androgen deficiency occurs in hypopituitarism, but other causes may lead to androgen deficiency, including Addison's disease, corticosteroid therapy, chronic illness, estrogen replacement (leads to elevated SHBG and, therefore, low free testosterone), premenopausal ovarian failure, or oophorectomy.
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              FIGO's staging classification for cancer of the ovary, fallopian tube, and peritoneum: abridged republication

              Jaime Prat, (2015)
              Over the past quarter of a century, several scientific developments have challenged traditional concepts in ovarian cancer. First, it was recognized that ovarian cancer is not a homogeneous disease, but rather a group of diseases-each with different morphology and biological behavior. Approximately 90% of ovarian cancers are carcinomas (malignant epithelial tumors) and, based on histopathology, immunohistochemistry, and molecular genetic analysis, at least five main types are currently distinguished: high-grade serous carcinoma (HGSC, 70%); endometrioid carcinoma (EC,10%); clear-cell carcinoma (CCC,10%); mucinous carcinoma (MC, 3%); and low-grade serous carcinoma (LGSC, 10 mm in greatest dimension), even if there are no retrospective data supporting quantification of the size of metastasis in IIIA1. Involvement of retroperitoneal lymph nodes must be proven cytologically or histologically. Stage IV is defined as distant metastasis and includes patients with parenchymal liver/splenic metastases and extra-abdominal metastases; 12% to 21% of patients present with stage IV disease [7]. Extension of tumor from omentum to spleen or liver (stage IIIC) should be differentiated from isolated parenchymal metastases (stage IVB).

                Author and article information

                Endocrinol Diabetes Metab Case Rep
                Endocrinol Diabetes Metab Case Rep
                Endocrinology, Diabetes & Metabolism Case Reports
                Bioscientifica Ltd (Bristol )
                04 September 2017
                : 2017
                : 17-0075
                [1 ]Department of Endocrinology , Royal College of Surgeons in Ireland, Connolly Hospital Blanchardstown, Dublin, Ireland
                [2 ]Departments of Endocrinology
                [3 ]Histopathology , Mater Misericordiae University Hospital, Dublin, Ireland
                [4 ]Department of Radiology , Connolly Hospital Blanchardstown, Dublin, Ireland
                Author notes
                Correspondence should be addressed to K Aljenaee; Email: k.jenaee@ 123456gmail.com
                © 2017 The authors

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.

                : 1 July 2017
                : 14 July 2017
                Unique/Unexpected Symptoms or Presentations of a Disease


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