Disorders of Androgen Excess

Abstract

A 24-year-old female presented with menstrual irregularity for the last 12 years. She had menarche at the age of 12 years, and soon after she started having menorrhagia. She received oral contraceptive pills (OCPs) for a period of 9 months. After discontinuation of OCPs, she had oligomenorrhea. She did not have thorough evaluation but continued to receive OCPs intermittently. However, for the last 6 months, she had secondary amenorrhea and did not have menstrual bleed on OCPs. She had progressive increase in hair growth all over the body along with weight gain of 10 kg for the past 3 years. There was no history of galactorrhea, striae, easy bruisibility, or proximal myopathy. She resorted to cosmetic measures including laser for her hirsutism without significant improvement. She was married for 1 year and had primary infertility. There was no history of hypertension or diabetes. She did not have family history of hirsutism or menstrual irregularity. On examination, her BMI was 24.4 kg/m2, pulse rate 80/min, and BP 120/90 mm Hg with no postural drop. Her Ferriman–Gallaway score was 26/36. There was no acne, temporal recession, or low-pitch voice, but she had clitoromegaly and male torso without any features of defeminization. She did not have features of protein catabolism like striae, bruise, and proximal myopathy or any stigma of acromegaly. On investigation, serum sodium was 138 mEq/L, potassium 4.7 mEq/L, and creatinine 0.82 mg/dl. Hormonal workup showed serum T4 8.0 μg/dl (4.8–12.7),TSH 2.5 μIU/ml, prolactin 10.4 ng/ml (4–23), 0800h cortisol 317 nmol/L (171–536), ONDST 24.5 nmol/L (<50), LH 9.9 mIU/ml (1.7–8.6), FSH 5.0 mIU/ml (3.5–12.5), estradiol 76.8 pg/ml (12.5–166), testosterone 10.2 nmol/L (0.2–2.9), DHEAS 944 μg/dl (148–407), and 17α-hydroxyprogesterone (17α-OHP) 2.2 ng/ml (<2). CECT abdomen revealed a well-defined mass of 4.3 × 3 cm arising from the medial limb of the left adrenal gland with no evidence of calcification, necrosis, or hemorrhage with absolute washout of 69% at 10 min suggestive of adrenal adenoma. In addition, there were bilateral bulky ovaries with multiple tiny cystic areas suggestive of polycystic ovaries. 24 h urinary metanephrines and normetanephrines were normal. She underwent laparoscopic left adrenalectomy uneventfully. Histopathology was consistent with the diagnosis of adrenal adenoma. Two weeks after surgery, hormonal profile showed serum LH 16.1 mIU/ml (1.7–8.6), FSH 4.7 mIU/ml (3.5–12.5), estradiol 115 pg/ml (12.5–166), testosterone 2.2 nmol/L (0.2–2.9), and DHEAS 174 μg/dl (148–407). At 6 weeks of follow-up, her hirsute score was same, but the frequency of cosmetic measures was reduced. She has not yet resumed her cycles.