Post-menopausal virilisation accompanied by insulin resistance is rare and presents a diagnostic challenge. Ovarian hyperthecosis is characterised by ovarian stromal cell proliferation, leading to androgen excess and insulin resistance due to impairment of insulin signalling pathways. Here, we present a case of a 58-year-old post-menopausal woman with new onset virilisation, type 2 diabetes and metabolic syndrome due to ovarian hyperthecosis, who was successfully treated with bilateral oophorectomy resulting in normalisation of hyperandrogenism and improvement in glycaemic control.
The patient presented with a one-year history of virilisation with coarse facial hair growth, male pattern baldness and hair thinning. She was not Cushingoid. Her background was significant for suboptimally controlled type 2 diabetes (HbA1c 9.2%), hypertension, hypercholestoleraemia and obesity (BMI 35.9 kg/m2). Androgen levels were markedly elevated: total testosterone 9.9 nmol/L (RR 0.2-1.1nmol/L), androstenedione 18.4 nmol/L (1-13nmol/L) and free testosterone 135pmol/L (1-22pmol/L). SHBG 57 nmol/L (16-120nmol/L) and DHEAS 4.6umol/L (1-7umol/L) were normal. Gonadotrophins were not suppressed: LH 16.3IU/L and FSH 21.7IU/L. Progesterone (<1.6nmol/L) was within post-menopausal levels and oestradiol was initially borderline elevated 118 pmol/L (<103 pmol/L), possibly due to aromatisation of excess testosterone. Her 24-hour urinary free cortisol and late-night salivary cortisol were not elevated, excluding Cushing syndrome. Abdominal CT and MRI imaging revealed a bulky uterus, normal adrenals and no pelvic lesion. Pelvic ultrasound revealed fibroids with endometrial thickening and her ovaries were unable to be visualised. She underwent laparoscopic hysterectomy and bilateral oophorectomy. Histopathology confirmed ovarian hyperthecosis. Post-operatively, androgen & oestradiol levels normalised, and glycaemic control improved (Hba1c 6.8%) with metformin. Interestingly, she developed transient menopausal vasomotor symptoms presumably due to resolution of higher-than-normal oestradiol levels.
This case highlights the importance of considering ovarian pathology in the evaluation of post-menopausal virilisation and insulin resistance. Normalisation of androgen levels following resection likely contributed to the observed glycaemic improvements.