SAT-163 - Occult Ovarian Hyperthecosis in A Postmenopausal Woman with Severe Hyperandrogenism: A Diagnostic Challenge

Ovarian hyperthecosis is a rare but important cause of severe hyperandrogenism in postmenopausal women, resulting from diffuse ovarian stromal luteinization with autonomous testosterone secretion. Diagnosis is frequently delayed because ovaries often appear normal on imaging.

A 69-year-old postmenopausal woman presented with progressive hirsutism over four years involving the face, abdomen, breasts, and thighs without virilization. Laboratory evaluation revealed markedly elevated total testosterone levels in the 90 ng/dL range with normal DHEA-S, 17-hydroxyprogesterone, cortisol suppression testing, and plasma metanephrines, indicating a non-adrenal source of androgen excess. Pelvic ultrasound demonstrated normal-sized ovaries without masses, and CT imaging revealed a small, stable, benign-appearing adrenal adenoma unchanged since 2019.

Despite negative imaging, ovarian hyperthecosis was suspected based on isolated testosterone elevation in a postmenopausal patient. Mechanistically, excess ovarian androgen production leads to increased peripheral aromatization to estrogen, contributing to insulin resistance and endometrial proliferation. Consistent with this physiology, further evaluation revealed a thickened, heterogeneous endometrium, and biopsy demonstrated atypical endometrial hyperplasia.

The patient underwent robotic total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. Final pathology revealed stage I endometrioid adenocarcinoma of the uterus. Although the ovaries were initially reported as unremarkable, additional histopathologic review demonstrated ovarian stromal hyperplasia with hyperthecosis. Following surgery, serum testosterone levels normalized and the patient reported significant improvement in hirsutism, confirming the ovaries as the source of androgen excess.

This case emphasizes that ovarian hyperthecosis should be suspected in postmenopausal women with marked testosterone elevation despite normal imaging. Early recognition is critical given its metabolic consequences and association with estrogen-mediated endometrial pathology. Bilateral oophorectomy is both diagnostic and curative.

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