QuizMe 22

Secondary Amenorrhea

A nulliparus 42 year old lady presents with amenorrhea for the past 4 months. She has also noticed a
gradual increase in hair growth around her body that started six months ago. Patient is not on any form of contraception.  

  • BMI is 34
  • Excessive hair growth on the face,upper arms, chest and lower back,with a Ferriman-Gallwey score of 30.

  • Serum testosterone level: 225 pg/ml(elevated)
  • DHEAS level: 110 mcg/dL (Normal)
  • Serum cortisol level (Normal)
  •  17 hydroxyprogesterone level (Normal)
  • Hemoglobin level : 10 g/dl (anemic)
  • TFT : normal
  • Pregnancy test: negative
  • USG : showed a regular uterus, PCOS ovaries with no other pathologies
  • Endometrial biopsy: revealed  disordered proliferative phase endometrium

shows 2.5-cm solid mass within the right ovary

  • Overnight dexamethasone suppression test
  •  CT scan of the adrenals
  • Pelvic MRI
  • Laparoscopic oophorectomy
  •  Staging laparotmy

Laparoscopic oophorectomy

The patient above is an example of an atypical presentation of hyperandrogensim.The most common cause of andrgen excess in women is the benign, where hirsutism and secondary amenorrhea describe the classical presentation. However the age of our patient does not align with a typical PCOS; which is unlikely to be newly diagnosed beyond the third decade of life.This, alongside the relatively rapid progression of symptoms,indicate a need for additional investigations to be performed, to rule out other possiblecauses of hyperandrogenism. 

Ultrasonography is the ideal modality to image ovaries when assessing hyperandrogenemia, whether the underlying
pathology is PCOS or tumors.

Overnight dexamethasone test is beneficial where there is clinical suspicion of Cushing’s syndrome. Given the normal serum cortisol levels, and the high testosterone levels, Cushing is no longer as probable.

CT scan of the adrenals would prove valuable when investigating for an androgen secreting adrenal mass. Despite the mutual
clinical presentation, and the elevated testosterone levels in either scenario, the DHEAS levels of our patient are normal.
Hence, an adrenal source of the androgens is less likely.Androgen secreting tumors are often benign. The most common location of androgen secreting tumors in women is the ovary, where they appear as small, solid masses with nonspecific appearance.

The next step following the ultrasonography report would be to perform a laparoscopic oophorectomy. This will provide a sample
for pathology, and may even prove curative in most cases.

The final pathology from the extracted ovum will determine the need for staging. If deemed necessary, a staging laparotmy can followas a separate procedure.

  • Onset before 15 yrs of age
  • Serum testosterone 2x the upper limit
    of normal
  • Rapid progression of symptoms
  • Development of virilization
  • Unluhizarci K, Kaltsas G, KelestimurF. Non polycystic ovary syndrome-related endocrine disordersassociated with hirsutism.Eur J Clin Invest. 2012
  • Dennedy MC, Smith D, O’Shea D,McKenna TJ. Investigation of patientswith atypical or severe hyperandrogenaemia including
    androgen-secreting ovarian teratoma. Eur J Endocrinol. 2010
  • D M, D I, A MJ, J B-M. Androgen-Secreting Ovarian Tumors. FrontHorm Res [2019]. Available from: https://pubmed.ncbi.nlm.nih.gov/31499493/
  • Martin KA, Anderson RR, Chang RJ,Ehrmann DA, Lobo RA, Murad MH, et
    al. Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab [2018]. Available from:https://academic.oup.com/jcem/article/103/4/1233/4924418