Table 1.
Differential diagnosis and presentation of androgen excess in postmenopausal women
| Diagnosis | Presentation in Postmenopausal Women |
|
|---|---|---|
| Nontumorous hyperandrogenism Endogenous causes |
||
| Inherited disorders | PCOS |
Sx: Premenopausal history of anovulatory cycles and hyperandrogenism Data: Elevated T and DHEAS |
| NCCAH |
Sx: Premenopausal history of anovulatory cycles and hyperandrogenism Data: Elevated 17-hydroxyprogesterone after ACTH stimulation |
|
| Obesity-induced hyperandrogenism |
Sx: Progressive weight gain without return to baseline weight; normal menses until reaching threshold weight Data: Elevated T but otherwise normal laboratory tests and imaging studies |
|
| Hyperthecosis |
Sx: Premenopausal history of anovulatory cycles and hyperandrogenism; postmenopausal virilization Data: Very high T, modest elevations in DHEAS; pelvic US with bilateral ovarian enlargement (≥10 cm3) |
|
| Endocrinopathies | Cushing syndrome |
Sx: Stigmata of glucocorticoid excess Data: Elevated cortisol on UFC, 1 mg DST, and/or salivary cortisol |
| Hyperprolactinemia |
Sx: Galactorrhea; headaches and/or visual disturbances with prolactinoma Data: Elevated serum prolactin level |
|
| Acromegaly |
Sx: Stigmata of GH excess Data: Elevated serum insulin-like growth factor-1, nonsuppressed GH with oral glucose tolerance testing |
|
| Nontumorous hyperandrogenisms Iatrogenic causes |
||
| Medication use | Glucocorticoids |
Sx: Stigmata of glucocorticoid excess Data: Elevated cortisol on laboratory tests, suppressed gonadotropins |
| Androgens Antiepileptics |
Sx: Rapid virilization temporally related to medication/supplement start Data: Severe elevations in T and/or DHEAS; suppressed gonadotropins |
|
| Medication abuse | Anabolic steroids Pellets |
Sx: Rapid virilization temporally related to medication/supplement start Data: Severe elevations in T and/or DHEAS; suppressed gonadotropins |
| Tumorous hyperandrogenism Adrenal causes |
||
| Adrenal adenomas |
Sx: mild to moderate hyperandrogenism and hypercortisolism Data: Elevated T, usually with concurrent mild to moderate hypercortisolism; suppressed ACTH and DHEAS |
|
| Adrenal carcinomas |
Sx: Rapid virilization often with stigmata of hypercortisolism Data: T ≥150 ng/dL, DHEAS >800 ng/mL, with cosecretion of other adrenal hormones, usually glucocorticoids; >8- to 10-cm mass seen on imaging |
|
| Tumorous hyperandrogenism Ovarian causes |
||
| Sertoli-Leydig cell tumors |
Sx: Rapid virilization Data: T 150 ng/dL; larger tumors (3–12 cm) at presentation, unilateral |
|
| Granulosa cell tumors |
Sx: Predominantly estrogen-secreting but 10% cosecrete androgens leading to rapid virilization; postmenopausal bleeding, endometrial hyperplasia, and endometrial carcinoma Data: T ≥150 ng/dL; larger tumors (3–12 cm) at presentation, cysticappearing |
|
| Metastatic tumors cystadenomas |
Sx: Rapid virilization; in metastatic tumors, signs of systemic illness Data: Paracrine action of β-hCG stimulates androgen secretion, stromal hyperplasia |