Steroid cell tumor not otherwise specified of bilateral ovaries: A rare cause of post menopausal virilization
A 54-year-old gravida two, para two post menopausal woman presented with a 6 month history of progressively worsening facial hair growth and receding hairline. She required daily shaving and was troubled by the excessive loss of scalp hair. There was no history of bleeding per vagina, abdominal pain, or distension. On examination, she had hirsutism with a Ferriman-Gallwey score of 13/36. She had greasy skin and although post-menopausal she had non-atrophic breasts. Pelvic examination revealed clitoromegaly. There were no striae, acne, and bruising or proximal muscle weakness.\nHormonal assessment revealed an inappropriately high serum follicle-stimulating hormone (FSH) level of 1.1 mIU/mL (post menopause >30 mIU/mL), serum luteinizing hormone (LH) level of 3.2 mIU/mL (post menopause >30 mIU/mL), and a serum testosterone level of 7.31 ng/ml (normal 0.4-0.76 ng/mL). Additionally, she had a serum dehydroepiandrosterone sulfate (DHEA-S) level of <15 μg/dL (normal 35-430 μg/dL) and a serum testosterone after dexamethasone suppression of 6.32 ng/ml (not suppressed). The hormone profile demonstrated normal values for serum prolactin, cortisol, thyroid-stimulating hormone, and human chorionic gonadotrophin. Tumor marker CA-125 was 0.55 u/ml (1.9-16.3). Other hematological and biochemical parameters were normal. Imaging by transvaginal ultrasound and computed tomography of abdomen and pelvis revealed no ovarian masses. Thus, ovarian venous sampling was carried out under radiological guidance, but the left ovarian vein cannulation was technically difficult and the procedure was relatively unsuccessful except for revealing that the right ovary was a source of testosterone in this patient [].\nThe patient, therefore, underwent hysterectomy and bilateral salpingo-oophorectomy. During the laparotomy, straw-colored ascitic fluid was evacuated but found to be negative for malignant cells. The right ovary was slightly enlarged (4 × 1.5 × 1.3 cm) showing a slightly elongated, nodular appearance. Left ovary was normal in appearance (3 × 1.6 × 1.4 cm) []. The cut surface of both ovaries showed multiple white spots. There were no peritoneal lesions. Microscopic sections of both ovaries revealed infiltrating islands and cords of tumor cells exhibiting round to oval nuclei and abundant eosinophilic cytoplasm [Figures and ]. There were no features to suggest malignant behavior such as nuclear atypia, hemorrhage, necrosis or increased mitotic activity. Reinke's crystals were not observed. Immunohistochemically, tumor showed intense reactivity to alpha inhibin. Brown-colored pigment was also noted in the cytoplasm []. The final diagnosis was bilateral ovarian steroid cell tumor NOS. Histologically, the tumor exhibited benign characteristics. Tumor was confined to both ovaries whereas bilateral tubes and parametrial tissue were normal. Sections of the uterus revealed inactive endometrium with adenomyosis.\nBy 3 weeks post surgery, her serum testosterone had returned to normal range: 0.38 ng/mL and the clinical signs of hyperandrogenism resolved. She currently remains asymptomatic with normal testosterone levels and imaging at 6 months and 12 months after surgery.