(101) Ovarian Hyperthecosis as a Cause of Hypersexualization in a Post-menopausal Female
Authors: Wasserman M C , Stewart L E 
Published: May 2023

Abstract

Introduction
Ovarian Hyperthecosis (OH) is a rare benign virilizing ovarian syndrome characterized by androgen overproduction due to stromal and thecal hyperplasia resulting in hirsutism and virilization(1). It is believed to be similar to polycystic ovarian syndrome (PCOS) however, presents with more robust androgen overproduction and an ovarian vein ratio of androstenedione/testosterone less than one, compared with values around 20 in pre-menopausal females and patients with PCOS(2). Specifically in post-menopausal women, the phenotypical presentation is due to unmasking of the increased thecal cell testosterone release which results from lack of granulosa cell mediated aromatization of testosterone to estradiol.(3) Some have described treatment of OH with medications that inhibit ovarian production of estrogen and progesterone especially in pre-menopausal women. However, results are mixed and oophrectomy seems to be the most effective treatment modality for OH(3).

Objective
Here we describe a case of OH resulting in elevated androgen levels and distressing hypersexualization in a post-menopausal female who was effectively treated with bilateral oophorectomy resulting in normalization of laboratory values and resolution of hypersexualization.

Methods
The patient is a 75-year-old female with past medical history significant for bipolar disorder, Sjogren’s syndrome and hypothyroidism who presented to the office for evaluation of recurrent vulvovaginitis and urinary tract infections related to vigorous and frequent sexual activity. She reported symptoms of hypersexuality developing a few years prior to presentation at which time she began engaging in sexual activity 2-3 times daily and masturbating with a variety of objects. She had also noted new heavy facial hair and scalp hair loss. There were no changes in her medical history at the time. She was bothered by the increased need for sexual stimulation and orgasm, prompting further evaluation and treatment. Her exam was notable for vulvar contact dermatitis, mild vulvovaginal atrophy, and no prolapse or urinary incontinence. Vaginal infection testing was negative. Results of an endocrine work up are summarized in Table 1. Abdominal imaging showed normal adrenal glands and ovaries. An MRI of the brain showed a normal pituitary gland. She had been started on Prozac by her psychiatrist, which reduced her libido but worsened her mania and therefore was discontinued. A diagnosis of OH was suspected and bilateral oophorectomy was planned.

Results
The patient underwent a laparoscopic bilateral salpingo-ophrectomy with surgical pathology confirming stromal hyperplasia and hyperthecosis. Post-operatively, her labs rapidly normalized. She noted normalization of her libido, significant improvement in vulvar contact dermatitis and increased scalp hair growth.

Conclusions
Bilateral oophorectomy in a post-menopausal woman with OH was an effective treatment to normalize androgen levels and restore normal libido resulting in resolution of vulvar contact dermatitis from excessive masturbation. Although an uncommon diagnosis, this disease is an important consideration in the workup of excess androgen production in post-menopausal women.

Disclosure
No