# Luteinized Ovarian Thecoma in a Postmenopausal Women Presenting with Virilization

Authors: Athula Kaluarachchi; Jeevan P. Marasinghe; Thuwan M. Batcha; Preethika Agunawela
Journal: Obstetrics and Gynecology International
 (2009)

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## Abstract

We report a case of luteinizing thecoma in a 58-year-old postmenopausal woman who presented with progressive androgenic features and hypertension of one year duration. She did not notice a significant change in her body weight or appetite. Her total serum testosterone level was 4.5 ng/mL. Ultrasound scan revealed a normal-sized uterus and a right-sided solid ovarian mass of 5 cm× 5 cm. Left ovary was normal. She had a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and an omentectomy performed. Histological examination confirmed the diagnosis of luteinized thecoma. This case illustrates the necessity to consider the rare possibility of luteinized ovarian thecoma as a cause for virilization in a menopausal woman.


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## Body

## 1. Introduction

Virilization due to hyperandrogenism caused by
a luteinized
thecoma in a postmenopausal woman is extremely rare.


## 2. Case Report

A 58-year-old
postmenopausal woman of two living children presented to the university gynecological
unit, National Hospital of Sri Lanka, Colombo, complaining of
progressive hair loss and male-type hair distribution of one year duration. These
symptoms were accompanied by lower abdominal pain for the last four months
duration. She did not notice a significant change in her body weight or
appetite. There was no postmenopausal bleeding or vaginal discharge.She was diagnosed
to have hypertension
for the last one and half year duration and was on regular treatment with a
good control of blood pressure. She had undergone hemithyroidectomy at the age
of 44 years due to a cold nodule. Histology had revealed a follicular adenoma
and she was treated with L-thyroxine 50μg
daily.On examination,
she had alopecia, frontal balding, and hirsuitism involving the face, chin,
upper back, chest, upper and the lower abdomen giving a score of 14 from
modified Ferriman and Gallwey scoring system (Figure1(a)).(a) On examination, she had alopecia, frontal balding, and hirsuitism giving a score of 14 from modified Ferriman and Gallwey
scoring system. (b) Computed tomography of the
abdomen and pelvis revealed a well-defined solid tumor in right adnexal region
(arrow). (c) Laparotomy revealed a
solid ovarian tumor of 5 cm with an intact capsule in the right ovary. (d) Haematoxyline and eosine-stained
sections (magnification10×100) revealed cell nets comprising uniform cells
with round bland nuclei and eosinophilic cytoplasm. They were surrounded by a
proliferation of elongated spindle cells.
(a)(b)(c)(d)She had clitoromegally. Her respiratory and
cardiovascular systems were normal. Pelvic examination revealed a solid right
ovarian mass of 5 cm size and it was confirmed by pelvic ultrasound scan. It
was a solid mass with an intact capsule. The uterus and the other ovary were
normal and there was no free fluid. Liver and the other abdominal organs were
normal. Computed tomography (CT-scan) of the abdomen and pelvis revealed a well-defined
solid tumor of5.5×3×6 cm in right adnexal region (Figure 1(b)). Other pelvic structures and the
suprarenal glands were normal. Her
investigation results were as in Figure 2.Figure 2Laparotomy
revealed a solid ovarian tumor of 5 cm with an intact capsule in the right ovary.
The left ovary and the uterus were normal (Figure1(c)). There was no free fluid.
There were no intraperitoneal deposits. Total abdominal hysterectomy and bilateral
salpingo-oophorectomy along with infracolic omentectomy were performed. Patient made an uneventful
recovery and was discharged on the fourth postoperative day.Histological
examination of sections from the right ovarian mass stained with haematoxyline and
eosine revealed cell nets comprising uniform cells with round bland nuclei and
eosinophilic cytoplasm. Mitotic figures were sparse. They were surrounded by a
proliferation of elongated spindle cells with bland nuclei (Figure1(d)). A
histological diagnosis of luteinized
thecoma was made. The capsule of the mass was intact. The other ovary, uterus,
cervix, and the omentum were normal. The endometrium was nonreactive with
atrophic changes.The patient was reviewed two months after the surgery. Hirsuitism was still there, but there was regression of virilism. Her serum testosterone was 0.09 ng/mL (reference
ranges—female—0.06–0.82 ng/mL) when
she was reviewed ten months after surgery and there was a significant decrease
in both hirsuitism and virilism.


## 3. Discussion

Hyperandrogenism
is one of the most common endocrine disorders in women accounting for large
number of visits to the general practitioners and the gynecologists. Polycystic ovary syndrome
accounts for majority of them in the reproductive aged women. Virilization due
to hyperandrogenism is rare in postmenopausal women. Hyperandrogenism due to a
luteinized thecoma in a postmenopausal woman is extremely rare. Review of the
indexed literature (MEDLINE 1966–2008, English language; search terms: luteinized
thecoma, Postmenopausal) revealed only a handful of cases of luteinized thecoma
in a postmenopausal patient who had presented with virilization and alopecia [1]. There
were few other reported cases of ovarian thecoma in postmenopausal woman, where
the presenting symptoms were androgenic manifestations, bleeding, and abdominal
pain [2, 3]. The histology of these patients did not reveal luteinization.Ovarian thecoma
is a rare hormonally active tumor of stromal cell origin and represents less than 1%
of all ovarian tumors. It occurs most often in perimenopausal and
postmenopausal women [4]. Seventy percent of thecomas secrete
oestrogens and usually presents with postmenopausal bleeding and with endometrial
hyperplasia or malgnancy [5]. Nevertheless, androgens and exceptionally
progesterone or corticosteroids are occasionally produced [6]. When the
tumor contains luteinized cells, which is observed in 10% of thecomas [6],
they secrete androgens and lead to virilization which was observed in our patient.
Typical picture of androgen secretion is oligomenorrhoea, defeminization, and
progressive virilization (acne, hirsuitism, temporal balding, enlargement of
clitoris, deepening of the voice, and muscular development). Our patient
developed complete change of the external appearance within a short period of
time. This change created a socially embarrassing situation which limited her social interaction as well as physical performances.The diagnosis of a virilizing ovarian tumor is most often complicated by the findings of
clinical features
suggestive of Cushing's syndrome. However, in our patient an adrenal tumor and
Cushing's syndrome were excluded by ultrasound scan, CT, of the abdomen and by
biochemical tests.Elevation of serum
testosterone level above 2 ng/mL has been proposed as a significant level which
indicates the presence of an androgen secreting tumor. Testosterone levels in
polycystic ovarian disease and stromal hyperthecosis are often below this level. Serum
testosterone level of 4.5 ng/mL in our patient was strongly indicative of the
presence of an androgen secreting ovarian tumor [7]. Size of most
ovarian thecomas ranges
from 5–10 cm and is bilateral in 3% of cases [8]. Our patient had a unilateral tumor measuring about 5 cm which was
detected on ultrasound and CT-scan.Surgical
intervention is generally adopted as the primary mode of treatment. Owing to
the postmenopausal status of our patient, it was recommended to proceed with
total abdominal hysterectomy and bilateral salpingo-oophorectomy as therapy for
a presumed ovarian malignancy. However, histology of the affected ovary did not
reveal any possibility of malignancy. Serum testosterone level returned to
normal after surgery and the patient was happy and contended when she was
reviewed ten months after surgery since there was significant improvement in
her clinical status. This case illustrates the necessity to consider the rare
possibility of luteinized ovarian thecoma as a cause for virilization in a
menopausal woman.



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