Investigation of female virilism
The most difficult decision in the management of women with hyperandrogenism eg acne, hirsuties, polycystic ovaries etc is when exhaustive investigation should be instituted. Since the treatment of hirsute women presenting with nontumourous hyperandrogenism will be similar whether the androgen is from the adrenals or ovaries, it is only necessary to identify those women with an androgen secreting tumour. This chart suggests the criteria for investigation should be the presence of any of the following features: an elevated random plasma testosterone, a short history of hirsuties or features of systemic virilism eg cliteromegaly, increased muscle bulk, deep voice, androgenetic alopecia or amenorrhoea.
Evidence for identification of androgen secreting tumours
Derksen et al reported a series of 2 adrenal adenomas and 12 carcinomas in which hirsutism was the presenting symptom. The women with adenomas were described as being severely virilised. Half (6) of the women with carcinoma had clinical signs of Cushing's syndrome; and of the remaining 6 cases, 4 were severely virilised and the other 2 women presented with abdominal pain.
Functioning ovarian tumours which secrete androgens and therefore cause virilisation are rare and represent only 1% of all ovarian tumours (Woodruff & Parmely 1963). In these cases, hirsuties is a nearly universal feature. Amenorrhoea develops rapidly in all premenopausal patients and systemic virilisation with alopecia, cliteromegaly, deepening of the voice and a male habitus develops in about half of the patients (Sandberg & Jackson 1963, Moltz et al 1984). Meldrum and Abraham (1979) reviewed the literature of 43 women with virilising ovarian tumours: 7/43 had plasma testosterone < 7.0 nmol/L but all were clinically virilised, one 65 year-old woman was reported as not virilised but her plasma testosterone was > 12 nmol/L.
- Derksen J, Nagesser Sk, Meinders AE, Haak HR, van de Velde CJH. Identification of virilising adrenal tumours in hirsute women. N Eng J Med 1994;331:968-973.
- Friedman CI, Schmidt GE, Kim MH, Powell J. Serum testosterone concentrations in the evaluation of androgen-producing tumors. Am J Obstet Gynecol 1985;153:44-49.
- Meldrum DR, Abraham GE. Peripheral and ovarian venous concentration of various steroid hormones in virilising ovarian tumours. Obstet Gynecol 1979;53:36-43.
- Moltz L, Pickartz H, Sorensen R, Schwartz U, Hammerstein J. Ovarian and adrenal vein steroids in seven patients with androgen-secreting ovarian neoplasms: selective catheterization findings. Fertil Steril 1984;42:585-593.
- Sandberg EC, Jackson JR. A clinical analysis of ovarian virilizing tumors. Am J Surg 1963;105:784-792.
- Woodruff JD, Parmley TH. Virilizing ovarian tumors. In: Hirsutism and Virilism: Pathogenesis and Management. Eds Mahesh VB, Greenblatt RB. Wright PSG, London. 1983:129-158.