Diagnostic dilemmas in hyperandrogenism and pregnancy (#249)
Introduction: Hyperandrogenism can cause a range of symptoms from mild hirsutism to virilisation. Severe forms are uncommon in pregnancy but if present, may lead to virilisation of a female foetus. Rapid onset of hirsutism should prompt thorough evaluation for androgen secreting tumours.
Case description: We present the case of a 34 year old indigenous lady with a one and half year history of oligomenorrhoea associated with an 8-month history of new onset hirsutism. Biochemical work-up revealed significantly elevated serum testosterone levels upto 16nmol/L and mildly raised LH levels. US of abdomen and CT abdomen failed to find any ovarian or adrenal pathology as a cause for her elevated testosterone levels. She subsequently had an MRI scan which revealed normal ovaries but also demonstrated an intrauterine pregnancy with gestational age of 15 weeks. Her serum testosterone levels remained elevated during this period. Subsequently, the patient was discovered to have an incompetent cervix and was treated as an in-patient with regular progesterone pessaries. Unfortunately she had pre-term labour and neonatal death at 20 weeks.
The diagnosis of hyperandrogenism was complicated in this case by the presence of heterophile antibodies detected on her testosterone assay. Imaging was consistently negative apart from the diagnosis of pregnancy.
Discussion points include:
1. Diagnosis of androgen secreting tumours
2. Pitfalls of testosterone assay in women
3. What is a normal testosterone level in pregnancy?
4. Potential risk of virilisation of female foetus
5. Risk of miscarriage in hyperandrogenic mothers