Exponentially elevated testosterone in a middle-aged woman with polycystic ovarian syndrome: A therapeutic response to luteinising hormone-releasing hormone agonist.

Abstract

We report a case of a 43-year-old lady referred to the Endocrinology department by her general practitioner (GP) for exponentially elevated testosterone and amenorrhoea persisting for 5 months, excessive weight gain of 153 kg and an elevated testosterone level of 14.8 nmol/L(0.7-2.8 nmol/L). Her body mass index (BMI) was 58.3 kg/m2. Thyroid profile, Prolactin, Cortisol, and 17 hydroxyprogesterone were all within the normal range. Luteinising hormone (LH) and follicle stimulating hormone (FSH) were normal initially. Dehydroepiandrosterone (DHEA) was slightly low. Surprisingly, a contrast-enhanced computer tomography (CT) scan revealed portal vein thrombosis, presenting an unexpected finding in the context of the patient's clinical presentation. Ultrasound pelvis and magnetic resonant imaging (MRI) adrenals did not reveal any abnormalities. The diagnostic process meticulously ruled out potential causes of elevated testosterone, including congenital adrenal hyperplasia, thyroid dysfunction, hyperprolactinemia, adrenal and ovarian tumours, or an exogenous source of testosterone. In view of her amenorrhoea, clinical and biochemical hyperandrogenism, the diagnosis of polycystic ovarian syndrome (PCOS) was reached as per the Rotterdam criteria.1 Although PCOS can be associated with elevated testosterone levels but exponentially high levels of testosterone for example more than 6 nmol/L, as in our patient's case, is not frequently seen in PCOS and such elevated levels warrant further investigations to rule out adrenal or ovarian tumours.2 Given the patient's elevated BMI and the presence of a portal vein thrombus, combined oral contraceptive pills (COCPs) were deemed unsuitable for treatment. Pregnancy was ruled out and given the clinical presentation and laboratory findings, therapeutic intervention was initiated with Leuprorelin, a luteinising hormone-releasing hormone (LHRH) agonist, which is usually used in patients with prostate cancer to lower the testosterone.3,4 She was commenced on Leuprorelin subcutaneous injection once a month for almost 6 months. The response to treatment was notable, resulting in a significant decrease in serum testosterone levels from 14.8 nmol/L to 7.4 nmol/L. Although restoration of regular menstruation wasn't achieved, she started having intermittent spotting and a marked reduction in testosterone levels was noted. However, upon discontinuation of Leuprorelin, testosterone levels began to rise again, reaching 11 nmol/L. In light of this observation, a clinical decision was made to extend the Leuprorelin treatment for an additional 6 months. Simultaneously, the patient was being evaluated by a weight management team for potential bariatric surgery. This case highlights the efficacy of Leuprorelin in the management of hyperandrogenism, particularly in cases where elevated testosterone levels are implicated. The therapeutic response observed underscores the importance of considering LHRH agonists as a treatment option in such scenarios. Further research is warranted to elucidate the long-term effects and optimal dosing regimens of Leuprorelin in similar cases as there is limited data to suggest its use for hyperandrogenism in PCOS. Also, exponentially high levels of testosterone are not routinely seen in patients with PCOS but can be expected as in this case when all the other causes of elevated testosterone were ruled out.Copyright � 2024