Case Description: A 58-year-old woman presented with severe hyperandrogenism (serum testosterone 15.7-31.0 nmol/L; by LCMS) with menopausal serum LH and FSH, and virilisation but no adrenal or ovarian mass lesions on imaging. Multi-steroid profiling (15 steroids) of adrenal and ovarian vein samples identified strong gradients in left ovarian vein (10-30-fold vs peripheral serum in 17OHP4, 17 OHP5, A4, T, DHEA), no abnormal adrenal steroid gradients but right ovarian vein could not be cannulated. An opportunistic second left ovarian vein cannulation confirmed an 18-fold gradient in T and > 60-fold gradients in 17OHP4, 17OHP5, A4 and DHEA. Presumptive diagnosis of OHT was confirmed by a single dose of a pure GnRH antagonist (80 mg Degarelix acetate, Ferring) producing a rapid (< 24 hr) and complete suppression of all ovarian steroids, as well as serum LH and FSH, lasting at least 8 weeks, associated with clinical improvement in virilization. Side-effects include transient injection site reaction and flushing. A second injection was administered at week 8, again with mild injection site reaction and transient vaginal spotting. Serum testosterone remained suppressed at 313 days after the first dose despite recovery of gonadotropins to menopausal levels by day 278 days after first injection. No evidence of any ovarian lesion was reported on surveillance ultrasound.
Conclusions: This case illustrates the diagnosis and long-term treatment of OHT in a postmenopausal woman with severe hyperandrogenism without adrenal or ovarian lesion using multi-steroid LCMS profiling of ovarian and adrenal vein samples. A single dose of a depot pure GnRH antagonist produced rapid and long-term complete suppression of ovarian steroidogenesis for over 10 months. This illustrates the utility of a depot pure GnRH antagonist for rapid confirmation of diagnosis as well as for inducing long-term remission of severe hyperandrogenism from OHT while avoiding pelvic surgery.