A woman presented with virilization symptoms and elevated testosterone; however, a neoplastic source of excess androgen was not found on imaging. Eventually, the patient revealed she was exposed to transdermal testosterone used by her partner. This case highlights the importance of considering exogenous androgens in the differential diagnosis of virilization.
Androgen excess is a common condition affecting reproductive-aged women. Clinical features of androgen excess vary depending on the duration and severity. Mild cases may result in hirsutism, alopecia, acne, and ovulatory dysfunction. In contrast, virilization is associated with markedly elevated levels of circulating androgens and is generally suggestive of an androgen-secreting neoplasm. Signs of virilization include voice deepening, sagittal/frontal balding, clitoromegaly, severe hirsutism, and increased muscle mass. Rarely, the source of the androgen excess is not readily identifiable. In these cases, it is important to consider an exogenous androgen source. If discovered, unnecessary laboratory tests, diagnostic imaging, and invasive procedures can be avoided.
We present a case of a reproductive-aged woman with signs of virilization, who was found to be exposed to topical testosterone cream used by her partner.
Case Report
A 22-year-old woman presented to her primary care provider with history of acne and hirsutism of her face, inner thighs, lower back, and linea alba worsening over a 4-month period. She was also found to have clitoral enlargement and scalp alopecia. She was treated with oral contraceptive pills (OCP) with some improvement in her hirsutism. She denied any changes in muscle mass or voice deepening, and she denied the intentional use of exogenous androgens.
She had an elevated total testosterone level (225 ng/dL). Dehydroepiandrosterone sulfate (DHEAS), 24-hour urine cortisol, 17-hydroxyprogesterone, fasting glucose, insulin, thyroid-stimulating hormone (TSH), and prolactin were normal. Ultrasound and CT scan showed no evidence of an ovarian tumor or adrenal masses. She was treated with spironolactone and OCP and noted improvement in the acne and hirsutism. Because the source of hyperandrogenemia was not identified, she was offered ovarian vein catheterization to localize the source of the androgen overproduction. She declined because she was concerned about the risks associated with this invasive procedure. Instead, she was monitored with follow-up ultrasounds.
Three months later, a 6-mm cyst in the left ovary was found. She was offered a laparoscopic evaluation of this cyst if it persisted in a follow-up ultrasound 1 month later. However, the cyst resolved. Laboratory tests were repeated, and her total testosterone level became normal.
The patient then moved and was referred to our center given the history of unexplained high testosterone levels. At that time, her symptoms of acne, hirsutism, clitoromegaly, and alopecia had improved, her testosterone level was normal, and ultrasound showed normal ovaries. On further discussion with the patient, it was discovered that her partner was a bodybuilder and had been using topical testosterone cream on his chest and upper arms for muscle mass enhancement. Before relocating, she separated from him, and her exposure significantly decreased. Her androgen levels remained normal 3 months later, and the spironolactone was subsequently discontinued.
The Table demonstrates the trend in her androgen levels during the course of her exposure to testosterone cream.
| Date | Total T, ng/dL | Free T, pg/mL | LH, mIU/mL | FSH, mIU/mL | DHEAS, mg/dL | DHEA, ng/mL | A, ng/dL | E2, pg/mL |
|---|---|---|---|---|---|---|---|---|
| Feb. 11 | 225 | 1.9 | 215 | 8.9 | ||||
| Feb. 19 | 2.6 | 7.5 | 20 | |||||
| Mar. 5 | 224 | 50 | ||||||
| July 21 | 57 | 16 | ||||||
| May 17 (patient’s initial visit to us) | 38 | 0.4 | 215 | 105 |
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