A dermoid in disguise: An unusual cause of postmenopausal hyperandrogenism: A case report

Abstract

Background: Hyperandrogenism developing after menopause is an uncommon clinical presentation that warrants careful evaluation to rule out an underlying androgen-secreting neoplasm. Mature cystic teratoma (dermoid cyst) is the most common benign ovarian germ-cell tumour and is conventionally considered hormonally inactive. Rarely, however, mature cystic teratomas can manifest with severe hyperandrogenism and virilization due to functional cellular elements within the tumor, making the diagnosis particularly challenging.

Case summary: A 60-year-old postmenopausal woman presented with a three-year history of progressive hirsutism that had rapidly accelerated over the preceding six months, alongside frontotemporal alopecia. Physical examination revealed a modified Ferriman-Gallwey score of 8 and male-pattern hair loss. Biochemical evaluation demonstrated profound hyperandrogenemia, with a markedly elevated total testosterone level of 25.7 nmol/L. An adrenal etiology was effectively excluded by normal serum dehydroepiandrosterone sulfate (DHEAS) concentrations (63.2 ug/dL). Pelvic magnetic resonance imaging (MRI) revealed a 5.8 × 10.0 × 8.6 cm multiloculated complex left adnexal mass containing fat and cystic components, highly suggestive of an ovarian dermoid cyst (O-RADS MRI 2). The patient underwent exploratory laparotomy comprising a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Histopathological and immunohistochemical analyses confirmed a mature cystic teratoma containing luteinized thecal cells that were positive for inhibin and focally positive for calretinin. Following surgical excision, the patient's serum testosterone rapidly normalized to 1.1 nmol/L, and she exhibited significant clinical improvement of her hirsutism at her 2-3 month follow-up.

Conclusion: This case demonstrates that mature cystic teratomas, specifically those undergoing luteinized thecal cell transformation, can be a rare but significant source of severe postmenopausal hyperandrogenism. Clinicians should not dismiss an adnexal mass as a simple hormonally inert dermoid cyst when evaluating postmenopausal virilization. Surgical resection provides definitive histological diagnosis and immediate therapeutic resolution.

[J Assoc Clin Endocrinol Diabetol Bangladesh, 2026;5(Suppl 1): S57]