| name | endo-hirsutism-adrenal-ct-ovarian-us-if-tumor-suspected |
| description | Image the adrenal glands with CT and the ovaries with transvaginal ultrasound when biochemical evaluation suggests an androgen‑secreting tumor, such as markedly elevated DHEAS or testosterone, rapid progression of hirsutism, or virilization. Trigger phrases include “sudden‑onset hirsutism,” “virilization (clitoromegaly, deepening voice),” “DHEAS > 700 µg/dL,” “testosterone in male range,” or “progressive hirsutism despite therapy.” |
Image adrenal glands and ovaries when androgen‑secreting tumor is suspected
STEP 1 — Gather Information
Collect history of onset and progression of hirsutism, signs of virilization, menstrual pattern, medication/supplement use; perform physical exam including Ferriman–Gallwey score and inspection for clitoromegaly, deepened voice, increased muscle mass; obtain labs: total and free testosterone, DHEAS, 17‑hydroxyprogesterone, androstenedione; note any abrupt rise in androgen levels.
STEP 2 — Rule In / Rule Out
Is there biochemical evidence suggestive of an androgen‑secreting tumor? (e.g., DHEAS > 700 µg/dL, testosterone in the male range, disproportionate DHEAS elevation, or rapid androgen rise).
- Yes: Proceed to imaging.
- No: Consider functional hyperandrogenism (PCOS, NCCAH, idiopathic) and manage medically.
STEP 3 — Classify or Stratify
Interpret adrenal CT and ovarian US:
- Adrenal mass → adrenal tumor.
- Ovarian mass → ovarian tumor.
- No identifiable mass → no radiographic tumor.
STEP 4 — Decide
- If adrenal mass detected, refer to endocrine surgery for possible adrenalectomy.
- If ovarian mass detected, refer to gynecologic oncology for further evaluation and possible oophorectomy.
- If imaging is negative but suspicion remains, consider repeat imaging with MRI or PET/CT and continue biochemical monitoring; otherwise, treat underlying functional hyperandrogenism.
Clinical Guardrails / Mimics / Pitfalls
Do not exclude a tumor based solely on normal CT/US if clinical suspicion remains high; small (<1 cm) lesions may be occult and require specialized imaging. Avoid unnecessary radiation in pregnancy—use MRI or ultrasound instead. Remember to assess for concomitant Cushing’s syndrome when an adrenal mass is found. Do not mistake severe PCOS or NCCAH for a tumor without correlating imaging and biochemical trends.
Concrete Clinical Example
A 28‑year‑old woman reports 3 months of rapidly progressive facial hair, clitoromegaly, and a deepening voice. Labs show total testosterone 150 ng/dL (male range) and DHEAS 800 µg/dL. Pelvic US reveals normal ovaries; adrenal CT demonstrates a 1.5 cm left adrenal nodule. She is referred for adrenalectomy.
Source: Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2018, DOI:10.1210/jc.2018-00241
