Ovarian hyperthecosis

Ovarian hyperthecosis (OHT) is a condition where there is a presence of luteinized thecal cells within a hyperplastic ovarian stroma.

Clinical presentation

Clinical manifestations include hyperandrogenism, obesity, hypertension, and impaired glucose tolerance. Virilization has been reported to be more common in premenopausal women, whereas oestrogenic effects seem more common in postmenopausal women.

Pathology

The ovarian stroma is at least moderately hyperplastic and has luteinized thecal cells which may occur as single cells, small nests, or occasionally nodules.

OHTOvarian hyperthecosis and polycystic ovarian syndrome (PCOS) are manifestations of the same heterogeneous disturbance of androgen metabolism. Histopathological differentiation between PCOS and OHTovarian hyperthecosis exists in the location of luteinized thecal cells. In OHTvarian hyperthecosis they exist within the stroma and in PCOS they exist along the periphery of the follicle.

Laboratory findings

Testosterone and dehydroepiandrosterone sulphate (DHEA-S) isare the first hormones to be measured. Testosterone levels are nearly always above the postmenopausal range and are higher than the levels observed in PCOS. Imaging of the adrenal glands and ovaries is warranted if the serum total testosterone level is >150 ng/dL.

Associations

• endometrial hyperplasia

• endometrial carcinoma probably due to increased androgen production by luteinized thecal cells, which then serve as precursors for oestrogen production

• ovarian fibrothecoma

Radiographic features

Ultrasound

Variable appearance but most ovaries appear normal. They may have a nodular appearance. Increased ovarian size with increase in the ovarian stroma may also be seen; however, unlike PCOS the number of follicles tend to be normal. The ovarian size is increased beyond the expected limits in postmenopausal women. 

MRI

Role of MRI is yet to be proven. Symmetric bilateral ovarian enlargement, with homogeneous T2-hypointensity and mild enhancement of the ovaries, may be seen.

A CT or MRI of the adrenals is important for women with high levels of DHEA-S. 

Treatment and prognosis

• postmenopausal women: bilateral oophorectomy is suggested; however, if the patient has multiple comorbidities, then long-term GnRH agonist treatment may be an option when malignancy has been excluded

• premenopausal women: treatment is the same as for PCOS; once malignancy has been excluded

Differential diagnosis

• polycystic ovarian syndrome: may have a similar appearance, but with multiple numbers of small follicles

• ovarian fibroma