What is the recommended evaluation and management for a 54-year-old female patient with elevated free testosterone (8.6) and total testosterone (71), potentially indicating hyperandrogenism?

Evaluation and Management of Elevated Testosterone in a 54-Year-Old Female

This 54-year-old woman requires immediate evaluation for an androgen-secreting tumor, as her total testosterone of 71 ng/dL approaches the threshold that suggests virilization and potential malignancy.

Immediate Diagnostic Priorities

Confirm and Assess Severity

• Repeat the testosterone measurement using a morning sample (8-10 AM) with the same laboratory method to confirm elevation 1, 2
• Total testosterone >50-70 ng/dL in postmenopausal women is concerning for an androgen-producing tumor and warrants urgent investigation 3
• Free testosterone measurement by equilibrium dialysis provides the most accurate assessment of bioavailable androgens 1

Essential Hormonal Panel

• Measure DHEA-S immediately: levels >600 μg/dL indicate an adrenal source (adrenal adenoma or carcinoma) 2
• Measure LH and FSH: low or inappropriately normal LH with elevated testosterone suggests an autonomous androgen-producing tumor rather than PCOS 1, 4
• Measure 17-hydroxyprogesterone to exclude non-classical congenital adrenal hyperplasia, though this is less likely at age 54 5
• Check prolactin if LH is low or low-normal to exclude hyperprolactinemia 1, 5

Clinical Assessment

History Focus

• Timing of symptom onset is critical: rapid onset of virilization (within months) strongly suggests tumor, while gradual progression over years suggests PCOS or ovarian hyperthecosis 5, 3
• Document hirsutism severity, acne, androgenic alopecia, voice deepening, clitoromegaly, and increased muscle mass 6, 3
• Assess for metabolic features: abdominal obesity, insulin resistance, type 2 diabetes 3

Physical Examination Specifics

• Evaluate for virilization signs: clitoromegaly, male-pattern baldness, voice changes, increased muscle mass 6, 3
• Assess hirsutism using a standardized scoring system (modified Ferriman-Gallwey score) 6
• Examine for Cushing's features (striae, central obesity, proximal weakness) 5

Imaging Studies

Ovarian Imaging

• Transvaginal ultrasound is first-line for ovarian evaluation, looking for solid masses or hyperthecosis 3
• If ultrasound is inconclusive or shows abnormality, proceed to pelvic MRI for better characterization 4, 3

Adrenal Imaging

• If DHEA-S is elevated (>600 μg/dL), obtain adrenal CT or MRI immediately to identify adrenal adenoma or carcinoma 4, 2, 3

Differential Diagnosis Priority

Most Likely Causes at This Testosterone Level

1. Ovarian hyperthecosis: diffuse ovarian stromal luteinization, often associated with insulin resistance 2, 3
2. Androgen-secreting ovarian tumor: Sertoli-Leydig cell tumor, steroid cell tumor 5, 3
3. Adrenal adenoma or carcinoma: if DHEA-S is markedly elevated 2, 3
4. PCOS persisting into menopause: less likely with this degree of elevation but possible 3

Less Likely but Must Exclude

• Cushing's syndrome: perform overnight dexamethasone suppression test or 24-hour urinary free cortisol if clinical features present 5
• Exogenous androgen use: specifically ask about supplements, "anti-aging" treatments, or partner's testosterone gel exposure 4

Management Algorithm

If Testosterone >150 ng/dL or Rapid Virilization

• Immediate referral to gynecologic oncology and endocrinology 4, 3
• Bilateral oophorectomy is often both diagnostic and curative for ovarian sources 3
• Surgical removal of adrenal tumor if identified 4, 3

If Testosterone 50-150 ng/dL (This Patient's Range)

• Complete the hormonal and imaging workup within 2-4 weeks 4, 3
• Refer to endocrinology for specialized management 4
• If imaging identifies a mass, surgical consultation is mandatory 3
• If no tumor found and hyperthecosis suspected, consider bilateral oophorectomy versus medical management based on symptom severity 3

If No Tumor Identified

• Antiandrogen therapy (spironolactone 100-200 mg daily) for symptomatic relief of hirsutism and acne 3
• Address metabolic complications: screen for diabetes, dyslipidemia, cardiovascular risk 3

Monitoring Requirements

• Hematocrit/hemoglobin at baseline and follow-up: elevated testosterone can cause polycythemia 4
• Lipid profile and cardiovascular risk assessment 4
• Liver function tests if antiandrogen therapy initiated 4
• Repeat testosterone levels every 3-6 months initially, then annually once stable 4

Critical Pitfalls to Avoid

• Do not delay imaging when testosterone exceeds 50-70 ng/dL in a postmenopausal woman—this level demands tumor exclusion 3
• Do not attribute symptoms to "normal menopause" without proper investigation 3
• Do not use analog free testosterone assays; insist on equilibrium dialysis or calculate free androgen index 1, 2
• Do not assume PCOS without excluding more serious causes in this age group 3