Testosterone and DHEA-S Secreting Adrenal Cortical Adenoma in a Postmenopausal Woman: A Rare Functional Incidentaloma

Postmenopausal hyperandrogenism is uncommon and should prompt evaluation for an underlying androgen-secreting source. Although ovarian causes are more frequent, adrenal tumors remain an important consideration and may occasionally be malignant. We report a 53-year-old postmenopausal woman who presented with progressive hirsutism, scalp hair loss, and mild clitoromegaly. Laboratory evaluation showed markedly elevated total testosterone and dehydroepiandrosterone sulfate levels with suppressed gonadotropins. Pelvic ultrasonography showed no ovarian mass. CT demonstrated a 3.5 × 2.4 cm left adrenal mass with precontrast attenuation of 31 Hounsfield units and an enhancement washout pattern not typical of an adrenal adenoma. MRI showed a 3.6 × 2.1 cm left adrenal lesion with arterial hyperenhancement, restricted diffusion, and no signal drop on out-of-phase imaging. Biochemical testing excluded pheochromocytoma, primary aldosteronism, and clinically significant cortisol co-secretion. The patient underwent laparoscopic adrenalectomy, and pathology confirmed a 3.6 cm adrenal cortical adenoma with negative margins, positive inhibin, Melan-A, and steroidogenic factor-1 staining, and Ki-67 <3%. Postoperative androgen levels normalized, and adrenal insufficiency was excluded by cosyntropin stimulation testing. This case highlights the importance of integrating clinical presentation, biochemical localization, adrenal imaging, differential diagnosis, and pathology when evaluating severe postmenopausal hyperandrogenism.