A 1.6cm Androgen Secreting Ovarian Leydig Cell Tumor Evades Detection on Multiple Imaging Modalities

A 61-year-old woman with a history of ovarian tumor and hysterectomy presented with virilization symptoms, including increased hair growth and scalp hair loss. Despite elevated androgen levels, multiple imaging techniques, including transvaginal ultrasound, CT, and MRI, failed to detect any adnexal mass. However, a left oophorectomy revealed a 1.6cm Leydig cell tumor in the left ovary, which was the source of the hyperandrogenism. Postoperative tests showed normalization of testosterone and 17-hydroxyprogesterone levels. This case, along with a review of published cases, highlights that Leydig cell tumors can be challenging to detect on imaging and suggests maintaining a high suspicion for ovarian sources of hyperandrogenism in postmenopausal patients even when imaging results are negative.