Enlarged multicystic ovaries in an infertile woman: Thinking beyond controlled ovarian stimulation

Functional gonadotroph adenoma (FGA) is a rare, slow-growing pituitary tumour which presents in the reproductive age group with abnormal uterine bleeding (AUB), infertility and ovarian hyperstimulation syndrome. We present the case of a 25-year-old woman who presented to the endocrinology clinic with complaints of AUB and infertility. Pelvic ultrasonography showed a thickened endometrium (15 mm) with bilateral enlarged cystic ovaries (Right ovary -227cc, Left ovary-202cc). The patient had no history of ovarian stimulation. The follicular phase hormonal profile showed elevated follicle-stimulating hormone (FSH) (14.7 IU/L), suppressed luteinising hormone (0.216 IU/L), raised oestradiol (1552 pg/ml), normal thyroid-stimulating hormone (3.42 m IU/ml) and slightly increased prolactin levels (44.9 ng/ml). A magnetic resonance imaging of the brain showed a pituitary macroadenoma. She underwent transnasal transsphenoidal surgery for the adenoma. Histopathology revealed a FGA. FGA should be considered a differential diagnosis in women presenting with AUB and bilateral cystic ovaries. Elevated FSH with elevated oestradiol levels must prompt a search for FGA in a pre-menopausal woman. A high index of suspicion is required to suspect and diagnose FGA and to institute timely and appropriate treatment.