Enigma of postmenopausal virilisation: bilateral Leydig cell tumours as the culprit

A postmenopausal woman in her 50s presented with progressive hirsutism, virilisation and markedly elevated serum testosterone levels (>1500 ng/dL). Routine laboratory, adrenal and imaging evaluations were largely unremarkable except for a small left adnexal mass on MRI. With normal dehydroepiandrosterone sulphate (DHEAS) and cortisol levels, an ovarian source of androgen excess was suspected. The patient underwent total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. Histopathology revealed bilateral Leydig cell tumours, an exceptionally rare finding. Postoperatively, serum testosterone normalised, and virilisation regressed significantly. This case highlights the importance of considering androgen-secreting ovarian tumours in postmenopausal women with rapidly progressive virilisation, even when imaging is inconclusive. Bilateral Leydig cell tumours are exceedingly uncommon but should be suspected when severe hyperandrogenism is present. Surgical removal remains the definitive diagnostic and therapeutic approach, ensuring hormonal normalisation and symptom resolution while preventing prolonged morbidity associated with delayed diagnosis.