sex cord - stromal tumors of ovary account for approximately 5 - 8% of all ovarian tumors ( 15 ) .
they are composed of granulosa cells , theca cells , sertoli cells , leydig cells and fibroblasts singly or in various combinations ( 2 , 6 ) .
leydig stromal tumor is a rare member of this group that accounts for less than 0.1% of all ovarian tumors ( 7 , 8) .
they are usually benign , unilateral ( 2 , 610 ) and characterized by the presence of crystals of reinke in the steroid cells ( 8 , 9 , 11 ) .
they produce testosterone , leading to hyperandrogenism and virilization ( hirsutism , voice deepening , clitoromegaly , increased muscle mass , et al ) in woman who are mostly postmenopausal ( 7 , 8 , 11 ) . here
we report a 41-years old woman with virilization and an ovarian leydig stromal cell tumor .
a 41-year - old woman with a 5-year history of amenorrhoea was admitted to our hospital because of relapsing vaginal bleeding , hirsutism , acne , some skin lesion especially on her abdomen , deepening of the voice and feeling of pressure in the pelvic for past 6 months .
she first had gone to a dermatologist office with an excessive hair growth on the body and acne . because of an abnormality in her serum androgen and a pelvic mass in the ultrasonography , physician referred her to a gynecologist . 
 
adreno - corticotropin hormon ( acth ) , dehydro - epiandrostone sulfate ( dheas ) , thyroid function test and urine free cortisol level with a volume of 1300ml were normal .
ultra sound revealed a uterus with 12.5 x 3.8x7 cm in diameters with a myomatosis pattern and an endometrial length of 7 mm .
a heterogenous mass of about 62x65 mm with multiple calcification areas was seen in right adenex , so an ovarian mass or pedunculated myoma was suggested . on her transvaginal examination ,
right adenex fullness with a uterus larger than normal size in a postmenopausal woman was detected . 
 

she underwent an exploratory laparatomy , total hysterectomy , infracolic omentectomy , bilateral salpingo - oophorectomy and peritoneal washings . 
 
 in pathologic report , macroscopic
finding includes an encapsulated creamy  gray solid mass with smooth and lobulated external surface , with areas of orange discoloration . in microscopy : ovarian stroma , leydig cells and spindle stromal cells without atypia were seen ( figs . 1 , 2 ) . 
  ovarian stroma with leydig cells and spindle stromal cells ( hematoxylin eosin staining ) polygonal and spindle cells of tumor with obvious vasculature ( hematoxylin eosin staining ) a benign leydig stromal cell tumor was reported with no omental or lymph node involvement and cytology of peritoneal washing was negative for malignant cell .
operative follow - up , serum testosterone level decreased , and there was regression of the virilizing changes .
sex cord - stromal tumors are groups of tumors composed of granulosa cells , theca cells , sertoli cells , leydig cells and fibroblasts of stromal origin , singly or in various combinations ( 2 , 6 )
. they account for approximately 5 - 8% of all ovarian tumors and because they are rare tumors , there is a limitation in understanding their natural history , management , and prognosis 
 ( 15 ) .
women older than 50 years of age show the most incidence of ovarian sex cord - stromal tumors although a significant proportion occurs in premenopausal women ( 2 ) .
leydig stromal cell tumor is a rare case of these tumors that mostly occurs in a post menopausal women ( 2 , 7 , 8 , 11 , 12 ) . in two reports with series of cases ,
the average age of patients was 60 years ( 6 ) although the patient in this study was younger . 
 
ovarian tumors that induce virilization ( like hirsutism , enlargements of clithoris , the voice deepening , etc ) constitute less than 0.2% of hyperandrogenism .
the time to onset of symptoms is usually faster in these tumors than the other causes of hyperandrogenism such as polycystic ovary syndrome ( pcos ) ( 12 ) , similar to our patient whose symptoms appear within months . 
 
leydig stromal cell tumors account for less than 0.1% of all ovarian tumors ( 7 , 8 , 12 ) .
evidence of virilization as a result of hyper androgenism , is seen in approximately one - half of the patients , and one - third have presented with estrogenic manifestation ( 6 ) .
about 30% of patients such as patient in this study may have endometrial hyperplasia and dysfunctional uterine bleeding ( 13 ) .
when abnormal vaginal bleeding is present or a thickened endometrial lining on ultrasound detected , endometrial biopsy must be done to exclude endometrial cancer prior to surgery ( 12 ) .
when the tumor is removed , the virilizing changes will regress but may not disappear .
aetiologies of the estrogenic changes include : estrogen secretion by the tumor , peripheral conversion of androgen , associated stromal hyperthecosis or a combination of these factors .
this tumor is distinguished from the sertoli - leydig cell tumor by the absence of a sex - cord component ( follicular granulosa cells which are homologue of sertoli cells in the testis ) ( 6 ) . 
 
the stromal component resembles the theca cell tumor , and the presence of crystals reinke in the steroid cell identifies them as leydig cells ( 6 , 11 ) .
some ovarian leydig cell tumors arise in the hilus from hilar leydig cells which can be identified in over 80% of normal adult ovaries .
other leydig cells tumors that are located within the ovarian stroma are referred to as non hilar leydig cell tumors , and the term leydig cell not otherwise specified is used when it is impossible to be certain about the origin ( 6 , 9 ) . 
 
the main treatment of the sex cord stromal ovarian tumors is surgery ( 2 ) . unfortunately clinical presentation and sonographic appearance
a conservative surgery with unilateral salpingo - oophorectomy and a careful staging are justified reasonable for patients who want to preserve their fertility with the absence of extraovarian spread .
if advanced - stage disease or bilateral ovarian involvement is present or the patient does not want to preserve her reproductive potential , abdominal hysterectomy and bilateral salpingo - oophorectomy should be performed .
this includes a thorough exploration of the abdominal cavity , washing for cytologic analysis , multiple biopsies , omentectomy , and pelvic and para - aortic lymph node sampling or dissection ( 2 ) . in some cases ,
androgen secreting tumors response to gonadotropin releasing hormone agonist , therefore in patients who surgery is not straightforward such as high surgical risk , this treatment can be used ( 12 , 13 ) . 

although polycystic ovary syndrome ( pcos ) and non - malignant androgen excess disorders are common causes of hyper - androgenism , other aetiologies such as ovarian tumors should be considered .
a complete evaluation should be done in a woman with skin disorder ( such as hirsutism and acne ) that can be related to hyperandrogenism . 

 leydig stromal cell tumor is a rare ovarian tumor that belongs to the group of sex - cord stromal tumors . 
 they produce testosterone leading to hyperandrogenism . 
 we present a 41yr old woman with symptoms of virilization and a mass of right adenex via ultra sonography , and a rise of total and free serum testosterone . 
 an ovarian source of androgen was suspected and a surgery performed . 
 a diagnosis of leydig - stromal cell tumor was confirmed.our report is a reminder that although idiopathic hirsutism and other benign androgen excess disorder like polycystic ovarian syndrome ( pcos ) are common , ovarian mass should be considered in differential diagnosis . 
Introduction
Case report
Discussion
Conclusion