Diagnosis, Labs, and Finding the Source

Confirming a diagnosis of ovarian stromal hyperthecosis (OH) is often a step-by-step process of “ruling out” more common or urgent conditions. Because OH shares features with both PCOS and certain rare tumors, doctors rely on a combination of highly precise blood tests and detailed imaging ^[1][2].

The Essential Blood Tests

When your body is producing too much androgen, the first goal is to find the “engine” driving it. Your care team will likely order a panel of tests to see if the hormones are coming from your ovaries or your adrenal glands ^[3]. Before testing, it is critical to report any supplements (such as over-the-counter DHEA), bodybuilding supplements, anabolic steroids, or hormonal creams you use, as these can severely elevate your lab results ^[4].

• Total Testosterone (via LC-MS/MS): This is the most critical test. Standard hormone tests (immunoassays) used for women are sometimes inaccurate near the female reference range. LC-MS/MS (Liquid Chromatography-Mass Spectrometry) is the “gold standard” laboratory method for measuring testosterone precisely ^[5][6].
• DHEA-S: This hormone is made almost entirely by the adrenal glands. If your DHEA-S is highly elevated (often over 700 μg/dL, though thresholds vary by age and lab), doctors will look more closely at your adrenal glands rather than your ovaries ^[3][7]. However, a normal DHEA-S does not absolutely exclude an adrenal issue.
• SHBG and Free Testosterone: Measuring Sex Hormone Binding Globulin (SHBG) helps doctors calculate your “free” (active) testosterone, which provides a clearer picture of how much hormone is actually affecting your body ^[5]. (Note that calculated free testosterone is often preferred because direct assays can be unreliable).
• Other Labs: You may also have tests for Androstenedione, 17-hydroxyprogesterone (to evaluate for nonclassic congenital adrenal hyperplasia rather than ruling out the adrenals entirely), and LH/FSH (to assess your menopausal status) ^[3][8].

Imaging: Looking for the Source

Once high testosterone is confirmed, the next step is imaging to see what the ovaries look like. The goal here is primarily to look for a virilizing ovarian tumor ^[9].

• Transvaginal Ultrasound: This is usually the first imaging tool used. In hyperthecosis, the ovaries may look entirely normal, or they may appear uniformly enlarged and solid. They typically do not have the specific fluid-filled sacs seen in PCOS ^[10][11].
• Pelvic MRI: An MRI provides a more detailed view. It can help distinguish between homogeneous (uniform) enlargement—which points toward hyperthecosis—and a specific nodule or mass on one side, which could indicate a tumor ^[2][12].
• Adrenal Imaging (CT or MRI): If your DHEA-S levels are high or adrenal sources are suspected, your doctor may also order a scan of your midsection to check the adrenal glands ^[13].

It is important to know that imaging can sometimes be “negative” (normal) even when hyperthecosis or a small tumor is present, as the overactive cells or small tumors are often too small to see on a scan ^[14][10]. Also, hyperthecosis can sometimes affect just one ovary.

The “Gold Standard” Diagnosis: Histopathology

While labs and scans provide clues and a strong clinical working diagnosis, the definitive tissue diagnosis of ovarian stromal hyperthecosis is through histopathology—examining the ovary tissue under a microscope ^[1]. This usually happens after the ovaries have been surgically removed (oophorectomy) as part of a treatment decision ^[2].

A pathologist will look for:

1. Luteinized Theca Cells: These are specific cells that have become enlarged and active, appearing as small “nests” or clusters within the ovary’s supportive tissue ^[1][15].
2. Stromal Hyperplasia: An overall increase in the density and volume of the ovary’s supportive tissue ^[16].
3. Bilateral Involvement: Unlike tumors, which are usually on one side, hyperthecosis frequently affects both ovaries ^[11][17].

Diagnostic Completeness Checklist

When reviewing your records or preparing for an appointment, check if you have the following information: