From the Guidelines
The next step in the workup for isolated persistently elevated testosterone should include a comprehensive evaluation to identify the underlying cause, starting with measurement of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels to assess pituitary function, as recommended by the American Urological Association (AUA) guideline 1. To further investigate the cause of elevated testosterone, the following steps should be taken:
- Measure serum LH and FSH levels to evaluate pituitary function and determine if the elevation is due to primary or secondary hypogonadism
- Obtain a comprehensive metabolic panel and complete blood count to rule out other underlying conditions
- Consider measuring serum estradiol levels, especially if the patient presents with breast symptoms or gynecomastia, as elevated estradiol levels can indicate an underlying condition such as a testicular or adrenal tumor 1
- If LH levels are low or low/normal, consider a pituitary MRI to rule out non-secreting adenomas, as recommended by the AUA guideline 1
- Testicular ultrasound may be necessary to rule out testicular tumors, especially if LH levels are elevated
- Adrenal imaging with CT or MRI should be performed if laboratory values suggest an adrenal source of excess testosterone These steps are crucial to identify the underlying cause of elevated testosterone and provide appropriate management to prevent long-term complications and improve quality of life.
From the Research
Next Steps in Workup for Isolated Persistently Elevated Testosterone
- The next step in the workup for isolated persistently elevated testosterone is to perform a DHEAS assay, as recommended by 2, if the testosterone level is twice the upper limit of normal.
- According to 2, a DHEAS level over 600 mg/dl indicates a diagnosis of androgen-secreting adrenal cortical adenoma.
- If DHEAS is normal, the diagnosis could be either ovarian hyperthecosis, normally associated with insulin resistance, or androgen-secreting ovarian tumour, as stated in 2.
- It is also important to consider other potential causes of elevated testosterone, such as the use of medication having an estrogenic effect, hyperthyroidism, or liver disease, as mentioned in 2.
- In cases where testosterone is elevated, but clinical symptoms of hyperandrogenism are not present, it is essential to interpret the results with care, taking into account factors such as SHBG levels, weight, metabolic syndrome, and familial history of diabetes, as discussed in 2 and 3.
- Further evaluation may involve imaging studies, such as ultrasonography or magnetic resonance imaging, to detect any potential tumors or adrenal rest tissues, as described in 4.
- The clinical manifestations of hyperandrogenism, including hirsutism, acne, androgenic alopecia, and virilization, should be thoroughly evaluated, as outlined in 3.