What is the relationship between Polycystic Ovary Syndrome (PCOS) and testosterone levels?

From the Guidelines

Polycystic Ovary Syndrome (PCOS) is strongly associated with elevated testosterone levels, which is a hallmark and diagnostic feature of the condition.

Key Findings

• The most accurate androgen measurements for diagnosing biochemical hyperandrogenism in PCOS are total testosterone (TT) and free testosterone (FT), with a pooled sensitivity of 0.74 and 0.89, respectively, and a specificity of 0.86 and 0.83, respectively 1.
• Liquid chromatography-tandem mass spectrometry (LC-MS/MS) is the reference standard for assessing steroids, including androgens, and should be utilized for androgen measurement due to its high accuracy 1.
• Free androgen index (FAI) is a reliable biomarker for diagnosing biochemical hyperandrogenism in PCOS, with a pooled sensitivity of 0.78 and specificity of 0.85 1.
• Androstenedione (A4) and dehydroepiandrosterone sulfate (DHEAS) may be considered as second-line diagnostic androgen markers for PCOS, but have poorer specificity than TT, cFT, or FAI 1.

Diagnostic Approach

• TT and FT should be used as the first-line laboratory tests to assess biochemical hyperandrogenism in the diagnosis of PCOS, using LC-MS/MS for measurement 1.
• If TT or FT is not elevated, A4 and DHEAS may be considered, noting their poorer specificity 1.
• FAI can be employed as an alternative to TT and FT, especially when LC-MS/MS is not available 1.

From the Research

Relationship Between PCOS and Testosterone Levels

• Women with Polycystic Ovary Syndrome (PCOS) often exhibit elevated levels of testosterone, which is a key diagnostic feature of the condition 2, 3.
• Studies have shown that PCOS patients have significantly higher levels of total testosterone (TT) and free testosterone compared to healthy controls 2.
• The testosterone to dihydrotestosterone (DHT) ratio (TT/DHT ratio) has been found to be significantly higher in PCOS patients, and is associated with an adverse metabolic phenotype 2.
• Testosterone levels in women with PCOS have been found to decrease with age, with a significant reduction in total and non-SHBG-bound testosterone levels observed in women over 42 years of age 3.

Effects of Testosterone on PCOS

• Elevated testosterone levels in PCOS patients have been linked to various adverse effects, including hyperandrogenism, metabolic disturbances, and impaired glucose tolerance 2, 4.
• Testosterone therapy has been found to affect the expression of certain genes, including PPARγ and P450arom, in ovary granular cells of PCOS patients 5.
• The "maladaptive extremes of adaptation" model suggests that relatively high levels of testosterone in PCOS patients may be associated with benefits in certain contexts, such as increased strength and muscularity 6.

Correlations and Associations

• The TT/DHT ratio has been found to be correlated with various adverse anthropometric, hormonal, lipid, and liver parameters, as well as parameters of glucose metabolism in PCOS patients 2.
• Testosterone levels have been found to be associated with dominance in females, with higher testosterone levels exhibiting clear evidence of high dominance 6.
• Elevated testosterone levels have been found to be associated with higher strength, muscularity, and athleticism in females, including those with PCOS 6.