What is the best course of treatment for a patient with hyperandrogenism and abnormal hormone levels?

Management of Hyperandrogenism with Elevated Testosterone and Free Testosterone Levels

The patient requires immediate evaluation for possible adrenal tumor or non-classical congenital adrenal hyperplasia (CAH) due to markedly elevated total testosterone (1254) and free testosterone (185) levels with normal LH (4.3) and high SHBG (70.3).

Laboratory Interpretation

The patient's laboratory values show:

• Total testosterone: 1254 (markedly elevated)
• Free testosterone: 185 (markedly elevated)
• SHBG: 70.3 (elevated)
• LH: 4.3 (normal range)

This pattern indicates hyperandrogenism with a concerning profile that requires further investigation.

Diagnostic Approach

1. Rule Out Adrenal Tumor

• Adrenal CT or MRI is urgently needed to rule out adrenocortical carcinoma (ACC) or other adrenal tumors 1
• Adrenal tumors can cause significantly elevated DHEA-S and testosterone levels

2. Additional Laboratory Testing

• Measure DHEA-S levels to assess adrenal androgen production
• Measure 17-hydroxyprogesterone to evaluate for non-classical CAH 1
• Measure androstenedione levels
• Cortisol levels (morning) and ACTH to assess adrenal function

3. Endocrinology Referral

• Immediate referral to endocrinology is warranted given the severity of hormone abnormalities 2, 1

Treatment Algorithm

If Adrenal Tumor is Found:

1. Surgical intervention is typically necessary 1
2. Pre-surgical endocrinology consultation for hormone management
3. Post-surgical follow-up with serial testosterone measurements

If Non-Classical CAH is Diagnosed:

1. Initiate glucocorticoid replacement therapy with hydrocortisone 15-20 mg daily in divided doses 1
2. Goal: Normalize androgen levels while avoiding cushingoid features
3. Monitor androstenedione and other adrenal androgens every 3-6 months
4. Adjust hydrocortisone dose incrementally (by 2.5-5 mg) based on clinical and laboratory response 1

If PCOS is Diagnosed (less likely given the extreme elevation):

1. Lifestyle modifications (weight loss if applicable)
2. Consider anti-androgen therapy
3. Regular monitoring of metabolic parameters

Monitoring and Follow-up

• Regular clinical assessment every 3-6 months
• Hormone measurements (testosterone, androstenedione, 17-hydroxyprogesterone) every 3-6 months
• Monitor for clinical signs of androgen excess (acne, hirsutism) and glucocorticoid excess (weight gain, striae)
• Adjust medication based on clinical and biochemical response

Important Considerations

• Avoid exogenous testosterone therapy as it would worsen the condition 2
• Patients requiring glucocorticoid therapy need education on stress dosing during illness or surgery 1
• Medical alert identification should be provided if adrenal insufficiency is diagnosed 2
• Monitor for potential long-term health consequences of hyperandrogenism (cardiovascular risk, metabolic syndrome)

Common Pitfalls to Avoid

• Do not dismiss extremely high testosterone levels as a laboratory error without confirmation
• Do not delay imaging studies when testosterone levels are this elevated
• Avoid attributing symptoms solely to PCOS without ruling out more serious conditions like adrenal tumors
• Do not reduce hydrocortisone below 10mg daily if prescribed, as this increases risk of adrenal crisis 1
• Avoid discontinuing prescribed hydrocortisone despite side effects, as this could be life-threatening 1

The extreme elevation of both total and free testosterone with normal LH suggests an adrenal source of excess androgens rather than testicular overproduction, making adrenal imaging and comprehensive endocrine evaluation the most urgent priorities.