Is increased body odor a sign of hyperandrogenism in women?

Increased Body Odor as a Sign of Hyperandrogenism in Women

Yes, increased body odor is a recognized clinical sign of hyperandrogenism in women, particularly when it presents as early-onset body odor in prepubertal children along with other androgenic symptoms. 1

Clinical Manifestations of Hyperandrogenism

Hyperandrogenism presents with several clinical manifestations that can be categorized by their prevalence and severity:

Common Clinical Signs:

• Hirsutism: Excessive terminal hair growth in a male pattern distribution (most common sign, present in up to 80% of cases) 2
• Acne: Particularly persistent or severe acne that is resistant to conventional treatments
• Menstrual irregularities: Including oligomenorrhea or amenorrhea
• Androgenic alopecia: Hair thinning in the central scalp region
• Increased body odor: Particularly early-onset body odor in prepubertal children 1

Less Common/Severe Signs:

• Virilization (clitoromegaly, deepening voice, increased muscle mass)
• Truncal obesity
• Infertility

Diagnostic Approach for Suspected Hyperandrogenism

When increased body odor is present along with other signs of hyperandrogenism, the following diagnostic approach is recommended:

1. Clinical Assessment:

• Document timing of symptom onset (sudden vs. gradual)
• Assess severity of symptoms
• Look for clustering of symptoms (body odor + hirsutism + acne + menstrual irregularities)
• In prepubertal children, early-onset body odor accompanied by axillary/pubic hair, accelerated growth, advanced bone age, and genital maturation warrants immediate evaluation 1

2. Laboratory Testing:

• First-line testing (based on 2023 International PCOS Guidelines):

  • Total testosterone (TT) - highest diagnostic accuracy when measured by LC-MS/MS 1
  • Free testosterone (FT) - ideally measured by equilibrium dialysis or calculated from high-quality TT and SHBG measurements 1
  • Free Androgen Index (FAI) - calculated from TT to SHBG ratio 1

• Second-line testing (if first-line tests are negative but clinical suspicion remains):

  • Androstenedione (A4)
  • Dehydroepiandrosterone sulfate (DHEAS) 1
  • Note: These have poorer specificity than TT or FT

3. Additional Evaluation:

• In prepubertal children with early body odor and other signs:
  • Growth charts
  • Hand film for bone age assessment 1
• In women with menstrual irregularities:
  • LH:FSH ratio (>2 suggests PCOS) 3
  • Pelvic ultrasound (to assess for polycystic ovaries)

Common Causes of Hyperandrogenism

1. Polycystic Ovary Syndrome (PCOS): Most common cause (75% of cases) 4

   • Diagnosis requires 2 of 3: hyperandrogenism, ovulatory dysfunction, polycystic ovaries

2. Non-classic Congenital Adrenal Hyperplasia (NCCAH):

   • Diagnosed with elevated basal or ACTH-stimulated 17-hydroxyprogesterone levels 4

3. Idiopathic Hirsutism:

   • Diagnosis of exclusion after ruling out other causes 5

4. Rarer causes (require exclusion, especially with severe or rapid-onset symptoms):

   • Androgen-secreting tumors (ovarian or adrenal)
   • Cushing's syndrome
   • Hyperprolactinemia 4

Clinical Pearls and Pitfalls

• Pearl: Early-onset body odor in children should prompt evaluation for premature adrenarche or other causes of hyperandrogenism 1

• Pitfall: Relying solely on direct immunoassay methods for androgen measurement, which have lower accuracy compared to LC-MS/MS 1

• Pearl: The presence of virilization (clitoromegaly, voice deepening) should raise suspicion for an androgen-producing tumor 2, 4

• Pitfall: Failing to consider non-classic congenital adrenal hyperplasia in women with hyperandrogenism and oligomenorrhea 4

By recognizing increased body odor as a potential sign of hyperandrogenism, especially when occurring with other androgenic symptoms, clinicians can initiate appropriate diagnostic evaluation and management to address the underlying hormonal imbalance.