Can a female patient with hyperandrogenism (elevated testosterone levels) continue intramuscular (IM) testosterone injections?

Testosterone Therapy in Female Patient with Elevated Testosterone

A female patient with a testosterone level of 22 ng/dL should not continue intramuscular testosterone injections, as this represents hyperandrogenism that requires investigation rather than continued testosterone administration.

Understanding Elevated Testosterone in Women

Elevated testosterone in women (hyperandrogenism) is a concerning clinical finding that requires thorough investigation before any hormone therapy decisions are made:

• Normal female testosterone ranges are significantly lower than 22 ng/dL, with typical levels being much lower
• Hyperandrogenism in women can lead to multiple endocrine and metabolic disorders 1
• Very high testosterone levels (>2-3 SD above normal reference range) typically warrant prompt investigation 2

Potential Causes of Elevated Testosterone in Women

Several conditions can cause hyperandrogenism in women that should be ruled out:

• Polycystic ovary syndrome (PCOS) - most common cause of hyperandrogenism in premenopausal women 2, 3
• Ovarian steroid cell tumors (SCTs) - rare but serious cause of elevated testosterone 2
• Adrenal disorders including tumors, hyperplasia, and congenital adrenal hyperplasia 4, 5
• Iatrogenic causes - including inappropriate testosterone administration 4

Evaluation Recommendations

Before considering any testosterone therapy, the following evaluation should be completed:

• Confirm elevated testosterone with repeat testing (at least two measurements) 6

• Consider laboratory interference - diethyl ether extraction may help confirm true elevation 2

• Additional hormone testing:

  • Sex hormone-binding globulin (SHBG)
  • Free testosterone (more sensitive indicator of hyperandrogenism) 3
  • Dehydroepiandrosterone sulfate (DHEAS)
  • Androstenedione 4

• Imaging studies if testosterone remains elevated:

  • Magnetic resonance imaging of adrenal glands and ovaries 4

Risks of Testosterone Therapy in Women with Hyperandrogenism

Continuing testosterone injections in a female patient with already elevated levels poses several risks:

• Virilization effects (hirsutism, acne, voice deepening, clitoromegaly) 4

• Metabolic complications:

  • Hypercholesterolemia
  • Insulin resistance
  • Hypertension
  • Increased cardiovascular risk 4

• Potential for erythrocytosis (elevated hematocrit) 7, 6

  • Injectable testosterone carries greater risk of erythrocytosis than topical preparations 7
  • May require dose reduction or discontinuation if hematocrit rises above reference range 7

Management Approach

1. Immediately discontinue testosterone injections due to already elevated levels
2. Complete diagnostic workup as outlined above
3. Treat the underlying cause of hyperandrogenism rather than continuing exogenous testosterone
4. If testosterone therapy is eventually indicated for specific conditions:
   • Target appropriate female testosterone ranges
   • Consider transdermal formulations which may have less risk of erythrocytosis than injections 7, 6
   • Implement proper monitoring protocols including testosterone levels, hematocrit, and clinical symptoms 6

Monitoring Recommendations

If testosterone therapy is ever reinitiated after addressing the underlying hyperandrogenism:

• Initial follow-up 1-2 months after starting therapy 6
• Monitoring every 3-6 months during the first year 6
• Yearly monitoring thereafter once stable 6
• Regular assessment of hematocrit/hemoglobin levels 7, 6
• Monitoring for cardiovascular risk factors 7

Conclusion

The current testosterone level of 22 ng/dL represents hyperandrogenism that requires investigation and management of the underlying cause rather than continued testosterone administration. Continuing testosterone injections could worsen hyperandrogenism and lead to adverse health outcomes.