What is the treatment for elevated androgen (hyperandrogenism) levels?

Treatment for Hyperandrogenism

The first-line treatment for hyperandrogenism is anti-androgen therapy with spironolactone, combined with lifestyle modifications if applicable, while avoiding exogenous testosterone therapy which would worsen the condition. 1

Diagnostic Evaluation

Before initiating treatment, a proper diagnostic workup is essential to identify the underlying cause:

• Laboratory assessment:

  • Total and free testosterone levels
  • DHEA-S levels (to assess adrenal androgen production)
  • 17-hydroxyprogesterone (to evaluate for non-classical congenital adrenal hyperplasia)
  • LH/FSH ratio (>2 suggests PCOS)
  • Morning cortisol and ACTH levels 1, 2

• Imaging studies:

  • Adrenal CT or MRI if adrenal tumor is suspected
  • Pelvic ultrasound if PCOS is suspected 1

Treatment Algorithm

1. Determine the Source of Hyperandrogenism

For Ovarian Hyperandrogenism (e.g., PCOS):

• First-line: Combined oral contraceptives (COCs) 3
  • Suppress ovarian androgen production
  • Increase sex hormone-binding globulin (SHBG)
  • Reduce free testosterone levels

For Adrenal Hyperandrogenism (e.g., Congenital Adrenal Hyperplasia):

• First-line: Glucocorticoid replacement therapy 1
  • Hydrocortisone 15-20 mg daily in divided doses
  • Goal: Normalize androstenedione and other adrenal androgens

2. Anti-Androgen Therapy

• Spironolactone: 25-100 mg daily, can be titrated up to 200 mg daily 4

  • Blocks androgen receptors
  • Has additional anti-androgenic effects by inhibiting androgen production
  • Monitor for hyperkalemia, especially in patients with renal impairment

• Other options:

  • Cyproterone acetate (not available in US)
  • Flutamide (limited use due to hepatotoxicity) 5

3. Adjunctive Measures

• Avoid medications that worsen hyperandrogenism:

  • ACE inhibitors 3
  • Exogenous testosterone 1

• Lifestyle modifications:

  • Weight loss if overweight/obese
  • Regular exercise
  • Stress reduction 3, 1

Special Considerations

Pregnancy

• Androgens are contraindicated during pregnancy due to risk of fetal virilization
• For women planning pregnancy, discuss alternative treatments 3

Postmenopausal Women

• Rule out androgen-producing tumors, which are more common in this population
• Consider MRI of adrenal glands or ovaries if testosterone levels are markedly elevated 6

Monitoring and Follow-up

• Clinical assessment every 3-6 months:

  • Signs of androgen excess (hirsutism, acne, menstrual irregularities)
  • Signs of treatment side effects

• Laboratory monitoring:

  • Hormone measurements (androstenedione, 17-hydroxyprogesterone) every 3-6 months
  • Potassium levels if on spironolactone 1, 4

Common Pitfalls to Avoid

1. Delayed treatment: Treatment of acne and hirsutism should not be withheld during ongoing evaluation for possible PCOS 2

2. Unrealistic expectations: Improvement in clinical symptoms (especially hirsutism) may take 6-12 months; patients should be counseled accordingly 7

3. Inadequate monitoring: Failure to monitor for side effects of medications, particularly hyperkalemia with spironolactone 4

4. Overlooking serious causes: Rapid onset of virilization may indicate an androgen-producing tumor requiring urgent evaluation 5, 6

5. Discontinuing treatment prematurely: Anti-androgen therapy typically needs to be continued long-term, as symptoms often recur when treatment is stopped 7

By following this structured approach, hyperandrogenism can be effectively managed, leading to improvement in both physical symptoms and quality of life.