Treatment Options for High Testosterone and High LH Levels
The most effective treatment for high testosterone and high LH levels depends on the underlying cause, with antiandrogens being the first-line therapy for most patients, particularly when symptoms of hyperandrogenism are present. 1
Diagnostic Evaluation
Before initiating treatment, a thorough diagnostic workup is essential:
- Morning total and free testosterone levels
- Sex hormone-binding globulin (SHBG) levels
- LH and FSH levels
- Clinical signs of hyperandrogenism (hirsutism, acne, androgenic alopecia)
- Evaluation for potential causes:
- Androgen resistance/insensitivity
- Congenital adrenal hyperplasia
- Liver disease
- Polycystic ovary syndrome (in women)
Treatment Algorithm Based on Underlying Cause
1. Androgen Resistance/Insensitivity
For patients with androgen receptor mutations causing partial androgen insensitivity:
- High-dose testosterone therapy may be considered to overcome receptor resistance 2
- Response varies based on the specific mutation:
- Mutations in the hormone binding domain may respond better than mutations in the DNA binding domain
- Monitor sebum excretion as a sensitive marker of androgen response
2. For Women with PCOS and Hyperandrogenism
First-line therapy: Combined oral contraceptives (COCs) 1
- Suppresses ovarian androgen production
- Increases SHBG
- Reduces free testosterone
- Improves acne and hirsutism
Second-line therapy: Antiandrogens 1
- Spironolactone (50-200 mg daily)
- Finasteride (2.5-5 mg daily)
- Monitor potassium levels with spironolactone if risk factors for hyperkalemia exist
For metabolic concerns: Metformin (1500-2000 mg daily) 1
- Improves insulin sensitivity
- Can help restore ovulation
- Addresses metabolic concerns
3. For Aging Men with Elevated LH and Normal Testosterone
This condition, known as compensated hypogonadism, requires careful monitoring as it often represents a transitional state:
Lifestyle modifications are the first-line approach 1, 3:
- Weight loss if overweight
- Increased physical activity
- Smoking cessation
- Healthy diet
- Moderate alcohol consumption
Monitor for progression to primary hypogonadism, which occurs more frequently in these men (OR = 15.97) 3
Avoid testosterone replacement therapy unless testosterone levels drop below normal range, as it will suppress LH through negative feedback 4, 5
Special Considerations for Fertility
For men with idiopathic infertility, selective estrogen receptor modulators (SERMs) may provide limited benefits 6
FSH analogues may be considered to improve sperm concentration, pregnancy rate, and live birth rate 6
Avoid testosterone monotherapy in men concerned about fertility, as it suppresses gonadotropins and spermatogenesis 6
Assisted reproductive technologies (ART), particularly intracytoplasmic sperm injection (ICSI) during IVF, may be necessary 1
Monitoring and Follow-up
- Regular hormone measurements every 3-6 months initially, then annually
- Assessment of clinical symptoms
- Evaluation for development of comorbidities, particularly cardiovascular disease
- Monitor for changes in cognitive and physical function in men with persistently high LH 3
Important Caveats
- High testosterone with high LH may indicate androgen resistance, where testosterone's biological activity is reduced despite high levels 7
- The combination can be a biomarker for deteriorating health in aging men 3
- Treatment should address both hormonal abnormalities and any underlying conditions
- Testosterone replacement is contraindicated unless true hypogonadism develops, as it will further suppress the hypothalamic-pituitary-gonadal axis 5