Should a woman with elevated Follicle-Stimulating Hormone (FSH), hyperandrogenism (free testosterone 58.8, bioavailable testosterone 128, total testosterone 539) decrease her testosterone cypionate dose while taking an oral combination birth control pill?

Management of Elevated Testosterone Levels in a Woman on Testosterone Cypionate and Oral Contraceptives

Recommendation

The woman should decrease her testosterone cypionate dose due to signs of hyperandrogenism evidenced by elevated free, bioavailable, and total testosterone levels. 1

Understanding the Clinical Picture

The patient presents with:

• Currently taking 10 mg testosterone cypionate
• Elevated FSH
• Elevated free testosterone (58.8)
• Elevated bioavailable testosterone (128)
• Elevated total testosterone (539)
• Concurrent use of oral combination birth control pill

These laboratory values indicate significant hyperandrogenism while on testosterone therapy, which requires dose adjustment.

Interpretation of Laboratory Values

• Elevated testosterone levels: The patient's free testosterone (58.8), bioavailable testosterone (128), and total testosterone (539) are all elevated above the normal female range. This indicates excessive testosterone supplementation. 1

• Elevated FSH: This suggests the body is attempting to compensate for hormonal imbalance. When combined with oral contraceptives, this pattern suggests the testosterone dose is too high, as oral contraceptives typically suppress FSH. 2, 3

• Oral contraceptive interaction: Combined oral contraceptives (COCs) normally increase sex hormone-binding globulin (SHBG) and decrease free testosterone by approximately 61%. 3 The fact that testosterone levels remain elevated despite COC use further confirms the testosterone dose is excessive.

Management Algorithm

1. Reduce testosterone cypionate dose:

   • Decrease from current 10 mg dose to 5 mg initially
   • The FDA-approved testosterone cypionate dosing for replacement therapy is individualized, but the current dose is showing signs of excess 1

2. Maintain oral contraceptive:

   • Continue current COC as it provides protection against endometrial hyperplasia that can occur with excess testosterone 4
   • COCs help increase SHBG which can bind excess testosterone 3

3. Laboratory monitoring:

   • Recheck testosterone levels (free, bioavailable, total) in 4-6 weeks after dose adjustment
   • Monitor FSH levels to assess normalization
   • Evaluate for improvement in clinical signs of hyperandrogenism

Rationale for Dose Reduction

Testosterone cypionate is not FDA-approved for routine use in women and requires careful monitoring. The current dose is causing:

• Hyperandrogenism as evidenced by laboratory values
• Potential risk for virilization with continued exposure to high testosterone levels
• Hormonal imbalance as suggested by elevated FSH despite COC use

Clinical Considerations and Cautions

• Virilization risk: Prolonged exposure to high testosterone levels can cause irreversible virilization including clitoromegaly, deepening of voice, and hirsutism 4

• Metabolic effects: High testosterone in women can adversely affect lipid profiles and potentially increase cardiovascular risk 5

• Contraceptive efficacy: Hormonal imbalance may affect contraceptive efficacy, though the COC should still provide protection 4

• Monitoring parameters: Besides testosterone levels, monitor for clinical signs of hyperandrogenism including acne, hirsutism, and menstrual irregularities 5

• Avoid abrupt discontinuation: Gradually reducing the dose rather than abrupt discontinuation helps prevent hormonal fluctuations 1

Special Considerations with Combined Oral Contraceptives

The concurrent use of COCs adds complexity:

• COCs containing ethinyl estradiol increase SHBG, which should bind more testosterone and lower free testosterone levels 3
• Despite this effect, the patient's free testosterone remains elevated, further indicating the testosterone dose is too high
• The COC may be providing some protection against endometrial hyperplasia that can occur with excess testosterone 4

By reducing the testosterone cypionate dose while maintaining the oral contraceptive, the patient should achieve better hormonal balance with reduced risk of adverse effects from hyperandrogenism.