What are the evaluation and treatment options for a 19-year-old girl with hyperandrogenism (elevated testosterone levels)?

Evaluation and Treatment of Hyperandrogenism in a 19-Year-Old Female

The most appropriate approach for a 19-year-old female with elevated testosterone is to first determine the source of androgen excess through specific laboratory testing, followed by targeted treatment based on the underlying cause, with polycystic ovary syndrome (PCOS) being the most likely diagnosis. 1, 2

Initial Evaluation

Laboratory Assessment

• First-line testing:

  • Total testosterone assay (primary screening test) 2
  • Free testosterone (more sensitive indicator of hyperandrogenism than total testosterone) 1
  • Sex hormone-binding globulin (SHBG) 2
  • Dehydroepiandrosterone sulfate (DHEAS) to assess adrenal contribution 2
  • Androstenedione 3

• Additional testing based on clinical suspicion:

  • If testosterone is twice the upper limit of normal, DHEAS assay is essential 2
  • Consider testing for late-onset congenital adrenal hyperplasia 1
  • Evaluate for Cushing's syndrome if clinically suspected 3
  • Check prolactin levels (hyperprolactinemia can affect hormone levels) 4

Imaging Studies

• If testosterone levels are markedly elevated or if DHEAS >600 mg/dl, imaging is warranted:
  • MRI of adrenal glands (for suspected adrenal source) 3
  • Pelvic ultrasound (for suspected ovarian pathology) 4
  • MRI of pituitary if prolactin is elevated 4

Differential Diagnosis

The most common causes of hyperandrogenism in a 19-year-old female include:

1. Polycystic Ovary Syndrome (PCOS) - most common cause in teenage girls 1
2. Late-onset congenital adrenal hyperplasia 1
3. Exaggerated adrenarche 1
4. Androgen-secreting tumors (ovarian or adrenal) - rare but serious 1, 3
5. Cushing's syndrome 1
6. Hyperprolactinemia 1

Treatment Approach

For PCOS (Most Likely Diagnosis)

• Lifestyle modifications:

  • Weight loss if overweight/obese
  • Increased physical activity
  • Healthy diet
  • Moderate alcohol consumption 4

• Hormonal therapy:

  • Combined oral contraceptives to regulate menstrual cycles and reduce androgen levels
  • Anti-androgens (spironolactone) for hirsutism and acne

For Adrenal Hyperandrogenism

• If late-onset congenital adrenal hyperplasia is diagnosed, low-dose glucocorticoid therapy may be indicated

For Androgen-Secreting Tumors

• Surgical intervention is the primary treatment 3
• For patients unfit for surgery, medical management with GnRH agonists/antagonists may be considered 3

For Hyperprolactinemia

• Dopamine agonist therapy
• Regular follow-up with hormone measurements every 3-6 months initially, then annually 4

Monitoring and Follow-up

• Regular monitoring of hormone levels (every 3-6 months initially)
• Address modifiable factors such as weight management, reduction of alcohol consumption, and smoking cessation 4
• Monitor for metabolic complications (insulin resistance, dyslipidemia, hypertension) 3, 5

Important Considerations and Pitfalls

• Beware of normal testosterone levels with clinical hyperandrogenism - SHBG is reduced in overweight patients, metabolic syndrome, or those with family history of diabetes, which can mask elevated free testosterone 2

• Don't miss androgen-secreting tumors - These rare conditions (1-3 per 1000 hirsute patients) require prompt diagnosis and treatment 3

• Consider the psychological impact - Both low and high testosterone levels can contribute to depression in women 5

• Recognize that testosterone imbalance affects multiple systems - Beyond cosmetic concerns, hyperandrogenism can lead to hypercholesterolemia, insulin resistance, hypertension, and cardiac disease 3