From the Guidelines
For a female patient with slightly elevated testosterone and estrogen levels, normal progesterone, FSH, and LH, and well-controlled hypothyroidism, I recommend a comprehensive workup including a pelvic ultrasound, DHEA-sulfate, and androstenedione tests to identify potential causes like polycystic ovary syndrome (PCOS), adrenal disorders, or ovarian tumors. The patient's slightly elevated testosterone and estrogen with normal gonadotropins (FSH/LH) suggest a potential ovarian or adrenal source of excess hormone production, which these tests can help differentiate 1.
Key Diagnostic Tests
- Pelvic ultrasound to evaluate for polycystic ovaries or ovarian tumors
- DHEA-sulfate to rule out non-classical congenital adrenal hyperplasia
- Androstenedione to evaluate for adrenal or ovarian tumors
- Consider adding a prolactin test to rule out hyperprolactinemia, which can be associated with hypothyroidism and may impact reproductive hormone levels 1
Rationale
The patient's normal progesterone, FSH, and LH levels, along with well-controlled hypothyroidism, suggest that the slightly elevated testosterone and estrogen levels may be due to an ovarian or adrenal source. The comprehensive workup recommended above can help identify potential causes of these hormonal imbalances.
Additional Considerations
- Continued monitoring of thyroid function is important as thyroid disorders can influence reproductive hormone levels, even when seemingly well-controlled
- A complete metabolic panel and lipid profile may also be important to assess the patient's metabolic health, as hormonal imbalances can have a significant impact on metabolic function 1
From the Research
Diagnostic Tests for Elevated Testosterone and Estrogen Levels
Given the patient's slightly elevated testosterone and estrogen levels, normal progesterone, Follicle-Stimulating Hormone (FSH), and Luteinizing Hormone (LH), and a history of hypothyroidism, the following diagnostic tests are recommended:
- Measurement of testosterone and androstenedione by liquid chromatography-tandem mass spectrometry to assess hyperandrogenism 2
- Free androgen index (FAI) calculation to evaluate androgen excess 2, 3
- LH:FSH ratio to assess pituitary-gonadal function 2, 4
- Transvaginal ultrasound to evaluate ovarian morphology and detect polycystic ovaries 5, 4
- Color Doppler analysis to assess ovarian stromal blood flow 3
- Oral glucose tolerance test (OGTT) to evaluate insulin sensitivity and detect hyperinsulinemia 3
- Measurement of sex hormone-binding globulin (SHBG) to assess androgen binding and transport 2, 3, 4
Rationale for Diagnostic Tests
The recommended diagnostic tests are based on the patient's clinical presentation and the need to evaluate hyperandrogenism, insulin sensitivity, and ovarian function. The tests are supported by studies that demonstrate their utility in diagnosing polycystic ovary syndrome (PCOS) and related disorders 6, 2, 3, 5, 4.
Key Findings from Relevant Studies
- Metformin therapy can reduce hyperinsulinemia, insulin resistance, and hyperandrogenism in women with PCOS 6
- Liquid chromatography-tandem mass spectrometry is a reliable method for measuring testosterone and androstenedione in women with PCOS 2
- Hyperinsulinemia is associated with increased ovarian stromal blood flow and angiogenesis in women with PCOS 3
- Polycystic ovaries can be detected by transvaginal ultrasound, and ovarian morphology is related to androgen status 5, 4