What are the treatment options for hyperandrogenism (elevated testosterone levels)?

Treatment Options for Hyperandrogenism (Elevated Testosterone Levels)

For patients with hyperandrogenism, treatment should focus on identifying the underlying cause and implementing targeted therapies to normalize hormone levels, with oral contraceptives containing anti-androgenic progestogens being the first-line treatment for most women.

Diagnostic Evaluation

Before initiating treatment, a thorough diagnostic evaluation is essential:

• Total testosterone assay is recommended as the first-line diagnostic test 1
• Morning total testosterone concentration should be drawn between 8 AM and 10 AM 2
• Free testosterone level by equilibrium dialysis and sex hormone-binding globulin (SHBG) level should be measured in patients with obesity 2
• If testosterone levels are twice the upper limit of normal, DHEAS assay should be performed to rule out androgen-secreting adrenal tumors 1
• Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) should be measured to distinguish primary from secondary causes 2

Treatment Options for Women

First-Line Treatments

• Oral contraceptives (OCs) are the mainstay of treatment for hyperandrogenism in women 3
  • OCs reduce androgen production and increase SHBG, resulting in decreased free testosterone levels 3
  • OCs with predominant estrogen effect may improve mild to moderate forms of acne, seborrhea, hirsutism, and androgenetic alopecia 3

Second-Line Treatments

• OCs containing anti-androgenic progestogens (such as cyproterone acetate) are recommended for women who don't respond to standard OCs 3
  • For severe acne and hirsutism, higher doses of cyproterone acetate (25-100 mg/day) may be needed for 6-12 months 3
  • For androgenetic alopecia, low-dose OCs containing cyproterone acetate are effective with optimal results after at least 12 months of therapy 3

Additional Treatment Options

• Spironolactone - an aldosterone antagonist with anti-androgenic properties
• Flutamide - a non-steroidal anti-androgen
• Finasteride - a 5α-reductase inhibitor that prevents conversion of testosterone to dihydrotestosterone (DHT)
• Metformin - particularly useful when hyperandrogenism is associated with insulin resistance or polycystic ovary syndrome

Treatment Options for Men

Hyperandrogenism in men is less common but can occur at any age 4:

• Treatment depends on the underlying cause and clinical manifestations
• In older men, elevated total testosterone may be due to increased SHBG rather than true hyperandrogenism 4
• For true hyperandrogenism:
  • Address underlying causes (tumors, exogenous testosterone use)
  • Anti-androgens may be considered in severe cases
  • Regular monitoring of prostate health is essential, as elevated testosterone may affect prostate volume 4

Special Considerations

Fertility Concerns

• Exogenous testosterone therapy should not be prescribed to men who are currently trying to conceive, as it can interrupt normal spermatogenesis 2
• For men with testosterone deficiency desiring to maintain fertility, alternative therapies may include 2:
  • Aromatase inhibitors
  • Human chorionic gonadotropin (hCG)
  • Selective estrogen receptor modulators (SERMs)

Monitoring

• Patients receiving treatment for hyperandrogenism should be monitored regularly for:
  • Hormone levels (testosterone, free testosterone)
  • Clinical improvement of symptoms
  • Potential side effects of medications
  • In men, prostate-specific antigen (PSA) and hematocrit should be monitored 2

Clinical Manifestations by Hormone Pattern

Different patterns of hormone imbalance can lead to different clinical presentations 5:

• High testosterone with low estradiol: aggression, depression, increased libido, and substance abuse risk 5
• High testosterone with high estradiol: increased risk of type II diabetes, cardiovascular disease, and breast cancer 5
• In men, elevated DHT levels are particularly associated with androgenic alopecia, while elevated total and free testosterone levels commonly present with acne 4

Treatment Duration and Follow-up

• Treatment is typically long-term as symptoms may recur after discontinuation 3
• After initial improvement, maintenance therapy with suitable low-dose formulations is recommended 3
• Regular follow-up every 3-6 months is advised to assess treatment efficacy and adjust medications as needed

Remember that hyperandrogenism treatment should be tailored based on the severity of symptoms, underlying cause, and patient's specific concerns regarding fertility, cosmetic issues, and metabolic health.