What is the treatment approach for individuals with hyperandrogenism (high testosterone levels)?

Treatment Approach for Hyperandrogenism (High Testosterone Levels)

The treatment of hyperandrogenism should focus on addressing the underlying cause while using anti-androgenic medications such as spironolactone as the primary pharmacological intervention to reduce testosterone effects. 1

Diagnostic Evaluation

Before initiating treatment, proper diagnosis is essential:

• Morning total testosterone concentration should be drawn between 8 AM and 10 AM 1
• Free testosterone level by equilibrium dialysis and sex hormone-binding globulin (SHBG) should be measured, especially in patients with obesity 1, 2
• Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) measurements help distinguish primary from secondary causes 1
• If testosterone is twice the upper limit of normal, perform DHEAS assay to rule out androgen-secreting adrenal tumors 2
• Normal testosterone levels with clear clinical symptoms require careful interpretation, as SHBG is often reduced in overweight individuals or those with metabolic syndrome 2

First-Line Treatment Options

Pharmacological Interventions

• Spironolactone: An aldosterone antagonist with anti-androgenic properties

  • Initial dosage: 25-100 mg daily, administered in single or divided doses 3
  • Can be titrated at two-week intervals based on clinical response 3
  • Doses greater than 100 mg/day generally do not provide additional benefit 3
  • Monitor for hyperkalemia, especially in patients with renal impairment 3

• Finasteride: A 5α-reductase inhibitor that prevents conversion of testosterone to dihydrotestosterone (DHT) 1

  • Particularly effective for androgenic alopecia and hirsutism

Special Considerations

• For men with fertility concerns: Exogenous testosterone therapy should not be prescribed to men who are currently trying to conceive 1

  • Alternative options include aromatase inhibitors and human chorionic gonadotropin (hCG) 1

• For women with PCOS (common cause of hyperandrogenism):

  • Combined approach targeting metabolic and hormonal abnormalities 4
  • Weight management for overweight/obese patients 4

Monitoring and Follow-up

• Regular follow-up every 3-6 months to assess treatment efficacy and adjust medications 1
• Monitor clinical improvement of symptoms (hirsutism, acne, menstrual irregularities) 1
• In men receiving treatment:
  • Monitor prostate-specific antigen (PSA) and hematocrit regularly 1
  • Perform digital rectal examination during follow-up visits 5
  • Consider temporarily withholding therapy, reducing dosage, or performing phlebotomy if hematocrit rises above the reference range 5

Potential Complications and Considerations

• Cardiovascular effects: Monitor for fluid retention, especially in patients with heart failure or renal insufficiency 5
• Polycythemia: Higher testosterone levels stimulate erythropoiesis; monitor hematocrit/hemoglobin 5
• Prostate concerns: In men, monitor for prostate cancer through PSA testing and digital rectal examination 5
• Metabolic effects: Testosterone therapy within physiologic range generally has neutral effects on lipid profiles 5

Treatment Based on Underlying Cause

• Primary hyperaldosteronism: Spironolactone 100-400 mg daily, either as preparation for surgery or long-term maintenance therapy 3
• Adrenal source: Address underlying adrenal pathology; consider DHEAS levels over 600 mg/dl as indicative of adrenal cortical adenoma 2
• Ovarian source: Treatment depends on specific pathology (PCOS, hyperthecosis, or ovarian tumor) 2, 4

Pitfalls and Caveats

• Do not use testosterone therapy in eugonadal men 5
• Avoid testosterone therapy for weight reduction or cardiometabolic enhancement 5
• Be cautious with spironolactone in patients with renal impairment due to hyperkalemia risk 3
• Normal testosterone levels do not rule out hyperandrogenism if clinical symptoms are present; consider free testosterone and SHBG levels 2
• Testosterone levels can be affected by various medications, thyroid disorders, and liver disease 2