From the Guidelines
Elevated testosterone levels in women are significant as they can indicate underlying health conditions, such as polycystic ovary syndrome (PCOS), and cause various symptoms, including irregular menstrual cycles, infertility, acne, and excess facial and body hair. The diagnosis of hyperandrogenism in women typically involves blood tests to measure hormone levels, and treatment depends on the underlying cause. According to the most recent and highest quality study 1, the detection of hyperandrogenism in women with PCOS can be accomplished clinically through assessment of hirsutism, acne or androgenic alopecia, or via biochemical testing of circulating androgen concentrations. Some key points to consider in the diagnosis and treatment of hyperandrogenism in women include:
- The use of liquid chromatography-tandem mass spectrometry (LC-MS/MS) as the reference standard for assessing steroids, including androgens 1
- The measurement of total testosterone (TT) and free testosterone (FT) as the first-line laboratory tests to assess biochemical hyperandrogenism in the diagnosis of PCOS 1
- The consideration of androstenedione (A4) and dehydroepiandrosterone sulfate (DHEAS) as additional diagnostic tests if TT or FT are not elevated, despite high clinical suspicion 1
- The importance of lifestyle modifications, such as weight loss and exercise, and hormonal contraceptives, anti-androgen medications, and metformin as treatment options for PCOS. Overall, the significance of hyperandrogenism in women lies in its potential to indicate underlying health conditions and cause a range of symptoms, and the importance of accurate diagnosis and treatment to improve morbidity, mortality, and quality of life outcomes.
From the Research
Hyperandrogenism in Females
- Hyperandrogenism, or elevated testosterone levels, is a significant factor in female reproductive health disorders, including polycystic ovary syndrome (PCOS) and infertility 2, 3, 4.
- Total testosterone is the most clinically relevant hormone in investigating hyperandrogenic states and infertility in premenopausal women, with very high levels (>2-3 SD of normal reference) often associated with hyperandrogenic signs, menstrual irregularities, and rapid onset of virilization 2.
- However, some women with extremely high testosterone levels may not exhibit virilization signs, highlighting the importance of rigorous evaluation to minimize misinterpretation and errors in diagnosis and therapeutic approach 2.
Clinical Manifestations and Diagnosis
- Hyperandrogenism can manifest as hirsutism, acne, and menstrual dysfunction, with serum testosterone levels varying depending on the presence and severity of these symptoms 5.
- The detection of hyperandrogenemia is challenging due to the limitations of commercially available androgen assays and the wide range of reference values provided by laboratories 6, 5.
- A study found that the upper limit of testosterone in a reference population was 28 ng/dL, which is significantly lower than the upper limit of reference ranges provided by commercial laboratories (95 ng/dL) 5.
Treatment and Management
- Spironolactone, a non-selective mineralocorticoid receptor antagonist, has been shown to be effective in treating hyperandrogenism in women, with low-dose therapy resulting in significant reductions in testosterone, luteinizing hormone, and prolactin values 3, 4.
- Very low-dose spironolactone has also been found to protect against insulin-resistant metabolic disturbances in experimentally-induced PCOS rats by suppressing elevated circulating testosterone 4.