How to Know If You Have Excess Androgen as a Girl
You likely have excess androgen if you experience hirsutism (excessive male-pattern hair growth), persistent acne, irregular or absent periods, or male-pattern hair loss, and these symptoms should prompt specific blood tests to confirm the diagnosis. 1
Clinical Signs and Symptoms to Look For
Primary Indicators of Hyperandrogenism
The most recognizable symptoms are hirsutism and acne, which should be taken seriously due to their association with underlying medical disorders and substantial impact on quality of life. 2
Key physical signs include:
- Hirsutism: Excessive terminal hair growth in male-pattern areas (face, chest, back, abdomen) 1, 2
- Persistent or severe acne: Particularly if resistant to standard treatments 1
- Androgenic alopecia: Male-pattern hair loss or thinning at the crown 1
- Clitoromegaly: Enlargement of the clitoris (indicates more severe androgen excess) 1
- Truncal obesity: Central weight distribution 1
Menstrual and Reproductive Signs
- Oligomenorrhea: Infrequent periods (cycles longer than 35 days) 1
- Amenorrhea: Absent periods 1
- Infertility or difficulty conceiving 1
Associated Metabolic Signs
- Acanthosis nigricans: Dark, velvety skin patches on the neck, armpits, under breasts, or groin (indicates insulin resistance) 1
- Obesity with elevated body mass index 1
Diagnostic Testing Algorithm
First-Line Laboratory Tests
Free testosterone (FT) and total testosterone (TT) measured by liquid chromatography with tandem mass spectrometry (LC-MS/MS) are the most accurate first-line tests for biochemical hyperandrogenism. 3
If LC-MS/MS is unavailable, the free androgen index (FAI) provides good diagnostic accuracy. 3
Elevation of free or total testosterone above adult female normative values is a key diagnostic feature of biochemical hyperandrogenism. 2
Second-Line Laboratory Tests (if testosterone levels are normal but symptoms persist)
- Androstenedione (A4) 3, 4
- Dehydroepiandrosterone sulfate (DHEAS): Indicates adrenal androgen production 1, 4
- LH/FSH ratio: A ratio >2 suggests polycystic ovary syndrome (PCOS) 3, 5
- 17-hydroxyprogesterone: Screens for nonclassic congenital adrenal hyperplasia 1, 2
Additional Screening Tests
When hyperandrogenism is confirmed, consider:
- Thyroid-stimulating hormone (TSH): Rules out thyroid disease 1
- Prolactin level: Excludes hyperprolactinemia 1, 4
- Fasting glucose and 2-hour oral glucose tolerance test: Screens for diabetes and insulin resistance 1
- Fasting lipid panel: Assesses cardiovascular risk 1
When to Pursue Testing
Routine endocrinologic testing is NOT recommended for most patients with acne alone. 1
Testing IS warranted when you have acne PLUS any of these additional signs:
- Hirsutism 1
- Oligomenorrhea or amenorrhea 1
- Androgenic alopecia 1
- Infertility 1
- Clitoromegaly 1
- Truncal obesity 1
Important Conditions to Rule Out
Most Common Cause
Polycystic ovary syndrome (PCOS) is the most common cause of hyperandrogenism in teenage girls and young women. 1, 6
Other Causes to Exclude
- Nonclassic (late-onset) congenital adrenal hyperplasia 1
- Cushing's syndrome: Look for buffalo hump, moon face, hypertension, abdominal striae, easy bruising 1
- Androgen-secreting tumors of ovary or adrenal gland (suggested by very high testosterone levels or rapid symptom onset) 1, 5
- Thyroid disease 1
- Hyperprolactinemia 1
- Exogenous androgen use: Medications or supplements 1
Critical Pitfalls to Avoid
During puberty, there is physiological hyperandrogenism that overlaps significantly with PCOS symptoms, making diagnosis difficult in adolescents. 2 This means some irregular periods and acne may be normal during the first few years after menarche.
Treatment should not be withheld while awaiting a definitive diagnosis if symptoms are distressing, as the psychological impact can be substantial. 2
In women with acanthosis nigricans, consider associated insulinoma or malignancy (particularly gastric adenocarcinoma), not just insulin resistance. 1