Role of Hormonal Investigations in Androgenic Alopecia
Hormonal testing is generally not necessary for diagnosing androgenic alopecia in women unless clinical signs of androgen excess (hirsutism, severe cystic acne, virilization, galactorrhea, or menstrual irregularities) are present. 1
When Hormonal Testing is NOT Required
Most women with androgenic alopecia have normal menses, normal pregnancies, and no signs of hyperandrogenism. 1 In these cases:
- The diagnosis is primarily clinical, based on the characteristic pattern of hair loss: increased thinning over the frontal/parietal scalp with greater density over the occipital scalp, retention of the frontal hairline, and presence of miniaturized hairs 1
- Early age of onset (between 12-40 years) and the specific distribution pattern are sufficient for diagnosis 1
- Extensive hormonal workup adds little diagnostic or therapeutic value in uncomplicated cases 1
When Hormonal Testing IS Indicated
Hormonal investigations should be pursued when symptoms and signs of androgen excess are present, including: 1
- Hirsutism (excessive terminal hair growth in male-pattern areas) 2
- Severe unresponsive cystic acne 2, 1
- Virilization (clitoromegaly, voice deepening) 2
- Galactorrhea 1
- Oligomenorrhea or amenorrhea (irregular or absent periods) 2
- Infertility 2
- Acanthosis nigricans (suggesting insulin resistance) 2
Recommended Hormonal Testing Panel
When testing is indicated, the following approach should be used:
First-Line Tests:
- Total testosterone (TT) and free testosterone (FT) measured by liquid chromatography with tandem mass spectrometry (LC-MS/MS) for highest accuracy 2
- If LC-MS/MS is unavailable, calculate the free androgen index (FAI) as an alternative 2
- Avoid direct immunoassay methods for free testosterone due to poor accuracy at low serum concentrations 2
Second-Line Tests (if TT/FT not elevated):
- Androstenedione (A4) 2
- Dehydroepiandrosterone sulfate (DHEAS) to assess adrenal androgen production 2
- LH/FSH ratio (>2 suggests PCOS) 2
Additional Screening Tests:
- Thyroid-stimulating hormone (TSH) to rule out thyroid disease 2
- Prolactin levels to exclude hyperprolactinemia 2
- Fasting glucose and 2-hour oral glucose tolerance test to screen for diabetes and insulin resistance 2
- Fasting lipid panel to assess cardiovascular risk 2
Clinical Significance of Hormonal Findings
Research demonstrates that abnormal hormone profiles occur in 67% of women with alopecia alone and 84% of women with alopecia plus other hyperandrogenism symptoms. 3 Specifically:
- Elevated 3α-androstanediol glucuronide (3α-AdiolG) correlates with severity of alopecia and reflects peripheral androgen metabolism 3
- Low sex hormone-binding globulin (SHBG) inversely correlates with alopecia severity 3
- These findings reflect the contribution of both secretory and metabolic components in alopecia development 3
Important Caveats
- SHBG fluctuations can affect total testosterone and FAI results, influenced by age, weight, and medications like oral contraceptives 2
- The presence of hormonal abnormalities helps identify underlying conditions (PCOS, nonclassic congenital adrenal hyperplasia, Cushing's syndrome, androgen-secreting tumors) that require specific management 2
- Rapidly developing symptoms or very high testosterone levels warrant investigation for androgen-secreting tumors 2
Treatment Implications
When hyperandrogenism is confirmed, combined oral contraceptives (COCs) are first-line treatment to regulate menstrual cycles and reduce hyperandrogenism. 2 Additionally, metabolic complications, particularly insulin resistance, should be screened for and managed with lifestyle modifications including diet and exercise for overweight/obese patients. 2