Symptoms of Very High Testosterone Levels
The clinical presentation of elevated testosterone differs dramatically by sex: in women, hyperandrogenism causes hirsutism, acne, menstrual irregularities, and androgenic alopecia, while in men, symptoms are less pronounced and may include acne, male-pattern baldness, and prostate enlargement. 1
Symptoms in Women
Dermatologic Manifestations
- Hirsutism (excessive terminal hair growth in male-pattern areas such as face, chest, and abdomen) is the hallmark sign of hyperandrogenism in women 1
- Persistent or severe acne, particularly if resistant to standard dermatologic treatments, is a significant indicator 1
- Androgenic alopecia (male-pattern hair loss with frontal and vertex thinning) occurs due to androgen effects on scalp hair follicles 1, 2
- Seborrhea (increased sebum production) commonly accompanies other cutaneous signs 2
Virilization Signs (Severe Hyperandrogenism)
- Clitoromegaly (clitoral enlargement) indicates more severe androgen excess 1
- Deepening of the voice occurs with androgen-secreting tumors 3
- Development of male body habitus with increased muscle mass 4
Menstrual and Reproductive Dysfunction
- Oligomenorrhea (infrequent menstrual periods) is a common presenting symptom 1
- Amenorrhea (complete absence of menstruation) indicates significant hormonal disruption 1
- Infertility or difficulty conceiving results from chronic anovulation 1
Metabolic Signs
- Truncal obesity with central fat distribution is frequently observed 1
- Acanthosis nigricans (dark, velvety skin patches in body folds) indicates insulin resistance accompanying hyperandrogenism 1
Symptoms in Men
Dermatologic Manifestations
- Acne is more prevalent in men with elevated total and free testosterone levels, particularly in younger patients 5
- Androgenic alopecia (male-pattern baldness) is characteristic of elevated dihydrotestosterone (DHT) levels 5
- Increased facial and body hair growth 6
Prostate Effects
- Prostate enlargement occurs with chronically elevated testosterone, particularly in older men with elevated sex hormone-binding globulin (SHBG) 5
- Benign prostatic hyperplasia symptoms may develop, though testosterone replacement studies show variable effects on voiding symptoms 3
Other Manifestations
- Increased lean muscle mass and strength 6
- Decreased fat mass 6
- Increased sexual desire 6
- Testicular atrophy can occur with exogenous testosterone use due to suppression of gonadotropins 3
Critical Diagnostic Considerations
When to Suspect Pathologic Hyperandrogenism
- Rapid onset of virilization symptoms suggests androgen-secreting tumor rather than polycystic ovary syndrome (PCOS) 1
- Very high testosterone levels (>200 ng/dL or twice the upper limit of normal in women) warrant immediate evaluation for adrenal or ovarian tumors 7
- Elevated DHEAS (>600 μg/dL) indicates adrenal source and raises concern for adrenocortical carcinoma 3, 7
Age-Related Patterns
- In peripubertal girls, premature pubarche (early pubic hair development) is the most common presentation 4
- In reproductive-age women, PCOS accounts for 95% of hyperandrogenism cases 1
- In older men, elevated total testosterone may reflect increased SHBG rather than true hyperandrogenism 5
Important Clinical Pitfalls
Normal total testosterone does not exclude hyperandrogenism - free testosterone or free androgen index should be measured when clinical signs are present, as SHBG reduction (common with obesity, metabolic syndrome, or insulin resistance) can lower total testosterone while free testosterone remains elevated 7
Exogenous androgen use (anabolic steroids, supplements, or testosterone therapy) must be excluded as a cause of hyperandrogenism symptoms 1
Polycythemia (elevated hematocrit) develops in men receiving testosterone therapy, with incidence ranging from 2.8% to 43.8% depending on formulation and dose 3