What is the further workup for a woman with hyperandrogenism (elevated testosterone levels)?

Workup for Hyperandrogenism in Women

Measure morning total testosterone (8-10 AM) and repeat if elevated to confirm, then proceed with DHEAS, free testosterone or calculated free testosterone (cFT), and sex hormone-binding globulin (SHBG) to determine the source and severity of androgen excess. 1

Initial Laboratory Testing

First-Line Androgen Assessment

• Obtain morning total testosterone between 8 AM and 10 AM and repeat if elevated to confirm the finding, as testosterone levels can vary 1, 2
• Measure DHEAS when total testosterone is twice the upper limit of normal (or >2-3 SD above reference range) to distinguish adrenal from ovarian sources 3, 4
  • DHEAS >600 mg/dL suggests androgen-secreting adrenal cortical adenoma 3
  • Normal DHEAS with very high testosterone suggests ovarian hyperthecosis or androgen-secreting ovarian tumor 3

Free Testosterone Measurement

• Obtain free testosterone by equilibrium dialysis (gold standard) or calculated free testosterone (cFT) along with SHBG, especially in obese patients 1, 2
• cFT has pooled sensitivity of 0.89 and specificity of 0.83 for detecting biochemical hyperandrogenism 2
• Free androgen index (FAI) is an alternative with sensitivity of 0.78 and specificity of 0.85 2
• LC-MS/MS methods are superior to direct immunoassays for testosterone measurement, with higher accuracy 2

Assay Method Considerations

• If using immunoassays and results don't match clinical picture, consider diethyl ether extraction to rule out laboratory interference 4
• Direct immunoassays have lower specificity (0.78) compared to LC-MS/MS (0.92) or immunoassay after extraction (0.93) 2

Severity-Based Diagnostic Approach

Mild Hyperandrogenism (Testosterone <2x Upper Limit)

• Measure LH and FSH to evaluate for polycystic ovary syndrome (PCOS) 1
• Check 17-hydroxyprogesterone (17-OHP) to exclude non-classical congenital adrenal hyperplasia (NCCAH) 5
  • Elevated basal or ACTH-stimulated 17-OHP confirms NCCAH 5
• Measure prolactin to exclude hyperprolactinemia, particularly with recent-onset oligomenorrhea 5

Severe Hyperandrogenism (Testosterone >2-3x Upper Limit or Virilization)

• Immediately evaluate for androgen-secreting tumors of ovarian or adrenal origin 3, 4, 6
• Measure DHEAS, testosterone, 17β-estradiol, 17-OH progesterone, androstenedione, 11-deoxycorticosterone, progesterone when suspected adrenocortical carcinoma (ACC) or virilization is present 2
• Perform pelvic ultrasonography to evaluate for ovarian tumors 1
• Consider adrenal imaging (CT or MRI) when DHEAS is markedly elevated 2, 6

Additional Hormonal Testing

When Cushing's Syndrome is Suspected

• Perform 1 mg dexamethasone suppression test (DST) taken at 11 PM with serum cortisol measured at 8 AM 2
  • Cortisol <50 nmol/L excludes cortisol hypersecretion 2
  • Cortisol >138 nmol/L indicates cortisol hypersecretion 2
• Measure 24-hour urinary free cortisol if DST is abnormal 5

For Adrenal Incidentalomas with Hyperandrogenism

• Screen for pheochromocytoma with plasma or 24-hour urinary metanephrines if adrenal mass has ≥10 Hounsfield units on non-contrast CT 2
• Measure aldosterone/renin ratio if hypertension or hypokalemia is present 2

Imaging Studies

Ovarian Imaging

• Pelvic ultrasonography for suspected ovarian source (normal DHEAS with elevated testosterone) 1, 6
• Ovarian androgen-secreting tumors occur in 1-3 per 1000 patients with hirsutism 6

Adrenal Imaging

• Adrenal CT or MRI when DHEAS >600 mg/dL or suspected adrenal tumor 2, 6
• Adrenal tumors are less common than ovarian tumors but cause postmenopausal virilization 6

Important Clinical Caveats

Laboratory Interpretation Pitfalls

• Obesity lowers SHBG, which may affect total testosterone interpretation and falsely lower values 1, 3
• Normal testosterone with clear hyperandrogenic symptoms (hirsutism, acne) requires measurement of free testosterone or FAI, as SHBG is reduced in metabolic syndrome 3
• Commercial laboratory reference ranges (often up to 95 ng/dL) are too broad and miss 84% of hyperandrogenemia cases; upper limit should be approximately 28 ng/dL 7

Timing and Patient Preparation

• Ensure patient has been out of bed for 2 hours and seated for 5-15 minutes before aldosterone testing 2
• Potassium repletion and medication substitution may be needed for accurate hormonal assessment 2

Rapid-Onset or Severe Virilization

• Recent onset of severe hyperandrogenism with virilization demands urgent tumor evaluation 4, 5, 6
• Very high testosterone levels (>2-3 SD) without virilization should raise suspicion for laboratory interference 4

Baseline Assessments Before Treatment

• Measure hemoglobin/hematocrit as baseline 1
• Assess cardiovascular risk factors including lipids, blood pressure, and glucose 1
• Measure inhibin B in postmenopausal women with hyperandrogenism 6