From the Guidelines
For a 41-year-old female with testosterone levels of 112.00 ng/dL, approximately double the normal range, without significant symptoms, I strongly recommend rechecking the testosterone level in 4-6 weeks, preferably in the morning when levels are most stable, as the initial step in evaluation. This approach is based on the understanding that isolated elevated testosterone levels may not necessarily indicate a pathological condition, and confirmation of the finding is essential before proceeding with further investigations 1.
When retesting, it is crucial to ensure the patient fasts for 8-12 hours and avoids strenuous exercise for 24 hours prior to blood draw to minimize potential influences on testosterone levels. Additionally, a thorough review of the patient's medication list is necessary to identify any potential causes of elevated testosterone, such as certain contraceptives, glucocorticoids, or anabolic steroids.
While waiting for the repeat test results, considering the patient's age and the absence of significant symptoms, it might be premature to order a wide range of additional tests. However, if the elevated testosterone level is confirmed, further evaluation including tests for free testosterone, DHEAS, androstenedione, 17-hydroxyprogesterone, and possibly a pelvic ultrasound should be considered to evaluate for conditions such as polycystic ovarian syndrome (PCOS) or adrenal/ovarian tumors, as suggested by the guidelines for investigating reproductive endocrine disorders 1.
It's also important to note that PCOS, a common cause of hyperandrogenism, is characterized by chronic anovulation, and its pathogenesis involves insulin resistance, hyperinsulinaemia, and metabolic dysregulation, which can have long-term consequences on morbidity, mortality, and quality of life 1. Therefore, even in the absence of significant symptoms, persistent elevation of testosterone warrants thorough investigation to rule out underlying conditions that may require treatment to prevent long-term metabolic and reproductive consequences.
From the Research
Diagnostic Approach
- The patient's testosterone level is double the normal level, but she does not exhibit significant symptoms of hyperandrogenism, such as hirsutism, acne, or virilization 2.
- According to the study by 2, clinical manifestations of hyperandrogenism include hirsutism, acne, androgenic alopecia, and virilization, but isolated presence of any of these manifestations is not used as a diagnostic criterion for hyperandrogenism.
- The study by 3 suggests that when evaluating a patient for hyperandrogenism, it is essential to assess the severity of symptoms, the time of onset, and the dynamics of symptom progression.
Differential Diagnosis
- The patient's high testosterone level could be indicative of an androgen-secreting ovarian tumor, although this is a relatively rare condition 3, 4.
- Other possible causes of hyperandrogenism include polycystic ovary syndrome, congenital adrenal hyperplasia, Cushing's disease, and acromegaly 3, 5, 6.
- The study by 5 notes that women with rapid onset of hirsutism over a few months or signs of virilization are at high risk of having an androgen-secreting tumor.
Next Steps
- Given the patient's asymptomatic presentation, a recheck of her testosterone level may be warranted to confirm the initial result and rule out any laboratory errors 2.
- If the high testosterone level is confirmed, further evaluation, including laboratory tests and imaging studies, may be necessary to determine the underlying cause of hyperandrogenism 3, 5.