From the Guidelines
Elevated testosterone and DHEA in a 37-year-old female should be evaluated for polycystic ovary syndrome (PCOS) or other androgen-producing conditions, with initial workup including comprehensive hormone testing and pelvic ultrasound to assess ovarian morphology, as recommended by the 2023 International PCOS Guidelines 1. The diagnostic workup should prioritize the measurement of total testosterone (TT) and free testosterone (FT) using mass spectrometry, as these have been shown to have high diagnostic accuracy for biochemical hyperandrogenism in PCOS, with TT having a pooled sensitivity of 0.74, specificity of 0.86, and AUC of 0.87, and FT having a pooled sensitivity of 0.89, specificity of 0.83, and AUC of 0.85 1. If PCOS is diagnosed, first-line treatment typically includes:
- Lifestyle modifications with weight loss if applicable
- Oral contraceptives containing ethinyl estradiol with a progestin like drospirenone (Yaz, Yasmin) or norgestimate to reduce androgen levels
- Metformin 500mg twice daily may be added, particularly with insulin resistance
- Anti-androgens such as spironolactone 50-200mg daily can address hirsutism and acne Additional testing, including ACTH stimulation test and adrenal imaging, may be necessary if symptoms suggest adrenal hyperplasia or tumor, and Cushing's syndrome should be ruled out with overnight dexamethasone suppression test 1. It is essential to note that the association between acne severity and androgen levels remains unclear, and routine endocrinologic testing is not indicated for most patients with acne, but patients presenting with acne and clinical signs or symptoms of hyperandrogenism may warrant further endocrine testing for hyperandrogenism 1.
From the Research
Elevated Testosterone and DHEAS in a 37-Year-Old Female
- Elevated levels of testosterone and DHEAS in women can be indicative of various conditions, including polycystic ovary syndrome (PCOS) and androgen-secreting neoplasms 2.
- A study published in 1999 found that elevated circulating total testosterone levels and DHEAS levels can be used as screening methods for detecting ovarian and adrenal androgen-secreting neoplasms, respectively 2.
- However, the study also noted that the measurement of testosterone and DHEAS is not a cost-effective method of screening for these tumors due to the low frequency of the disorder and the fact that clinical evaluation alone is often sufficient screening 2.
Treatment Options for Elevated Testosterone and DHEAS
- Combined oral contraceptives (COCs) plus spironolactone have been shown to be effective in reducing testosterone levels and improving symptoms of PCOS, including hirsutism and menstrual dysfunction 3.
- Metformin, an insulin sensitizer, has also been used to treat PCOS and has been shown to improve insulin resistance, reduce testosterone levels, and increase ovulation and pregnancy rates 4, 5.
- A network meta-analysis published in 2020 found that atorvastatin, a statin, was more effective than other management strategies, including metformin, spironolactone, and COCs, in reducing total testosterone levels in women with PCOS 6.
Management of PCOS
- The choice of treatment for PCOS should be based on symptoms, with consideration of the potential benefits and risks of each treatment option 5.
- Combination treatment with metformin and COCs may be beneficial for women with PCOS, as it can target both hyperinsulinemia and hyperandrogenism, two major endocrine disturbances seen in PCOS 5.
- Further research is needed to define the optimal dosage and timing of metformin treatment in women with PCOS, as well as its potential role in reducing the risk of miscarriage and improving fertility outcomes 4.