Androgens & PCOS: Excess Levels & What It Means

PCOS and Other Possible Causes of Hyperandrogenism

High levels of sex hormones called androgens are a defining sign of polycystic ovary syndrome (PCOS), a hormonal disorder that impacts individuals assigned female at birth. Other symptoms of PCOS include irregular or absent periods, as well as cysts or small sacs found in the ovaries, which are glands that produce eggs.

This article explains the signs and symptoms of high levels of androgens, or hyperandrogenism, and how these can impact PCOS. It will also cover what else can cause high androgen levels, how these levels can impact your overall health, as well as treatment options.

What Are Androgens?

Androgens are essential hormone that help with:

  • Reproductive function
  • Emotional well-being
  • Mental sharpness
  • Muscle function and growth
  • Bone strength
  • Body and pubic hair growth
  • Sexual desire, or libido
  • Fat cell action and location

In those assigned female at birth, androgen hormones are created in fat cells and the ovaries. They are also made in the adrenal glands, which are located above the kidneys and are responsible for releasing various hormones.

Androgen Hormones

Androgen hormones are steroid hormones, which are a group of hormones that are released by the ovaries, testes, or adrenals. These include:

  • Androstenediol (A5), which is used to make the sex hormones estrogen and testosterone
  • Androstenedione (A4), which is used to make estrogen and testosterone
  • Androsterone, a byproduct of testosterone breaking down
  • Dehydroepiandrosterone sulfate (DHEAS), which is made into estrogen or testosterone
  • Dihydrotestosterone (DHT), a byproduct of testosterone
  • Testosterone, which is associated with the development of sex characteristics, bone health, and sex drive

What Is Hyperandrogenism?

Hyperandrogenism is when androgens are higher than they should be.

There are two kinds of hyperandrogenism and both kinds may qualify an assigned female as having PCOS:

  • Clinical hyperandrogenism is when there are visible signs or symptoms that show that androgen production may be higher than expected. These can be seen or experienced without medical testing.
  • Biochemical hyperandrogenism is when lab work shows high levels of androgen hormones in the bloodstream.

It is possible to have clinical signs of hyperandrogenism and for all blood work to come back normal. It is also possible to have labs indicate high androgen levels, with little to no clinical signs.

Signs of Hyperandrogenism - Illustration by Joules Garcia

Verywell / Joules Garcia

What Are the Signs and Symptoms of Hyperandrogenism?

Signs and symptoms of hyperandrogenism may include abnormal hair growth, acne, male pattern baldness, and virilization, which is when assigned females develop traits associated with assigned males.

Abnormal Hair Growth

Hair growth usually associated with assigned males, like facial hair or hair on the chest and back can be a sign of hyperandrogenism. The medical term for this is hirsutism. Between 50 and 80 percent of assigned females with this type of hair growth have PCOS. However, not all individuals with PCOS experience this symptom.

Some individuals remove this type of hair growth and may not realize it’s a potential symptom of a medical condition. Be sure to tell your healthcare provider if you’re experiencing this.  

Acne

In adulthood, mild acne is not considered abnormal. However, moderate to severe acne, especially when accompanied by other symptoms, may indicate high levels of androgens.

Male Pattern Balding

Individuals may experience hair loss as they get older. However, when assigned females experience hair loss that looks similar to “male pattern balding,” this may be a sign of hyperandrogenism.

Male-pattern balding is when hair loss occurs either by the hairline, resulting in a receding hairline, or around the crown of the head. This is different than female pattern balding, where hair thins out on the top of the head, but the hairline itself remains unchanged.

Virilization

Virilization is when assigned females develop traits associated with assigned males. These may include a deepening voice and muscle bulk. While this is a possible clinical sign of hyperandrogenism, it is not usually seen with PCOS.

Recap

Signs and symptoms of hyperandrogenism may include hirsutism, acne, hair loss, and virilization.

How Are Androgen Levels Tested?

When diagnosing PCOS, it's important to test androgen levels. This is done through blood work. What is considered within the normal range for androgens will vary based on the specific lab, so be sure to discuss your results with your doctor.

Normal Ranges of Androgens

Total testosterone: This is the total amount of all the testosterone in your bloodstream. Levels should be between 6.0 and 86 nanograms per deciliter (ng/dl) in assigned females. In PCOS, total testosterone may be slightly elevated.

Free testosterone: This testosterone is unattached to any proteins and is a small percentage of the total testosterone. Normal levels of free testosterone are between 0.7 and 3.6 picograms per milliliter (pg/mL). Free testosterone levels may be elevated in PCOS.

Androstenedione: Normal levels in assigned females are between 0.7 to 3.1 ng/mL. Elevated levels may indicate PCOS.

DHEAS: For assigned females in their 20s, a normal level is usually in the high 300s. Those in their 30s may have normal levels in the 200s.

How Do I Interpret My Lab Results?

If your healthcare provider has diagnosed you with PCOS, but your lab results show normal androgen levels, you may feel confused. Keep in mind that not everyone agrees on how to diagnosis PCOS:

  • Some healthcare providers say that you don't need high androgen levels to be diagnosed with PCOS.
  • The Androgen Excess and PCOS Society argue that excess androgens are necessary to qualify for a diagnosis of PCOS.
  • One of the most commonly used diagnostic criteria used for PCOS—the Rotterdam criteria—notes that either lab work or visible signs of hyperandrogenism qualify. They also don't require elevated androgen levels for a diagnosis.

If you have infrequent periods that are more than 35 days apart and occur only four to nine times a year, you may receive a diagnosis of PCOS, even without high androgen levels or any visible signs of hyperandrogenism.

What Else Can Cause High Androgen Levels?

The majority of assigned females with hyperandrogenism have PCOS. That said, there are other possible causes of hyperandrogenism which can lead to symptoms similar to PCOS:

  • Congenital adrenal hyperplasia is a group of inherited conditions where certain enzymes that help make hormones are missing from the body. These conditions affect the adrenal glands and can impact the body's ability to make androgens, along with other hormones.
  • Cushing's disease occurs when the body has too much cortisol, a stress hormone, either by overproduction or via medication. Overproduction may be caused by a growth on the adrenal gland or pituitary gland, which helps with hormone regulation. This growth may lead to high levels of a hormone that helps with cortisol production which can increase androgens.

What Health Issues Are Caused by High Androgens?

In assigned females, increased androgen levels can lead to irregular periods, facial hair growth, and difficulty becoming pregnant. These high levels are also responsible for some other risk factors that often accompany PCOS.

Fat Distribution

Androgens seem to play a role in where fat is stored in the body. Assigned males tend to carry fat mostly in the belly region, while assigned females tend to carry it around the buttocks and thighs. High androgen levels can lead assigned females to carry more fat in their stomach region.

Keep in mind that obesity is a risk factor for PCOS. That said, it's also possible for lean assigned females to have PCOS.

Insulin Resistance

The risk of insulin resistance is higher in assigned females with PCOS and it is thought that androgen levels play a role in this. Insulin resistance is when the body doesn't respond to the hormone insulin like it should. Insulin helps the body control blood sugar levels.

Some studies have indicated that reducing elevated levels of testosterone in women helps reduce or improve insulin resistance. 

Cardiovascular Problems

Having either abnormally high or low levels of androgens is associated with an increased risk of heart problems in assigned females.

Recap

Health issues associated with high androgen levels for assigned females include:

  • Fat distribution shifting from thighs and buttocks to stomach
  • Heart problems
  • Insulin resistance


How Is Hyperandrogenism Treated?

Treatment for hyperandrogenism will vary since PCOS and hyperandrogenism don’t always present the same way.

All treatments have their advantages and disadvantages, and medications may carry side effects and risks. Be sure to talk to your healthcare provider about which option may be best for you.

Birth Control

For those who aren’t trying to get pregnant, hormonal birth control pills may be used to reduce androgens and treat symptoms. Combined estrogen-progesterone birth control may be tried first to treat PCOS symptoms. But, you may need to try a few options before finding the birth control that helps you feel best.

Not everyone does well on birth control and some prefer to avoid taking hormonal medications.

Anti-Androgen Drugs

Another possible treatment is anti-androgen medication, which reduces the effects of excess androgens. This may be used alone or in combination with birth control pills. They should not be used if you are trying to get pregnant.

Anti-androgen drugs include:

  • Spironolactone may be used to treat irregular hair growth, or hirsutism.
  • Cyproterone acetate may be used along with birth control pills to treat unwanted hair growth and acne.
  • Flutamide, a drug usually used to treat prostate cancer, may be used in PCOS to treat hirsutism.

Insulin Reducing Drugs

Metformin, which improves insulin sensitivity, may be used to treat PCOS-related androgen symptoms, including unwanted hair growth and acne. Metformin can also be taken if you’re trying to get pregnant.

FDA Warning

On May 28, 2020, the Food and Drug Administration issued a warning about potential elevated nitrosamine impurity levels in certain lots of extended-release metformin. If you take metformin, do not stop taking your medication, but contact your doctor about this warning to see if you need to take a different medication.

Hair Removal

Some may choose to directly remove unwanted hair growth, but keep in mind that most of these options will only work temporarily. Some possibilities include waxing, threading, laser hair removal, and electrolysis. 

Acne Treatments

There are a number of over-the-counter acne treatments, but for those with PCOS-related acne, these may not make a significant difference. You may want to see a dermatologist, a doctor who specializes in treating skin, hair, and nails. They may prescribe you treatments that are more effective than over-the-counter options.

Recap

Hyperandrogenism may be treated with birth control, anti-androgen drugs, insulin reducing drugs, hair removal methods, and acne medications.

Summary

Hyperandrogenism describes when androgens are higher than they should be. Visible signs of hyperandrogenism and/or blood work that shows high levels of androgens can qualify an assigned female as having PCOS.

Symptoms of hyperandrogenism may vary from person to person. Congenital adrenal hyperplasia and Cushing's disease may also cause hyperandrogenism and can trigger symptoms similar to PCOS.

Treatment may include various medications, as well as hair removal methods.

A Word From Verywell

Hyperandrogenism is the cause of some of the more visible symptoms of PCOS. These may lead to feelings like embarrassment or frustration, and may even reduce your quality of life. Be sure to let your healthcare provider know if you’ve been having difficulties with these symptoms.

While PCOS does not have a cure, there are treatments available to reduce your symptoms.

Frequently Asked Questions

  • Where is androgen produced in assigned females?

    Androgens are produced in the ovaries and in the adrenal glands.

  • How can you naturally decrease elevated androgens?

    One study found that almonds decreased levels of androgens in individuals with PCOS. Another study found that drinking spearmint herbal tea for 30 days led to a significant decline of testosterone levels. Eating nutritious foods and maintaining a healthy weight are also thought to help minimize PCOS symptoms.

  • What causes high androgen levels in PCOS?

    When the ovaries and adrenals experience a disruption in their functioning, they may overproduce androgen.

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