Androgens & PCOS: Excess Levels & What It Means

PCOS and Other Possible Causes of Hyperandrogenism

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Elevated androgens are one of the three possible defining signs of polycystic ovarian syndrome. According to the most commonly used diagnostic criteria, a woman must have two out of the following three to be diagnosed with PCOS: irregular or absent menstrual cycles, polycystic ovaries (as seen on an ultrasound), or evidence of hyperandrogenism.

What are androgens? What does it mean when they are elevated, and what androgen levels are normal? Is PCOS the only condition that leads to elevated androgens in women?

What Are Androgens?

Androgens are often referred to as the “male” hormones, but these hormones are present and essential in both men and women. They are vital to normal reproductive function, emotional well-being, cognitive function, lean muscle function and growth, and bone strength. In fact, you may be surprised to learn that women have more androgens than estrogens circulating in their body. (That said, men overall produce more androgens than women.)

Androgens play many roles in the human body. Some androgen hormone effects include the stimulation of body and pubic hair growth, sexual desire (libido), muscle growth, and fat cell action and location. In both men and women, androgens are the precursor to estrogens. The androgen-into-estrogen action is one of the primary roles of androgen hormones in women.

In women, androgen hormones are created in the adrenal glands, the ovaries, and in fat cells.

The androgen hormones include:

What Is Hyperandrogenism?

Hyperandrogenism is when androgens are higher than they should be or there are clinical signs that androgens are higher than they should be. Even though men have naturally higher levels of androgens, hyperandrogenism can occur in both men and women.

The majority of women with hyperandrogenism have PCOS. That said, there are other possible causes of hyperandrogenism that must be ruled out before a diagnosis of PCOS can be made. (More on that below.)

There are two “kinds” of hyperandrogenism: clinical and biochemical. Having either kind may qualify a woman as having PCOS. Clinical hyperandrogenism is when there are visible signs or symptoms that indicate that androgen production may be higher than expected. These are things that can be seen or experienced without medical testing. Biochemical hyperandrogenism is when lab work shows abnormally 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, and it’s possible to have labs indicate excess androgens but there be little to no clinical signs.

What Are the Clinical Signs of Hyperandrogenism?

Clinical signs include:

Abnormal hair growth on the face, chest, or back: Hair growth usually associated with men, like facial hair or chest hair, can be a clinical sign of hyperandrogenism. The medical term for this is hirsutism. Between 75 and 80 percent of women with male-like hair growth have PCOS, but not all women with PCOS experience this symptom. Many women remove this excess hair growth and may not realize it’s a potential symptom of a medical problem. Be sure to tell your doctor if you’re experiencing hirsutism.  

Acne: Acne during adolescence is common in teenage boys and girls. Even in adulthood, mild acne is not considered to be abnormal. However, moderate to severe acne, especially when accompanied by other troublesome symptoms, can be an indicator of excess androgens.

Male pattern-balding: Both men and women may experience hair loss as they age. However, when women experience “male pattern balding,” especially at a younger age than might be expected, this can be a possible sign of clinical hyperandrogenism.

Male-pattern balding is when hair loss occurs either by the hairline, resulting in a receding hairline, or when balding occurs on 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: This is when a woman develops traits associated with men, like a deepening voice or more male-like muscle growth. While this is a possible clinical sign of hyperandrogenism, it is not usually seen with PCOS. Other possible causes of hyperandrogenism should be considered.

Biochemical Hyperandrogenism

Biochemical hyperandrogenism is when blood work indicates that androgen levels are higher than normal. Testing androgen levels when making a diagnosis of PCOS is important. Even if there are clinical signs of hyperandrogenism already evident, blood work can help rule out other possible causes of hyperandrogenism.

Below are the androgens that may be tested and what levels are normal. The normal ranges may vary with the lab, so always consult with your doctor when trying to understand your own results.

Normal Ranges of Androgens

Total testosterone: Levels should be between 6.0 and 86 ng per dl in women. In PCOS, total testosterone may be slightly elevated. Extremely high levels of total testosterone may indicate an androgen-secreting tumor.

Free testosterone: Normal levels of free testosterone are between 0.7 and 3.6 pg per mL. Free testosterone levels may be elevated in PCOS.

Androstenedione: Normal levels in women are between 0.7 to 3.1 ng per mL. Elevated levels may indicate PCOS.

DHEA-S: Normal levels in women are between 35 and 430 ug/dl. Women with PCOS may have levels over 200, which fall within the normal but high range. Extremely high levels of DHEA-S may indicate an androgen-secreting tumor.

Can You Still Have PCOS But Have Normal Androgen Levels?

Maybe your doctor has diagnosed you with PCOS, but you see that your labs indicate normal levels for androgens. Does this mean you don’t have PCOS? This is a somewhat complicated question because not everyone agrees on how to diagnosis PCOS.

Most experts say that increased androgen levels are not necessary to be diagnosed with PCOS. However, the Androgen Excess (AE) and PCOS Society argues that irregular cycles and polycystic ovaries, without also excess androgens, is not enough to qualify as a diagnosis of PCOS.

However, here are some things to keep in mind. One, the most commonly used diagnostic criteria used for PCOS—the Rotterdam criteria—indicates that either biochemical or clinical signs of hyperandrogenism qualify.

In other words, for example, let’s say you have facial or chest hair. This is a clinical sign of hyperandrogenism. You don’t also need to have elevated labs to quality for the diagnosis of PCOS. Secondly, also according to the Rotterdam criteria, you don’t have to have elevated androgens to be diagnosed with PCOS.

If you have irregular (or absent) periods and polycystic ovaries, and there is no other explanation found for your irregular periods, you may receive a diagnosis of PCOS even if you don't have elevated androgens or any clinical signs of hyperandrogenism.

Other Diseases and Conditions With Elevated Androgens in Women

PCOS is partially a diagnosis of elimination. Before your doctor can say you have PCOS, she needs to confirm your symptoms can’t be explained by another hormonal disorder. Specifically, when it comes to androgens, there are two possible other causes of hyperandrogenism that your doctor will want to check for: congenital adrenal hyperplasia and Cushing’s disease.

Congenital adrenal hyperplasia (CAH) is an inherited disease that results in abnormal functioning of the adrenal glands. Men and women with CAH are missing a vital enzyme that impairs to production and regulation of certain hormones. One of the possible hormones affected are androgens.

Most people born with CAH are diagnosed when they are young, but there is a milder variation of the disease and doesn’t produce obvious symptoms until later in life. This is sometimes known as late-onset CAH or non-classic CAH. The symptoms of non-classic CAH can be very similar to PCOS. Before your doctor can diagnose you with PCOS, non-classic CAH should be ruled out first.

Cushing’s disease is another syndrome that can lead to symptoms similar to PCOS. Cushing’s disease occurs when the body is exposed to high levels of cortisol over an extended period of time. This can happen due to long-term oral steroid use, or it can also occur if the body itself creates the excess cortisol.

When the body itself causes Cushing’s syndrome, it may be caused by a non-cancerous tumor on the pituitary gland or adrenal gland. This growth may produce abnormally high levels of an androgen hormone, adrenocorticotropic hormone (ACTH). The excess androgens can be mistaken for PCOS. This is why Cushing’s disease must be ruled out first.

Other Health Issues Caused by Elevated Androgens

Increased androgen levels can cause irregular cycles, embarrassing symptoms (like facial hair growth), and infertility in women. But they are also responsible for some of the other risk factors that often accompany PCOS.

Fat distribution: Androgens seem to play a role in where fat is stored in the body. Have you ever noticed that men tend to carry fat mostly in their belly region, and women tend to carry fat in the buttocks and thighs? Elevated androgens may lead women to carry more fat in their abdominal region.

Obesity is a risk factor for PCOS. That said, it's also possible for lean or normal-weight women to have PCOS.

Insulin resistance: Insulin resistance is a risk factor of PCOS. Excess androgens may play a role. It has been found that women with higher levels of androgens tend to also be at a higher risk of insulin resistance.

Do the higher androgen levels cause insulin resistance? That isn’t entirely clear yet. However, some studies have indicated that reducing elevated levels of testosterone in women also helps reduced/improve insulin resistance. 

Cardiovascular problems: Having either abnormally high or low levels of androgens is associated with an increased risk of cardiovascular problems in women.

Treating Excess Androgens Associated with PCOS

Treatment of hyperandrogenism typically focuses on treating problematic symptoms. This will vary from person to person since PCOS and hyperandrogenism don’t always present the same way.

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

Birth control: For women who aren’t trying to get pregnant, hormonal birth control pills may be used to reduce androgens and also treat symptoms. Combined estrogen-progesterone birth control is usually 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 with the least unwanted side effects.

Not everyone does well on birth control, however, and some prefer to avoid taking hormonal medications. This is also not a solution for women trying to get pregnant.

Anti-androgen drugs: Another possibility is anti-androgen medication. These are drugs that reduce the effects of excess androgens circulating in your body. They may be used alone or in combination with birth control pills.

Anti-androgen drugs include spironolactone, CPA, and flutamide. Spironolactone may be used to treat irregular hair growth (hirsutism). CPA 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.

Anti-androgen drugs cannot be used if you are trying to get pregnant or not taking birth control. They can harm the unborn baby, most especially baby boys.

Insulin reducing drugs: Metformin may also be used to treat PCOS-related androgen symptoms, including unwanted hair growth and acne. Metformin can also be taken when you’re trying to conceive and is sometimes used as part of a fertility treatment protocol.

Hair removal: Directly removing unwanted hair growth is also an option. 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 are unlikely to make a significant difference. If hormonal treatments are not an option, seeing a dermatologist may be helpful. There are prescription treatments that may be more effective than what you can get at the local drug store.

A Word From Verywell

Hyperandrogenism is the cause of some of the more embarrassing and visible symptoms of PCOS. You may not have been aware that your chest or facial hair were possible symptoms of a medical problem. Be sure to let your doctor know if you’ve been having difficulties like these. This information can help in making a diagnosis. PCOS does not have a cure, but there are treatments available to reduce your symptoms. Some of these treatments are cosmetic and available over the counter, like acne creams and hair removal methods. But your doctor may be able to prescribe creams or medication to help, too.

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