Androgen; Diagnosis

Androgen; Diagnosis

Your androgen levels may be normal, too high (hyperandrogenism) or too low (hypoandrogenism). A health care professional can assess whether your symptoms suggest abnormal levels and can order a blood test to measure hormone levels. But results from blood tests are often misleading, and may not be conclusive because there is no agreement on just what constitutes “normal” androgen levels in women. Plus, levels fluctuate depending on a woman’s age, the timing of her menstrual cycle and her menopausal status. Nonetheless, it is easier to diagnose androgen levels that are too high than levels that are too low.

If you suspect you have a hyperandrogenic condition, it is important to seek a diagnosis and develop and begin a treatment plan. Hyperandrogenism can produce bothersome cosmetic symptoms like unwanted hair on your upper lip and chin. Psychologically, the clinical manifestations of hyperandrogenemia (persistent acne, excess facial or body hair, alopecia — thinning of hair on the scalp and obesity) can be devastating to young girls and women of reproductive age, and may contribute to feelings of low self-esteem, anxiety, depression and anti-social behavior.

Hyperandrogenic conditions are also associated with serious health problems like insulin resistance (a precursor to diabetes), diabetes, and heart disease.

Hyperandrogenic syndromes often go undiagnosed, even though symptoms may be treated. For example, you may be treated for acne, without being evaluated for glucose tolerance or asked about menstrual regularity. It may be up to you to tie together some of your hyperandrogenic symptoms and ask for a more integrated evaluation and treatment approach.

The signs and symptoms of hyperandrogenism are:

Hirsutism (excess facial or body hair)

Persistent acne and/or oily skin

Alopecia (thinning hair on the head)

Insulin resistance

Acanthosis nigricans (raisin-like skin tags)

High blood pressure

Low HDL cholesterol (“good cholesterol”) and high LDL cholesterol (“bad cholesterol”)

Obesity around the mid-abdomen

Irregular or absent periods or frequent skipped cycles

Enlargement of the clitoris

Deep or hoarse voice

If your symptoms include irregular or absent periods, you may have polycystic ovary syndrome (PCOS) — the most common condition associated with hyperandrogenism. The menstrual irregularity indicates infrequent or absent ovulation, making PCOS a leading cause of female infertility, which is often treatable.

Some women with hyperandrogenism may experience spontaneous ovulation, and pregnancies may occur. However, women with high androgen levels also have an increased risk of miscarriage.

Hyperandrogenic symptoms may also be caused by a genetic disease called congenital adrenal hyperplasia (CAH), which affects about one in 14,000 women. Severe cases can result in such extreme effects as genital malformation and virilization (facial hair, acne) at a young age.

Milder cases may look a lot like PCOS, with symptoms possibly including facial hair, irregular periods and high blood pressure. Women with mild CAH may also be shorter than their parents, vulnerable to infections and have a somewhat “masculine build,” with square shoulders and narrow hips.

A thorough medical history and physical examination provide the most important initial diagnostic information. Laboratory tests usually serve to confirm the presence of hyperandrogenemia. A blood test for total and free testosterone may be ordered, as well as a lipid profile (to measure cholesterol levels), luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin and a fasting glucose test. Several endocrine function tests may also be ordered to determine the site(s) of abnormal androgen secretion, such as DHEAs. Thyroid tests are usually included in the evaluation.

Hormone therapy, which consists of either estrogen and progestin (referred to as hormone therapy, or HT) or estrogen–only therapy (ET) and birth control pills containing estrogen, are other treatment options. Oral estrogens boost sex hormone binding globulin (SHBG levels), thus reducing levels of free testosterone, which may be triggering symptoms. Glucocorticosteroids (often prescribed for asthma or inflammation) can also suppress production of androgens.

Androgen Deficiency

Androgen levels in women peak during their twenties. Then a decline in daily production begins that continues throughout a woman’s life. The only time a sudden drop off in androgen levels occur is in women who have had their ovaries removed (about half of all androgens are produced in a woman’s adrenal glands, and half in her ovaries.) By the time a woman reaches menopause, blood androgen levels are about half of what they were at their peak.

Low androgen levels in women during their reproductive years, as well as following menopause, result in three noticeable symptoms: low libido, fatigue and a reduced sense of well being. Low androgen levels also have been linked to bone loss and osteoporosis (a disease that causes thin, fragile bones), possibly explaining the phenomenon of bone loss in some women who receive estrogen therapy following menopause, or ovarian failure or surgical removal of the ovaries

Low sex drive and vaginal dryness are two common symptoms experienced by some women during the transition to menopause, making sex uncomfortable or painful. These changes have been related to low estrogen as well as low androgen levels. If you recognize any of the following changes, you should see your health care professional to discuss your concerns.

Have you noticed that it takes longer for your vagina to become lubricated before or during sex?

Have you noticed that the amount of vaginal lubrication is less?

Do you have discomfort or pain during vaginal penetration?

Do you have sex less frequently?

Do you and/or your partner wish you had sex more often?

Do you have difficulty reaching orgasm?

Has your desire for sex decreased?

To diagnosis androgen deficiency, your health care professional will consider symptoms such as low libido and fatigue. Other conditions that can cause similar symptoms will also need to be ruled out. Blood tests for testosterone and sex hormone binding globulin (SHBG) will likely be part of your evaluation. SHBG binds to testosterone, making it less available for influencing cellular actions.

Blood testing for testosterone in hypoandrogenic women is problematic. Health care professionals have not reached a consensus about what constitutes low levels in women, and levels at the lower end of the female range are difficult to measure. Some health care professionals use the lower fourth of the female range as a cutoff; others would consider therapy for symptomatic women whose levels fall below the midpoint of the normal female range for the particular test and lab used.

The causes of androgen deficiency are varied. The most common cause of low androgen is aging. If your symptoms bother you, you may want to talk to your health care professional about androgen replacement.

Androgen deficiency may be a problem if:

Your ovaries have been removed

You have undergone early menopause (generally defined as menopause occurring prior to age 40)

You have Turner’s syndrome, a genetic growth disorder that occurs in about one in 2,000 girls that arises when one, or part of one, of the two X chromosomes is missing (two X’s code for a female, an XY for a male). This is a condition in which the ovaries fail to develop.

You are postmenopausal

You have undergone chemotherapy or radiation treatment for cancer

Other conditions associated with low testosterone include hypothalamic amenorrhea (absence of menstrual periods resulting from excessive dieting and exercising) and hyperprolactinemia (characterized by high levels of prolactin, the hormone that drives milk production when a woman breastfeeds). Additionally, a variety of pituitary gland tumors are also associated with low testosterone (as well as other hormone) production.

Sometimes there is no obvious cause of androgen deficiency. Otherwise healthy women of reproductive age can suffer from low androgens, which can be diagnosed with blood tests and after other potential causes of low libido and fatigue are eliminated.

To exclude other potential causes of symptoms, your health care professional may ask you about past psychological or relationship problems and check for other potential causes of fatigue, such as hypothyroidism and iron deficiency.

If you are postmenopausal and are taking hormone replacement therapy (estrogen alone or an estrogen/progestin combination), your estrogen levels may be checked to ensure your estrogen dosage is high enough.

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Keywords: Androgens, androgen, androgen levels, low androgen levels, hyperandrogenism, hyperandrogenic, acne, ovaries, androgen deficiency, menopause, low libido, hormone therapy, estrogen, women

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