Hyperandrogenism

What is hyperandrogenism?

Hyperandrogenism happens when you have an excess amount of androgens in your body. Androgens are a group of sex hormones. They help start puberty and play a role in reproductive health and body development.

Hormones are chemicals that coordinate different functions in your body by carrying messages through your blood to your organs, muscles and other tissues. These signals tell your body what to do and when to do it.

Everyone makes androgens, but men or people assigned male at birth (AMAB) make more of them. Women or people assigned female at birth (AFAB) make about one-twelfth the amount of androgens of people AMAB. Testosterone is the most common androgen.

The testicles in the male reproductive system and the ovaries in the female reproductive system make androgens. Your adrenal glands, which sit on top of each of your kidneys, also produce these hormones. Other tissues, such as fat and skin, play roles in converting weak androgens into more potent (powerful) ones.

Hyperandrogenism causes different symptoms based on your age and sex. It has several possible causes and can be treated.

Is hyperandrogenism the same as PCOS?

While hyperandrogenism and polycystic ovary syndrome (PCOS) are closely connected, they’re not the same thing.

Hyperandrogenism is the defining sign of PCOS, a hormonal imbalance caused by the ovaries (the organ that produces and releases eggs) creating excess male hormones. It affects people AFAB.

While PCOS is a common cause of hyperandrogenism, hyperandrogenism can have other causes and can affect people AMAB. Similarly, PCOS has other symptoms aside from hyperandrogenism, including ovarian cysts.

Who does hyperandrogenism affect?

Hyperandrogenism can affect anyone — both children and adults. But it more commonly affects people assigned female at birth of reproductive age.

How common is hyperandrogenism?

Hyperandrogenism is fairly common in people assigned female at birth of reproductive age. It affects about 5% to 10% of that population.

Hyperandrogenism less commonly affects children and adults assigned male at birth.

What are the signs and symptoms of hyperandrogenism?

Hyperandrogenism has various symptoms depending on your sex and if you’ve been through puberty or not.

It’s important to note that you could have these symptoms of hyperandrogenism but have normal levels of androgens in your blood. This is because each of these symptoms has other possible causes. It’s also possible to have bloodwork tests show that you have high androgen levels while having mild or no physical symptoms.

If these symptoms develop rapidly and suddenly, it’s important to see your healthcare provider as soon as possible since the cause in this case is often an androgen-secreting tumor.

Symptoms of hyperandrogenism in pre-pubertal girls or children assigned female at birth (AFAB) include:

• Enlarged clitoris.
• Acne and oily skin.
• Excess body hair (hirsutism) that results in coarse, dark hair (instead of “peach fuzz”) on your upper lip, chin, chest, abdomen and/or back.

Symptoms of hyperandrogenism in pre-pubertal boys or children assigned male at birth (AMAB) include:

• Enlarged penis.
• Early or excess hair growth in the pubic area and armpits.
• Voice deepening.

Symptoms of hyperandrogenism in women or adults AFAB include:

• Acne and oily skin.
• Excess body hair (hirsutism).
• Abnormal menstruation (periods).
• Infertility.
• Androgenic alopecia (also known as male-pattern baldness).

In men or adults AMAB, the effects of hyperandrogenism depend on if the source of excess hormones is from your adrenal glands or an outside source (such as anabolic steroid injections). Elevated levels of adrenal androgens have few noticeable physical effects in adults AMAB, but it can suppress the function of your testes and cause infertility.

What causes hyperandrogenism?

In people assigned female at birth, the ovaries, adrenal glands and fat cells produce androgen hormones. In people assigned male at birth, the testicles and adrenal glands produce androgens.

There are also several other hormones that influence the production and release of androgens, such as luteinizing hormone (LH) and adrenocorticotrophic hormone (ACTH). Your pituitary gland releases both of these hormones.

If any one or more of these organs and/or hormones aren’t functioning properly, it can cause hyperandrogenism.

Hyperandrogenism has several possible causes, including:

• Polycystic ovarian syndrome (PCOS) — the most common cause.
• Congenital adrenal hyperplasia.
• Cushing disease.
• Androgen-secreting tumors.
• Certain medications.

Polycystic ovary syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is the most common cause of persistent hyperandrogenism beyond early puberty in adolescents and adults AFAB. Approximately 80% to 90% of people AFAB with hyperandrogenism have PCOS.

In PCOS, chronically elevated luteinizing hormone and insulin (hyperinsulinemia) levels lead to increased androgen production within your ovaries. In addition, hyperinsulinemia prevents your liver from producing sex hormone binding globulin (SHBG), which results in increased levels of free testosterone in your blood.

Congenital adrenal hyperplasia (CAH)

Congenital adrenal hyperplasia (CAH) consists of a group of genetic conditions affecting your adrenal glands.

In CAH, genetic mutations (changes) cause shortages of certain enzymes, such as 21-hydroxylase, that help your body produce needed hormones. For many people with CAH, the enzyme shortage causes their adrenal glands to overproduce other hormones, like testosterone.

Non-classical congenital adrenal hyperplasia, which involves a partial 21-hydroxylase deficiency, is the most common adrenal cause of hyperandrogenism. Approximately 2% of women or adults assigned female at birth with hyperandrogenism have late-onset nonclassical CAH.

Cushing disease

Cushing disease is a type of Cushing syndrome. Cushing syndrome is an uncommon syndrome that happens when your body has too much cortisol (a hormone).

Cushing disease is caused by a benign tumor located in your pituitary gland that releases too much ACTH (adrenocorticotropic hormone), which in turn increases cortisol.

Excess ACTH causes your adrenal glands to release excess androgens, which then causes hyperandrogenism.

Cushing syndrome has several other symptoms, including:

• Purple stretch marks across your belly.
• Rapid weight gain in your face, belly and neck.
• High blood pressure.

It’s important to see your healthcare provider as soon as possible if you have these symptoms.

Androgen-secreting tumors

Certain adrenal tumors and tumors in your ovaries or testicles can produce and release (secrete) androgens. This causes higher-than-normal androgen levels in your body. Hyperandrogenism caused by these kinds of tumors is often very severe and sudden.

Hyperandrogenism due to ovarian or adrenal tumors is rare. It’s responsible for only 0.2% of cases. But it’s important to see your provider right away if you have sudden symptoms of hyperandrogenism.

Certain medications

Certain medications can cause hyperandrogenism. The most common medications that cause it include:

• Anabolic-androgenic steroids (synthetic versions of testosterone that athletes sometimes misuse as performance-enhancing drugs).
• Synthetic progestins (medications that cause changes in the uterus and are used for multiple purposes).
• Antiepileptics (medications to prevent seizures).

How is hyperandrogenism diagnosed?

If you’re a woman or person assigned female at birth and are concerned you may have hyperandrogenism, your healthcare provider will perform a physical exam to assess the possible physical symptoms of hyperandrogenism, such as excessive body hair growth. They’ll also ask you several questions about your medical history, including:

• Your age when your breasts started to develop.
• Your age when you started to grow pubic hair.
• Your age when you had your first menstrual cycle (period).
• If you shave or have had laser hair removal.
• If you’ve used nonprescription anabolic steroids or testosterone.
• The frequency, length and heaviness of your periods.

If your provider suspects hyperandrogenism, they’ll likely order blood tests to measure certain hormone levels. These tests can help with a diagnosis.

What tests will be done to diagnose hyperandrogenism?

If you have signs or symptoms of hyperandrogenism, your provider may order certain blood tests, including:

• Total testosterone: This is the total amount of all the testosterone in your bloodstream. Total testosterone levels are often mildly elevated in people AFAB with PCOS. Highly elevated levels may indicate an ovarian or testicular tumor.
• Free testosterone: This testosterone is unattached to any proteins and is a small percentage of the total testosterone. Free testosterone levels may be elevated in people AFAB with PCOS.
• Androstenedione: Androstenedione is a steroid hormone that has weak, androgenic effects on your body. But it mainly acts as a stepping stone in the production of testosterone and estrogen within your body. Elevated levels may indicate PCOS.
• Dehydroepiandrosterone sulfate (DHEAS): DHEAS is a sex hormone that your adrenal glands release, so it’s a good marker for adrenal androgen production. A mildly elevated DHEAS level is common in people AFAB with PCOS. Highly elevated levels may indicate an adrenal tumor.
• 17-hydroxyprogesterone: Measuring levels of 17-hydroxyprogesterone in your blood is a screening test for non-classic congenital adrenal hyperplasia, which is one of the causes of hyperandrogenism.

Since each of the symptoms of hyperandrogenism has several other causes, your provider may order additional blood tests to rule out other possible causes of your symptoms.

Your provider may also order certain imaging tests to help diagnose the cause of hyperandrogenism, including:

• Pelvic ultrasound to look for ovarian cysts (another sign of PCOS) or tumors.
• Computed tomography (CT) or magnetic resonance imaging (MRI) scans to look for adrenal tumors.

Healthcare providers aim the medical treatment of hyperandrogenism at lowering ovarian or adrenal androgen production, reducing the free androgen levels and blocking the androgen action.

However, people with hyperandrogenism typically seek medical care for the treatment of its main symptoms, such as hirsutism, acne and irregular periods.

Medical treatment for hyperandrogenism

The medical treatment for hyperandrogenism depends on its cause. For example:

• Adrenal hyperandrogenism is slowed down by low-dose corticosteroids.
• Surgical removal may be necessary for ovarian, testicular or adrenal tumors. Oophorectomy (surgical removal of one or both ovaries) may be necessary for severe hyperandrogenism in menopausal or perimenopausal people.
• If you’re taking medications that are causing hyperandrogenism, your provider may recommend stopping the medication or taking a different one.

Antiandrogen drugs are also a common treatment for hyperandrogenism. They work by blocking the effects of androgens, such as testosterone.

Types of antiandrogen drugs include:

• Oral contraceptive (birth control pill) containing ethinyl estradiol (estrogen) and antiandrogenic progesterone: These include cyproterone acetate (co-cyprindiol or Diane®-35, Estelle® 35 and Ginet-84™), drospirenone (Yasmin®, Yaz®) or dienogest (Valette®). They can help treat acne, hirsutism and irregular periods.
• Spironolactone (Aldactone®): This antiandrogen treats hormonal acne and excessive body hair.
• Cyproterone: This medication can help treat PCOS, reduce testosterone levels and reduce the production of acne-causing oils.

Treatment of hyperandrogenism symptoms

People with hyperandrogenism may seek treatments specifically for their symptoms, including:

• Acne: Treatment for acne includes topical anti-acne agents, oral antibiotics such as tetracycline, antiandrogens (hormone therapy, including birth control pill) and isotretinoin pills.
• Hirsutism: Most people AFAB with hirsutism use physical methods of hair removal, such as waxing, shaving and laser hair removal. They may also take the birth control pill.
• Irregular periods: People AFAB may take hormonal birth control to try to regulate their periods.

When these symptoms are unresponsive to conventional therapy because of hormone imbalances, your provider may consider stronger antiandrogen medication.

Can hyperandrogenism be prevented?

Unfortunately, there’s no concrete way to prevent hyperandrogenism.

There’s no proven way to prevent PCOS, the most common cause of hyperandrogenism, but you can take small steps to reduce your symptoms. For example, eating nutritious foods, exercising regularly and managing your weight can help you reduce the effects of PCOS and hyperandrogenism.

What is the prognosis (outlook) of hyperandrogenism?

Therapies for most causes of hyperandrogenism are lifelong. In some cases, people AFAB with PCOS-related hyperandrogenism no longer have PCOS after significant weight reduction. Most people, however, need continued therapy throughout their lifetime to minimize signs and symptoms of hyperandrogenism.

The signs and symptoms of hyperandrogenism can affect your self-esteem and mental health. It’s important to see a psychologist or therapist if you’re experiencing stress, anxiety and/or depression due to these symptoms.

When should I see my healthcare provider about hyperandrogenism?

If you’ve been diagnosed with hyperandrogenism and are taking medication for it, you’ll likely need to see your healthcare provider regularly to make sure your treatment is working.

If hyperandrogenism is affecting your mental health, it’s important to see a psychologist or therapist for help.

A note from Cleveland Clinic

Hyperandrogenism is a fairly common condition in women or people assigned female at birth. While its signs and symptoms may make you feel embarrassed or ashamed, know that you’re not alone and that the condition is treatable. Talk to your healthcare provider about treatment options and be sure to see a psychologist or therapist if it’s affecting your mental health.