Elevated testosterone Levels in Women with Hair Loss

Testosterone Levels in Women with Hair Loss

There are many causes of elevated testosterone levels in women. Slightly elevated levels can sometimes be considered 'normal' with no underlying issues to be concerned about. Many patients with increased androgen levels have polycystic ovarian syndrome (PCOS) or underlying endocrine issues such as Cushing syndrome. However, elevated but can sometimes be associated with serious underlying conditions, including cancer. Patients with rapid onset of symptoms and signs along with hormone levels that are well above normal need rapid medical attention for proper diagnosis.

What is the 'cut off' for normal?

There are no hard and fast rules when it comes to cut off numbers. A full story is needed from the patient including how fast the symptoms appeared and how many symptoms are present. Is it hair loss? Is acne present? How about increased hair growth on the face (i.e. hirsutism)? Is the patient menopausal or post menopausal? Are menstrual cycles regular? Has there been weight loss or gain? Does the patient have increasing pain anywhere ? How about fatigue levels?

Causes of elevated testosterone levels in women

There are many causes of elevated testosterone levels in women. Patients with high testosterone levels should be sure to make an appointment with their doctor to review causes. A full history and full examination will be needed and more blood tests may be needed as well. Repeating the testosterone is often advisable too given that it can vary quite a bit day to day. A measurement in the morning is advised.

The top 10 causes of elevated testosterone include

1. Just a normal level for the patient

2. Polycystic ovarian syndrome (one of most common causes)

3. Ovarian hyperthecosis

4. medication induced (androgen replacement, anabolic steroids)

5. Cushing syndrome

6. Congenital adrenal hyperplasia

7. Ovarian tumors

8. Adrenal tumors

9. Hyperthyroidism

10. Prolactinomas

Cancers of the adrenal gland and ovaries are a very rare cause

Cancers of the adrenal gland are rare and about 2 new cases are diagnosed every year per 1 million people. Cancers of the ovary are more common and currently ovarian cancer is the sixth most common cancer in women. Less than 1 % of patients presenting with hirsutism and other signs of hyperandrogegism have an ovarian or adrenal tumor - but it is important to diagnose early. 

Generally speaking a plasma testosterone concentration three times above the normal level (i.e. above 8.7 nmol/L or 200 ng/dL) with a normal DHEAS level raises the suspicion that the patient could have an underlying benign or malignant ovarian cause of their symptoms. Furthermore, a plasma testosterone concentration three times above the normal level (i.e. above 8.7 nmol/L or 200 ng/dL) with an elevated DHEAS level (above 16.3 umol/L or 600 ug/dL) raises the suspicion that the patient could have an underlying benign or malignant adrenal cause of their symptoms.It could of course be normal, but when levels are in this range - a full work up is mandatory. 

Further testing with elevated androgens 

Further testing may be advised depending on the degree of hormone elevation and associated signs and symptoms. As mentioned, a full history and physical examination are needed for all patients with elevated androgens. Generally a full hormonal panel with free and total testosterone, DHEAS, LH, FSH, estradiol, SHBG, prolactin, 17 hydroxyprogesterone and TSH are ordered. Other tests include AFP (alpha feto protein) and B-hCG may be ordered. A pelvic ultrasound or CT scan may be ordered for women with markedly elevated levels. Further stimulation and suppression testing (i.e a dexamethasone suppression test for a potential androgen secreting adrenal tumor) may be ordered upon referral to an endocrinologist. 

Conclusion

There are many causes of increased androgens in women. When associated with increased hair growth on the face, irregular periods, acne or hair loss, androgen hormone levels are frequently elevated. Conditions such as polycystic ovarian syndrome (PCOS) or ovarian hyperthecosis are common and frequently responsible. However, women with markedly evaluated androgen levels (especially three times above normal) require a full work up including referral to endocrinology, radiology and gynaecology specialists.

Reference

Pugeat M et al. Androgen secreting adrenal and ovarian neoplasms. Contemporary Endocrinology: Androgen Excess Disorders of Women: Polycystic Ovarian syndrome and other disorders. Second Edition. Humana Press.