Hyperandrogenism is a hormonal disturbance associated with high levels of androgens in the body. Androgens are sex hormones, with the most relevant one being testosterone.
Hyperandrogenism can occur in people of any sex, although it’s more common and noticeable in individuals assigned female at birth. Symptoms of hyperandrogenism vary depending on the underlying cause but may include acne, irregular menstrual periods, and hirsutism (excessive hair growth on the face and body).
This article will review what hyperandrogenism is, its potential causes, accompanying symptoms, and treatment.
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A Note on Gender and Sex Terminology
Verywell Health acknowledges that sex and gender are related concepts, but they are not the same. To accurately reflect our sources, this article uses terms like “female,” “male,” “woman,” and “man” as the sources use them.
What Causes Hyperandrogenism?
The testicles and ovaries make androgens, with the testicles typically producing much more than the ovaries. This is a reason why they have been referred to as “male” hormones in the past. Androgens are also produced by the adrenal glands (located on top of the kidneys), skin, and fat tissue in people of any sex.
The pituitary gland, which sits just below the brain, produces hormones that influence the release of androgens from the above organs and glands. For example, the pituitary gland releases adrenocorticotrophic hormone (ACTH), which controls adrenal gland androgen production.
Hyperandrogenism has several causes. While not a complete list, potential causes include:
- Polycystic ovarian syndrome (PCOS) is the most common cause of hyperandrogenism. It’s associated with excess testosterone production by the ovaries and characteristic “cysts” (fluid-filled sacs) on the outer edges of the ovaries.
- Cushing disease is a non-cancerous tumor in the pituitary gland that produces too much ACTH, triggering excess androgen and cortisol (stress hormone) release.
- Congenital adrenal hyperplasia (CAH) is a rare genetic condition associated with impaired hormone production in the adrenal glands.
- Ovarian hyperthecosis is a disorder of severe hyperandrogenism caused by clusters of cells in the ovaries that produce androgens.
- Androgen-producing tumors are abnormal tissue masses within the ovaries, testicles, or adrenal glands that release male sex hormones.
- Certain medications like Danocrine (danazol) and androgen steroids like testosterone or DHEA supplements can cause androgen excess.
Is Hyperandrogenism the Same as PCOS?
Hyperandrogenism describes a state of androgen excess in the body, whereas PCOS is a medical condition. Nevertheless, hyperandrogenism is a hallmark feature of PCOS and the basis for the majority of the condition’s symptoms.
Who Does Hyperandrogenism Affect?
Depending on the underlying cause, hyperandrogenism can affect both children and adults. It can affect people of any sex, although it’s more common and noticeable in females of reproductive age.
Signs and Symptoms of Hyperandrogenism
Factors like sex, age, and the underlying cause affect the symptoms a person with hyperandrogenism may experience.
PCOS Symptoms
PCOS is the most common cause of hyperandrogenism, affecting around 6% to 15% of females in their childbearing years.
Symptoms of PCOS most commonly include acne, hirsutism, male-pattern balding, and irregular, infrequent, or absent menstrual periods. They usually begin around puberty but can also develop in early adulthood.
Hirsutism
Hirsutism describes excess body and facial hair in a distribution more typical for adults assigned male at birth, including thick, dark hair on the chest, stomach, upper arms, inner thighs, upper lip, and chin.
In addition to the above symptoms, many people with PCOS are overweight or have obesity. They are also vulnerable to developing type 2 diabetes, fatty liver, and mood disorders like anxiety and depression.
Cushing Disease Symptoms
Cushing disease can occur in people of any sex but is more common in females than males. It also usually affects adults, although it can develop in children.
Hyperandrogenism symptoms are prominent in females and include mild hirsutism on the face, scalp hair thinning, acne, and irregular menstrual periods. Males may also have acne.
Cushing syndrome is also associated with high cortisol levels, resulting in:
- Unusual weight gain, notably on the face, upper back, and neck,
- Skin changes, namely wide purple stretch marks across the abdomen and easy bruising
- Muscle weakness in the upper arms and legs
- Bone thinning (osteoporosis)
- High blood pressure
CAH Symptoms
Congenital adrenal hyperplasia affects 1 in 14,000 to 18,000 births and is usually caused by a partial or total deficiency of the 21-hydroxylase enzyme. The 21-hydroxylase enzyme produces various essential hormones in the adrenal gland, and symptoms vary depending on the degree of enzyme deficiency.
Classic CAH is associated with androgen excess and a deficiency of glucocorticoids (which regulate the immune system and metabolism) and mineralocorticoids (which control salt and water balance) in the body.
Females with classic CAH are usually diagnosed at birth due to ambiguous genitalia. The clitoris may be enlarged, resembling a penis, and the labia may be fused, resembling a scrotum. Males with CAH have typical-appearing genitalia.
Adrenal Crisis in Classic CAH
People of any sex with classic CAH can develop adrenal crisis, a life-threatening condition characterized by dehydration, low sodium levels, high potassium levels, and low blood sugar levels.
Non-classic CAH is a milder form of the disease and usually becomes evident in later childhood or adolescence. Symptoms can include:
- Premature puberty, which refers to pubic and underarm hair before age 8 in girls and 9 in boys
- Rapid growth and tall stature in childhood
- Acne in adolescents of any sex
- Hirsutism, menstrual irregularities, and voice deepening in teenage females
Ovarian Hyperthecosis Symptoms
Ovarian hyperthecosis occurs almost entirely in people with ovaries who have gone through menopause. People with this condition often report a history of slowly worsening acne and hirsutism, followed by more severe symptoms like male-pattern hair loss, enlarged clitoris, voice deepening, and increased muscularity.
In addition to the above symptoms, nearly all people with this condition have obesity and insulin resistance (the body does not respond to insulin as it should).
Androgen-Producing Tumor Symptoms
Androgen-producing tumors of the adrenal gland, ovary, or testicle are infrequent causes of hyperandrogenism. They can develop in children or adults. They may occur due to an ovarian tumor in postmenopausal people.
Symptoms of androgen-producing adrenal and ovarian tumors tend to be severe and manifest rapidly.
In young children (before puberty), symptoms may include an enlarged clitoris or enlarged penis. Excessive and early hair growth in the pubic area and underarms may also be present.
In adult females, symptoms can include significant hirsutism, a receding hairline, severe acne, increased muscle mass, enlarged clitoris, irregular menstrual periods, and voice deepening.
Very rarely, a person with a testicular tumor may develop signs and symptoms of excess androgen. These include premature puberty in children, weight gain, body odor changes, and a decreased sex drive in adults.
Summary of Hyperandrogenism Symptoms
Possible symptoms and signs of hyperandrogenism include:
- Hirsutism
- Irregular or absent menstrual periods
- Acne and oily skin
- Male-pattern balding
- Voice deepening
- Increased muscularity
- Enlargement of the clitoris or penis
- Fertility issues
- Premature puberty
How Is Hyperandrogenism Diagnosed?
If you think you (or your child) have symptoms or signs of hyperandrogenism, it’s important to see a healthcare provider.
During the diagnostic process, a provider will:
- Review your medical history and symptoms
- Check for abnormalities in a physical examination
- Evaluate the results of various tests, including blood work and possibly imaging tests
Medical History and Physical Exam
When evaluating for possible hyperandrogenism, a provider will ask about menstruation and fertility issues (if applicable) and the timing and presence of potential androgen-related symptoms like acne and hirsutism.
They will also inquire about medications/supplements and obtain a family history of hormone conditions.
During the physical exam, the provider will check for symptoms and signs of elevated androgen levels, such as premature puberty in children and acne, thinning scalp hair, increased body/facial hair, and deepening of the voice in females. An external genital exam may also be performed.
Blood Tests
Several different blood tests may be ordered to help sort out whether hyperandrogenism exists and, if so, the underlying cause.
Examples of such blood tests include:
- Total testosterone is normal or mildly elevated in PCOS and significantly elevated in ovarian hyperthecosis and ovarian tumors producing androgens.
- Dehydroepiandrosterone sulfate (DHEAS) is an androgen sex hormone released by the adrenal glands. It can be mildly elevated in PCOS and markedly elevated with an adrenal gland tumor.
- 17-hydroxyprogesterone is elevated in congenital adrenal hyperplasia.
- Blood cortisol levels and ACTH levels are elevated in Cushing’s disease.
Imaging Tests
Imaging tests are also often a component of the diagnostic process for hyperandrogenism. They may include:
- A pelvic ultrasound uses sound waves to take images of the reproductive organs. It’s used to evaluate “polycystic” ovaries in PCOS, enlarged ovaries in ovarian hyperthecosis, and ovarian tumors.
- An adrenal computed tomography (CT) scan uses X-rays to create 3D images of the adrenal glands. It can help identify an androgen-producing adrenal tumor.
- A magnetic resonance imaging (MRI) scan of the pituitary gland uses magnetic and radio waves to evaluate Cushing’s disease or other pituitary gland tumors.
Treatment Options for Hyperandrogenism
The treatment of hyperandrogenism depends on the underlying cause and may involve medication, surgery, lifestyle behaviors, or some combination.
Managing PCOS can be particularly complex, requiring an individualized approach. Therapies can include:
- Combination birth control pills to regulate menstrual periods
- Birth control pills or an anti-androgen drug called Aldactone (spironolactone) to treat hirsutism or acne
- Weight loss to manage insulin resistance and other symptoms if overweight or obese
- Femara (letrozole) if fertility issues are present
Surgery is generally the treatment of choice for Cushing’s disease, ovarian hyperthecosis, and androgen-secreting tumors.
If a medication is the hyperandrogenism culprit, stopping it under the guidance of a healthcare provider is advised.
Lastly, for classic congenital adrenal hyperplasia, the treatment is taking “steroids” like hydrocortisone and fludrocortisone to replace the deficient adrenal gland hormones.
Steroids or birth control pills (in females) may also be taken in those with non-classic congenital adrenal hyperplasia who have symptoms or signs of hyperandrogenism.
Managing the Effects of Hyperandrogenism
Some females experience symptoms of hyperandrogenism but have normal blood and imaging tests, indicating that their symptoms—often acne and hirsutism—are not due to a medical condition but rather due to their underlying genetic makeup or lifestyle factors like diet or stress.
The good news is that there are many cosmetic and medical strategies available to help manage symptoms of hyperandrogenism, even after optimizing treatment of the underlying cause (if one is present).
These might include:
- Hair removal strategies, either temporary or permanent, like threading, waxing, electrolysis, or laser therapy
- Scheduling an appointment with a dermatologist for acne: Several treatment options exist, including topical (on the skin) therapies and antibiotics.
- Talking with a therapist for emotional guidance or mood changes like anxiety or depression
- Seeing a registered dietitian nutritionist (RDN) to help you adopt eating habits based on health and weight loss goals
Complications and Long-Term Outlook
Potential complications and long-term outlook for hyperandrogenism depend on numerous factors, including cause and the promptness, extent, and quality of care provided.
As an example, complications of PCOS may include problems with fertility, issues with self-esteem and mood, and the development of future health problems like type 2 diabetes.
The best thing you can do is adopt a willing and proactive attitude in your (or your loved one’s) care. Find an experienced primary care physician, hormone specialist (endocrinologist), or surgeon (depending on the circumstance) with whom you are comfortable communicating.
Summary
Hyperandrogenism is a phenomenon of excess androgen sex hormones in the body. Symptoms vary based on factors like sex, age, and the degree of androgen excess but commonly include acne, excess hair growth, and irregular menstrual periods.
There are numerous potential causes of hyperandrogenism, including polycystic ovarian syndrome, genetic conditions like congenital adrenal hyperplasia, medications, and adrenal or ovarian tumors.
The diagnosis of hyperandrogenism requires a careful medical history, physical exam, blood tests (e.g., total testosterone), and imaging tests (e.g., pelvic ultrasound).
Treatment depends on the underlying cause and may involve medication like birth control pills to regulate menstrual cycles. Lifestyle and cosmetic strategies like weight loss and hair removal are also often implemented. Surgery is performed for rarer causes like androgen-producing tumors.
