Clinical and Hormonal Evaluation of Androgen Excess

Abstract

Androgen excess (hyperandrogenism) is one of the most common endocrine disorders of women. Clinical features of hyperandrogenism include hirsutism, ovulatory and menstrual dysfunction, and in some patients acne and androgenic alopecia. Biochemically, hyperandrogenism can be established by the presence of supranormal circulating levels of total or unbound testosterone (T), androstenedione, or the adrenal metabolite dehydroepiandrosterone sulfate (DHEAS). Specific disorders that result in androgen excess include the 21-hydroxylase-deficient nonclassic adrenal hyperplasia (NCAH), ovarian androgen-secreting neoplasms (ASNs), adrenal ASNs with or without Cushing’s syndrome, adrenocorticotropin hormone (ACTH)-dependent Cushing’s syndrome, the hyperandrogenism, insulin resistance, and acanthosis nigricans (HAIR-AN) syndrome, and the use or abuse of androgenic drugs. However, the bulk of androgen excess is secondary to the polycystic ovary syndrome (PCOS). Although not properly an androgen excess disorder, idiopathic hirsutism (IH) should be considered in the differential diagnosis of these women. Conceptually, the general approach to patients with androgen excess entails five steps: (1) screening for androgen excess; (2) confirmation of clinical and/or biochemical androgen excess; (3) exclusion of specific androgen excess or related disorders (e.g., 21-hydroxylasedeficient NCAH, ASNs, thyroid dysfunction, or hyperprolactinemia); (4) classification of those patients without a specific androgen excess disorder (i.e., those with “functional” hyperandrogenism) as having PCOS, IH, or occasionally unspecified functional androgen excess; and (5) identification of related morbidities, such as metabolic abnormalities in patients with PCOS or HAIR-AN syndrome, and endometrial abnormalities in patients with long-term ovulatory dysfunction.