Practical Approach to Hyperandrogenism in Women

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madman

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INTRODUCTION

The word androgen is derived from the Greek words andros and genao, which translate to “a man” and “produce or create,” respectively. Hyperandrogenism is therefore any state with excess production of “male” hormones, although these hormones are normally found in women at lower levels. The most clinically relevant hormone in hyperandrogenism is testosterone, which is converted peripherally to dihydrotestosterone (DHT), its biologically active form. The most common symptom of hyperandrogenism in women is hirsutism, and the most prevalent cause is polycystic ovarian syndrome (PCOS).1 The approach to hyperandrogenism in women differs depending on the stage of the woman’s life. This article will serve as a concise review of hyperandrogenism in women at various stages of adult life.




*Physiology of Androgens in Women

*Genetics

*History/Physical

-Age
-Ethnicity
-Duration of symptoms


*The most common symptoms of hyperandrogenism in women are as follows:
-Hirsutism
-Alopecia
-Acne
-Oligomenorrhea/amenorrhea


*Diagnostic Evaluation
-Laboratory investigation
-Imaging


*Differential Diagnoses

Premenopausal hyperandrogenism

-Polycystic ovarian syndrome
-Idiopathic hirsutism
-Non-classic congenital adrenal hyperplasia


Postmenopausal hyperandrogenism
-Ovarian hyperthecosis
-Ovarian and adrenal neoplasms
-Iatrogenic hyperandrogenism
-Gestational hyperandrogenism


*Treatment

Medical management

-Lifestyle
-Oral contraceptives
-Antiandrogens
-Spironolactone
-Finasteride
-Cyproterone acetate
-Local/topical treatment
-Glucocorticoids
-GnRH agonists
-Medications that reduce insulin levels or improve insulin action





SUMMARY

The approach to hyperandrogenism in women varies depending on the woman’s age and severity of symptoms. Once tumorous hyperandrogenism is excluded, the most common cause is PCOS. Hirsutism is the most common presenting symptom. The woman’s concern about her symptoms plays an important role in the management of the disease. Although measurement of testosterone is useful in identifying an underlying cause, care must be taken when interpreting the less accurate assays that are available commercially. Surgical resection is curative in tumorous etiologies, whereas medical management is the mainstay for nontumorous causes.
 

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Fig. 1. Androgen synthesis in ovaries and adrenal glands. 3bHSD, 3b-hydroxysteroid dehydrogenase; CYP11A1, cytochrome P450 cholesterol side-chain cleavage; CYP11B1, cytochrome P450 11b-hydroxylase; CYP17A1, cytochrome P450 17a-hydroxylase/17,20-lyase; CYP19A1, cytochrome P450 aromatase demethylation/A-ring aromatization; FSH, follicle stimulating hormone; HSD11B2, 11b-hydroxysteroid dehydrogenase type 2; LH, luteinizing hormone; SULT2A1, sulfotransferase 2A1.
Screenshot (8680).png
 
Fig. 3. Diagnostic approach to hyperandrogenism in women.CT – computed tomography; MRI – magnetic resonance imaging; NCCAH – non-classic congenital adrenal hyperplasia; PCOS – polycystic ovarian syndrome; US – ultrasound. *CT contraindicated in pregnancy, $See text for details, #Measured by LC-MS/MS.
Screenshot (8682).png
 
CLINICAL CARE POINTS

*Age-based diagnoses are important considerations

*Exclude androgen-secreting tumors first

*Total testosterone is the best assay for hyperandrogenism

*Do not assess testosterone levels or ovarian morphology in a patient using any form of hormonal contraception

*Non-tumorous hyperandrogenism can be treated medically

*Total testosterone is the best assay for clinical hyperandrogenism
 
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