ConditionHormones & metabolism
Androgen Excess (Hyperandrogenism)
Androgen excess, or hyperandrogenism, means the body makes too much of the "male" hormones such as testosterone, or is overly sensitive to them. In women it causes excess facial and body hair (hirsutism), acne, scalp hair thinning and irregular periods. Polycystic ovary syndrome (PCOS) causes most cases. Rarer causes include congenital adrenal hyperplasia and androgen-secreting tumors, which cause rapid virilization. Treatment combines lifestyle changes, birth control pills, anti-androgen medicines and hair removal.
Also called: Hyperandrogenism, high androgens, high testosterone in women, excess male hormones
At a glance
- What it is
- Too much androgen activity, causing hair growth, acne and period problems in women.
- Most common cause
- PCOS, responsible for roughly 3 in 4 cases.
- Other causes
- Nonclassic congenital adrenal hyperplasia, medicines, Cushing syndrome and rare tumors.
- Red flags
- Rapid onset, deepening voice, clitoral enlargement or very high testosterone.
- Treatment
- Weight management, combined birth control pills, spironolactone and laser hair removal.
When to get help
See a doctor within a day or two
- Rapidly worsening hair growth over weeks to months, especially with a deepening voice, increased muscle mass or enlargement of the clitoris (virilization)
- New androgen symptoms after menopause
- Signs of Cushing syndrome: rapid weight gain in the face and belly, purple stretch marks, easy bruising and muscle weakness
Book a routine appointment
- Excess hair on the face, chest, back or belly
- Persistent acne in adulthood that does not respond to usual treatment
- Irregular, infrequent or absent periods
- Thinning hair on the crown of the scalp
- Difficulty getting pregnant
What androgens do
Androgens include testosterone, dihydrotestosterone (DHT), DHEA-S and androstenedione. In women, they are made by the ovaries and adrenal glands in small amounts and are converted in the skin into DHT, which drives hair growth and oil production. Androgen excess can come from:
- too much production by the ovaries or adrenal glands
- less binding protein (sex hormone-binding globulin, SHBG), leaving more free testosterone, often due to insulin resistance and obesity
- increased skin sensitivity to normal androgen levels
Signs and symptoms
Skin and hair
- Hirsutism: coarse, dark hair in a male pattern on the upper lip, chin, chest, belly, lower back or thighs
- Acne, especially along the jawline and chin, often persisting past the teenage years
- Oily skin
- Female-pattern hair loss: thinning on the crown and widening part
Periods and fertility
- Irregular, infrequent or absent periods
- Difficulty ovulating and getting pregnant
Metabolic signs
- Weight gain around the belly
- Insulin resistance, sometimes with dark velvety skin in the neck or armpits (acanthosis nigricans)
Virilization (rare, more serious)
- Deepening voice
- Increased muscle bulk
- Enlarged clitoris
- Male-pattern baldness at the temples
- Decreased breast size
Virilization usually points to very high androgen levels from a tumor or untreated congenital adrenal hyperplasia.
Causes
| Cause | Typical features |
|---|---|
| Polycystic ovary syndrome | Starts around puberty, irregular periods, acne, hirsutism, often weight gain |
| Idiopathic hirsutism | Excess hair with normal periods and normal hormone levels |
| Nonclassic congenital adrenal hyperplasia | Genetic enzyme defect; similar to PCOS; more common in certain ethnic groups |
| Androgen-secreting ovarian or adrenal tumor | Rapid onset, virilization, very high testosterone or DHEA-S |
| Cushing syndrome | Weight gain, stretch marks, bruising, high blood pressure |
| Medicines | Testosterone, anabolic steroids, some progestins, valproate, danazol |
| Hyperprolactinemia and thyroid disease | Period problems, sometimes milky nipple discharge |
| Ovarian hyperthecosis | Usually after menopause, gradual virilization |
In men, androgen excess is uncommon and usually caused by anabolic steroid or testosterone use. In boys, early puberty from excess androgens needs specialist assessment.
Diagnosis
- History and examination: timing and speed of onset, periods, medicines and supplements, family history. Hair growth is scored with the modified Ferriman-Gallwey scale.
- Blood tests, ideally in the morning and early in the menstrual cycle: - total and free testosterone - DHEA-S (from the adrenal glands) - 17-hydroxyprogesterone (to screen for congenital adrenal hyperplasia) - prolactin and thyroid tests - pregnancy test, glucose and lipids - tests for Cushing syndrome if suspected
- Pelvic ultrasound to look at the ovaries.
- CT or MRI of the adrenal glands or ovaries if a tumor is suspected.
Treatment
Lifestyle
Losing 5% to 10% of body weight in people with overweight lowers insulin and free testosterone, improves periods and can reduce hair growth.
Medicines
- Combined oral contraceptive pills: first-line treatment. They reduce ovarian androgen production and raise SHBG.
- Anti-androgens such as spironolactone, usually added after 6 months if the pill alone is not enough. They must be used with reliable contraception because they can harm a male fetus.
- Eflornithine cream slows facial hair growth.
- Metformin may help insulin resistance and periods in PCOS.
- Glucocorticoids for congenital adrenal hyperplasia.
- Acne treatments and hair loss treatments such as minoxidil.
Medical treatment takes 6 months or more to show its full effect on hair, because hair grows slowly.
Hair removal
Shaving, waxing, threading and creams for quick results; laser hair removal and electrolysis for longer-lasting reduction. Laser works best on dark hair and light skin.
Surgery
Surgery is needed for androgen-secreting tumors.
Complications
PCOS-related androgen excess is linked with insulin resistance, type 2 diabetes, high cholesterol, sleep apnea, fatty liver, endometrial thickening from infrequent periods, and anxiety and depression related to appearance. Regular screening helps.
Frequently asked questions
What are the signs of too much androgen in women?
Common signs are excess dark hair on the face, chest or belly, persistent acne, oily skin, thinning scalp hair and irregular periods. Rare but serious signs include a deepening voice, increased muscle mass and enlargement of the clitoris, which need prompt medical assessment.
What is the most common cause of hyperandrogenism?
Polycystic ovary syndrome (PCOS) is by far the most common cause, accounting for most cases in women of reproductive age. Other causes include idiopathic hirsutism, nonclassic congenital adrenal hyperplasia, medicines, Cushing syndrome and, rarely, hormone-producing tumors.
How is high testosterone in women treated?
Treatment usually starts with lifestyle changes and a combined birth control pill, adding an anti-androgen such as spironolactone if needed. Hair removal methods help appearance. Underlying causes such as congenital adrenal hyperplasia or tumors are treated specifically.
Can androgen excess affect fertility?
Yes. Excess androgens, especially in PCOS, can stop regular ovulation, making it harder to get pregnant. Weight loss, ovulation-inducing medicines such as letrozole, and fertility treatments are effective for many women.
Sources
This guide was written from current patient and clinical guidance, including:
- Endocrine Society: Evaluation and treatment of hirsutism in premenopausal women (clinical practice guideline)
- Androgen Excess and PCOS Society: Position statements
- American College of Obstetricians and Gynecologists (ACOG): Polycystic ovary syndrome
- MedlinePlus (US National Library of Medicine): Hirsutism; Polycystic ovary syndrome
- NHS: Hirsutism