Hyperandrogenemia is a common hormonal disorder where the body has an excess of androgen hormones. These are a group of sex hormones including testosterone, androstendione, and dehydroepiandrosterone sulfate (DHEA sulfate). Free Androgen Index is the ratio of testosterone to sex hormone binding globulin (SHBG) and another indicator of hyperandrogenemia. Severe hyperandrogenemia occurs with highly elevated levels of androgen hormones.

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Impact of severe hyperandrogenemia on fertility

When you have too many androgen hormones, it can mess with your menstrual cycle. The cycle (number of days from the start of a period to the start of the next period) may become shorter or longer. Hyperandrogenemia also impacts ovulation, causing infrequent or missed ovulation. Without ovulation, it’s not possible to conceive.

Potential causes of severe hyperandrogenemia

Severe hyperandrogenemia may be due to:

  • Severe hyperinsulinemia (abnormally high levels of insulin in the blood due to insulin resistance) 
  • Severe hyperprolactinemia
  • Ovarian tumors
  • Nonclassic congenital adrenal hyperplasia (a genetic disorder affecting the adrenal glands)
  • Cushing’s syndrome (a condition in which the adrenal glands produce too much cortisol)
  • Anabolic steroids

While hyperandrogenemia usually happens in association with polycystic ovary syndrome (PCOS), severe hyperandrogenemia is rarely due to PCOS.

Symptoms of severe hyperandrogenemia

  • Acne
  • Severe hirsutism (excess hair growth on the face, neck, upper back, arms, legs, and chest)
  • Enlarged clitoris
  • Obesity
  • Ovarian tumors
  • Deeper voice
  • Increased muscle mass
  • Abnormal uterine bleeding
  • Irregular menstrual cycle and amenorrhea (missed periods)

Having excess androgen hormones is closely linked to weight gain.

Diagnosis of severe hyperandrogenemia

Severe hyperandrogenemia is diagnosed based on a blood test that measures your levels of androgen hormones and your symptoms.

The ACTH test is another blood test used to diagnose adrenal gland disorders. It measures the level of adrenocorticotropic hormone (ACTH) in the blood (a hormone produced by the pituitary gland which regulates cortisol) and can help to find the cause of hormonal imbalances.

When androgen levels are severely elevated, doctors may also order imaging tests to make a diagnosis, which can include:

  • Ultrasound
  • MRI scan of the abdomen
  • CT scan of the abdomen

These tests look for tumors which could be responsible for high levels of androgens in the blood.

If the cause for severe hyperandrogenemia can’t be found, you may be referred to a radiologist for an advanced blood test. During the test, blood is drawn from the arm and the adrenal and ovarian veins simultaneously to find the source of excess androgens.

Treatment to improve fertility

There are several ways to treat severe hyperandrogenemia to improve your symptoms and chances of conceiving. For instance, anti-androgens are a type of medication that bind to androgen receptors to block the effects of androgens on the body. These can be used in combination with oral contraceptive pills to suppress the production of androgen hormones by the ovaries, improve symptoms, and regulate the cycle within a few months.

If severe hyperandrogenemia is due to insulin resistance, metformin is an effective medication that can improve the body’s response to insulin and reduce androgen levels. Additionally, a low dose of glucocorticoids (such as cortisone) can decrease the adrenal glands’ production of androgens, normalize the menstrual cycle, and help with fertility.

There are also different medications you can take which trigger ovulation, such as clomiphene or letrozole. These increase your body’s production of reproductive hormones FSH and LH and have high success in helping women get pregnant.

Lifestyle changes are another key aspect of severe hyperandrogenemia treatment. Healthy nutrition can help to bring your hormones back in balance and normalize your cycle. Weight loss has been shown to decrease androgens and reduce hair growth in obese women (BMI > 30).

This article has been verified by a medical professional

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  • Ducie J and Altman K: “Severe Hyperandrogenism in a Patient: A Case Report.” Fert Stert. 2011;95(4):18-19. 
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  • ACTH blood test. Mount Sinai. Accessed 25 Oct 2022.
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  • The Practice Committee of the American Society for Reproductive Medicine: The evaluation and treatment of androgen excess. Fert Stert. 2006;86(5):S241-S247. 
  • Al K et al.: Validity of serum testosterone, free androgen index, and calculated free testosterone in women with suspected hyperandrogenism. Oman medical journal. 2012;27(6):471.
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