What Causes Elevated Testosterone in Women? A Doctor’s Guide

While testosterone is often thought of as a male hormone, it plays an essential role in women’s health as well. Testosterone in women is produced in the ovaries, adrenal glands, and peripheral tissues, and it is responsible for regulating libido, muscle mass, mood, and bone density. However, elevated levels of testosterone in women can lead to a variety of health problems, ranging from hirsutism (excessive hair growth) and acne to more serious conditions such as polycystic ovary syndrome (PCOS), infertility, and metabolic disorders.

Understanding the causes of high testosterone levels in women is crucial for healthcare professionals in diagnosing and treating underlying conditions. This comprehensive guide will explore the primary causes of elevated testosterone in women, the symptoms, diagnostic procedures, and treatment options available for managing the condition.

The Role of Testosterone in Women

Testosterone is one of several androgens (male hormones) that, while produced in smaller amounts in women compared to men, are vital for various physiological functions. In women, testosterone is involved in:

• Sexual health: It plays a role in libido and sexual satisfaction.
• Muscle and bone health: Testosterone supports muscle mass, strength, and bone density.
• Mood regulation: It contributes to mental well-being, helping to regulate mood and energy levels.

Normal testosterone levels for women typically range between 15 and 70 nanograms per deciliter (ng/dL). However, when these levels exceed the normal range, it can lead to hyperandrogenism, or an excess of androgens, which can trigger a variety of physical and metabolic symptoms.

Symptoms of High Testosterone in Women

Elevated testosterone levels in women can manifest through various symptoms, some of which may be subtle, while others are more pronounced. Recognizing these symptoms is key to early diagnosis and treatment.

Physical Symptoms

1. Hirsutism: Excessive hair growth in areas typically associated with male-pattern hair growth, such as the face, chest, and back.
2. Acne: Persistent or severe acne, particularly along the jawline or chin, is often linked to high androgen levels.
3. Alopecia: Thinning hair or male-pattern baldness, particularly around the crown of the head.
4. Deepening of the voice: A rare but notable symptom of elevated testosterone.
5. Increased muscle mass: Unexplained increases in muscle mass, especially if not related to exercise.
6. Oily skin: Androgens increase sebum production, which can lead to oily skin.
7. Enlargement of the clitoris: A less common but possible sign of high testosterone.

Reproductive Symptoms

1. Irregular menstrual cycles: High testosterone can disrupt the balance of hormones required for regular ovulation, leading to irregular periods or amenorrhea (absence of menstruation).
2. Infertility: Elevated testosterone can interfere with ovulation, making it difficult for women to conceive.

Psychological and Metabolic Symptoms

1. Mood swings: Elevated testosterone levels are associated with mood fluctuations, irritability, and even depression or anxiety.
2. Weight gain: Testosterone imbalances are linked to increased abdominal fat and difficulty maintaining a healthy weight.
3. Insulin resistance: High testosterone is often connected to insulin resistance, increasing the risk of type 2 diabetes.

Causes of High Testosterone in Women

Several underlying conditions and lifestyle factors can cause elevated testosterone levels in women. While some causes are related to hormonal imbalances, others involve genetic or environmental factors. Below are the most common causes.

1. Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is the most common cause of high testosterone levels in women, affecting an estimated 5% to 10% of women of reproductive age. PCOS is a hormonal disorder characterized by enlarged ovaries with small cysts, irregular periods, and excessive production of androgens.

How PCOS Causes High Testosterone

Women with PCOS have an imbalance in the regulation of the reproductive hormones luteinizing hormone (LH) and follicle-stimulating hormone (FSH), leading to increased ovarian production of testosterone. Additionally, insulin resistance is a common feature of PCOS, which can further exacerbate hyperandrogenism by stimulating the ovaries to produce more testosterone.

Symptoms of PCOS:

• Irregular or absent menstrual periods
• Hirsutism and acne
• Weight gain, particularly around the abdomen
• Difficulty conceiving
• Increased risk of type 2 diabetes and metabolic syndrome

Diagnosis: PCOS is typically diagnosed based on clinical symptoms, blood tests to measure hormone levels, and ultrasound imaging of the ovaries.

Treatment: Treatment for PCOS-related high testosterone may include oral contraceptives to regulate hormone levels, anti-androgen medications (e.g., spironolactone), and insulin-sensitizing drugs like metformin to address insulin resistance.

2. Congenital Adrenal Hyperplasia (CAH)

Congenital adrenal hyperplasia (CAH) is a genetic disorder affecting the adrenal glands, where a deficiency in enzymes needed for cortisol production leads to an overproduction of androgens, including testosterone.

How CAH Causes High Testosterone

In CAH, the adrenal glands compensate for the lack of cortisol by overproducing adrenal androgens. These excess androgens can cause virilization, leading to masculinization symptoms in women, such as deepening of the voice, hirsutism, and menstrual irregularities.

Symptoms of CAH:

• Virilization (development of male physical traits)
• Early onset of puberty
• Abnormal menstrual cycles
• Infertility

Diagnosis: CAH is typically diagnosed through blood tests measuring adrenocorticotropic hormone (ACTH) levels, cortisol, and androgens. Genetic testing may also confirm the diagnosis.

Treatment: Management of CAH usually involves glucocorticoid therapy to replace cortisol and suppress excess androgen production. Anti-androgen medications may also be prescribed to reduce symptoms.

3. Androgen-Secreting Tumors

Androgen-secreting tumors are rare, but they can occur in the ovaries or adrenal glands, leading to excessive production of testosterone. These tumors can cause rapid-onset virilization, with symptoms that may worsen quickly.

Symptoms of Androgen-Secreting Tumors:

• Rapid development of male characteristics (deep voice, clitoromegaly, hirsutism)
• Severe acne
• Unexplained weight loss
• Amenorrhea or irregular periods

Diagnosis: These tumors are diagnosed through blood tests showing abnormally high androgen levels and imaging studies (e.g., MRI, CT scans) to locate the tumor.

Treatment: The primary treatment for androgen-secreting tumors is surgical removal of the tumor. If the tumor is malignant, additional therapies such as chemotherapy or radiation may be required.

4. Cushing’s Syndrome

Cushing’s syndrome occurs when the body is exposed to high levels of cortisol for prolonged periods, either due to overproduction by the adrenal glands or the use of corticosteroid medications. This hormonal imbalance can lead to increased androgen production.

How Cushing’s Syndrome Causes High Testosterone

The overproduction of cortisol in Cushing’s syndrome can stimulate the adrenal glands to produce excess androgens, leading to elevated testosterone levels in women.

Symptoms of Cushing’s Syndrome:

• Weight gain, particularly around the abdomen and face (moon face)
• Thin skin and easy bruising
• Hirsutism and acne
• High blood pressure and high blood sugar levels
• Irregular or absent menstrual periods

Diagnosis: Cushing’s syndrome is diagnosed through blood and urine tests measuring cortisol levels, as well as imaging studies of the adrenal glands.

Treatment: Treatment may involve surgical removal of the adrenal gland tumor or discontinuation of corticosteroid medications. In some cases, medications to control cortisol production may be prescribed.

5. Hyperthecosis

Ovarian hyperthecosis is a rare condition in which the ovaries produce excessive amounts of testosterone due to the proliferation of testosterone-producing cells. It is more commonly seen in postmenopausal women and can cause significant virilization.

Symptoms of Hyperthecosis:

• Significant hair growth on the face, chest, and back
• Male-pattern baldness
• Deepening of the voice
• Enlarged clitoris

Diagnosis: Hyperthecosis is diagnosed through hormone level tests showing elevated testosterone and ultrasound imaging or biopsy of the ovaries.

Treatment: Treatment may involve surgical removal of the ovaries or medical therapies to suppress androgen production.

6. Medications and External Factors

Certain medications and lifestyle factors can also lead to elevated testosterone levels in women.

Medications:

• Anabolic steroids: These drugs are synthetic versions of testosterone and are sometimes misused to enhance muscle mass, leading to elevated testosterone levels.
• Hormonal therapies: Some medications used for hormone replacement therapy or the treatment of conditions like endometriosis can lead to increased testosterone levels.
• Corticosteroids: Long-term use of corticosteroids may contribute to hormonal imbalances, including increased androgens.

Lifestyle Factors:

• Obesity: Excess fat tissue can lead to increased androgen production, as fat cells can convert hormones into testosterone.
• Intensive exercise: While moderate exercise is beneficial, excessive physical activity, particularly strength training and bodybuilding, can increase testosterone levels.

Treatment: Adjusting medications and addressing lifestyle factors, such as weight management and exercise moderation, can help regulate testosterone levels.

Diagnostic Tests for High Testosterone in Women

When a woman presents with symptoms of elevated testosterone, healthcare providers typically begin with a thorough medical history, physical examination, and a series of diagnostic tests.

Blood Tests

• Total testosterone levels: This test measures the overall amount of testosterone in the bloodstream.
• Free testosterone: This measures the testosterone that is not bound to proteins in the blood and is more biologically active.
• Androgen panel: Additional androgens, such as DHEA-S (dehydroepiandrosterone sulfate), may also be measured to assess adrenal function.
• LH and FSH levels: These tests can help differentiate between ovarian and adrenal causes of high testosterone.
• Cortisol levels: To evaluate for conditions like Cushing’s syndrome.

Imaging Studies

• Pelvic ultrasound: This is often used to examine the ovaries for signs of PCOS or tumors.
• CT or MRI scans: These may be used to visualize the adrenal glands and detect potential tumors.

Treatment Options for High Testosterone in Women

The treatment for high testosterone in women depends on the underlying cause of the hormone imbalance. Treatment options may include:

1. Lifestyle Changes

For women with obesity or insulin resistance, lifestyle modifications such as weight loss, dietary changes, and increased physical activity can help lower testosterone levels and improve symptoms.

2. Medications

• Oral contraceptives: These are commonly used to regulate hormone levels in women with PCOS and other conditions causing hyperandrogenism.
• Anti-androgen medications: Drugs like spironolactone can block the effects of androgens and reduce symptoms like hirsutism and acne.
• Metformin: This medication, commonly used for type 2 diabetes, can help lower insulin levels and improve hormonal balance in women with PCOS.

3. Surgery

For women with androgen-secreting tumors, surgery to remove the tumor is often the most effective treatment. In cases of ovarian hyperthecosis, ovariectomy (removal of the ovaries) may be necessary.

Conclusion

High testosterone levels in women can result from a variety of underlying conditions, ranging from common disorders like PCOS to more rare causes such as androgen-secreting tumors or congenital adrenal hyperplasia. Recognizing the symptoms of hyperandrogenism and understanding its causes are critical for healthcare professionals in providing accurate diagnoses and effective treatments. By addressing the root cause of elevated testosterone levels, women can manage their symptoms, restore hormonal balance, and improve their overall health and well-being.