Polycystic Ovary Syndrome (PCOS) is the most common cause of mildly elevated testosterone in females. However, it’s crucial not to assume that high testosterone levels are always due to PCOS, especially if androgen levels are very high and there is evidence of virilization.
Normal and Elevated Testosterone Levels
Normal testosterone levels for women are less than 1.5-2.0 nmol/L. PCOS rarely causes levels above 3.0 nmol/L and essentially never causes levels above 5.0 nmol/L, which is nearing the male range.
Virilization refers to the development of male characteristics such as deepening of the voice, significant male pattern balding, and clitoral enlargement. Testosterone levels above 5.0 nmol/L or signs of virilization should not be attributed to PCOS and should prompt investigation of other causes, particularly adrenal or ovarian hormone-producing tumors, which can be malignant.
Causes of Very High Androgens
1️⃣ Adrenal or Ovarian Hormone-Producing Tumors: Must be excluded with imaging as soon as possible due to the potential for malignancy, especially adrenal cancer.
2️⃣ Non-Classical Congenital Adrenal Hyperplasia: Diagnosed based on elevated 17-hydroxyprogesterone levels.
3️⃣ Ovarian Hyperthecosis Syndrome: Post-menopause proliferation of hormone-producing cells, difficult to diagnose as ovaries generally appear normal on ultrasound.
4️⃣ Exposure to Anabolic Steroids/Testosterone: Can occur if a partner is using topical testosterone or through contamination from gym supplements.
5️⃣ Severe Insulin Resistance Syndromes: Associated with severe diabetes, very lean body types, and acanthosis nigricans.
Key Takeaway
PCOS is a diagnosis of exclusion and, although common, it is almost never the cause of significantly elevated androgens. Symptoms such as increased body and facial hair, frontal balding, changes to voice, or genitalia can indicate elevated androgens due to serious conditions. These symptoms should be taken seriously by doctors, and important and common causes should be excluded.