Hyperandrogenism: High Testosterone and DHEA in PCOS

Polycystic Ovarian Syndrome (PCOS) is one of the leading medical conditions now impacting women of reproductive age, and can also have substantial impacts on a woman’s physical and emotional well-being. We’ve already covered symptoms and diagnostic testing of PCOS here, but let's dive deeper into one key hormonal disruption that seems to be particularly troublesome for my patient population – hyperandrogenism.

​Hyperandrogenism is common in PCOS, often seen as elevated testosterone and DHEA levels on blood work. And while these two hormones are often seen as synonymous when evaluating total androgenic burden, there is a significant difference between the two. Testosterone and DHEA are both classified as androgenic hormones, however some women with PCOS may have elevated testosterone, with normal DHEA levels, and vice versa. You also don't have to have cysts on your ovaries to present with hyperandrogenism (in fact, only about 20% of women with high androgens have cystic ovaries), and cysts on your ovaries don't always mean you’ll have high androgens. Have I lost you yet?

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High androgens are often to blame for many symptoms seen in PCOS, including

• Long menstrual cycles or irregular ovulation patterns
• Hair growth in areas not common on women, such as the chin, chest, nipples and navel
• Hair loss
• Acne and oily complexion

Where Do Androgenic Hormones Come From?

There are two primary sources of androgenic hormones in women: the adrenal glands, and the ovaries. The adrenal gland is responsible for producing DHEA, and makes up on average ~ 25% of our overall androgen production.
The ovaries, on the other hand, are responsible for producing testosterone. Small amounts of testosterone production is normal, and necessary. In fact, I often see women with low testosterone present with depression, extreme fatigue and an overall low affect. In healthy women, their granulosa cells in the ovaries transform testosterone into estrogen to help maintain proper hormone balance.
There is also a third androgenic hormone produced by both the adrenal gland and the ovaries called androstenedione. An imbalance in androstenedione levels is sometimes found in women with PCOS.
Lastly, its worth mentioning the role of 17-OH progesterone, which is not an androgenic hormone, but is commonly elevated in PCOS. If you’re presenting with PCOS like symptoms, but blood work in normal, its worth having this hormone tested, as it can convert directly into androgens in the periphery.

How Is Hyperandrogenism Managed?

Of course, management for hormones always begins with testing to determine where (and if) there is an imbalance. Next, the cause of the imbalance needs to be identified. In some women, their hormonal imbalance could be highly processed western diets, lifestyle choices (heavy alcohol, sugar, caffeine), and/or a lack of exercise. For others, it may be genetic (some research suggests we’re born with it). More updated research looks at the role of oxidative damage and the microbiomes influence on hormones.
It is vital that the root causes to high androgen production be addressed. Treatment plans should always involve the following to support hyperandrogenism:

• Reductase inhibitors – certain herbs and vitamins can reduce the functioning of an enzyme known as 5-alpha-reductase. This enzyme is responsible for converting testosterone into dihydrotestosterone, which may product symptoms up to 2.5x stronger than testosterone alone, and is highly associated with androgenic alopecia.
• An antioxidant – resveratrol, vitamin D and NAC are a few of my favorites. More an d more evidence is pointing at chronic inflammation as an important factor in metabolic syndrome, insulin resistance, and PCOS/diabetes. These antioxidants help reduce oxidative stress, optimize egg quality, and support a healthy ovulation.
• Blood sugar stabilization – diet and exercise are the key to supporting blood sugar. It’s not about extreme restrictions, but more so about learning which foods are most likely to spike blood sugar levels and replacing them with foods from the same category to help support steady blood sugar levels.
• Weight management – about 50% of testosterone is made in adipose tissue in women. Weight loss will help reduce androstenedione’s conversion of testosterone levels in the periphery.

​It is worth noting that PCOS research is still ongoing. While there is still much to be learned, much information has been obtained to help develop effective treatments that do not require hormone replacement (i.e. the birth control pill). By addressing hormonal imbalances associated with PCOS, it also supports an overall risk reduction to comorbidities seen with PCOS, like cardiovascular disease and diabetes.
For further information about PCOS, or to find out if you may have hyperandrogenism, contact Dr. Courtney Holmberg, Naturopathic Doctor in Toronto at 647-351-7282 to schedule an appointment today!
 
Sources:
https://www.ncbi.nlm.nih.gov/pubmed/22835450
https://www.ncbi.nlm.nih.gov/pubmed/17392600