Hyperandrogenism

What it is

Hyperandrogenism refers to an excess of androgens (steroid hormones such as testosterone, DHEAS, or androstenedione) relative to the reference values for a given person. It is one of the three diagnostic criteria for PCOS according to the Rotterdam consensus (2003), alongside oligo-ovulation and polycystic ovarian morphology.

To diagnose PCOS, at least 2 of these 3 criteria must be met — hyperandrogenism is therefore not mandatory, and its absence does not rule out PCOS.

Its two forms

Hyperandrogenism can present in two forms, which may coexist:

• Clinical — visible symptoms caused by androgen action on target tissues: acne (particularly along the jawline and lower face), hirsutism (excess hair growth in androgen-dependent areas: face, abdomen, back, thighs), androgenic alopecia (hair thinning at the crown or top of the scalp)
• Biochemical — elevated blood test levels (total testosterone, calculated free testosterone, DHEAS, androstenedione), sometimes without visible symptoms

It is possible to have significant skin symptoms with blood levels within the normal range (clinical hyperandrogenism without biochemical hyperandrogenism), and vice versa.

What amplifies it in PCOS

Several mechanisms contribute to hyperandrogenism in PCOS:

• Chronically elevated LH (luteinising hormone) stimulates ovarian theca cells to produce more androgens
• Insulin resistance — common in PCOS — directly amplifies ovarian androgen production
• Low SHBG (common in PCOS) increases the free and biologically active fraction of androgens, even when the total level remains within normal range

Key takeaways

• One of the 3 Rotterdam criteria for PCOS diagnosis
• Can be clinical (symptoms), biochemical (blood levels), or both
• Its absence does not rule out PCOS (phenotype D)
• Amplified by insulin resistance and low SHBG
• Diagnosis is established by a doctor, not by a single blood test