Hormone Journal

Hyperandrogenism

Medically reviewed by Hormone Journal Editorial Team · Last reviewed 2026-05-22

Hyperandrogenism is excess androgen activity in women — affecting up to 10% of reproductive-age females — causing hirsutism, acne, hair loss, and irregular periods.

What it is

Hyperandrogenism is one of the most common endocrine disorders in women of reproductive age, affecting an estimated 5–10% of this population, with polycystic ovary syndrome (PCOS) accounting for more than 70% of all cases. Also called androgen excess, hyperandrogenism refers to a state in which androgens — the hormone group that includes testosterone, dehydroepiandrosterone sulfate (DHEA-S), and androstenedione — are present at levels above the normal female range, or where tissues respond to them with abnormal sensitivity.

Although androgens are often labelled "male hormones," the ovaries and adrenal glands produce them in smaller amounts in women, where they support bone density, libido, and muscle maintenance. When production or tissue sensitivity tips past the normal threshold, the result is a recognizable cluster of signs: hirsutism (excess coarse facial and body hair), acne, androgenetic alopecia (scalp hair thinning), oily skin, menstrual irregularities, and, in severe cases, virilization.

A clinically important distinction exists between biochemical hyperandrogenism (elevated androgens on blood tests without visible signs) and clinical hyperandrogenism (visible physical signs with or without measurable hormone elevation). The two do not always align, partly because tissue sensitivity to androgens varies between individuals. Canadian patients are typically assessed through LifeLabs or Dynacare panels that measure total testosterone, free testosterone, DHEA-S, and sex hormone-binding globulin (SHBG).

Causes and mechanism

Excess androgens reach tissues through three routes: overproduction by the ovaries or adrenal glands, reduced clearance, or heightened receptor sensitivity in target tissues such as hair follicles and sebaceous glands.

CauseFrequencyKey mechanism
PCOS~70–80% of casesElevated LH signalling + insulin resistance drive ovarian androgen overproduction
Non-classic congenital adrenal hyperplasia (NCCAH)~5–10%21-hydroxylase deficiency diverts adrenal steroid precursors into androgen synthesis
Idiopathic hyperandrogenism~5–10%Normal measured androgens but increased peripheral tissue sensitivity
Cushing's syndromeUncommonAdrenal overactivity raises both cortisol and adrenal androgens
Androgen-secreting tumors (ovarian or adrenal)RareAutonomous androgen secretion; typically causes rapid-onset virilization
MedicationsVariableAnabolic steroids, danazol, valproate, some progestogens

Insulin resistance deserves particular attention: elevated insulin directly stimulates ovarian theca cells to produce testosterone and simultaneously suppresses SHBG, which raises the fraction of free (biologically active) testosterone even when total testosterone appears borderline.

Symptoms and diagnosis

Skin and hair signs are the most visible features. Hirsutism — coarse, dark hair in androgen-sensitive zones such as the upper lip, chin, chest, abdomen, and inner thighs — is graded using the Ferriman-Gallwey score, where a score above 8 is considered clinically significant in most populations. Jawline and chin acne that persists beyond adolescence, crown-pattern scalp thinning, and seborrhoea (excessively oily skin) are also common presentations.

Reproductive and metabolic signs include oligomenorrhoea or amenorrhoea, anovulatory cycles, and reduced fertility. Rapid-onset virilization — voice deepening, clitoral enlargement, marked muscle gain — is uncommon and should prompt urgent evaluation for an androgen-secreting tumor.

Diagnostic workup typically includes:

  1. Total and free testosterone (elevated in most true hyperandrogenism)
  2. DHEA-S (markedly elevated levels point toward an adrenal source)
  3. SHBG (low levels amplify free androgen bioavailability)
  4. Early-morning fasting 17-hydroxyprogesterone (screens for NCCAH)
  5. LH, FSH, prolactin, and TSH (to assess for PCOS, hyperprolactinaemia, thyroid dysfunction)
  6. Pelvic ultrasound (ovarian morphology; excludes ovarian tumors)
  7. ACTH stimulation test if 17-hydroxyprogesterone is borderline elevated

Treatment options

Treatment is guided by the underlying cause, the predominant symptoms, and whether pregnancy is desired.

For hirsutism and hormonal acne: Combined oral contraceptives are the standard first-line option for women not seeking pregnancy — they suppress LH-driven ovarian androgen production and raise SHBG, reducing free testosterone. Spironolactone (typically 50–200 mg/day) blocks androgen receptors in hair follicles and sebaceous glands and is highly effective for both hirsutism and acne; reliable contraception is required alongside it. Topical options include retinoids and azelaic acid for acne, and eflornithine cream for facial hirsutism.

For PCOS-related hyperandrogenism: Metformin addresses the insulin resistance that drives ovarian androgen excess. In overweight women with PCOS, even a 5–10% reduction in body weight can meaningfully lower testosterone levels and restore more regular cycles.

For NCCAH: Low-dose glucocorticoids (prednisolone or dexamethasone) suppress adrenal androgen overproduction.

For androgen-secreting tumors: Surgical removal is the primary treatment.

Cosmetic approaches — laser hair removal, electrolysis, waxing — manage hirsutism symptomatically but do not address the hormonal cause.

When to see a clinician in Canada

Seek assessment from a family physician, gynecologist, or endocrinologist if you notice excess facial or body hair that has developed or worsened over months, persistent jawline acne, crown-pattern scalp thinning, or irregular periods alongside any of these signs. Rapid-onset virilizing symptoms — voice changes, clitoral enlargement — warrant urgent referral to rule out a hormone-secreting tumor.

Hyperandrogenism is frequently underdiagnosed; symptoms are often dismissed as cosmetic. A targeted hormonal panel (available through LifeLabs or Dynacare across most provinces) can identify the cause and guide effective treatment. Canadian women can access initial assessment through their family physician, a SOGC-affiliated gynecologist, or virtual care platforms such as Felix, Maple, Cleo, Phoenix, or others — though complex cases involving possible tumor causes or NCCAH should be seen in person by an endocrinologist or reproductive endocrinologist.

Limitations and open questions

Research is still emerging on several aspects of hyperandrogenism. The optimal testosterone assay method remains debated — liquid chromatography-tandem mass spectrometry (LC-MS/MS) is more accurate than immunoassay for measuring low female-range testosterone, but it is not yet universally available through Canadian community labs. Cutoff values for "normal" female testosterone also vary between laboratories and assay platforms, which can complicate diagnosis.

The long-term cardiovascular and metabolic implications of untreated hyperandrogenism — independent of PCOS — are not fully characterized. Evidence on the role of anti-androgen therapy in reducing these risks is limited. Health Canada has not issued specific guidance on hyperandrogenism management separate from PCOS guidelines, and the SOGC's PCOS-focused recommendations do not fully address non-PCOS causes of androgen excess. For postmenopausal women, the clinical significance of mild androgen excess and when to treat it remains an area of active investigation.

FAQs

Is hyperandrogenism the same as PCOS?

They are related but not interchangeable. PCOS is diagnosed when at least two of three criteria are met: irregular periods, polycystic ovarian morphology on ultrasound, and clinical or biochemical hyperandrogenism. Hyperandrogenism is one possible feature of PCOS — but you can have PCOS without it, and you can have hyperandrogenism from entirely separate causes such as non-classic congenital adrenal hyperplasia or an androgen-secreting tumor. Roughly 70–80% of hyperandrogenism cases are PCOS-related, meaning a meaningful minority have a different underlying cause that requires its own workup.

Can hyperandrogenism be treated without medication?

For some women, particularly those with PCOS and insulin resistance, lifestyle changes can produce real hormonal improvements. A 5–10% reduction in body weight in overweight women with PCOS has been shown to lower testosterone levels and restore more regular cycles. A low-glycaemic diet reduces the insulin stimulus that drives ovarian androgen production. That said, for women with significant hirsutism, persistent acne, or anovulation, lifestyle changes alone are usually insufficient, and medical treatment — combined oral contraceptives, spironolactone, or metformin — is typically needed alongside them to achieve adequate symptom control.

Does hyperandrogenism affect fertility?

Yes. Elevated androgens disrupt normal follicle development and ovulation, leading to irregular or absent periods and anovulatory cycles that directly reduce the chance of conception. For women with PCOS-related hyperandrogenism who want to conceive, ovulation induction with letrozole is now the preferred first-line approach per current Endocrine Society guidance, with pregnancy rates per cycle significantly higher than with clomiphene in this population. Treating the underlying androgen excess — whether through weight loss, metformin, or other means — also improves ovulatory function over time.

Is spironolactone safe for treating hyperandrogenism in Canada?

Spironolactone is widely prescribed in Canada for hirsutism and hormonal acne and is generally well tolerated. Common side effects include increased urination, breast tenderness, and menstrual irregularities. Because spironolactone can feminize a male fetus, it must not be used during pregnancy, and reliable contraception is required for anyone who could become pregnant while taking it. Potassium levels should be monitored — particularly in the first few months — as the drug can cause hyperkalaemia, especially in women with kidney impairment. It is available as a generic in Canada and is covered under most provincial formularies when prescribed for an approved indication.

What blood tests diagnose hyperandrogenism, and can I get them in Canada?

The core panel includes total testosterone, free testosterone (or calculated free testosterone using SHBG), DHEA-S, and SHBG. Depending on clinical suspicion, a clinician may also order early-morning 17-hydroxyprogesterone (to screen for non-classic congenital adrenal hyperplasia), LH, FSH, prolactin, and TSH. These tests are available through LifeLabs and Dynacare across most Canadian provinces and are typically covered by provincial health insurance when ordered by a physician for a clinical indication. One practical caveat: immunoassay-based testosterone measurements — the most common method in community labs — are less accurate at the low levels typical of women than LC-MS/MS testing, which can occasionally lead to false-normal results in women with mild biochemical hyperandrogenism.

Sources

All glossary termsUpdated 2026-05-22