If you suffer hair loss, facial hair (hirsutism), or acne, then you know all about androgen excess. Androgen means “male-hormone”, and your doctor may have gone so far as to test you for testosterone and other androgens. Or she may not have bothered to test, and simply diagnosed you based on symptoms. Either way, she probably prescribed an androgen-suppressing drug such as spironolactone.
But let’s think this through a bit more. Why do you have androgen excess? What else can you do about it?
Birth Control with High Androgen Index
The simplest and most preventable cause of androgen excess is hormonal birth control. Some (not all) types of birth control use synthetic progestins that have a “high androgen index”, which means they are testosterone-like. They are androgenic and promote hair-loss, and this effect is well known amongst the medical community — but rarely mentioned to patients.
Are you taking a “testosterone-like” birth control? Read the label.
Progestins with a high androgen index include medroxyprogesterone (Depo-provera injection), levonorgestrel (many pills, Norplant implant, Mirena IUD, and morning-after pill), norgestrel, and etonogestrel (many pills, Nuvaring, Nexplanon implant).
Progestins with a low androgen index include drospirenone (which is spironolactone), norgestimate, and cyproterone, and of course natural progesterone. The body’s own progesterone is anti-androgenic because it inhibits 5 alpha-reductase, which is why natural progesterone is good for hair.
Treatment is to switch birth control. Choose a less androgenic progestin, or even better: Choose a non-hormonal method such as Fertility Awareness Method, condoms, or copper IUD. Once you stop the progestin, your androgen symptoms should subside, but unfortunately, hair loss can sometimes endure for months or even years.
Hypersensitivity to a Normal Amount of Androgen
A slightly more perplexing cause of excess androgens is an apparent hypersensitivity of the androgen receptor. This is the diagnosis when there are high androgen symptoms but normal levels of androgens on a blood test. When hair loss is the main symptom, androgen hypersensitivity is called androgenic (or androgenetic) alopecia.
Androgen hypersensitivity is surmised to be genetic, but that explanation is not very satisfactory because previous generations of young women did not suffer the same epidemic of hair loss. A more likely explanation is either exposure to androgenic progestins (discussed above), or intriguingly: Inflammation at the androgen receptor, as explored in this 2011 research. I have found that my patients’ androgen-sensitivity improves when they reduce chronic inflammation.
Treatment is to reduce sensitivity of the androgen receptor by reducing inflammation. You can do that by: 1) Not smoking, 2) Avoiding inflammatory foods such as sugar, wheat, and dairy products, 3) Eating anti-inflammatory vegetables (phytonutrients improve female hair loss), 4) Reestablishing healthy intestinal bacteria, 5) Supplementing with the anti-inflammatory mineral zinc, and 6) Optimising progesterone, because progesterone has a natural anti-androgen effect.
Adrenal Androgen Excess
Your adrenal glands make about 50 percent of your total androgens. You can estimate how much androgen is coming from your adrenal glands by measuring a hormone called dehydroepiandrosterone sulfate (DHEA-S) on blood test. If only DHEA-S is elevated, but testosterone and androstenedione are normal, then you have predominantly adrenal androgen excess. If you have DHEA-S, testosterone, and androstenedione are all elevated, then you have ovarian androgen excess (discussed below).
One cause of adrenal androgen excess is a relatively common genetic condition called non-classic (or late-onset) congenital adrenal hyperplasia (NCAH), which is diagnosed by a blood test for a hormone called 17-OH-progesterone .
Treatment of congenital adrenal hyperplasia is low dose hydrocortisone to down-regulate adrenal androgen production. Interestingly, low dose hydrocortisone was also historically used to treat PCOS, and is still used by some doctors today.
Adrenal androgen excess is also the key feature in about 20 percent of women diagnosed with polycystic ovarian syndrome (PCOS). Predominantly adrenal-androgen PCOS is quite a different condition from ovarian-androgen PCOS (see below), in that it is not driven by insulin resistance or underlying conditions that impair ovulation. It is driven by factors that affect the adrenal glands, such as stress. I truly hope that PCOS’s upcoming name change will distinguish between adrenal-androgen PCOS and ovarian-androgen PCOS, and therefore save us all a lot of confusion.
Proposed causes of adrenal-androgen PCOS include genetics, and stress around the time of puberty. I strongly suspect that endocrine disrupting chemicals (EDCs) also play a role, but that research is still in its infancy.
Treatment of adrenal-androgen PCOS is to normalise adrenal function. This is probably the type of PCOS that responded to the low-dose cortisone historically prescribed for PCOS. Adrenal-androgen PCOS also responds to stress-reduction, and to hypothalamic-pituitary-adrenal (HPA) regulating supplements such as magnesium, phosphatidylserine, and rhodiola. Adrenal-androgen PCOS may also require androgen blocking supplements such as diindolylmethane (DIM). For a full discussion of adrenal-androgen PCOS, please see Fiona McCulloch’s post: Treating adrenal androgen excess.
Ovarian Androgen Excess
Now we come to a condition that is synonymous with androgen excess in women: Polycystic ovarian syndrome (PCOS). The key defining feature of PCOS is ovulatory dysfunction, and the over-production of testosterone and androstenedione by the ovaries.
PCOS is not an ovarian disease per se. The ovulatory dysfunction is an expression or symptom of a larger set of underlying hormonal and metabolic problems such as insulin resistance and inflammation.
But don’t ovarian cysts cause PCOS?
Polycystic ovarian syndrome got its name from the way ovaries look on ultrasound. You would be forgiven then for thinking the small multiple follicles cause the condition, but they don’t. They are simply an indicator that ovulation did not occur that month. Any woman can have polycystic ovaries on occasion, including a woman on the pill, and a woman with perfectly normal hormones. Don’t be misdiagnosed by an ultrasound. See the Surprising Truth About PCOS.
Is PCOS genetic?
Yes, genes play a role in PCOS, as does exposure to androgens or environmental toxins in utero. That is a depressing thought, because it might mean you were born with the condition. It doesn’t work like that. A genetic tendency does not mean you will always suffer the symptoms. You can modify your genetic expression with diet, lifestyle, and other natural treatments.
Treatment of ovarian-androgen PCOS is to correct the underlying insulin resistance (or other metabolic problem) and thereby reestablish regular ovulation. That usually means quitting sugar, and using insulin-sensitising supplements such as myo-inositol, magnesium, and berberine. Exercise and the diabetic drug metformin are also helpful. Non-insulin-resistant types of PCOS can benefit from the androgen-reducing herbal formula Peony & Licorice. See my book Period Repair Manual and 4 Types of PCOS.
What is your experience with androgen excess? What has helped you?
Yours in Health,