If you suffer hair loss, facial hair (hirsutism), or acne, then you know all about androgen excess or high male hormones.
You may have been given the diagnosis of PCOS but there are actually several different reasons for androgen excess in women including androgen hypersensitivity, adrenal androgen excess, high prolactin, menopause, and hormonal birth control with a high androgen index.
Hormonal birth control with a “high androgen index”
The simplest and most preventable cause of androgen excess is hormonal birth control. Some types of birth control contain a progestin with a “high androgen index” which means it’s “masculinizing” and causes side effects such as hair loss and acne.
Are you taking a masculinizing type of birth control? Read the label.
Progestins with a high androgen index include levonorgestrel (many pills, Norplant implant, Mirena hormonal IUD, and the morning-after pill), norgestrel, gestodene, desogestrel, norelgestromin, norethindrone, and etonogestrel (many pills, Nuvaring, Nexplanon implant).
Progestins with a low androgen index include drospirenone (which is the exact same drug as spironolactone), norgestimate, dienogest, cyproterone, and of course body-identical progesterone. Real progesterone has anti-androgen properties because it inhibits the enzyme 5 alpha-reductase. That’s why natural progesterone is good for hair.
Treatment is to switch birth control. Choose a less masculinizing progestin, or even better: Choose a non-hormonal method such as Fertility Awareness Method (FAM), condoms, or copper IUD. Once you stop the masculinizing progestin, your androgen symptoms should improve.
Hypersensitivity to a normal amount of androgen
Hypersensitivity to androgens means there are symptoms of high androgens despite normal levels on a blood test. When hair loss is the main symptom, androgen hypersensitivity is called androgenic (or androgenetic) alopecia.
Androgen hypersensitivity is supposedly genetic, but that explanation is not very satisfactory because previous generations of young women did not suffer the hair loss and androgen symptoms we see today.
There are other explanations:
- Birth control (progestins) with a high androgen index.
- Coming off anti-androgenic birth control such as drospirenone (Yasmin), which can cause a temporary surge in androgens or temporary post-pill PCOS. Read How to prevent and treat post-pill acne.
- Chronic inflammation, as explored in this 2011 research.
- The relative “testosterone dominance” of menopause.
- Elevated prolactin, which increases the adrenal androgen DHEAS (see below) and up-regulates the 5-alpha-reductase enzyme (causing more activation of testosterone to DHT).
Treatment of androgen excess due to birth control is to stop taking a progestin with a high androgen index.
Treatment of post-pill PCOS is to give it some time and consider taking a natural anti-androgen supplement.
Treatment of inflammatory hypersensitivity of the androgen receptor is to reduce chronic inflammation and consider taking an anti-androgen supplement such as natural progesterone.
Treatment of prolactin-induced androgen excess is with vitamin B6 and the herbal medicine Vitex.
Adrenal androgen excess (including adrenal PCOS)
If you have high adrenal androgen (DHEAS) but normal ovarian androgens (testosterone and androstenedione), then you have adrenal androgen excess.
High adrenal androgens can be caused by one of the following situations:
- The genetic condition non-classic (or late-onset) congenital adrenal hyperplasia (CAH). It accounts for up to 9 percent of cases of androgen excess and is often misdiagnosed as PCOS. The test is 17-OH progesterone followed by genetic testing.
- Elevated prolactin, because it increases DHEAS.
- Adrenal PCOS, which applies to about 10 percent of women with a PCOS diagnosis. It quite a different condition from ovarian-androgen PCOS (see below), in that it’s not driven by insulin resistance or other factors that impair ovulation. Instead, it’s driven by factors that affect the adrenal glands, such as stress.
👉 Tip: The coming name change for PCOS may help to distinguish between adrenal-androgen PCOS and ovarian androgen PCOS.
Treatment of congenital adrenal hyperplasia (CAH) is low-dose hydrocortisone to down-regulate adrenal androgen production.
Treatment of adrenal androgen PCOS is to normalize the HPA (adrenal) axis function with supplements such as magnesium and B-vitamins (see the Adrenal PCOS section in Chapter 7 of Period Repair Manual).
Ovarian androgen excess (classic PCOS)
The defining feature of PCOS is anovulation and the over-production of androgens by the ovaries. PCOS is best defined as the situation of androgen excess when all other causes of androgen excess have been ruled out.
👉 Tip: Menopause is another time of relative androgen excess or “testosterone dominance.”
Treatment of classic PCOS is to correct the underlying driver of androgen excess (such as insulin resistance) and thereby reestablish regular ovulation and down-regulate androgen production. Cyclic progesterone therapy can also be helpful.
For more information, read: