This document discusses hyperandrogenism and its diagnosis. It defines hyperandrogenism as androgen excess, which affects 5-10% of women. The most common cause is polycystic ovarian syndrome (PCOS), accounting for 80-85% of cases. Clinical signs of hyperandrogenism include hirsutism, acne, seborrhea and androgenic alopecia. The document outlines methods for diagnosing and evaluating hyperandrogenism, including the modified Ferriman-Gallwey scale for assessing hirsutism and various hormone tests and ultrasound criteria for diagnosing PCOS. Exclusion of related disorders like thyroid disease, Cushing's syndrome, and congenital adren

1. HYPER-ANDROGENISM:
UPDATE OF DIAGNOSIS
ACNE Hirsutism Alopecia
Dr. Sharda Jain
Dr. Jyoti Agarwal
Dr. Jyoti Bhaskar
Dr. Abhishek Parihar

2. HYPER-ANDROGENISM:
UPDATE OF DIAGNOSIS
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3. Hyperandrogenism
• Androgen excess
– Affects between 5 - 10% of women
in the reproductive age
• Poly-cystic Ovarian Syndrome (PCOS)
– Prevalence @ 80-85%
among women with androgen excess
O Bulent et al. Diagnosis of hyperandrogenism: clinical criteria. Best Practice & Research Clinical Endocrinology & Metabolism Vol. 20, No. 2, pp. 167–176, 2006

4. Hyperandrogenism
• There is considerable heterogeneity in clinical
findings among women with hyperandrogenism
• Clinical Phenotype could change over time even
in a single patient
O Bulent et al. Diagnosis of hyperandrogenism: clinical criteria. Best Practice & Research Clinical Endocrinology & Metabolism Vol. 20, No. 2, pp. 167–176, 2006

5. Clinical Manifestation of
Hyperendrogenism
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AAccaannttoossisis HHirirssuuttisismm
IRREGULAR
MENSES/
infertility
IRREGULAR HHAAIRIR L LOOSSSS
MENSES/
infertility

6. Clinical Signs of hyperandrogenism
• Hirsutism is a
common
manifestation of
hyperandrogenism
• Other clinical signs of
androgen excess include
* Acne,
* Seborrhea, and
* Androgenic alopecia. SAHA
O Bulent et al. Diagnosis of hyperandrogenism: clinical criteria. Best Practice & Research Clinical Endocrinology & Metabolism Vol. 20, No. 2, pp. 167–176, 2006

7. Clinical Signs of hyperandrogenism
• Depending on the
degree of
androgenization,
signs of
VIRILIZATION might
be observed in the
evaluation of a
patient with
hyperandrogenism

8. HIRSUTISM
• Excessive male-pattern - terminal
hair growth in women
• Affects up to 15% of women
• Results from ­ androgen production
and/or ­ sensitivity of the pilo-sebaceous
unit to androgens
O Bulent et al. Diagnosis of hyperandrogenism: clinical criteria. Best Practice & Research Clinical Endocrinology & Metabolism Vol. 20, No. 2, pp. 167–176, 2006

9. HIRSUTISM
• Observed in 70-80% of patients
with hyperandrogenism
• Leads to significant psychologic
morbidity and can negatively
influence the quality of life.
O Bulent et al. Diagnosis of hyperandrogenism: clinical criteria. Best Practice & Research Clinical Endocrinology & Metabolism Vol. 20, No. 2, pp. 167–176, 2006

10. HIRSUITISM
10% young girls have hirsutism
In 60-70% - PCOS is the cause

11. HISUTISM

12. Ferriman- Gallwey Scale
Modified Ferriman–Gallwey (F–G) hirsutism scoring system. Each of the nine body areas is rated from 0 (absence of
terminal hairs) to 4 (extensive terminal hair growth), and the numbers in each area are added for a total score. A
modified F–G score ≥ 6 generally defines hirsutism
O Bulent et al. Diagnosis of hyperandrogenism: clinical criteria. Best Practice & Research Clinical Endocrinology & Metabolism Vol. 20, No. 2, pp. 167–176, 2006

13. ACNE
• A common disorder of the Pilo-sebaceous
unit
• Commonly used classification - American
Academy of Dermatology, defines it as mild,
moderate and severe.
Yildiz BO: Diagnosis of hyperandrogenism: clinical criteria. Best Pract Res
Clin Endocrinol Metab 2006, 20(2):167-176

14. ACNE
• Evidence demonstrates a CLOSE ASSOCIATION
between Androgen & development of acne
• Has a MULTIFACTORIAL ETIOLOGY in which
androgens, skin lipids, inflammatory signals,
appear to be involved
Acne as an isolated symptom might not be
considered a sign of hyperandrogenism
Yildiz BO: Diagnosis of hyperandrogenism: clinical criteria. Best Pract Res Clin Endocrinol Metab
2006, 20(2):167-176

15. Types of Acne
Comedonal
(non-inflammatory)
Whitehead (closed): a
dilated hair follicle filled
with keratin, sebum, and
bacteria, with an
obstructed opening to the
skin.
Blackhead (open): a
dilated hair follicle filled
with keratin, sebum, and
bacteria, with a wide
opening to the skin capped
with a blackened mass of
skin debris.
Papulo-pustular
(inflammatory)
Papule:
Pustule:
Nodular
(inflammatory)
Nodule: bump
greater than
5mm in diameter.

16. Acne – 30%
Severe -80%
Moderate – 50%
Mild - 30%

17. Investigation Protocol
• Patients with severe
hirsutism and REGULAR
MENSES
– Testosterone
– DHEA-S
– Early morning 17-OH
progesterone
• Patients with severe
hirsutism and
IRREGULAR MENSES
– Testosterone
– DHEA-S
– Early morning 17-oH
progesterone
– FSH, LH & PRL
PELVIC USG TO BE IDEALLY PERFORMED
Davis S. Austr Fam Physician 1999;28:447-451

18. Summary
of Suggested Lab Test by
ACOG
 Prolactin level
 Testosterone level
 LH and FSH
 TSH
 Fasting glucose level or 2 hr OGTT
 Lipid profile, including total, LDL,HDL
 17-hydroxyprogesterone level*
*--Fasting level to r/o CAH

19. Bio chemical and Diagnostic Markers of
PCOD
Accepted everywhere
– Elevated androgen (i.e. testosterone > 60 or free
testosterone >0.75) levels
– Elevated LH:FSH ratio > 2:1
– Increased Insulin levels ( Not needed)
– Insulin resistance , (Clinical / Lab)
Lab diagnosis of insulin resistance is not needed
–Ultrasound appearance of PCO

20. Ultrasound
Rotterdam Criteria
• In one or both ovaries
Ovarian volume
> 10 ml
• 12 follicles, 2-9 mm in diameter
• Echo dense stroma
Typical “Black Pearl” Necklace

21. Screening Tests For PCOD
ACOG Recommendation
• ACOG recommends that all women with a
suspected diagnosis of PCOD should be
screened with
17-hydroxyprogesterone
level to R/O late onset CAH (Level C).
• PCOD and late onset CAH are
distinguished from each other only by
laboratory testing.

22. A Lab Tests suggested for
SUDDEN onset of Hyperandrogenism
Test Result
Total testosterone level Slightly elevated in PCOS
Total testosterone > 200 ng/dL -- suspicious for adrenal or ovarian tumor
therefore additional evaluation with pelvic US, CT or MRI indicated
Serum DHEAS level Slightly elevated in PCOS
DHEAS level > 8 ng/ml -- suspicious for adrenal tumor therefore additional
evaluation should include adrenal gland imaging with CT or MRI
24 hour urine cortisol or overnight dexamethasone
Urine free cortisol >20 ug/d is suggestive of
Cushing’s Syndrome

23. PCOS – Diagnostic Criteria
NIH 19901 Rotterdam 20031 AE*-PCOS Society
20061,2
If both the criteria are
met:
•Chronic anovulation
•Clinical and/or
biochemical signs of
hyper-androgenism
(with exclusion of
other etiologies, e.g.,
congenital adrenal
hyperplasia)
If two of three
criteria are met:
•Oligo- and/or
anovulation
•Clinical and/or
biochemical signs of
hyperandrogenism
•Polycystic ovaries
*AE: Androgen Excess
If both the criteria are
met (after excluding
other androgen excess
or related disorders a):
•Clinical and/or
biochemical signs of
hyperandorgenism
•Ovarian dysfunction
(Oligo-anovulation
and/or polycystic
ovarian morphology)
NIH: National Institute of Health, AE-PCOS:
Androgen Excess- Polycystic Ovarian Syndrome
1. National institutes of health evidence-based methodology workshop on polycystic ovary syndrome december 3–5, 2012
2. Azziz et.al. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report , Fert. Stert.; 91(2): 456-

24. EExxcclluussiioonn ooff RReellaatteedd DDiissoorrddeerrss
• Thyroid disorders
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• Hyperprolactinemia
• Cushing’s syndrome
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• Late onset congenital adrenal hyperplasia (CAH)
• Basal morning 17-OHP,(2-3 ng/ml))
• Ovarian and adrenal tumors DHEAS
• WHO I &III –FSH,LH,E2
• Syndromes of severe insulin resistance(HAIRAN
syn)

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