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If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.
High testosterone in women may bring to mind female bodybuilders with bulging muscles. In reality, that picture doesn’t match most women with high levels of testosterone.
Instead, a lot of women with high levels of testosterone experience unwanted symptoms like excess hair and infertility, to name just a couple. Let’s take a look at how testosterone affects women, why some women may have higher testosterone levels than others, and possible treatments.
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What is testosterone?
Most people think of testosterone as just the primary “male” sex hormone (androgen). Men indeed have approximately 20-25 times higher testosterone levels than women (Fabbri, 2016). But women need testosterone, too.
Specialized cells in the ovaries, called theca cells, manufacture testosterone in women. Testosterone is essential for its own sake, but it also gets converted to estrogen, the primary “female” hormone (Barbieri, 2019-a).
Testosterone exists in both men and women as either “free” testosterone or protein-bound testosterone; the combination of these two levels is your total testosterone concentration. In men, about 40% of testosterone binds to sex hormone-binding globulin (SHBG), leaving the remainder readily available for use. In women, more than 80% of their testosterone binds to SHBG, leaving much lower levels of free testosterone in the bloodstream (Fabbri, 2016).
Testosterone: what is it, what does it do, levels, treatment
Why do women need testosterone?
Testosterone is a vital part of a woman’s health and well-being and plays a key role in the following functions (Tyagi, 2017):
- Having a healthy sex drive (libido)
- Maintaining muscle mass and bone density
- Stabilizing mood
It’s important to remember that balance is critical—too high or too low testosterone can lead to problems. For example, certain medical conditions, like PCOS, can increase testosterone levels, resulting in other issues (Rasquin, 2020).
What happens when women have high testosterone levels?
When women have too much testosterone, it throws the ratio of female to male hormones out of balance. If levels of testosterone, or other androgens, get too high, women may experience the following symptoms (Hall, 2019):
- Excess body hair and facial hair growth (hirsutism)
- Weight gain or obesity
- Infertility issues
- Irregular menstrual cycles
- Mood changes
- Deepening of the voice
- Enlargement of the clitoris
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Causes of high testosterone levels in women
Elevated testosterone, also known as hyperandrogenism, may be due to several medical conditions, including polycystic ovarian syndrome (PCOS), congenital adrenal hyperplasia, and others (Hall, 2020; Barbieri, 2020).
Polycystic ovary syndrome (PCOS)
PCOS is a common cause of high testosterone levels. PCOS affects 5–15% of women aged 15–49 in the United States. It is a complex medical condition that can wreak havoc on a woman’s body (Rasquin, 2020).
PCOS is a hormonal imbalance that leads to symptoms like irregular menstrual cycles, obesity, increased body hair and facial hair (hirsutism), obesity, insulin resistance, and multiple small follicles on the ovaries. It is also one of the most common causes of infertility. Having PCOS increases a woman’s risk of developing diabetes, high blood pressure, high cholesterol, heart disease, and stroke. The cause of PCOS is not well understood but is likely due to a combination of lifestyle and genetic factors (CDC, 2020).
Congenital adrenal hyperplasia
Congenital adrenal hyperplasia (CAH) is a group of genetic disorders affecting the adrenal glands. The adrenal glands are small structures that sit on top of your kidneys and are responsible for producing several hormones needed for normal functioning.
Women with CAH make too many androgens and may have symptoms very similar to PCOS, including increased body and facial hair, irregular menstrual cycles, and infertility. This condition is usually diagnosed with special blood tests, and is more common in higher-risk groups like Mediterranean, Hispanic, and Ashkenazi Jewish women (Nieman, 2019).
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Other causes of high testosterone in women
In the past, women with abnormal hair growth, normal menstrual cycles, and normal testosterone levels were diagnosed with idiopathic hirsutism or hair growth due to unknown causes. However, because both the definitions of idiopathic hirsutism and PCOS have changed over the years, it’s likely that many women with this condition may actually have had PCOS (Barbieri, 2019-b).
One study showed that women with idiopathic hirsutism may have testosterone levels at the higher range of normal. The researchers also found that these women may have genetic changes that cause them to produce more testosterone in their skin, leading to increased hair growth (Taheri, 2015).
Cushing syndrome is another potential cause of high testosterone in women. In this condition, your adrenal glands secrete more hormones, like cortisol and androgens, than normal. Similarly, if you have an adrenal or ovarian tumor that secretes too many androgens, then your testosterone levels will be too high (Barbieri, 2019-b).
DHEA (dehydroepiandrosterone) side effects
If you suspect that you may have high testosterone levels, get medical advice from your healthcare provider. A good history and physical, along with blood tests can help determine whether you actually have abnormal levels. Your provider may check any or all of the following:
- Total testosterone and free testosterone
- Luteinizing hormone (LH)
- Follicle-stimulating hormone (FSH)
- Ultrasound imaging of ovaries and adrenal glands
If your provider uncovers an underlying cause of your high testosterone, like Cushing syndrome, tumors, or drug use, then treating that cause may improve your testosterone levels. However, many people will need medications to help them, including (Barbieri, 2020):
- Oral contraceptive pills (OCPs) or birth control pills—These may help treat high testosterone by increasing estrogen and progesterone levels while lowering androgens.
- Spironolactone—This is an anti-androgen drug that decreases the production of testosterone.
- Combination therapy using both of the above
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Follow your healthcare provider’s advice
Testosterone is essential for health and wellness for both women and men. However, the balance of female to male hormone levels is vital, and when you have a testosterone imbalance, problems can arise. Talk to your healthcare provider—together, you can come up with the right plan for you.
- Barbieri, R. L. & Ehrmann, D. A. (2020). Evaluation of premenopausal women with hirsutism. In P. J. Snyder, W. F. Crowley, & K. A. Martin (Eds.). Retrieved on March 3, 2021 from https://www.uptodate.com/contents/evaluation-of-premenopausal-women-with-hirsutism
- Barbieri, R. L. (2019-a). Steroid hormone metabolism in polycystic ovary syndrome. In P. J. Snyder, W. F. Crowley, & K. A. Martin (Eds.). Retrieved on March 3, 2021 from https://www.uptodate.com/contents/steroid-hormone-metabolism-in-polycystic-ovary-syndrome
- Barbieri, R. L. & Ehrmann, D. A. (2019-b). Pathophysiology and causes of hirsutism. In P. J. Snyder, W. F. Crowley, & K. A. Martin (Eds.). Retrieved on March 3, 2021 from https://www.uptodate.com/contents/pathophysiology-and-causes-of-hirsutism
- Centers for Disease Control and Prevention (CDC). (2020). PCOS (Polycystic Ovary Syndrome) and Diabetes. Retrieved on March 3, 2021 from https://www.cdc.gov/diabetes/basics/pcos.html
- Clark, R. V., Wald, J. A., Swerdloff, R. S., Wang, C., Wu, F., Bowers, L. D., & Matsumoto, A. M. (2019). Large divergence in testosterone concentrations between men and women: Frame of reference for elite athletes in sex-specific competition in sports, a narrative review. Clinical Endocrinology, 90(1),15–22. doi: 10.1111/cen.13840. Retrieved from https://pubmed.ncbi.nlm.nih.gov/30136295/
- Fabbri, E., An, Y., Gonzalez-Freire, M., Zoli, M., Maggio, M., & Studenski, S. et al. (2016). Bioavailable Testosterone Linearly Declines Over A Wide Age Spectrum in Men and Women From The Baltimore Longitudinal Study of Aging. The Journals Of Gerontology Series A: Biological Sciences And Medical Sciences, 71(9), 1202-1209. doi: 10.1093/gerona/glw021. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26921861/
- Hall, J. E. (2019). Evaluation and management of postmenopausal hyperandrogenism. In W. F. Crowley, R. L. Barbieri, & K. A. Martin (Eds.). Retrieved on March 3, 2021 from https://www.uptodate.com/contents/evaluation-and-management-of-postmenopausal-hyperandrogenism
- Nieman, L. K. & Merke, D. P. (2019). Diagnosis and treatment of nonclassic (late-onset) congenital adrenal hyperplasia due to 21-hydroxylase deficiency. In A. Lacroix & K. A. Martin (Eds.). Retrieved on March 3, 2021 from https://www.uptodate.com/contents/diagnosis-and-treatment-of-nonclassic-late-onset-congenital-adrenal-hyperplasia-due-to-21-hydroxylase-deficiency
- Rasquin Leon, L. I., & Mayrin, J. V. (2020). Polycystic Ovarian Disease. [Updated Jul 21, 2021]. In: StatPearls [Internet]. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK459251/
- Taheri, S., Zararsiz, G., Karaburgu, S., Borlu, M., Ozgun, M., Karaca, Z., et al. (2015). Is idiopathic hirsutism (IH) really idiopathic? mRNA expressions of skin steroidogenic enzymes in women with IH. European Journal of Endocrinology, 173(4), 447-454. doi: 10.1530/EJE-15-0460. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26194504
- Tyagi, V., Scordo, M., Yoon, R. S., Liporace, F. A., & Greene, L. W. (2017). Revisiting the role of testosterone: Are we missing something?. Reviews in Urology, 19(1), 16–24. doi: 10.3909/riu0716. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28522926/
- Udoff, L.C.. (2020). Overview of androgen deficiency and therapy in women. In W. F. Crowley, R. L. Barbieri, & K. A. Martin. (Eds.). Retrieved on March 3, 2021 from https://www.uptodate.com/contents/overview-of-androgen-deficiency-and-therapy-in-women