What Causes Excess Testosterone in Females?
If you have hirsutism you’ve probably wondered what causes the excess testosterone in your body and even more importantly what you can do about it. While it is normal for every woman to have both male and female hormones in her system, a hormonal imbalance can lead to various conditions. Hirsutism is one of them. Excess testosterone can have many different root causes and symptoms. In this article we try to the bottom of the questions “What causes excess testosterone in females?”
What is Testosterone?
Testosterone is the male sexual hormone. It is a steroid and stimulates development of male secondary sexual characteristics such as facial hair, muscle mass, deep voice etc. Testosterone is produced in the testis of males and adrenal glands of both males and females. Even in healthy women, a certain amount of testosterone is necessary for proper growth, maintenance and functioning of the body. This is why in females a small amount of testosterone is produced in the ovaries. A lack of testosterone may lead a woman to experience lethargy, lack of muscle mass, mood changes and weight gain. So although it is a male hormone, females need it too. But in adequate amounts only.
The Symptoms of Excess Testosterone in Females
Testosterone, as mentioned earlier, is the hormone responsible for giving secondary male sexual characteristics. If testosterone levels are too high in a female, you may notice the following changes occurring. These symptoms will happen gradually, so even before you notice, someone else may see the changes in you, especially if they are seeing you after some time.
Increased Body Hair
Your body hair will grow in excess and thicker. For example excess facial hair will be noticeable above the upper lip and around the chin, on the chest, the thighs, the arms. The hair can be dark and coarse. This male-pattern hair growth is also known as hirsutism.
While you gain body hair in certain areas, you may also lose hair on your head and it will be thinning. Balding may be visible with time and can be similar to male pattern baldness (temples and crown of your head). For women this balding can be a huge cosmetic concern.
Acne is caused by excessive production of sebum or natural oils due to over activity of the sebaceous glands. The pores which bring the oils to the skin’s surface get blocked by dead cells and thickened skin. When sebum is trapped within, bacteria called propionobacterium multiplies, which leads to acne. Overactivity of the sebaceous glands can occur due to excessive testosterone. Acne doesn’t only occur on the face, but often also on the neck, chest, back and upper arms.
Excess testosterone can lead to a change in your voice making it deeper like a male’s.
Just like a male, a female can develop more muscles if there is too much of testosterone.
Increased testosterone can also cause growth of your clitoris. The clitoris is the equivalent organ to the penis in males, which is why it is affected by excess testosterone.
Irregular Menstruation and Sub-fertility
For regular periods there should be a balance between estrogen and progesterone which are female hormones. If there is excess testosterone in a woman’s system, this balance will be lost. So menstruation will be irregular or there will be no menstruation at all (amenorrhea). Hormonal imbalance will lead to a dysfunction of the ovaries in females. Ovaries produce ova (eggs) monthly as part of the reproductive cycle. When the ovaries do not function well, ova are not made, making the female infertile.
Decreasing Size of Breast
When the hormonal balance is lost, a female will experience that her breasts are getting smaller.
Mood Changes and Poor Libido
When testosterone levels exceed the action of estrogen, a female can experience these symptoms.
Obesity and Weight Gain
Obesity and weight gain are not a direct result of excessive testosterone. In combination with insulin resistance, however, the excess male hormones can lead to a chance in the metabolism and lead to the craving of high fat foods and sweets. This can lead to obesity and weight gain.
What Causes Excess Testosterone in Females?
The amount of testosterone circulating in a female body depends on the production of testosterone and how it is broken down by the liver. Normal level of testosterone in a female should be between 15 – 70 ng/dl. Testosterone can be in excess in females, due to excessive production of it by the ovaries and adrenal glands or due to issues breaking it down such as in liver disease.
Commonly identified causes of excessive production of testosterone in females are familial hirsutism, polycystic ovarian disease, ovarian tumors, adrenal gland tumors and adrenocortical hyperplasia (congenital adrenal hyperplasia).
Familial Hirsutism refers to the condition where the female grows excessive amounts of coarse, dark hair in places where men typically grow hair such as face, chest, thighs and back. The genetics play a major role here and hirsutism can run in families as a family trait. Females with familial hirstutism have excessive amounts of testosterone in their bodies, and the main reason behind this is their genes.
Apart from hirsutism (excessive hair growth), these females will also have other signs of virilization due to effects of excessive testosterone. As mentioned earlier these are symptoms like male pattern balding, deep voice, acne, increasing muscle mass, enlarged clitoris and decreasing breast size.
There are also other causes of hirsutism such as Cushing’s Syndrome where the body is exposed to high levels of the cortisol hormone. This may be due to overproduction of cortisol in the adrenal gland or due to prolonged administration of prednisolone (which is taken in asthma, autoimmune disorders etc.). There are other medications which may also lead to hirsutism. Systemic corticosteroids and fluoxetine (Prozac) given for depression and Danazole which is used for treating endometriosis in females can cause hirsutism as side effects.
Polycystic Ovarian Syndrome (PCOS)
Polycystic ovarian syndrome is the most common cause of hirsutism in females. It is caused by excessive production of testosterone and imbalance of sex hormones. The affected female can get symptoms such as obesity, irregular menstruation, sub-fertility and multiple cysts (bubble like lesions) in ovaries along with hirsutism.
PCOS is a hormonal disorder which is commonly seen in females of reproductive age. Thile PCOS itself is caused by excessive male hormone (androgen) levels, the reason for this increase in male sex hormone is often unknown. Research suggests, that genes may play a big role. Due to hormonal imbalance the menstruation is delayed and periods are prolonged. Because of lack of production of eggs, periods can be rare.
In women with PCOS, the ovaries fail to produce mature eggs and release them regularly. These eggs will become follicles (small numerous fluid collections), and will look like a string of beads around the inner border of the ovaries which are enlarged in size. Polycystic ovaries can be identified by doing an ultra sound scan of the abdomen.
Insulin resistance is also associated with this condition, which can lead to type 2 diabetes and heart disease. PCOS develops due to excessive production of testosterone (androgen) from ovaries. Sometimes when there is an excess of insulin, the production of androgens is also increased. Insulin is a hormone which is produced by your pancreas. Insulin utilizes glucose in cells to produce energy. When the cells become resistant to insulin, the production of insulin can increase as well as your blood sugar levels. Insulin causes weight gain, as well as over production of androgens.
PCOS and its complications
- Infertility: Inability to conceive due to lack of production of eggs
- Diabetes: Insulin resistance leads to high blood sugar levels
- Depression and Mood Changes: Excessive testosterone levels have an impact on one’s mood
- Metabolic Syndrome: A syndrome which includes high blood sugar, high blood pressure, abnormal lipid profile and obesity which can increase the risk of heart disease
- Nonalcoholic Steatohepatitis: Fat is accumulated in the liver causing severe inflammation of the liver
Diagnosis of PCOS is done by a detailed pelvic examination, ultra sound scan of the abdomen and doing a series of blood tests to assess hormone levels. In addition to measuring androgen levels, testing blood sugar, cholesterol and triglyceride levels will also help to manage the condition.
Management of the condition has to address the individual symptoms which worry affected women like hirsutism, obesity, acne, sub-fertility and increased blood sugar levels. Frequent follow up is necessary for proper management.
Ovarian Tumors which Produce Excess Androgens
Not all tumors which arise in your ovaries produce excess testosterone. However about 10% of all ovarian tumors can secrete androgens which can lead to hirsutism and virilization. Some of these ovarian tumors which secrete testosterone are gonadoblastoma, ovarian carcinoid, surface epithelial tumors (Brenner tumor) and metastatic tumors. The production of testosterone in women with these tumors is very high, which means that the level of testosterone is significantly elevated (more than 200 ng/dl). Therefore the symptoms progress rapidly.
Once the diagnosis is made by ultrasound scan and testing hormone levels, the tumor will be surgically removed. In case of ovarian carcinoma (cancer), surgical removal is followed by chemotherapy (using strong medicines) and radiotherapy (using high energy x rays), that are combined to destroy all cancer cells in the body.
Frequent follow up is necessary after treatment.
Adrenal Tumors which Produce Excess Androgens
Sometimes tumors can occur in the adrenal glands which produce adrenal sex hormones such as androgens leading to hirsutism and virilization. Adrenal tumors can produce increased levels of cortisol and aldosterone hormones in addition to testosterone. This may cause high blood pressure, weight gain and diabetes.
These tumors, when benign, are called adrenal adenomas. When they are cancerous the symptoms are worse with a bad prognosis.
The treatment for adrenal tumors includes surgery. Adrenal carcinoma is also treated with additional chemotherapy and radiotherapy. Removal of the adrenal tumor can reduce the production of the cortisol hormone. Replacement therapy with hydrocortisone or prednisolone is necessary until the adrenal gland starts producing hormones normally.
If cancerous, the whole gland is removed and the replacement treatment will be life-long. Frequent follow up is a must after treatment.
Congenital Adrenal Hyperplasia / Adrenocortical Hyperplasia
Congenital Adrenal Hyperplasia (CAH) is an inherited disorder passed down in families by genes. Adrenal glands are enlarged and hormone production will be affected. When the cortisol levels are low, the body’s response to stress and illness is poor. When aldosterone levels are low, regulation of body’s sodium and potassium levels is disturbed which can be life threatening.
In CAH androgens are produced in excess which may be visible when the person develops hirsutism and virilization.
CAH, when severe, can be discovered in infancy. It affects the growth and development in children. Milder form of CAH may be evident in children and young adults.
Not all CAH patients produce excess testosterone and only a third will have symptoms of virilization. Affected female babies will have genital ambiguity due to enlarged clitoris and genitals at birth.
Apart from hirsutism and virilization, girls with CAH will grow rapidly during childhood but as they reach puberty early.
Once diagnosis is made, depending on symptoms, management is planned by a team of specialists including endocrinologist, geneticist, urologist, psychologist etc. The treatment should aim at reducing excessive androgen production and replacing deficient hormones. Medications include corticosteroids and mineralocorticoids to replace cortisol and aldosterone hormones respectively and salt supplements. Androgen levels are monitored frequently and treatment done accordingly.
With proper management, replacement hormone therapy and follow up these females can lead normal lives.
What Can We Do about Excess Testosterone Levels?
While a treatment plan, should always be done by a medical professional, there are some things you can do in order to prevent and support management of the condition.
Try to be active, eat nutritious and balanced meals and exercise regularly. This will help you to reduce weight as needed and minimize your symptoms. Yoga and meditation techniques have shown great promise as well. While being diagnosed with a hormonal imbalance, may be shocking at first and the symptoms may lead to a lot of distress, try to stay positive and follow the treatment plan as instructed. With time you will notice positive changes in your appearance and health.