Androgen-Thyroid Connection in Clinical Practice

The interaction between thyroid hormones and androgens is crucial for proper hormonal regulation. Both androgens like testosterone and DHEA regulate reproductive health and metabolism, while thyroid hormones are also essential for metabolism, fertility, and energy.

The current research indicates a bidirectional relationship between androgens and thyroid hormones. In this article, we will discuss the overlap between these two hormonal systems and how they can impact one’s health. 

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Androgens and Thyroid Hormones: A Clinical Overview 

Androgens are a class of steroid hormones responsible for sexual and reproductive development in men and women. The main androgens in the body include testosterone, DHEA, dihydrotestosterone (DHT), and androstenedione. These hormones not only regulate sexual and reproductive health, however, also influence cardiovascular disease, metabolic health, muscle mass, bone health, and neurodegenerative disease (5).

Thyroid hormones consist of a group of hormones that act together called thyroid releasing hormone (TRH), thyroid stimulating hormone (TSH), T3 & T4. The thyroid hormone cascade begins in the hypothalamus where TRH gets released. TRH signals the pituitary to release TSH. TSH then signals the body to produce predominately T4 and a small amount of T3. If the body is functioning properly, T4 gets converted to T3, which is the active form of thyroid hormone in the body. Active T3 regulates our metabolism, bone growth during childhood, fertility, and ovulation (41). 

Clinical Implications of Androgens on Thyroid Function

Less commonly discussed is the relationship between androgens and thyroid hormone. Both androgens and thyroid hormones have a critical role in regulating metabolism, energy, and reproductive function. Research shows that individuals with low testosterone who are given testosterone therapy show a decrease in thyroid autoimmunity antibodies. This correlates to testosterone therapy being potentially protective in those with thyroid autoimmunity (28). 

Impact of Thyroid Dysfunction on Androgen Levels and Health Outcomes 

Having too much or too little thyroid hormone can impact the amount of circulating testosterone, the main androgen in our body. Testosterone is produced in response to a release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary gland in the brain in both men and women (in different amounts between genders). A small percentage of testosterone is known as free testosterone, which works directly on the body to regulate metabolism and muscle mass. The majority of testosterone is bound to sex hormone-binding globulin (SHBG) (24, 33). 

SHBG is the key interplay between androgen production and thyroid hormone. Thyroid hormone is known to affect SHBG concentrations. Research has shown that individuals with hypothyroidism have lower levels of SHBG resulting in lower levels of total serum testosterone. On the contrary, hyperthyroidism results in an elevation of mean total testosterone and SHBG resulting in a decrease in free testosterone (23). 

Women with thyroid androgen imbalance have an increased risk of other endocrine abnormalities such as PCOS. Research shows that women with hypothyroidism have an increased risk of developing cystic ovaries due to elevated TSH and prolactin levels. When prolactin increases it stops ovulation and increases adrenal DHEA production contributing to the formation of polycystic ovaries. As we can see, the impact of thyroid dysfunction on androgen levels is complex and can result in several other endocrine abnormalities (42). 

Identifying Signs of Androgen-Thyroid Imbalance in Patients

Signs & symptoms of androgen-thyroid imbalance include: (28, 31, 45)

• Fatigue
• Decreased sex drive
• Depression 
• Infertility
• Decrease in hair growth
• Decrease in muscle mass
• Development of breast tissue (gynecomastia) in men
• Difficulty concentrating and hot flashes
• Erectile dysfunction in men
• Osteoporosis
• Menstrual abnormalities in women

Etiology of Androgen-Thyroid Imbalance: A Clinical Perspective 

Androgen-thyroid imbalance can result from various etiological factors. First up, are two common autoimmune disorders that impact the thyroid. Hashimoto’s Thyroiditis, which leads to hypothyroidism, and Graves’ Disease, which leads to hyperthyroidism. Both of these conditions result in an imbalance of thyroid hormone in the body resulting in altered levels of androgens (37). 

What causes thyroid autoimmunity? Research currently points towards several environmental toxicants and endocrine disrupters that can lead to thyroid autoimmunity. There is a higher prevalence of autoimmune thyroid disorders among individuals living near chemical plants, exposed to organochlorine pesticides, aluminum, mercury, and vanadium (4).  

Diagnostic Approaches to Androgen-Thyroid Imbalance

Diagnosing imbalances in androgen and thyroid hormones requires an integrative approach consisting of blood tests, patient history analysis, and on occasion imaging studies. To accurately diagnose a thyroid hormone imbalance, a functional medicine practitioner will run a complete thyroid panel, which includes TSH, T4 & T3 (total and free), and antithyroglobulin and thyroid peroxidase antibodies (13). 

Diagnosis of androgen imbalance is conducted by measuring free and total testosterone, DHEA-S, and SHBG. To gain the best insight into a patient's hormonal status, LH, FSH, progesterone, and prolactin should be ordered to rule out other causes of hormonal imbalance (18). 

In cases, where possible thyroid malignancy is suspected physicians can order a thyroid uptake and a scan can help differentiate between toxic goiter, Graves’ disease, and thyroid cancer. (26)

Clinical Management of Androgen-Thyroid Imbalance

Management of patients with androgen thyroid imbalances involves a multidisciplinary approach. Starting with lifestyle, research shows individuals with poor sleep quality and smoking have an increase chance of developing autoimmune thyroid conditions, which may lead to an imbalance in androgen disorders (52). 

If the patient is diagnosed with hypothyroid or hyperthyroid disorders with androgen imbalance, treating them with the appropriate medication resulting in a return to a normal thyroid state has been shown to bring testosterone back into the normal range. (24)

It is important to educate patients with thyroid-androgen imbalance that thyroid disease responds very well when given the appropriate treatment. Patients should understand the goal of treatment is to align their androgen and thyroid levels within the reference range in order to alleviate symptoms (34). 

Monitoring Hormonal Health: A Guide for Practitioners

When undergoing hormone therapy, it is crucial to have continued hormone monitoring to ensure the treatment prescribed is effective in restoring hormonal balance. It is common when treating hormones to need to adjust the dosage to avoid unnecessary side effects caused by improper hormone levels. 

When treating hypothyroidism, it is recommended for adults taking levothyroxine to receive laboratory work (thyroid panel) every 3 months until symptoms have stabilized. Patients with hyperthyroidism on antithyroid drugs, are to receive a thyroid panel every 6 weeks until labs are within the reference range and then every 3 months for continued treatment. When working with patients who have androgen imbalance as a result of thyroid disease, physicians will monitor androgen levels alongside thyroid hormones to ensure treatment is progressing in the correct direction (35).  

Challenges in Clinical Management of Hormonal Imbalances

Diagnosis of androgen-thyroid imbalance is complex due to variations in patient presentation. Patients presenting with androgen thyroid imbalance may present with a wide range of symptoms resulting in the practitioner needing to rule out other endocrine abnormalities. Patients with abnormal androgen and thyroid levels may need further workup to rule out pituitary issues such as prolactinoma or adrenal disorders such as Cushing disease (17). 

Supporting Hormonal Balance Through Lifestyle Interventions 

Lifestyle factors such as diet, sleep, stress, and exercise can contribute to hormonal imbalance. While conventional doctors may jump straight to medication, there are several lifestyle interventions that may support hormone balance. Research shows that participating in stress reduction therapies such as yoga, cold immersion baths, and meditation can ameliorate hormone imbalance. Additionally, including dietary antioxidants such as zinc, selenium, vitamin C, carotenoids, and CoQ10 is effective in stabilizing hormone levels (20, 34)

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Key Takeaways

Managing patients with androgen-thyroid imbalances presents complex challenges and a throughout workup is needed to rule out all possible endocrine abnormalities.

In patients with androgen and thyroid imbalance, an in-depth physical exam, clinical history, and workup to rule out pituitary dysfunction, adrenal disease, and genetic etiology is crucial.

It is important for patients to be under the care of a trained physician when undergoing hormone replacement therapy.

For physicians, staying up to date on the current guidelines for androgen-thyroid imbalance is always needed due to new and current research emerging on this topic.