Androgens, a group of steroid hormones include testosterone, DHEA, dihydrotestosterone (DHT), and androstenedione. These hormones play a key role in several body systems and can cause undesired symptoms when imbalanced. Understanding the importance and root cause of androgen imbalance in women is essential for developing proper treatments. Through a holistic approach, healthcare professionals can empower and educate women to regain hormone imbalance (8).
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What Are Androgens?
Androgens are a class of steroid hormones that greatly impact sexual and reproductive development in both men and women. The most known androgen is testosterone and its impact on male health; however, androgens play a crucial role in female health as well. Several androgens found in women are testosterone, DHEA, dihydrotestosterone, and androstenedione. These androgens are produced in the ovaries and adrenal glands of women and contribute to the production of other female hormones such as estrogen. (8)
The Role of Androgens in Women
Androgens in women play a crucial role in overall health and wellness. Regarding reproductive health, androgens are responsible for maintaining proper maturation of ovarian follicles, libido, and sexual arousal. In the ovary, testosterone production increases throughout the follicular phase of the menstrual cycle and reaches its highest level at the time of ovulation and luteal phase of the menstrual cycle. Adequate levels of testosterone are important in women because they contribute to lean muscle mass, bone health, mood, energy, sexual desire, and fertility (52).
Androgens in women also play a role in metabolic regulation, cardiovascular disease, and neurodegenerative disease. Concerning metabolic function, proper androgen levels regulate glucose homeostasis which is responsible for maintaining stable blood sugar levels. Androgens also have a direct effect impact on the vasculature. It has been shown that lower levels of testosterone are associated with an elevated risk of developing cardiovascular disease (3, 38).
Signs of Androgen Imbalance in Women
Too much or too little androgens can lead to imbalances. Here are some examples of what that might look like:
Androgen Excess in Women
Androgen excess in women refers to elevated levels of testosterone, DHEA, and DHT in the blood. This can occur due to numerous underlying factors and results in a wide range of health issues as outlined below.
Polycystic Ovary Syndrome (PCOS): Characterized by high levels of testosterone, DHT, and DHEA. The underlying cause of PCOS is due to insulin sensitivity, unregulated inflammation, and possibly genetics. PCOS contributes to the following symptoms (42):
- Irregular or heavy periods due to lack of ovulation
- Ovarian cysts contributing to PMS and painful periods
- Acne and oily skin
- Weight gain
- Hirsutism: dark hair growth on the abdomen, face, and chest
- Infertility
Other conditions and symptoms associated with elevated androgen levels in women include (4):
- Alopecia
- Hirsutism
- Weight gain due to insulin resistance
- Acanthosis nigricans
- Deepening of the voice
- Irritability and mood swings
Androgen Deficiency in Women
In women, plasma androgens decrease with advancing age and other underlying health conditions. The following are signs and symptoms of possible low androgens in women (7, 48):
- Fatigue
- Poor concentration
- Low sex drive
- Depressed mood
- Loss of muscle mass and strength
- Infertility
- Insomnia
- Headaches
Causes of Androgen Imbalance in Women
Many factors can contribute to androgen imbalance. Androgen deficiency can occur as a normal part of aging for females. Research has shown that women in their 40s have half the amount of androgens in their blood compared to women in their 20s. As females reach menopause, testosterone production in the ovaries drops dramatically leading to an overall decrease in androgens. Androgen deficiency can occur at any time throughout a woman's life. Other causes of androgen deficiency are Addison’s disease, corticosteroid therapy, hypopituitarism, chronic illness, estrogen replacement therapy, premature ovarian failure, or surgical removal of the ovaries (9).
In terms of androgen excess, the most common underlying cause is PCOS as we already discussed. Other causes of androgen excess in women include congenital adrenal hyperplasia, Cushing’s disease, insulin resistance syndromes, and in rare cases androgen-secreting tumors of the ovary and/or adrenal glands. Conducting a proper physical exam and gathering a good clinical history is essential in women presenting with non-PCOS androgen excess to rule out more serious conditions (18).
Diagnosing Androgen Imbalance in Women
Diagnosis of androgen imbalance is conducted through blood tests and symptom assessment. To assess testosterone in women, functional medicine physicians will order a total and free testosterone blood test. Both free and total testosterone tests are needed because most of the testosterone in our bodies is bound to SHBG leaving a small percentage to be used as free testosterone. It is also important to measure DHEA-S, another androgen hormone that can help physicians gain a broader idea of hormone levels in the body (20).
To gain a holistic picture of androgen imbalance, functional medicine practitioners may run other hormone tests such as thyroid hormone, LH, FSH, progesterone, glucose, and insulin levels to rule out other conditions that may be playing a role in the patients’ androgen imbalance. Proper medical history is needed for insight into the patient’s symptoms, menstrual history, and/or medications and supplements that could be contributing to an imbalance in the body (20).
For the most comprehensive evaluation of androgen balance, we can measure female hormones using urinary testing. The DUTCH Plus Test offers a remarkable view of hormone levels as well as hormone metabolites allowing for deeper insight into hormone metabolism and potential causes of imbalance (31).
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Androgen Therapy in Women
Hormone replacement can be life-changing for those with androgen imbalance. In the case of androgen deficiency, supplementing with testosterone and/or DHEA can greatly restore the proper functioning of steroid hormones in the body. For postmenopausal women with androgen deficiency, research has shown an improvement in sexual function with low-dose testosterone therapy. The use of DHEA supplementation (oral or vaginal application) has also been shown to lower side effects of genitourinary syndrome in menopausal women (52, 63).
For women who are still menstruating, the use of DHEA supplementation can work wonders on increasing androgen levels. DHEA is an androgen precursor produced in the adrenal glands that has been shown to improve brain function, libido, and endothelial cell function. For women with adrenal insufficiency, DHEA therapy has been shown to increase circulating androgen levels and contribute to increased energy, libido, and resolution of sexual dysfunction (47).
Risks of Self-Administering Androgen Therapy
When starting androgen therapy, it is crucial to be under the care of a healthcare provider who can measure levels throughout treatment. When individuals self-prescribe androgen therapy it can lead to long-term side effects due to supraphysiologic dosing. To avoid undesired side effects, a trained physician will monitor hormone levels before and during treatment to ensure physiologic dosing (52).
Treating Androgen Imbalance in Women
Currently, there are several different avenues for treating both androgen excess and deficiency in women. In androgen excess, conventional medicine may use birth control, medications (spironolactone, finasteride, metformin) to deal with the side effects of high androgen levels. In functional medicine, diet, lifestyle, and herbal medicine can help treat the underlying cause of androgen excess. Starting with nutrition therapy, research has shown that a low glycemic diet and ketogenic diet helped alleviate symptoms of PCOS. Research has also shown the use of inositol, NAC, and vitamin D can all aid in the treatment of androgen excess (27, 40, 54, 59).
For androgen deficiency, there are several lifestyle modifications and herbal allies that can aid in symptom improvement while addressing the root cause. First, lifting weights has been shown to build muscle while elevating testosterone production in women. Second, adding healthy sources of fat is the foundation for increasing steroid hormone production. Some examples of high-quality dietary fat include coconut oil, pasture-raised eggs, nuts, olive oil, and avocadoes. The use of herbs such as Maca can increase testosterone levels and aid in increasing libido related to low androgen levels. (48, 51, 68)
Side Effects of Androgen Therapy
If androgen replacement is continued long-term without monitoring of blood hormone levels it can cause toxic levels of testosterone leading to undesired effects. For women specifically, androgen therapy may cause the following (52):
- Voice changes (deepening of the voice)
- Alopecia
- Clitoromegaly
- Acne
- Hirsutism
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When to Contact Your Healthcare Provider
If you have recently gone through menopause or are experiencing some of the symptoms discussed in this article, it is advised to seek a functional medicine practitioner who can properly examine your lifestyle, and symptoms, and run appropriate labs. It is crucial to stay under the care of a trained physician while undergoing androgen therapy for the best health outcomes.
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