Polycystic Ovary Syndrome (PCOS) is the most common endocrine disorder affecting women of reproductive age worldwide. It is a complex health condition defined by symptoms resulting from an underlying hormonal imbalance. This syndrome involves a disruption in the normal communication between the brain, pituitary gland, and ovaries, which is necessary for reproductive health. PCOS often manifests with reproductive issues, such as irregular menstrual cycles, and various metabolic problems.
Hyperandrogenism The Core Hormonal Feature of PCOS
Elevated levels of androgens, often called “male hormones,” are a characteristic feature of Polycystic Ovary Syndrome. This excess androgen condition is medically termed hyperandrogenism and is a defining aspect of PCOS. Testosterone is the most clinically relevant androgen, and its excess biological activity contributes significantly to PCOS symptoms.
The diagnosis of PCOS frequently relies on the Rotterdam criteria, which require the presence of clinical or biochemical hyperandrogenism. Biochemical hyperandrogenism is confirmed by blood tests measuring elevated total or free testosterone. Free testosterone is considered more biologically active because it is not bound to Sex Hormone-Binding Globulin (SHBG). The Free Androgen Index (FAI), calculated from total testosterone and SHBG, is also used to assess active androgen levels.
Underlying Mechanisms Driving High Testosterone
The excess production of testosterone in PCOS is driven by metabolic and endocrine factors. A major contributing factor is insulin resistance, which affects many women with PCOS. When body tissues resist insulin, the pancreas produces higher levels of the hormone, leading to hyperinsulinemia.
This excess insulin acts directly on the ovaries, stimulating the theca cells to produce more androgens, including testosterone. High insulin levels also reduce the liver’s production of SHBG, the protein that binds to testosterone. The resulting decrease in SHBG increases the proportion of unbound, biologically active free testosterone circulating throughout the body.
The pituitary gland also influences ovarian stimulation and androgen production. Many women with PCOS exhibit an elevated ratio of Luteinizing Hormone (LH) to Follicle-Stimulating Hormone (FSH). This heightened LH secretion promotes the overproduction of androgens by the ovarian theca cells.
Common Physical and Reproductive Symptoms
High androgen levels lead to a range of noticeable physical and reproductive changes in women with PCOS.
Physical Symptoms
The most common physical manifestation is hirsutism, the growth of coarse, dark hair in a male-pattern distribution, such as on the face, chest, or back. High androgens stimulate hair follicles in these areas, causing unwanted hair growth. High testosterone also affects the skin, commonly resulting in severe acne and oily skin. Androgens overstimulate the sebaceous glands, causing them to produce excess sebum and leading to persistent breakouts. Conversely, high androgens can cause androgenic alopecia, or male-pattern hair loss, which presents as thinning hair on the crown of the head.
Reproductive Symptoms
Reproductively, excess androgens disrupt the normal development and release of an egg from the ovary (ovulation). This disruption often leads to oligo-anovulation, characterized by irregular periods (oligomenorrhea) or the complete absence of menstruation (amenorrhea). When ovulation is chronically inhibited, small, immature follicles accumulate around the edge of the ovaries, giving them the “polycystic” appearance on an ultrasound.
Approaches to Managing High Androgen Levels
Management of elevated androgen levels in PCOS focuses on addressing the underlying mechanisms and the resulting symptoms. Lifestyle changes are foundational to treatment, particularly interventions aimed at improving insulin sensitivity. Adopting a balanced diet and regular exercise helps regulate blood sugar levels, reducing the stimulatory effect of insulin on ovarian androgen production.
For direct hormonal management, combined oral contraceptive pills are frequently prescribed because they suppress ovarian androgen production and increase SHBG levels, lowering free testosterone. Anti-androgens, such as spironolactone, work by blocking the effects of androgens at the receptor level in target tissues like the skin and hair follicles.
Insulin-sensitizing medications, such as metformin, are also used to manage PCOS, as they improve the body’s response to insulin. By reducing hyperinsulinemia, these drugs indirectly help decrease ovarian androgen synthesis.