New Guidelines Expand Understanding of Androgen Excess in Women

In a significant shift in clinical practice, the Society for Endocrinology has published updated guidelines aimed at diagnosing and managing androgen excess in women, moving beyond the traditional focus on polycystic ovary syndrome (PCOS). The new recommendations, released on July 18, 2025, emphasize the necessity of considering a wider array of potential causes, including androgen-secreting tumors and adrenal disorders, particularly in women exhibiting rapid-onset symptoms or virilization.

The guidelines call for early identification and tailored treatment based on the underlying etiology of androgen excess, which may lead to irreversible physical changes if untreated. Dr. Elaine Frade, head of the Department of Female Endocrinology, Andrology, and Transgender Health at the Brazilian Society of Endocrinology and Metabolism, stated, "The etiological investigation should be prompt and accurate, as treatment depends on the underlying cause. Symptoms can also have a significant psychosocial impact and may, in some cases, leave permanent effects."

Historically, PCOS has been recognized as the most common cause of hyperandrogenism due to its prevalence and the associated symptoms of oligo-anovulation, clinical signs of hyperandrogenism, and polycystic ovarian morphology. The Rotterdam criteria, widely accepted for diagnosing PCOS, require the presence of at least two of these criteria. Nonetheless, the Society's new guidelines stress that a more diverse diagnostic approach is critical, as conditions like ovarian hyperthecosis and adrenal tumors can also lead to similar symptoms.

The updated guidelines define hyperandrogenism based on total testosterone levels exceeding 86 ng/dL or free testosterone levels above 3.2 ng/dL. Additionally, they advocate for the use of liquid chromatography-tandem mass spectrometry (LC-MS/MS) over traditional immunoassays to enhance diagnostic accuracy, particularly given the low testosterone concentrations typically found in women. Dr. Karen de Marca Seidel, director of the Brazilian Society of Endocrinology and Metabolism, highlighted the importance of proper sample preparation, which includes fasting and timing of blood sample collection.

Despite the advancements in diagnostic methods, challenges remain. The accessibility of LC-MS/MS testing is limited in several countries, including Brazil, due to high costs and inadequate insurance coverage. As a result, many labs still rely on preliminary immunoassays before conducting more precise testing. Dr. Frade remarked, "While LC-MS/MS is the gold standard, its availability is still limited in many countries due to high costs and limited insurance coverage."

Moreover, the guidelines underscore the importance of recognizing exogenous androgen use as a potential cause of hyperandrogenism. This often overlooked factor can stem from hormone implants, anabolic steroids for aesthetic purposes, or off-label hormone therapies. Seidel noted, "Exogenous androgen use may now be one of the most common, yet underrecognized, causes of androgen excess in women in Brazil."

The treatment recommendations vary based on the underlying causes. For PCOS, lifestyle changes, pharmacologic treatments, and hormonal contraceptives are typically employed. In cases of ovarian hyperthecosis, bilateral oophorectomy may be necessary. Conversely, adrenal tumors producing androgens usually require surgical intervention, with adjunctive therapies such as chemotherapy considered in malignant instances.

The guidelines also prioritize patient education regarding the complexities of managing hyperandrogenism. According to Dr. Frade, establishing a realistic treatment plan is essential. "Even with effective management of the underlying cause, some clinical manifestations may be permanent or show only limited improvement," she cautioned. This emphasizes the need for ongoing patient support and education to align expectations with achievable treatment outcomes.

In conclusion, the 2025 guidelines from the Society for Endocrinology represent a pivotal shift in the understanding and management of androgen excess in women, advocating for a broader diagnostic framework and highlighting the importance of personalized treatment strategies. As awareness of these conditions grows, continued research and collaboration among healthcare professionals will be crucial in improving outcomes for women affected by hyperandrogenism.