Top 5 Tests for Monitoring Androgen Levels

1. Free Androgen Index (FAI)
   • Measures active testosterone by calculating the ratio of total testosterone to SHBG.
   • Useful for diagnosing PCOS and identifying symptoms like unwanted hair growth or irregular periods.
2. Total Testosterone
   • Provides a complete picture of testosterone levels (free + bound).
   • Helps detect androgen excess, ovarian tumors, or adrenal-related issues.
3. DHEAS (Dehydroepiandrosterone Sulfate)
   • Evaluates adrenal gland function and distinguishes between adrenal and ovarian androgen sources.
   • Elevated levels may indicate adrenal tumors or PCOS.
4. Androstenedione
   • Assesses adrenal and ovarian androgen production.
   • Key for diagnosing conditions like congenital adrenal hyperplasia (CAH) or severe PCOS.
5. Dihydrotestosterone (DHT)
   • Measures the most potent androgen, linked to hair loss and hirsutism.
   • Useful for monitoring treatment and diagnosing 5-alpha-reductase deficiency.

Quick Comparison

These tests provide a comprehensive view of your hormonal health, helping pinpoint the root causes of symptoms like acne, hair loss, or irregular cycles. Accurate testing paired with tailored treatment can restore balance and improve your well-being.

The Case of PCOS: Evaluating Ovarian and Adrenal Hormones

1. Free Androgen Index (FAI) Assessment

The Free Androgen Index (FAI) is a key tool for gauging active testosterone levels in women. While total testosterone levels might give a broad overview, FAI provides a sharper focus on the testosterone that’s actually available to influence the body.

How FAI Helps in Hormonal Health

FAI is calculated using a simple formula: the ratio of total testosterone to sex hormone-binding globulin (SHBG), multiplied by 100. This matters because over half of the testosterone circulating in the body is bound to SHBG, leaving it biologically inactive. In women, less than 0.7% of testosterone is free and active.

FAI Formula:
FAI = 100 × (total testosterone ÷ SHBG)

Both total testosterone and SHBG are measured in nanomoles per liter (nmol/L), and since FAI is a ratio, it doesn’t have a unit. This calculation is essential for pinpointing active testosterone levels, which play a direct role in shaping treatment plans.

Why FAI Matters for PCOS and Androgen Issues

For women with polycystic ovary syndrome (PCOS), FAI testing is particularly insightful. Studies show that elevated FAI levels are closely linked to functional ovarian hyperandrogenism, a common feature of PCOS.

Understanding FAI Ranges

FAI levels can vary by age, and knowing these ranges is critical for proper diagnosis. Here’s a quick reference for women:

Reliability of FAI Testing

The Endocrine Society notes, “FAI is often used as a surrogate for FT, and the FAI correlates well with FT in women but not men”. This makes it a trusted tool for evaluating symptoms like unwanted facial hair, hair thinning, or irregular periods.

Interestingly, research also connects FAI levels to quality of life in women with PCOS, with body mass index (BMI) playing a role in this relationship. This highlights the importance of accurate FAI measurement when assessing hormonal health and crafting treatment plans.

For women dealing with androgen-related concerns, Oana Health incorporates FAI testing into its hormone panels, ensuring personalized care that addresses the root causes of symptoms.

2. Total Testosterone Measurement

Total testosterone measurement includes both free and bound testosterone, offering a complete picture of circulating testosterone levels. This test is vital for diagnosing and managing androgen-related conditions.

Clinical Utility for Hormonal Health Management

Measuring total testosterone is especially important in conditions like PCOS, where even slight elevations can disrupt normal menstruation and ovulation. Normal values range from 6.0–86 ng/dL, but research shows that women with higher testosterone levels face a 2.4 times greater relative risk and 5.7 times higher odds of having PCOS.

However, external factors like oral contraceptives can lower total testosterone levels, impacting test reliability. Experts recommend waiting at least three months after discontinuing oral contraceptives before testing. The accuracy of results largely depends on the testing method used.

Accuracy and Reliability of Testing Methods

The method used to measure testosterone greatly influences the test's reliability. Liquid chromatography–mass spectrometry (LC-MS/MS) is considered the gold standard due to its high sensitivity and precision, especially at low testosterone concentrations. Studies highlight that LC-MS/MS delivers more accurate results (AUC 0.851) compared to CLIA methods (AUC 0.766).

Additionally, LC-MS/MS provides more consistent and stable results than CLIA, which tends to show higher variability. For this reason, major medical organizations now endorse tandem mass spectrometry for testosterone testing, while direct immunoassays are not recommended for assessing PCOS.

Relevance to PCOS and Androgen-Related Conditions

In women with PCOS, total testosterone measurement is a key diagnostic tool, as 60–80% of PCOS patients display elevated androgen levels. While most women with PCOS have testosterone levels ≤150 ng/dL (≤5.2 nmol/L), normal testosterone levels do not rule out PCOS. A broader evaluation of multiple androgen markers is often necessary.

Research from East Asia has shown that LC-MS/MS is more effective at predicting hyperandrogenism compared to CLIA methods, further emphasizing the importance of using the right testing technique.

Interpretation Thresholds and Diagnostic Value

Understanding testosterone levels is critical for accurate diagnosis and treatment planning:

Testosterone levels ≥200 ng/dL should be investigated immediately, as they could signal androgen-secreting tumors. Similarly, DHEAS levels above 700 ng/mL might indicate such tumors and require further gynecologic evaluation.

For women experiencing symptoms like unwanted facial hair, hair thinning, or irregular periods, testing both free and total testosterone is often recommended. If testosterone levels are within the normal range, additional markers like androstenedione and DHEAS may be assessed, though they are generally less specific.

At Oana Health, we utilize advanced testing technologies to ensure precise testosterone measurements, enabling us to create personalized treatment plans tailored to your unique hormonal profile.

3. DHEAS (Dehydroepiandrosterone Sulfate) Testing

DHEAS testing measures the levels of dehydroepiandrosterone sulfate, a hormone primarily produced by the adrenal glands and, to a lesser extent, the ovaries. This test is a key tool for evaluating adrenal function and identifying androgen-related disorders.

Clinical Role in Hormonal Health

DHEAS testing offers critical insights into adrenal health and helps distinguish whether excess androgens are originating from the adrenal glands or the ovaries. One of its strengths is its stability - DHEAS levels don’t fluctuate much throughout the day. This consistency makes it a reliable marker for diagnosing hormonal imbalances, such as those causing acne or excessive hair growth. It’s also useful in identifying conditions like congenital adrenal hyperplasia, adrenal tumors, or adrenal insufficiency. These applications highlight its importance in understanding DHEAS’s role in PCOS and other androgen-related disorders.

Connection to PCOS and Androgen Disorders

While DHEAS testing isn’t the primary diagnostic tool for polycystic ovary syndrome (PCOS), it plays a supporting role in understanding the condition. Elevated DHEAS levels are observed in 20–30% of PCOS cases, although research using age-specific norms found elevations in only 8.1% of women with PCOS. Since DHEAS can convert into more potent androgens, it’s linked to symptoms like hirsutism, acne, and irregular menstrual cycles. Interestingly, DHEAS levels peak between ages 20 and 30, then gradually decline by about 2% annually after age 30. This data complements other androgen measurements, giving clinicians a fuller picture of hormonal health.

Interpreting DHEAS Levels

To make sense of DHEAS results, age-specific reference ranges are essential, as normal levels shift throughout a woman’s life:

Levels at or above 600 mcg/dL may point to an androgen-secreting adrenal tumor, while very low levels could indicate conditions like Addison’s disease or hypopituitarism. These thresholds are also helpful for diagnosing adrenal insufficiency .

In women with PCOS, DHEAS is sometimes the only abnormal androgen detected, occurring in about 10% of cases. However, its diagnostic value for PCOS is limited unless paired with significantly elevated testosterone levels.

At Oana Health, DHEAS testing is part of a broader hormonal evaluation. By applying age-specific reference ranges, we ensure accurate interpretations, enabling tailored treatments for PCOS and other androgen-related conditions.

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4. Androstenedione Testing

Androstenedione testing measures a hormone that serves as a precursor to testosterone and estrogen. By examining this hormone, clinicians can better understand androgen production pathways and pinpoint the causes of hormonal imbalances, particularly those that impact women's health.

Clinical Importance in Hormonal Health Management

This test plays a crucial role in diagnosing and managing various endocrine disorders. Androstenedione is primarily produced by the adrenal glands (regulated by ACTH) and the ovaries, which helps differentiate between adrenal and ovarian sources of excess androgens.

One of its key applications is in diagnosing congenital adrenal hyperplasia (CAH). In CAH, androstenedione levels are often elevated by 5 to 10 times the normal range. This makes it especially helpful when assessing androgen excess linked to polycystic ovary syndrome (PCOS).

Connection to PCOS and Androgen-Related Disorders

For women with PCOS, androstenedione testing provides valuable insights into androgen excess. Research indicates that women with PCOS have significantly higher androstenedione levels compared to healthy individuals, with a relative risk of 3.0 and an odds ratio of 4.8 for elevated levels. High levels of this hormone have been associated with symptoms like hirsutism, acne, and irregular menstrual cycles. When other hormone test results are inconclusive, measuring androstenedione can help refine the diagnosis, often pointing to more severe cases of PCOS.

Reference Ranges and Diagnostic Insights

Interpreting androstenedione levels requires an understanding of both standard reference ranges and the clinical context. Normal serum levels typically fall between 0.7 and 3.1 ng/mL (or 30–200 ng/dL). However, levels exceeding 500 ng/dL may signal the presence of an androgen-secreting tumor. For monitoring CAH, levels up to 100 ng/dL are generally acceptable if testosterone levels remain normal.

Mildly elevated androstenedione levels are often linked to idiopathic causes or PCOS. On the other hand, levels above 500 ng/dL strongly suggest the possibility of an androgen-producing tumor, as over 90% of patients with benign adrenal tumors producing androgens show levels well beyond this threshold.

At Oana Health, androstenedione testing is a vital part of our comprehensive androgen testing panel. By combining these results with other diagnostic measures, we create tailored treatment plans to address PCOS and other conditions related to androgen excess effectively.

5. Dihydrotestosterone (DHT) Testing

Dihydrotestosterone (DHT) is recognized as the body's most powerful androgen. It is derived from testosterone through the action of the enzyme 5-alpha-reductase, known for its strong receptor binding and extended half-life.

Role in Hormonal Health Management

DHT testing builds on the insights provided by other androgen tests, offering a more detailed hormonal profile. It plays a key role in diagnosing and managing androgen-related conditions. For instance, it helps identify 5-alpha-reductase deficiency, where DHT levels may drop to about 30% of their normal range. It’s also valuable in evaluating hair loss and monitoring treatment effectiveness . A high testosterone-to-DHT ratio can serve as a marker for diagnosing 5-alpha-reductase deficiency.

Testing Methods and Accuracy

Several methods are available for accurately measuring DHT levels. Free DHT blood tests measure the unbound hormone circulating in the bloodstream, while urine tests provide a broader view of overall androgen metabolism. Among the testing techniques, LC-MS/MS stands out for its superior sensitivity, especially when detecting low DHT levels. Immunoassays are also used but may not match the precision of LC-MS/MS .

Connection to PCOS and Related Conditions

Recent studies suggest a link between increased DHT production through alternative pathways (often referred to as "backdoor biosynthesis") and certain PCOS symptoms. These include higher body weight, increased fat accumulation, elevated cholesterol, and enlarged fat cells.

Interpreting DHT Levels

In the bloodstream, DHT typically accounts for about 10% of circulating testosterone levels. However, its local production in peripheral tissues can result in concentrations up to ten times higher than testosterone in those areas. Because blood levels may not fully reflect tissue concentrations, clinicians often interpret DHT levels alongside other clinical indicators.

At Oana Health, DHT testing is a vital component of our androgen assessment approach. By combining DHT insights with other androgen evaluations, we gain a deeper understanding of conditions like PCOS and hair loss. This comprehensive view helps us create targeted treatment plans that address the root causes of androgen-related symptoms.

Test Comparison Table

Understanding the differences between androgen tests is key for effective hormone monitoring. Each test targets specific biomarkers, serving distinct clinical purposes and offering varying levels of precision based on the methods used.

Here's a quick-reference table summarizing the tests discussed earlier, highlighting their primary uses and strengths:

Key Insights on Testing Methods:

• Immunoassays: These are budget-friendly and straightforward but can lack precision due to cross-reactivity. They often require larger sample volumes and typically measure only one hormone at a time. For instance, immunoassays tend to overestimate testosterone and androstenedione while underestimating DHEA and DHT.
• LC-MS/MS: Widely regarded as the gold standard, this method excels in specificity and accuracy. It can measure multiple hormones from a small sample. However, it is less automated and requires specialized equipment.

Clinical Applications and Considerations:

• For conditions like PCOS, where 65–75% of women exhibit hyperandrogenism, accurate hormone measurement is critical. DHEAS levels above 700 ng/dL often point to adrenal tumors, while mild elevations are more commonly linked to PCOS.
• LC-MS/MS is particularly reliable for women with suspected androgen excess, as it detects even mild testosterone elevations that could be missed by radioimmunoassays.
• In cases where SHBG abnormalities affect total testosterone readings, bioavailable testosterone becomes the preferred metric for accurate assessment.

Conclusion

Keeping an eye on androgen levels is a key step in managing PCOS and other hormone-related conditions in women. These tests are the cornerstone of a focused diagnostic process.

"Androgens are an essential part of reproductive health and overall health for all people. But they require a careful balance to do so." - Cleveland Clinic

Each of the five tests - FAI, Total Testosterone, DHEAS, Androstenedione, and DHT - offers a unique piece of the puzzle when it comes to understanding your hormonal health. Together, they provide a comprehensive view of your hormonal profile. This level of precision is critical, especially given that while hirsutism affects 4% to 11% of women in the general population, it occurs in 65% to 75% of women with hyperandrogenism and PCOS.

Regular monitoring based on these tests not only helps in tracking treatment progress but also plays a vital role in preventing complications. Telehealth options, like those provided by Oana Health, make this process more accessible with at-home sample collection, virtual consultations, and tailored, cost-effective treatments for hormonal imbalances.

Effective hormone management relies on accurate testing paired with personalized treatment strategies. Whether you're facing elevated testosterone, adrenal issues, or PCOS symptoms, the right combination of diagnostic tools and care can help restore hormonal balance and improve your well-being. If you're experiencing symptoms of imbalance, connecting with a healthcare professional - through traditional means or telehealth services - can be a crucial first step toward better health.

FAQs

Which androgen test is best for my symptoms?

The right androgen test for you depends on your specific symptoms and medical history, so working with a healthcare provider is key. Here are some commonly used tests:

• Total Testosterone Test: Measures the total amount of testosterone in your blood, including both free and protein-bound testosterone.
• Free Testosterone Test: Specifically evaluates the active testosterone circulating in your body.
• Free Androgen Index (FAI): Compares total testosterone levels to sex-hormone binding globulin (SHBG) to estimate androgen activity.

These tests are often used to diagnose conditions like polycystic ovary syndrome (PCOS) or androgen excess, which can lead to symptoms such as acne, unwanted facial hair, or irregular menstrual cycles. Your healthcare provider can recommend the most suitable test based on your symptoms and overall health objectives.

How do lifestyle factors impact androgen level tests, and what should I do to prepare?

Lifestyle choices, such as diet, physical activity, and maintaining a healthy weight, play a big role in influencing androgen levels. For instance, sticking to a balanced diet with a low glycemic index can help keep hormones in check. On the flip side, a sedentary lifestyle combined with poor eating habits often disrupts hormonal balance.

When preparing for an androgen level test, fasting for several hours beforehand is usually recommended because eating can temporarily impact hormone levels. You might also need to pause certain medications, like steroids or hormone therapies, if your doctor advises it. Scheduling your appointment in the morning is often ideal since testosterone levels are typically at their peak early in the day. Be sure to follow your healthcare provider's specific instructions to ensure the most accurate results.

What causes high DHEAS levels, and how are they connected to PCOS and other health conditions?

High levels of DHEAS (Dehydroepiandrosterone sulfate) can stem from several underlying issues, such as Polycystic Ovary Syndrome (PCOS), adrenal gland disorders, or even certain tumors. In cases of PCOS, elevated DHEAS is often tied to higher androgen levels, leading to symptoms like excessive facial hair, acne, and irregular menstrual cycles.

Other possible causes include adrenal hyperplasia, a condition that disrupts normal adrenal gland function, or, in rare instances, hormone-sensitive cancers. When DHEAS levels are abnormally high, it usually signals an imbalance in adrenal or hormonal activity. This often calls for a thorough evaluation by a healthcare provider to pinpoint the cause and decide on the best course of action.

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