Hyperandrogenism means too much androgen is active in your tissue. Androgens such as testosterone belong in every woman, just in small amounts. When that balance shifts, you usually notice it first in your skin and your hair, and then in your cycle.
In roughly three quarters of women with this picture, PCOS is the explanation. That is exactly where I think most articles on the subject go wrong: they treat hyperandrogenism and PCOS as the same thing. Which means the remaining quarter get sent the wrong way.
Below are seven signs, followed by the distinction that decides which direction you look.
What is hyperandrogenism exactly?
It is not a diagnosis in itself but a finding: clinical signs of androgen excess, with or without raised values in your blood. Those two often do not track together. You can have clear symptoms with a normal testosterone, and a mildly raised value without noticing anything.
That happens because your skin and hair follicles differ in how sensitive they are to androgen. Two women with the same value can therefore present completely differently.
The symptoms weigh more heavily than the number.
1. Hair growth in places you are not used to
Coarser, darker hair on your upper lip, chin, chest, abdomen or back is called hirsutism. It is about the type of hair, not the amount: vellus hair turning darker and thicker is the signal.
This is the most common visible sign of androgen excess in premenopausal women (PMID 29522147). What counts as normal varies widely by family and background, so the change relative to your own situation matters more than a comparison with others.
If this occurs alongside a known PCOS diagnosis, PCOS and excess hair goes deeper into it.
2. Acne that persists past twenty or returns
Androgens drive your sebaceous glands. If acne persists past your teens or comes back around thirty, a hormonal component may be involved.
The pattern gives a hint. Spots along your jawline, chin and neck fit a hormonal cause more often than acne on your forehead. Which values fit is in hormonal acne.
3. Thinning hair at your parting and crown
In women the hairline usually does not recede the way it does in men. What you see instead is a widening parting and a crown where more scalp shows through.
Confusingly, hair loss can also fit iron deficiency or an underactive thyroid, and both are more common in women. They are therefore usually ruled out first, see hair loss in women.
4. A cycle that lengthens or stops
Androgen excess disturbs follicle maturation, which makes ovulation irregular or absent. A cycle beyond 35 days is the first sign.
This signal weighs heavily, because it separates a cosmetic complaint from a disrupted ovulation. If your period stops altogether, amenorrhoea is the wider frame.
5. Oily skin and oily scalp
The same sebaceous glands that produce acne also make your skin and scalp oilier. Women often notice it as hair getting greasy faster than it used to.
On its own it is a weak signal. Alongside one of the other six it becomes informative.
6. More fat around your waist
Higher androgen exposure often travels with insulin resistance, and that combination shifts fat to your abdomen. The two reinforce each other: insulin lowers your SHBG, leaving more free testosterone.
That circle is explained in PCOS and insulin resistance and on the protein side in SHBG in women.
7. Rapid change: voice, muscle, virilisation
This signal sits apart from the six above, because it is about pace. A deepening voice, clear muscle growth, a receding hairline or an enlarged clitoris developing within months does not fit the gradual picture of PCOS.
That combination warrants assessment by your GP without waiting. It more often points to an adrenal or ovarian source needing separate investigation.
What can the cause be?
PCOS is by far the most common explanation, but the four other routes decide what investigation follows. What separates the causes is usually not the height of your testosterone, but the pace at which it developed and which other value moves with it.
| Cause | How it usually runs | Value that stands out |
|---|---|---|
| PCOS | Gradual from puberty, long cycle | Raised free androgen index, low SHBG |
| Late-onset adrenal enzyme disorder | Resembles PCOS, sometimes from a younger age | Raised 17-OH-progesterone |
| Adrenal source | Variable, sometimes faster | DHEA-S well above the age band |
| Medication | Starts after beginning a drug | Often normal values |
| Idiopathic | Gradual, cycle stays regular | All values normal |
| Rare: hormone-producing growth | Fast, with virilisation | Markedly raised testosterone or DHEA-S |
Take two women who both have a calculated free androgen index of 8. One is 24, has had a 40 day cycle since she was sixteen and an SHBG of 18 nmol/l: that fits the PCOS picture. The other is 41, always had a 28 day cycle, and over six months hears her voice drop with a DHEA-S of 20 micromoles per litre. Same index, and yet a completely different follow-up.
The last row is rare and it is on the list, because pace makes the difference rather than rarity.
Which blood values fit?
The usual starting point is total testosterone together with SHBG, so the free androgen index can be calculated. Requesting the total alone often yields a normal result in a woman who genuinely has symptoms.
That calculation remains an estimate. With an abnormal SHBG it becomes less reliable, precisely where you want to use it (PMID 10523012). The international PCOS guideline therefore uses the calculated free value rather than the total alone (PMID 37580861).
Depending on your story, DHEA-S, 17-OH-progesterone, LH, FSH and prolactin join in. A raised early-morning 17-OH-progesterone is the pointer toward the late-onset adrenal enzyme disorder (PMID 30272171).
If you use the combined pill, this profile is hard to read: the oestrogen raises your SHBG markedly and pushes your free androgen down. So discuss timing with your GP. If you want a picture taken, PCOS screening fits these values, with background at total testosterone and DHEA and DHEA-S.
When do you make contact sooner?
With symptoms developing over months rather than years, with a deepening voice, with clear muscle growth without training, and with hair growth visibly increasing while your cycle stops. That combination belongs to a different route than the gradual one.
With a gradual picture, an ordinary appointment fits. What helps is a timeline: since when, how fast, and what else changed in the same period in medication or weight.
Thuisarts and the NHG information for Dutch GPs describe the same order: history and examination first, then targeted blood testing. The wider overview of which hormone test fits when is in hormone testing in women. Always discuss an abnormal result with your GP.
References
- Martin KA, Anderson RR, Chang RJ, et al. Evaluation and treatment of hirsutism in premenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2018;103(4):1233-1257. PMID 29522147.
- Speiser PW, Arlt W, Auchus RJ, et al. Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2018;103(11):4043-4088. PMID 30272171.
- Teede HJ, Tay CT, Laven JJE, et al. Recommendations from the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Eur J Endocrinol. 2023;189(2):G43-G64. PMID 37580861.
- Vermeulen A, Verdonck L, Kaufman JM. A critical evaluation of simple methods for the estimation of free testosterone in serum. J Clin Endocrinol Metab. 1999;84(10):3666-3672. PMID 10523012.
- Thuisarts. I have excess hair growth. Available via thuisarts.nl.
Every blood test result at Lunara includes a professional assessment by a BIG-registered doctor. For treatment decisions, discuss your results with your GP.
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