OG30.2 | Hyper-Androgenism — Summary & Reflection

KEY TAKEAWAYS

Hyperandrogenism results from excess androgen activity and ranges from the common and benign (idiopathic hirsutism, PCOS) to the rare and serious (androgen-secreting tumour). The clinical severity spectrum runs from hirsutism (mFG score ≥8 = significant) to virilisation (clitoromegaly, voice deepening, male-pattern alopecia, breast atrophy) — the latter demands urgent investigation.

Causes are classified by source: ovarian (PCOS 70-80%; androgen-secreting tumour — rare but urgent); adrenal (late-onset CAH 4-8% of hyperandrogenic women; Cushing syndrome; adrenal carcinoma); exogenous (drugs); idiopathic (normal androgens, increased 5α-reductase).

The diagnostic cornerstone is biochemical: total testosterone >200 ng/dL → urgent CT imaging; 17-OHP >2 ng/mL → ACTH stimulation test (peak >10 ng/mL = CAH); DHEAS >700 µg/dL → adrenal source.

Management follows the cause: PCOS → lifestyle/COC/metformin/letrozole; late-onset CAH → hydrocortisone (not COC); androgen-secreting tumour → surgery; idiopathic hirsutism → cosmetic + COC/spironolactone. Spironolactone always requires concurrent contraception (teratogenic). Hormonal treatment slows new growth; existing terminal hair requires cosmetic removal.

REFLECT

Priya returns after her CT scan, which shows a 3 cm right ovarian mass. She is referred for laparoscopic right salpingo-oophorectomy; histology confirms a Sertoli-Leydig cell tumour. Her testosterone normalises within weeks. Reflect on the following:
- What clinical clue in Priya's initial presentation (tempo, examination finding) was the key differentiating feature from PCOS hirsutism?
- Had Priya been prescribed a COC pill at her first visit without investigation, what might have happened?
- Across both the PCOS SDL and this SDL, you have seen how the same surface presentation (hirsutism + oligomenorrhoea) can arise from five different causes requiring five different treatments. How will you build a reliable mental algorithm for approaching any woman presenting with androgen excess in your clinical practice?
- Which investigation threshold — 17-OHP >2 ng/mL or testosterone >200 ng/dL — do you feel you are most likely to forget in a busy outpatient setting? Identify one strategy to make it automatic.
This reflection follows Kolb's experiential learning cycle. Priya's outcome is the concrete experience that anchors the abstract taxonomy of hyperandrogenic causes you have just studied.