What Are The Root Causes of PCOS? Part 2 – Androgen Excess

If you haven’t already checked out my blog on the Diagnostic Criteria and Four Types of PCOS, dig into that HERE. This is Part 2 – Androgen Excess, in a 4-Part PCOS blog series discussing The Root Causes of PCOS. I hope that understanding the root causes of PCOS, will help you better navigate this lifelong disorder at all stages of your life.

Check out Part 1-Insulin Resistance HERE.

PCOS (AKA: Polycystic Ovary Syndrome) is the most common endocrine disorder in reproductive-age women. The worldwide prevalence is 5-10%. That’s A LOT of women. The association of PCOS with infertility has been well studied and thought to be responsible for up to 40% of female infertility. (Krysiak R, et al. 2006)

Clues that PCOS is Lurking Behind the Scenes

• Anovulation
• Menstrual irregularity
• Hyperandrogenism
  • acne
  • androgenic alopecia (hair loss on the head)
  • hirsutism (dark, coarse hair growth on the face, chin, chest, back, and abdomen)
• Infertility
• Insulin resistance
• Obesity
• Increased abdominal adiposity
• Polycystic ovaries on ultrasound

The top four root causes of PCOS

• Insulin Resistance
• Androgen Excess (Hyperandrogenism)
• Inflammation
• Genetics

Let’s dive in!

1. Insulin Resistance and Impaired Glucose Tolerance

Check out Part 1 on Insulin Resistance HERE!

2. Androgen Excess

What Are Androgens?

Androgens are hormones such as testosterone, DHEAs, androstenedione, and dihydrotestosterone (DHT). These hormones contribute to the skin and hair symptoms seen in PCOS, including:

• Acne
• Loss of hair on the head, known as androgenic alopecia
• Coarse hair growth on the chin, upper lip, mid-chest, abdomen, and back, known as hirsutism
• Anovulation
• Irregular menstruation.

The secretion, formation, and response to these hormones are complex, much of which is beyond this post’s scope, but I wanted to cover some of the basics. You’ll notice that each of these is either released from the ovaries (in response to insulin and luteinizing hormone (LH)), the adrenal glands (in response to the brain and stress), both or a product of another androgen (as is the case with DHT).

• Androstenedione
  • produced by the ovaries and adrenal glands (~50% each)

• Testosterone
  • released from the ovaries (~25%), adrenal glands (~25%), and converted from androstenedione (~50%)
  • increased insulin floating around the body causes the theca cells of the ovary to ramp up testosterone production

• Dihydrotestosterone (DHT)
  • converted in body tissues from its precursor hormone testosterone
  • 3x as potent as testosterone
  • Certain tissues have more or less of the enzyme 5-alpha reductase, which converts testosterone into DHT. It seems that in women with PCOS, even if testosterone levels aren’t off the charts high, there is increased activity of this enzyme in hair follicles and sebaceous glands.
  • Super high levels of DHT (3x more potent than testosterone) cause:
    • slow growth and destruction of head hair follicles (leading to thinning hair) AND faster, thicker growth of face, chest, & back hair
    • shedding of head hair too soon (leading to hair loss) AND hair that takes longer to fall out on the face, chest, and back
    • increased acne
  • DHT is the main culprit of hair loss and acne

• DHEA and DHEAs
  • primarily produced by the adrenal glands, but a small amount is produced by the ovaries
  • released in concert with cortisol from the adrenal glands during times of stress, blood sugar dysregulation, elevated insulin, and prolactin
  • High levels of DHEA (adrenal androgen excess) is more common in lean PCOS

Androgens cause changes in the brain’s secretion of gonadatropin releasing hormone (GnRH), which is the signal to the ovaries to release either follicle stimulating hormone (FSH) or luteinizing hormone (LH). When androgens are high, the brain tells the ovaries to release more LH. The small amount of FSH released prompts follicular maturation but not enough to cause those follicles to produce either a surge of estrogen or LH that would normally cause ovulation. And the extra LH sends feedback to the ovaries to produce more androgens. UGGG!

How Do you test for androgen excess?

Unfortunately, blood tests for androgens aren’t all that great but they are the standard, so it’s worth checking them. If they’re high, PCOS is definitely worth extra investigation. If they aren’t elevated, but you have acne, hair loss on your head, or hair growth on your face, etc., don’t place too much emphasis on the fact that your androgens are not above the reference range. If you have these symptoms, that is enough to consider PCOS.

Most women with PCOS have serum Total Testosterone within the normal range. Elevated Free Testosterone accounts for the vast majority of abnormal lab findings, but an accurate assessment is challenging, as is the measurement of DHT. DHEAs will be elevated in ~25% of women with PCOS. Androgens also naturally decrease with age, so the reference ranges can become unreliable over time. Finally, there can also be genetic alterations within the androgen receptors of skin and hair follicles which make them extra sensitive to androgens and this is very difficult or impossible to measure in bloodwork.

Are There Other Reasons For Hair Loss And Acne besides pcos & androgen excess?

There definitely are, so it’s super important to consider them when you’re sussing out what might be happening with your health. There can be many layers to your concerns. Some of the most common causes include:

• Nutritional deficiencies from poor gut health, malabsorption, or a crummy diet
• Low iron and ferritin
• High prolactin
• Autoimmune disease
• Thyroid disease

Integrative & Functional Therapeutic Options for androgen excess

Check out Part 1 and Part 3 of this blog series for nutrition & lifestyle considerations that really support the root causes of androgen excess, such as INSULIN RESISTANCE, INFLAMMATION, and STRESS.

As always, it is VERY important to work with a provider that understands the indications, contraindications, and dosing strategies of the following therapies for Androgen Excess. Even though these are natural substances, it doesn’t mean they are without the potential for harm. Please check out the links at the bottom of this post for integrative providers.

Natural Oral Anti-Androgens

• Licorice (Glycyrrhiza glabra)
  • shown to decrease testosterone levels (Armanini D, et al. 2004, Takeuchi T, et al. 1991)

• Chamomile (Matricaria chamomilla)
  • shown to cause a decrease in testosterone in women with PCOS (Heidary M, et al. 2018)

• Berberine
  • reduces testosterone, fasting glucose, fasting insulin, HOMA-IR, and increases sex hormone binding globulin (SHBG) (An Y, et al. 2014)

• Spearmint Tea (Mentha spicata)
  • reduces free and total testosterone (Grant P, 2010)

• Green Tea (Camellia sinensis)
  • reduces testosterone and DHT (acting as a 5-alpha-reductase inhibitor) (Tehrani HG, et al. 2017)

• White Peony (Paeonia lactiflora)
  • inhibits testosterone synthesis (as an aromatase inhibitor, an enzyme that converts estrogen to testosterone) (Takeuchi T, et al. 1991)

• Reishi (Ganoderma lucidum)
  • 5-alpha-reductase inhibitor (the enzyme that converts testosterone to DHT) (Liu J, et al. 2006, Nahata A, et al. 2014)

• Saw Palmetto (Serenoa repens)
  • 5-alpha-reductase inhibitor (Evron E, et al. 2020)

Natural Topical Anti-Androgens

• Rosemary (Salvia rosmarinus, formerly known as Rosmarinus officinalis)
  • Topical application of Rosemary essential oil promotes hair growth by inhibiting 5-alpha-reductase, and ultimately DHT (a form of testosterone) in the follicle. (Murata K, et al. 2013, de Macedo LM, et al. 2020)
  • Mix 3 drops of organic rosemary essential oil with 2 tsp of jojoba oil. Gently massage the mixture into the scalp about 30 minutes prior to hair washing, 2-3 times per week.
  • CAUTION: Sensitivity or allergic response to rosemary essential is common. Test a small drop of the mixture on the skin and wait 24 hours to see if a reaction occurs. If any redness, itching or irritation occurs DO NOT apply this mixture to the scalp. If a reaction is developed over time, stop using the mixture immediately.
  • Promotion of hair growth can take months and usually requires a multifactorial approach.

Conventional Therapeutic Options For androgen excess

• Hormonal Contraceptives, AKA “The Pill“ (not all of the hormones mentioned are included in a pill, some are injectable or implanted)
  • This is a hugely controversial topic, but important so I’ll provide the basics if you’re considering this option.
  • Although this is a first-line treatment in conventional medicine, it’s obviously not appropriate for women who want to get pregnant because it suppresses ovulation, and can come with a whole host of post-pill headaches when it’s discontinued.
  • Although it appears to be helpful with the symptoms of increased androgens, the progestins (synthetic progesterone) can be androgenic and make things worse, have the potential to increase insulin resistance, all increase risk of blood clots (especially the contraceptives containing anti-androgenic properties), and are not very effective for hirsutism.
  • Not all OCPs are the same. They have varying degrees of androgenic and anti-androgenic properties.
    • Strongest androgenic properties (most likely to aggravate acne, alopecia, and hirsutism): contraceptives containing depot-medroxyprogesterone acetate (DMPA), etonogestrel, levonorgestrel, and norgestrel
    • Moderate androgenic properties: contraceptives containing desogestrel, gestodene, and norethisterone
    • Low androgenic properties: contraceptives containing norgestimate
    • Anti-androgenic properties: contraceptives containing drospirenone

• Spironolactone
  • Used most commonly for hirsutism
  • Decreases testosterone and blocks the androgen receptor
  • Can take 6+ months to see a benefit
  • Contraindicated when trying to conceive, pregnant, and breastfeeding

• Steroids: Prednisone & Dexamethasone
  • Suppresses adrenal gland production of androgens, especially DHEA
  • A common side effect is weight gain which is problematic for many women with PCOS

Cosmetic Options for Hirsutism caused by androgen excess

• Shaving
  • Although this can be done on your own, it often needs to be done daily and can be stressful as the hair growth is visible quickly.

• Plucking
  • A good option because it can be done at home, but can cause irritation and inflammation of the follicles.

• Waxing
  • This option is generally well-tolerated and lasts longer than shaving but similar to plucking it can cause irritation and inflammation of the follicles. Many women have no issue with waxing, but if you’re not one of those women you may be prone to acne and folliculitis after having this done.

• Electrolysis
  • While electrolysis can be a bit painful and expensive, it is permanent. Be aware that some women experience scarring so if you’re considering this, try a small inconspicuous area first.

• Laser
  • This is also a permanent option, and like electrolysis, is expensive. It seems to cause less scarring but is most effective if you have lighter skin and darker hair.

Hopefully, you have a better understanding of why you might have androgen excess, why these hormones are causing things like acne, hair loss, and hirsutism, and some options for turning that train around. I know this can be uber distressing! Again, please check out Part 1 and Part 3 of this blog series for nutrition & lifestyle considerations that really support the root causes of androgen excess, such as insulin resistance, inflammation, and stress.

If you have Androgen Excess and PCOS, consider working with a holistically-minded provider who can offer a thorough assessment of your whole health and provide personalized therapeutic options. You don’t have to do this alone! 🙂 

I always hope that my posts are supportive of your journey. There are additional resources and references below. Leave me a comment, check back often, and reach out if you need a partner in this process! Thanks so much for reading. 

If you haven’t done so already, check out my other PCOS Related Blog Posts! Parts 3 & 4 of this Root Causes of PCOS series will be posted soon.

Disclaimer: This website and post include general information about nutrition, health, and fertility. This content is not medical advice. It is not a replacement for medical advice, diagnosis, or treatment of any health condition or illness. With that said, if the reader or any other person has a medical condition, concern, or illness, they should consult with their personal doctor or another appropriately licensed healthcare provider. The reader should also never disregard professional medical advice or delay in seeking advice because of something discussed in this information. It is imperative to consult your doctor or another appropriately licensed healthcare provider before implementing any changes to your diet, fitness routine, lifestyle, medications, or nutritional supplements.

Information provided in this document and the use of any products or services related to this document by you does not create a doctor-patient relationship between you and Tamara Darragh, ND. 

Statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease.

Additional Resources

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Disclaimer: This website and post include general information about nutrition, health, and fertility. This content is not medical advice. It is not a replacement for medical advice, diagnosis, or treatment of any health condition or illness. With that said, if the reader or any other person has a medical condition, concern, or illness, they should consult with their personal doctor or another appropriately licensed healthcare provider. The reader should also never disregard professional medical advice or delay in seeking advice because of something discussed in this information. It is imperative to consult your doctor or another appropriately licensed healthcare provider before implementing any changes to your diet, fitness routine, lifestyle, medications, or nutritional supplements.

Information provided in this document and the use of any products or services related to this document by you does not create a doctor-patient relationship between you and Tamara Darragh, ND. 

Statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease.

References

• An Y, Sun Z, Zhang Y, Liu B, Guan Y, Lu M. The use of berberine for women with polycystic ovary syndrome undergoing IVF treatment. Clin Endocrinol (Oxf). 2014 Mar;80(3):425-31.

• Armanini D, Mattarello MJ, Fiore C, Bonanni G, Scaroni C, Sartorato P, Palermo M. Licorice reduces serum testosterone in healthy women. Steroids. 2004 Oct-Nov;69(11-12):763-6.

• de Macedo LM, Santos ÉMD, Militão L, Tundisi LL, Ataide JA, Souto EB, Mazzola PG. Rosemary (Rosmarinus officinalis L., syn Salvia rosmarinus Spenn.) and Its Topical Applications: A Review. Plants (Basel). 2020 May 21;9(5):651.

• Evron E, Juhasz M, Babadjouni A, Mesinkovska NA. Natural Hair Supplement: Friend or Foe? Saw Palmetto, a Systematic Review in Alopecia. Skin Appendage Disord. 2020 Nov;6(6):329-337.

• Heidary M, Yazdanpanahi Z, Dabbaghmanesh MH, Parsanezhad ME, Emamghoreishi M, Akbarzadeh M. Effect of chamomile capsule on lipid- and hormonal-related parameters among women of reproductive age with polycystic ovary syndrome. J Res Med Sci. 2018 Apr 26;23:33

• Grant P. Spearmint herbal tea has significant anti-androgen effects in polycystic ovarian syndrome. A randomized controlled trial. Phytother Res. 2010 Feb;24(2):186-8.

• Krysiak R, et al. Update on the management of polycystic ovary syndrome. Pharmacol Rep. 2006; 58:614.

• Liu J, Kurashiki K, Shimizu K, Kondo R. 5alpha-reductase inhibitory effect of triterpenoids isolated from Ganoderma lucidum. Biol Pharm Bull. 2006 Feb;29(2):392-5.

• Murata K, Noguchi K, Kondo M, Onishi M, Watanabe N, Okamura K, Matsuda H. Promotion of hair growth by Rosmarinus officinalis leaf extract. Phytother Res. 2013 Feb;27(2):212-7.

• Nahata A, Dixit VK. Evaluation of 5α-reductase inhibitory activity of certain herbs useful as antiandrogens. Andrologia. 2014 Aug;46(6):592-601. doi: 10.1111/and.12115. Epub 2013 May 26.

• Takeuchi T, Nishii O, Okamura T, Yaginuma T. Effect of paeoniflorin, glycyrrhizin and glycyrrhetic acid on ovarian androgen production. Am J Chin Med. 1991;19(1):73-8.

• Tehrani HG, Allahdadian M, Zarre F, Ranjbar H, Allahdadian F. Effect of green tea on metabolic and hormonal aspect of polycystic ovarian syndrome in overweight and obese women suffering from polycystic ovarian syndrome: A clinical trial. J Educ Health Promot. 2017 May 5;6:36.