Table of contents:

1. Testosterone - testing
2. Hormone testing - norms
3. Insulin resistance - testing
4. Insulin resistance - treatment

In this article we look at levels of male sex hormones in women. Their determination is part of testing for polycystic ovarian syndrome and adrenal disorders.

Testosterone - testing

Testosterone - the androgen with the more potent biological action. It is mainly formed from androstendione (approximately 60 %). The rest is produced directly by the ovaries and adrenal glands (20 % each). Weaker androgens include androstendione, produced half each by the ovaries and adrenal glands, dehydroepiandrosterone(DHEA) and its sulphate(DHEAS) produced almost exclusively by the adrenal glands.

Only a small percentage of testosterone is in the free form responsible for its biological action, the rest being bound to albumin and sex hormone-binding globulin(SHGB). Reduced SHGB levels are therefore associated with an excess of biologically active testosterone and are often found in PCOS (polycystic ovary syndrome).

Androgen levels are relatively constant throughout the cycle except during the perovulatory period, when their concentrations increase. We are therefore quite free to choose the day of the cycle suitable for testing.

Thetestosterone test is a basic test. Further determination of androgen levels is indicated in the case of hirsutism (the presence of hair in areas that are unusual for women), suspicion of PCOS or the search for causes of excess testosterone in the body.

Elevated levels of DHEA or DHEAS indicate an adrenal, and testosterone alone (especially in combination with a high LH:FSH ratio) an ovarian source of excess testosterone.

In addition, 17-OH progesterone concentrations in the first phase of the cycle can also be investigated. 17-OH progesterone in the first phase of the cycle is produced exclusively by the adrenal glands (and in the second phase also by the corpus luteum). Under the influence of enzymes, 17-OH progesterone is converted to gicosteroids and high concentrations of 17-OH progesterone may signal the absence of one of these enzymes. This is a sign of late-onset adrenal-gonadal syndrome. Elevated androstendione is found in both PCOS (polycystic ovary syndrome) and adrenal dysfunction with the latter usually having much more elevated concentrations than the former.

Hormone tests - norms

hormone	Standard 1	Standard 2	Conversion rate
testosterone	15-84 ng/dl	0.4-3.0 nmol/l	1 ng/dl = 3.47 nmol/l
androstendione	0.7-3.1 ng/ml	2.5-10 nmol/l	1 ng/dl = 3.49 nmol/l
DHEAS	40-390 ug/dl	-	1 ng/ml = 2.7 umol/ml
17-OH. pylori	0.2-1 ng/ml	0.6-3 nmol/l	1 ng/ml = 3 nmol/l
SHGB	18-114 nmol/l	-	-

Comments:

1. Moderately elevated testosterone levels can occur in obese women. Weight reduction in such a case leads to normalisation of its levels.
2. High concentrations of prolactin increase adrenal androgens.
3. Oestradiol levels correlate with SHGB levels. Chronic lack of ovulation (low oestradiol) may, therefore, lead to a decrease in SHGB levels and an increase in the biologically active fraction of testosterone.

Infertility - what tests should be carried out? photo: panthermedia

Insulin resistance - testing

The link between polycystic ovary syndrome (PCOS) and insulin resistance has received increasing attention in recent years. Insulin resistance is a condition in which tissue sensitivity to insulin is reduced. This leads to increased insulin secretion and then to impaired glucose tolerance. Excessive insulin promotes overproduction of testosterone and lowers SHGB causing more 'adverse hormones' to act in the body.

One test that can be performed in this case is the glucose load test (other tests, e.g. the sugar clamp, are more reliable but less convenient and available). The sugar test is performed on an empty stomach, then 75g of glucose is administered and the test is repeated after one hour.

when	Glucose	insulin
fasting	< 110 mg/dl or 6.1 mmol/l	< 20 mIU/ml
after 1 hour	< 180 mg/dl or 10 mmol/l	< 80 mIU/ml
after 2 hours	< 140 mg/dl or 8 mmol/l	< 40 mIU/ml

Insulin resistance - treatment

Treatment consists of preparations that improve insulin sensitivity. In Poland, preparations containing metformin derivatives are available. The longer the treatment, the better the results. In many cases regular menstruation and ovulation return. But often the results in terms of achieving a pregnancy are comparable to those achieved with ovulation stimulation.

The treatment has beneficial effects on PCOS patients who have problems ovulating with Clomiphene Citrate, especially those who are also overweight (BMI >25). Reliable clinical trials have been conducted on this subject, confirming that this treatment increases not only the ovulation rate, but also the percentage of pregnancies achieved.