The most common cause of high testosterone in women is polycystic ovary syndrome (PCOS). Other causes include testosterone or DHEA use, certain medications, nonclassic congenital adrenal hyperplasia, Cushing syndrome, severe insulin resistance, and, rarely, an androgen-producing tumor of the ovary or adrenal gland.
High testosterone is a form of hyperandrogenism, which means excess androgen activity. Women naturally produce testosterone in the ovaries and adrenal glands, so a mildly abnormal result does not automatically point to a serious condition.
Main Causes of High Testosterone in Women
| Cause | Common clues |
|---|---|
| Polycystic ovary syndrome, or PCOS | Irregular periods, excess facial or body hair, acne, scalp hair thinning, infertility, insulin resistance |
| Medications or hormone exposure | Testosterone therapy, DHEA supplements, anabolic steroids, danazol, or contact with topical testosterone |
| Nonclassic congenital adrenal hyperplasia | Hirsutism, acne, irregular periods, symptoms beginning in adolescence or early adulthood |
| Cushing syndrome | Weight gain, easy bruising, purple stretch marks, muscle weakness, high blood pressure or high blood sugar |
| Ovarian or adrenal tumor | Rapid symptom development, virilization, or markedly elevated testosterone or DHEAS |
| Ovarian hyperthecosis | Gradually increasing testosterone and virilization, especially after menopause |
| Low sex hormone-binding globulin, or SHBG | Normal total testosterone but elevated free testosterone, often linked to insulin resistance or obesity |
| Idiopathic hirsutism | Excess coarse hair despite normal testosterone and regular periods |
1. PCOS
PCOS can cause the ovaries to produce excess testosterone and other androgens. Insulin resistance may worsen androgen excess because high insulin levels can stimulate ovarian androgen production and reduce SHBG. Lower SHBG leaves more testosterone unbound and available to tissues.
Common PCOS symptoms include:
- Irregular, infrequent or absent periods
- Coarse hair on the face, chest, abdomen or thighs
- Acne or oily skin
- Thinning hair at the scalp
- Difficulty becoming pregnant
- Weight gain or difficulty losing weight
- Dark, velvety skin patches associated with insulin resistance
PCOS usually develops gradually. Rapid virilization, such as a suddenly deeper voice or rapid muscle gain, is not typical of PCOS and needs assessment for another cause.
2. Testosterone, DHEA and Other Medications
Testosterone can rise after taking or being exposed to androgenic hormones. Possible sources include:
- Prescribed testosterone
- DHEA supplements
- Anabolic steroids
- Danazol
- Some medications used for epilepsy or other conditions
- Accidental skin-to-skin exposure to topical testosterone used by a partner
A medication or supplement may raise total testosterone directly. It may also change SHBG and increase free testosterone. Tell the clinician about prescription medicines, over-the-counter products, bodybuilding supplements and hormone creams.
3. Adrenal Gland Disorders
The adrenal glands produce androgen precursors, including DHEA and DHEAS. Adrenal conditions can therefore cause androgen excess.
Nonclassic Congenital Adrenal Hyperplasia
Nonclassic congenital adrenal hyperplasia is an inherited condition that can increase adrenal androgen production. It may appear during adolescence or adulthood with:
- Facial or body hair growth
- Acne
- Irregular periods
- Infertility
- Symptoms that resemble PCOS
When this condition is suspected, clinicians commonly order an early-morning 17-hydroxyprogesterone test.
Cushing Syndrome
Cushing syndrome occurs when the body has excessive cortisol. It can result from an adrenal or pituitary disorder, or from long-term use of corticosteroid medicines such as prednisone. It may also cause acne and excess hair growth.
Features that make Cushing syndrome more likely include easy bruising, purple stretch marks, muscle weakness, high blood pressure and high blood glucose.
4. Ovarian or Adrenal Tumors
Androgen-producing tumors are uncommon. They need prompt assessment when symptoms develop quickly or testosterone is markedly elevated.
A tumor is more concerning when a woman develops rapid:
- Facial or body hair growth
- Severe acne
- Scalp hair loss
- Voice deepening
- Increased muscle mass
- Enlargement of the clitoris
- Decreased breast size
An ovarian tumor more often raises testosterone, while an adrenal tumor may raise DHEAS. These patterns are not always conclusive, so clinicians may repeat hormone testing and use imaging of the ovaries or adrenal glands.
Rapidly progressive symptoms, new androgen excess after menopause or severe biochemical abnormalities warrant prompt medical assessment.
5. Ovarian Hyperthecosis
Ovarian hyperthecosis occurs when ovarian tissue produces excess testosterone. It is considered more often in postmenopausal women with gradually worsening androgen-related symptoms, particularly when testosterone is high but adrenal androgen levels are not.
The condition can resemble an ovarian tumor or severe PCOS. Specialist testing and pelvic imaging may be needed.
6. Low SHBG Can Raise Free Testosterone
A testosterone result can include several measurements:
- Total testosterone: The amount of testosterone in the blood, including hormone that is bound to proteins and hormone that is unbound.
- Free testosterone: Testosterone that is not tightly bound to proteins and is more available to tissues.
- SHBG: A protein that binds testosterone and affects how much remains free.
A woman may have normal total testosterone but high free testosterone when SHBG is low. Insulin resistance, obesity and PCOS can reduce SHBG. For this reason, clinicians may measure total testosterone, free testosterone and SHBG instead of relying on total testosterone alone.
Can Symptoms Occur With Normal Testosterone?
Yes. Some women have hirsutism, acne or scalp hair thinning even when blood testosterone is within the laboratory reference range. Hair follicles can be more sensitive to androgens, and androgen activity can differ in the skin.
This may be called idiopathic hirsutism, particularly when menstrual cycles are regular and no endocrine disorder is found. The Endocrine Society also notes that unwanted local hair growth alone does not always require androgen testing when periods are regular and there are no other signs of hormone excess.
How Doctors Investigate High Testosterone
Evaluation may include:
- A repeat total testosterone test, particularly when the result does not match the symptoms.
- Free testosterone or a calculated free androgen index.
- SHBG.
- DHEAS to assess possible adrenal involvement.
- Early-morning 17-hydroxyprogesterone to screen for nonclassic congenital adrenal hyperplasia.
- Pregnancy testing, thyroid or prolactin testing when indicated.
- Cortisol testing when symptoms suggest Cushing syndrome.
- Pelvic ultrasound or adrenal imaging when testosterone is very high, symptoms are rapidly progressive or a tumor is suspected.
Testosterone testing is technically difficult at the low concentrations normally found in women. Current guidance prefers highly accurate liquid chromatography-tandem mass spectrometry, or LC-MS/MS, over some direct immunoassays. Combined oral contraceptives also change SHBG and testosterone measurements, so a clinician should interpret the results rather than comparing them with an online reference range.
When to Seek Medical Care
Arrange an appointment with a primary care clinician, gynecologist or endocrinologist if you have high testosterone on a blood test, new coarse facial hair, irregular periods, persistent acne, scalp hair thinning or difficulty becoming pregnant.
Seek prompt assessment if symptoms appear rapidly. This is especially important with voice deepening, clitoral enlargement, rapid muscle gain, sudden severe acne or new androgen symptoms after menopause. These features are less typical of PCOS and may point to another source of androgen excess.