High DHEA and Testosterone in PCOS

What Does Your Androgen Pattern Mean?

If you have received bloodwork showing elevated DHEA-S, elevated testosterone, or both, you may have been told your androgens are high without much explanation of what that actually means. This is a common experience. DHEA-S and testosterone are two different androgens produced by two different sources in the body, and the pattern of which is elevated, and whether one is being converted into the other, tells a clinician something specific about your PCOS.

DHEA-S (dehydroepiandrosterone sulfate) is produced by the adrenal glands. Testosterone is produced primarily by the ovaries. In PCOS, one or both can be elevated, and the clinical significance depends on the pattern. DHEA-S is a relatively weak androgen on its own: it is when the ovaries convert DHEA into testosterone that most androgenic effects occur. Testosterone is far more potent and drives the majority of androgenic symptoms.

Written by Dr. Fiona McCulloch, ND, author of 8 Steps to Reverse Your PCOS, which includes an entire chapter on adrenal androgen excess in PCOS. Peer reviewer, 2023 International PCOS Guidelines.

Why Your Androgen Results Can Be Hard to Interpret

Many women receive bloodwork listing both DHEA-S and testosterone without a clear explanation of what each result means or why the distinction matters. Some are told simply that their androgens are high, without being told which ones. Two nuances that standard reference ranges often miss: DHEA-S is age-dependent and may be elevated for your age even when it falls within the standard reference range. And testosterone at the top of the normal range can still be clinically significant in PCOS; in clinical practice, the target is completely normal testosterone levels, not just a result that falls below the upper limit.

These androgens are a significant part of PCOS for many women. Symptoms like hirsutism, acne, and hair loss are driven primarily by testosterone, the more potent androgen. Understanding which androgens are elevated, and why, is an important step in making sense of your results.

Sources of Androgens in PCOS

The Ovary as a Source of Androgens

The ovary’s primary androgen is testosterone. Testosterone is produced by specialized cells in the follicles which surround the eggs, the theca cells. In women with PCOS, the theca cells are overactive and proliferate excessively, producing too much testosterone. As the follicles are often poorly developed in women with PCOS, they lack enough of another important component, the granulosa cells. The granulosa cells normally take testosterone and convert it into estrogen, in a process known as aromatization. In women with PCOS, the aromatization process is not effective due to the poor development of the granulosa cells, and as such, there is a buildup of testosterone which was produced by the ovary.

The two primary sources of androgens in PCOS: testosterone from the ovaries and DHEA-S from the adrenal glands.

The Adrenal Glands as a Source of Androgens

In 40–50% of women with PCOS, there is also another source of androgens: the adrenal glands. The adrenal glands produce all of the DHEA in the body. It is important to note that about half of another androgenic hormone, androstenedione, is produced by each of the adrenals and ovaries.

For a closer look at how DHEA-S differs from ovarian androgens and what testing can reveal, see our page on understanding your DHEA-S results in more detail.

What Your Androgen Pattern Means for Your Health

When a clinician reviews your androgen results, the key question is not simply whether DHEA-S or testosterone is elevated. It is the relationship between them, and whether the ovaries are converting adrenal DHEA into the more potent testosterone, that shapes the clinical picture.

Both DHEA-S and testosterone elevated (adjusted for age)

When both are raised proportionally, this suggests the ovary is utilizing DHEA and converting it into testosterone. This pattern carries greater clinical significance because testosterone is far more potent than DHEA-S and drives most androgenic symptoms and metabolic effects. The ovarian conversion of DHEA into testosterone is a key factor in the severity of androgen-related concerns.

Only DHEA-S elevated, testosterone normal or low

When DHEA-S is elevated but testosterone remains normal, this suggests the ovary is not converting DHEA into testosterone. This is generally less concerning: DHEA-S alone causes minimal androgenic action compared to testosterone. Research supports the observation that this adrenal-dominant androgen pattern is associated with better metabolic outcomes.

Testosterone elevated or high within the reference range

In PCOS, testosterone at the top of the normal range can still be clinically significant. A result that falls “within range” does not necessarily mean it is optimal. In clinical practice, the target when managing PCOS is completely normal testosterone levels, not simply a result below the upper limit of the reference range.

The distinction between these patterns matters for metabolic and cardiovascular health. High testosterone levels contribute to insulin resistance, which in turn lowers sex hormone-binding globulin (SHBG) and increases free testosterone, creating a self-reinforcing cycle. This helps explain why the pattern where the ovary is converting DHEA into testosterone carries higher metabolic risk. Regarding cardiovascular health specifically, research indicates that the raised cardiovascular risk profile seen in women with elevated androgens is driven primarily by testosterone rather than DHEA-S. For women with isolated DHEA-S elevation, this is an important distinction.

A 2012 study by Lerchbaum and colleagues examined 280 women with PCOS, calculating the ratio between DHEA-S (adrenal androgen) and total testosterone (ovarian androgen) for each participant. The median ratio was 4.40. Women with a higher proportion of adrenal androgens relative to ovarian androgens had better outcomes across multiple measures, including body mass index, waist circumference, hirsutism scores, menstrual cycle length, lipid profiles, and inflammatory markers.

A similar finding emerged from a 2007 study by Carmina and Lobo, which assessed 238 young women with elevated androgens. The women with the highest levels of DHEA-S had the lowest levels of inflammatory markers. Interestingly, although women with high DHEA-S had higher testosterone levels overall, they also had lower insulin, lower LDL cholesterol, and higher HDL cholesterol, a counter-intuitive finding suggesting that the source of androgen elevation is clinically meaningful.

For more on approaches to managing adrenal androgen excess, see our page on integrative approaches for adrenal androgen excess. For broader context on how different PCOS presentations affect health, see PCOS patterns and associated health risks.

For a broader look at how your androgen pattern fits into the full hormonal picture, including thyroid, insulin, cortisol, and metabolic health, see our hormone health overview.

If you are already receiving care for PCOS, you may notice that your DHEA-S remains elevated while your testosterone normalizes. This is a commonly observed pattern and is generally not a cause for concern: DHEA-S alone does not cause significant androgenic action when testosterone has been brought to completely normal levels. The clinical treatment target in PCOS is the normalization of testosterone, not necessarily the reduction of DHEA-S.

Understanding Your Full Androgen Picture

Dr. Fiona McCulloch, ND, has focused on PCOS in clinical practice for over 25 years. She is a Fellow of the American Board of Naturopathic Endocrinology, a peer reviewer of the 2023 International PCOS Guidelines, and author of Eight Steps to Reverse Your PCOS, which dedicates an entire chapter to adrenal androgen excess. She has also published a clinical article on treating adrenal androgen excess in PCOS. Understanding your androgen pattern involves looking at the full picture: the ratio between DHEA-S and testosterone, age-adjusted interpretation, and how your androgen pattern connects to insulin resistance, inflammation, and cardiovascular health.

If you are looking for an individualized assessment of your PCOS androgen pattern, learn about our PCOS consultation in Toronto.

Common Questions About DHEA and Testosterone in PCOS

What causes high DHEA levels in females?

In PCOS, the adrenal glands produce excess DHEA-S: this occurs in approximately 40–50% of women with the condition. DHEA-S is age-dependent, meaning it naturally declines over the lifespan, and a level that falls within the standard reference range may still be high relative to your age. Elevated DHEA-S can also occur in contexts outside of PCOS, so individual assessment is important to determine the cause and significance.

Learn more about DHEA-S and adrenal androgens in PCOS.

What is the difference between DHEA-S and testosterone?

DHEA-S is produced by the adrenal glands and is a weaker androgen. Testosterone is produced primarily by the ovaries and is far more potent: it drives most androgenic symptoms such as hirsutism, acne, and hair loss, and has a greater impact on metabolic and cardiovascular health. The good news is that DHEA-S is not as strong as testosterone. The key clinical question when both are elevated is whether the ovaries are converting DHEA into testosterone, which determines the clinical significance of the pattern.

Is high DHEA-S serious?

It depends on the pattern. Isolated DHEA-S elevation, where testosterone is normal, is generally less concerning because the ovaries are not converting DHEA into the more potent testosterone. DHEA-S alone causes minimal androgenic action. When both DHEA-S and testosterone are elevated together, this suggests greater ovarian involvement and carries more clinical significance. Cardiovascular risk in particular is driven primarily by testosterone, not DHEA-S. An individualized assessment helps determine what your specific pattern means.

Can you have high DHEA-S but normal testosterone?

Yes, this pattern is relatively common in PCOS and is generally associated with better metabolic outcomes. Research by Lerchbaum (2012) and Carmina (2007) found that women with higher adrenal androgens relative to ovarian androgens tended to have lower insulin, better cholesterol profiles, and lower inflammatory markers. This pattern suggests the ovaries are not converting DHEA into testosterone. It is still a finding that warrants monitoring, but it is a more favorable androgen pattern overall.

Why is DHEA-S elevated in PCOS?

DHEA-S elevation in PCOS reflects adrenal androgen overproduction, which occurs alongside ovarian androgen excess in many patients. These are overlapping factors: a woman with PCOS may have both adrenal and ovarian sources of androgen elevation simultaneously. DHEA-S levels should be interpreted relative to age, as they naturally decline over the lifespan. What appears to be a normal level on a standard reference range may actually be elevated for your age group.

Does the source of androgens change how PCOS is managed?

In clinical experience, similar approaches generally address both adrenal and ovarian androgen presentations; the distinction does not require a fundamentally different program in most cases. When DHEA-S is very high, additional support for the adrenal axis may be considered. The emphasis is on individualized assessment rather than category-based approaches. During management, it is common for DHEA-S to remain elevated while testosterone normalizes: this is an expected and reassuring pattern. Learn more about integrative approaches for adrenal androgen excess.

Does high DHEA or testosterone affect fertility?

Androgens can inhibit ovulation and reduce healthy follicle development, which is one of the mechanisms through which PCOS affects fertility. However, women with PCOS generally have higher ovarian reserve, which can be an advantage in the fertility context. The clinical approach focuses on understanding and addressing the androgen pattern as part of a comprehensive fertility assessment. Learn more about how DHEA and testosterone affect egg quality and PCOS and fertility.

Review Your Androgen Pattern With a PCOS-Focused Naturopathic Doctor

A first visit is an opportunity to review your history, symptoms, and existing lab work, not a commitment to long-term treatment. The assessment looks at the full androgen picture: DHEA-S, testosterone, SHBG, insulin resistance markers, and how these factors interact in your individual case. Available in-person in Toronto or via virtual consultation across Ontario.

In-person appointments available in Toronto (North York). Virtual consultations available across Ontario.

References

Lerchbaum E, Schwetz V, Giuliani A, Pieber TR, Obermayer-Pietsch B. Opposing effects of dehydroepiandrosterone sulfate and free testosterone on metabolic phenotype in women with polycystic ovary syndrome. Fertil Steril. 2012 Nov;98(5)
Carmina E, Lobo RA. Prevalence and metabolic characteristics of adrenal androgen excess in hyperandrogenic women with different phenotypes. J Endocrinol Invest. 2007 Feb;30(2):111-6.