High DHEA and Testosterone in PCOS | Ovary vs Adrenal Androgens

PCOS (Polycystic Ovarian Syndrome) is a condition affecting approximately 10% of the female population. It is the number one most common reproductive health concern in women and affects not only fertility, but also emotional and physical well-being due to its far-reaching health implications. High DHEA-S and testosterone in PCOS are common, however what is the difference if any between these two androgenic hormones? Why do some women with PCOS have specific androgens that are high, or high in the normal range and most importantly, what does this mean?

PCOS is a wide umbrella term, describing a common condition of female hormonal imbalance.

  The Rotterdam criteria for the diagnosis of PCOS are:

  • Lengthy menstrual cycles, or delayed ovulation. Also known as oligomenorrhea.
  • Androgenicity, either clinical (for example hirsutism, acne, or male pattern hair loss), or elevated androgenic hormones such as DHEA-S, testosterone, bioavailable testosterone or androstenedione in the blood.
  • On ultrasound, a polycystic appearance to the ovaries. The ultrasound will reveal an ovary with multiple small follicles present.

There are both omnivorous and vegetarian plans available.

In my upcoming book on PCOS, I will go through the different phenotypes of PCOS and how to treat them effectively. It’s important to note that the understanding of PCOS is not yet complete. That being said, we do have a good amount of information on what makes up the unique variants of this common hormonal disorder.

In women with PCOS, androgens like testosterone are a very problematic part of the disorder. Most women suffer greatly with hirsutism, acne, and hair loss. Excessive androgens are also responsible for inhibiting ovulation and reducing healthy follicle development. High androgens are also associated with an increased risk of cardiovascular disease in PCOS. It has been found that women with elevated androgens have a similar cardiovascular risk profile as men. Cardiovascular disease is something which starts many years ahead, and as such it’s important to head it off before it causes major health problems. As such, it is crucial to determine both the level of and how to reduce the excessive amount of androgens in women with PCOS.

Sources of Androgens in PCOS

In PCOS, it has been found that there are actually two different sources of androgens, the ovary and the adrenal.

  • 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 aromatzation 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 Adrenal Glands as a Source of Androgens

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

Types of Variation in PCOS?

It has been found that women with PCOS might actually have different variants on the “types” of androgens that predominate in their conditions.

Some women are more “adrenal dominant” and others are more “ovary dominant” with respect to androgen production. It appears that there is a clear difference between the two with respect to risk for both inflammation and cardiovascular/metabolic disease risk.

A 2012 study comparing a group of 280 women with PCOS, looking at their adrenal and ovarian androgens. The ratio between DHEA-S (adrenal androgen) and total testosterone (ovarian androgen) were calculated for the group of women. The median value for the study group was 4.40. They then compared body mass index, waist circumference, hirsutism (according to the Ferriman-Gallwey score), inflammatory markers, and menstrual cycle length in the two groups.

Across the board, the group with the higher ratio of adrenal androgens had better outcomes with respect to body mass index and waist circumference, hirsutism and also had a shorter cycle length. The group with higher DHEA also had better lipid (cholesterol) profiles and lower levels of inflammatory markers. Although this study is quite small in size, it is interesting to note that the adrenal “typeology/phenotype” of androgen production appears to be protective in PCOS.

A similar result was found in another study, completed in 2007 on a group of 238 young women with high androgens. In this particular study, the women with the highest levels of DHEA, the adrenal androgens, were found to have the lowest levels of different 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.

As such it appears that the source of the androgens may make an impact on the metabolic and reproductive outcome of a woman with PCOS. As such it may be useful to test the levels of testosterone (ovarian) and DHEA-S (adrenal) androgens, to be able to predict the phenotype or severity of the syndrome, and as such make adjustments to treatment accordingly.

References

  1. 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)
  2. 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.

25 thoughts on “High DHEA and Testosterone in PCOS | Ovary vs Adrenal Androgens”

  1. Very interesting…I have PCOS, relatively low Testosterone, but high DHEA…how might the treatment differ between the two types (adrenal vs. ovarian)? It would be great to be able to mention the difference to my doc and hopefully improve results :D

    1. Hi Rebekah,

      Great question! I actually hope to address this in great detail in my book so please stay tuned for more info. It appears that in the adrenal form of PCOS, less emphasis should be placed on the metabolic components unless the woman is overweight. However in the ovarian form, it appears that the treatment of insulin resistance will be more central. In both cases hormonal balancing herbs and supplements can be used, however in the ovarian form there is greater emphasis on metabolism.

      best,

      1. hi Fiona,
        I have suffered PCOS as a lean woman for years now, and no one ever mentioned the distinction between ovarian/adrenal! i am on a strong anti androgen currently (cyrpoterone acetate) and just saw DHEA-S levels of 320! Do regular anti androgens not combat androgens made by the adrenal glands?
        What natural herbs can I take to reduce my DHEA-S? Saw Palmetto? My main symptom and the reason I am so dependent on medication – is male pattern baldness.
        Thanks so much!

        1. Hi there hona,

          I have just written a long article about this for a professional journal that will be out in January. Overall, the DHEA-S is stimulated by the brain. The adrenal itself makes too much DHEA. So first of all, if you are under any stresses, it will make your brain release ACTH which can increase the DHEA secretion. However if you are not under major stressors, this may not have a huge impact on your levels. Overall, DHEA is a protective androgen when compared to testosterone…however, when it converts into testosterone and especially DHT it can create the hair loss you are experiencing. Anti-androgens should work but will not lower your DHEA levels…there are also a host of natural anti androgens like spearmint tea, licorice, saw palmetto, ganoderma, kudzu root, green tea…the list goes on! I’ll go through this in my article. I hope this answer has been helpful for you :) And good luck..hair loss is very stressful.

  2. Grateful to have stumbled across your site. I am a 40 year old that was diagnosed with PCOS 8 years ago and had a complete hysterectomy 7 years ago. I was diagnosed with fibromyalgia 9 years ago and now am seeing an integrative DR. specializing in fibro. Last week, 3/2014 my blood work came back with 296 DHEA S. Since I do not have ovaries any longer I am gathering that my high DHEA S is adrenal PCOS? Honestly, I just now am learning that their is such a thing. I was told that all of my symptoms of PCOS would go away after my hysterectomy! Sigh…
    Can you shed more light for me, please? Can you direct me where I can go to educate myself on this and is there anything I should be doing, i.e., tests or certain doctors I should see to help figure this out? I have read a lot about adrenal tumors, benign and malignant that will raise the values of DHE S as well.
    Trying to make sense of it all.
    Thank You!

    1. Sorry for the delayed response! Yes, I would say that this is an adrenal dominant type of PCOS. Also, once you go through menopause, as you don’t have menstrual cycles, there are none of the menstrual related symptoms. However, the rest of the risks still exist – cardiovascular and metabolic diseases.

      I would for certain ask for a scan of the adrenals to rule tumours out. Second to that, I would begin checking your cholesterol panels, hs-CRP, homocysteine, HBA1C, fasting insulin on a regular basis, keep a healthy weight, exercise and eat healthful, whole foods.

      I hope that this helps and good luck!

      Dr. Fiona

  3. Hi there I was diagnosed with pcos and adrenal problems after the birth of my second daughter that was 34 years ago! I worked in Germany at the time and was seen by a prof Breustedt in Hamburg. I returned shortly after beginning treatment with dexamethasone , to Scotland , where the treatment stopped. I have battled continuously over the years providing a forwarding letter from the prof at that time but was continually brushed aside. I have had no treatment for approx 28 years but tried to control my weight gain by joining a gym and swimming most of my life. My parents passed away about 5 years ago and at the same time I was hitting the menopause my weight escalated and I then developed Psoiratic arthritis cine psoirisis . I understand the importance of a healthy weight but can’t seem to shift the pounds. I really truly loved your article explaining ovaries vs adrenals as this proves to me over and over that I did /do have a problem with my adrenal glands which my GP is adamant I don’t . Your article replicates those words of Prof Breustedt all those years ago and although I probably can’t be helped any more I have tried to pass on my diagnosis to both daughters and 3 granddaughters but to no avail as the stumbling block is my GP
    I guess it’s a whole lot of ignorance on the subject and the fact that a patient knows more about the problem than them is another factor and a battle of superiority in my case . Many many thanks for a beautifully explained article. I can’t wait to read your book and the next GP visit armed with more information on the continuous battle of the adrenal gland and it’s importance on everyone’s well being.
    My kindest regards

    1. Thank you so much Martha! I really appreciate your comment. Warmest wishes to you and I hope you will find a good solution to your concerns. There is a definite connection between autoimmunity and the adrenal forms of PCOS.

  4. hi,
    my hirsutism began at age 11 at puberty and i was put onto Diane birth control pills at 14 and told i would need help conceiving when the time came. i was diagnosed with adrenal type pcos at 19 after a biopsy of my ovary (no scans in 1981) and then extensive tests in a san franscisco teaching hospital (i live in south africa). i have always menstruated and from mid 20’s till 3 years ago had a regular short( 23-25 days) cycle. i am 50 now and began menopause 3 years ago. at that time my blood pressure shot up and now i am pre diabetic. i have always been overweight but healthy until menopause. i have been losing weight but incredibly slowly now, compared to before menopause. i am managing my health with diet and exercise and alternative means.

    if you can help me, i would like to know where i can find more information on adrenal type pcos syndrome and also pcos and menopause. i have not found much information on either. it is really great to find your site.
    thanks you for a great article and for your help
    Lauren

    1. Hi Lauren,

      Thank you so much for reading my article and for sharing your case! There really isn’t a lot of information on the adrenal type PCOS out there to read (YET)…however, my book will cover this in detail! Please stay in touch with me and I promise there will be a whole section devoted to this. One thing that is true is that stress is very aggravating for women with the adrenal forms of PCOS. Whatever you can do to minimize stress including yoga, meditation, deep breathing exercises…these will all help you. I will also have a section on PCOS and menopause in my book.

      warmest regards,

      Dr. Fiona

  5. Hi Dr. Fiona,

    I want to thank you very
    much for posting the articles and for your work. My wife has recently
    had a somewhat irregular period (previously everything was fine with maybe 1 skipped period per year) and went to her OBGYN, who quickly diagnosed her
    with PCOS, without giving much explanation. I’ve tried to do some
    research online, but haven’t found much that was consistent with my
    wife’s symptoms, it’s been very frustrating.

    On a blood test for hormone levels, she was found to have normal levels of Testosterone, Estrogen, etc., but high DHEA. She is very fit (underweight for her age), normal blood sugar, great health otherwise. It was a bit shocking to receive this diagnosis and to then be told to come in for her next yearly physical in one year, without any helpful advice.

    We are really hoping to have kids some day (we are both under 30 years old), so it was a little bit of shock to read about the lower fertility levels, risk of miscarriage, etc. for women with PCOS.

    What do you recommend as next steps? Her OBGYN said to call her back if she still doesn’t have her period after 3 months. You have posted that exercise, relaxation, Yoga are helpful, is there anything else you can suggest (including articles to read)?

    Thank you again.

    1. Thanks so much for reading, David!

      If your wife has high DHEA – first thing to find out is – is it DHEA-S or DHEA that is high. DHEA-S is primarily from the adrenals, while DHEA derives from the adrenals and the ovaries. Overall, women with PCOS who have high DHEA-S levels are generally more protected from insulin resistance and cardiovascular disease. If she’s been regularly ovulating in the past that is a very good sign. However, in some cases stress may actually impact women who have high DHEA-S, as the signals from the hypothalamus and pituitary to stress can stimulate more DHEA release from the adrenals – which can then disrupt menstrual cyclicity. I have just written an article for this for Naturopathic Doctor News Review, which is going to be released in January so please stay tuned. I can’t publish any snippets before then due to licensing, but if you follow my blog or follow me on Facebook I’ll certainly post it there once it is released! It has the supplements and general treatments detailed with lots of supporting research (it’s aimed at a doctor audience but I think it’s pretty readable!). One quick tip : L-theanine – it reduces ACTH stimulation and is a great nutrient that helps with alert calmness!

      Thanks again for your interest and for being such a great supporter of your wife :)

      Dr. Fiona

    2. Thanks so much for reading, David!

      If your wife has high DHEA – first thing to find out is – is it DHEA-S or DHEA that is high. DHEA-S is primarily from the adrenals, while DHEA derives from the adrenals and the ovaries. Overall, women with PCOS who have high DHEA-S levels are generally more protected from insulin resistance and cardiovascular disease. If she’s been regularly ovulating in the past that is a very good sign. However, in some cases stress may actually impact women who have high DHEA-S, as the signals from the hypothalamus and pituitary to stress can stimulate more DHEA release from the adrenals – which can then disrupt menstrual cyclicity. I have just written an article for this for Naturopathic Doctor News Review, which is going to be released in January so please stay tuned. I can’t publish any snippets before then due to licensing, but if you follow my blog or follow me on Facebook I’ll certainly post it there once it is released! It has the supplements and general treatments detailed with lots of supporting research (it’s aimed at a doctor audience but I think it’s pretty readable!). One quick tip : L-theanine – it reduces ACTH stimulation and is a great nutrient that helps with alert calmness!

      Thanks again for your interest and for being such a great supporter of your wife :)

      Dr. Fiona

      1. Hi Dr. Fiona,

        Thank you so much for your reply. This has been incredibly helpful and I am looking forward to reading the article once it is released. The level of DHEA-S is what has been found to be high. She is drinking green tea, spearmint tea, and will add try L-theanine shortly as well. Also taking a vitamin D supplement (she has a level that is below normal) and I know that is linked to metabolism health, immunity, etc. so is a good thing. I really appreciate the research that you are doing.

      2. Hi Dr. Fiona,

        Thank you again for your amazing insights – you are honestly our hero!
        My wife did most of the things you suggested- L-theanine, spearmint, green tea, exercise, Vitamin D. Regular period has been back for almost the whole year now (~35 day cycle for all of 2015 so far).

        Interestingly enough, my wife’s gynecologist had nothing to say but “Great!” when my wife told her that she did not go on birth control pills (the doctor’s advice), but instead did the activities listed above.

        For when we plan to have kids – what do you advise – should we see a reproductive endocrynologist just in case? Or if her period normalizes should we just forgot that she ever had the PCOS?

        Thank you again for your amazing advice.

        1. Wow, this is great David! never forget she has PCOS because it’s a lifelong disorder that has risks for cardiovascular disease and diabetes – and always keep an eye on things. That said, you guys are very proactive – so I am sure you will do that! When it comes to having kids, it might be good to get a baseline of hormones before starting but definitely give it a go since her period has been doing so well!

      3. Did this article ever come out? I’d love to read it! I have severe acne, a high DHEA-S (330), hirutism and fairly regular periods. I’m thin, so weight loss isn’t an issue, but would like to get rid of the acne and hopefully fall pregnant soon.

  6. Hi Dr. Fiona,
    Thanks to the comment below me, I googled the article you wrote for NDNR and I found it incredibly enlightening. I was diagnosed with PCOS in March 2013 (age 20) and have bounced around from doctor to doctor since then, always left wondering if the medical advice I give myself is of greater value.
    I took 100mg of spironolactone for a year and noticed some improvement in my hirsutism and acne, but an increase in hair loss (not male pattern, not in clumps, just generalized hair loss). After a year on 100mg, I was worried about what my scalp would look like if I continued to take such a high dose, so I decreased the dosage to 50mg. I saw no improvement in the amount of hair loss but I stuck with it for another 7 – 8 months. At this point in time, I had already made a cross country move and did not regularly see an endocrinologist. For the past 4 months or so, I quit taking my spironolactone and metformin cold turkey and noticed a pretty significant amount of hair growth on my scalp, but unfortunately, hair growth everywhere else and moderate to severe acne primarily on the jawline, but also on the chest and back (something I have not experienced for 4 years post-Accutane). I figured I could live with the excessive shedding if that meant less facial and body hair and less breakouts so I sought out a new endocrinologist and am now currently on 25mg spironolactone/day and 100mg metformin ER/day. I am very sad about this because I wanted to stay away from prescription drugs but had no idea how to better manage my symptoms with anything but diet and exercise. Exercise could use a little work but my diet has always been pristine.

    I know that was a long explanation for what I am about to say but… I would just like to say THANK YOU for sharing valuable knowledge on how to effectively manage PCOS without prescription drugs. And it gives me hope that there are more MDs/NDs out there with the knowledge to help PCOS sufferers better manage their symptoms – drug free!

    1. Thank you so much for commenting!! I have just posted the article to the blog here http://www.whitelotusclinic.ca/blog/dr-fiona-nd/pcos-treating-adrenal-androgen-excess/ so hopefully others here may read it.

      I myself have the elevated DHEA type of PCOS and also suffered with fairly severe cystic acne for many years. It is a struggle! Hopefully you found some helpful tips in the article. Just so you know, it is possible to reverse much of these hormonal effects, and it’s also true that the testosterone will reduce with age but you will still have to manage insulin resistance and inflammation for life.

  7. Hi Fiona,

    thanks for this post, it is very informative. I was wondering if you could give me some advice on what steps to take in my journey of self-healing.

    3 years ago, I started getting sick a lot (never really gotten sick in my childhood or adolescence), mostly from strep and I had to take antibiotics because of this. I had strep about 8 times in the past two years and am now stuck with post nasal drip and a sore throat that pops up every few weeks. A year and a half ago, I started noticing some fuzzy hair growth on my chin and areola after I took flonase for 2 months when my DR believed I had allergies ( did allergy test and not allergic to anything). I’ve always been self-conscious about my self-image so I went to an endocrinologist and she turned me away telling me it was natural. My periods have always been normal before the appointment.

    Fast forward a few months later and excess hair growth was getting slightly worse all over and my periods were going on 31-34 days instead of mt usual 28 day cycle. I went to a ND and she told me I have a hypothyroid issue, and low vitamin d levels. She prescribed me Naturethroid, Ovablend, and Vitamin D. After taking the thyroid med, my hair felt thicker on my head it wasn’t falling out and my feet weren’t as cold as they used to be. But my hair growth was worse and I had severe vaginal dryness. I took Ovablend for about 6 months and now my periods are nearly regular and I don’t have dryness. But my hair growth got significantly worse to the point where it’s all over my body–arms, full legs, back, bottom, stomach all over, chest and neck. Even my hands and ears have these tiny darker looking hairs that are new, my cheeks and nose have longer peach fuzz than usual.

    I want to avoid conventional allopathic medicine that will just suppress what my body is doing. I have elevated DHEA-S and higher testosterone levels in the “normal” range. I am mostly gluten and dairy free with the exception of a few treats once in a while.I am still on the natural dessicated thyroid (been 8 months now) and my hands and feet are again cold and my hair on my head is starting to fall out like it used to. I’m so depressed and hopeless because of the excess hair growth. I want to see a naturopath but need your advice on what to ask of her in regards to what I’ve been experiencing. I don’t think I have pcos (even did an ultrasound and it was normal) and no one has formally diagnosed me. What steps do I need to take to reverse this?

  8. Hi,
    I just received my bloodwork back from my internist. I am on Naturethroid, however, my doctor also believes that I have PCOS based on high DHEA sulfate and Testosterone levels. I would like more info on supplements that I can begin taking. How would I get my results in front of you for an opinion?

  9. Hi Dr. Fiona,

    Thank you for this informative article. I am 23 years old and have only had three periods (without cycle inducing medication) in my entire life. I do get my period with birth control and provera, but never without such medication. After going to several doctors, no one is quite sure what the problem is. I have hypothyroid and a vitamin d deficiency, but treating those alone doesn’t bring on a cycle.

    I just received blood work that for the first time indicate high levels of DHEA-S and free testosterone. If you have any insights, I’d love to hear it (though I am sure you are very busy).

    Anyways, thanks for posting this!

    Best,

    Madison

  10. I just started reading your book, it’s the best pcos source I’ve seen. Thanks so much for helping pcos ladies. My 17 year old daughter has hirsutime, chin acne, 5’7″ 192 lb, 38 day heavy cycle. Her 1200 calorie diet stopped producing weight loss. (She was 206 lb.) No cholesterol or sugar issues.

    In 2014, when she weighed 165 lb, her blood work showed testosterone 41 ng/dl, free testosterone 4.8 pg/ml, DHEA-S 208 ng/dL, androstendion 146 ng/dl.

    In 2016, at 182 lb, her testosterone rose to 62 ng/dL. Her vitamin D is 24 ng/dL. Her phosphorus 4.9 mg/dL. (Not sure of connection)

    I know from reading your blog that she has ovarian pcos which is mostly affected by insulin/metabolism. She cut out almost all fruit, all grain, all dairy, but the weight is stuck. Would you recommend inositol 2000 MG (we have just myo inositol powder. ) I saw your book’s insulin demand diet, and it appears the caloric intake is 1200 a day. Is that appropriate for her height and weight? Any other supplements to help with weight loss?

    Thanks so much

    Shirly

  11. Hi Fiona!
    I had a little girl a year ago. My periods were every 32 days before her and not they had gone away for 3 months and have been back for two months but 35 day cycles which I do seem to be ovulating based on LH test strips and BBT but around day 22-23 . Is a 35 day cycle too long? What is your description of a “normal” cycle?

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