Elevated Androgen Levels in Women with Alopecia Areata: What are the implications?

“Androgen Excess” and Polycystic Ovarian Syndrome (PCOS) Noted in Up to 42% of Women with Alopecia Areata

Patients with clinical evidence of elevated androgens or blood tests showing elevated androgens (testosterone, free testosterone or DHEAS) are said to have a condition known as “androgen excess;”  

There are many causes of androgen excess including polycystic ovarian syndrome, metabolic syndrome, and androgen secreting tumors. Many patients also have what is known as “idiopathic hyperandrogenism”, which simply refers to the phenomenon whereby blood tests show elevated androgens but there is no underlying endocrine issue of concern.

Although, some patients with androgen excess show no underlying medical issues, some patients have underylying medical issues such as irregular periods, insulin resistance, diabetes, and increased fat in the abdominal area. Some patients with androgen excess display features of the SAHA syndrome which includes seborrheic dermatitis and seborrhea, acne, hirsutism (hair growth on the face and other male patterned areas) and hair loss.

Hyperandrogenism in Patients with Alopecia Areata

In 2017, Ranasinghe and colleagues set out to evaluate the clinical characteristics of patients with alopecia areata who also had androgen excess. The criteria for inclusion in this study were 1) women exhibiting abnormal circulating hormone levels, and/ or 2) women with a history of ovarian dysfunction, and/or 3) women with clinical evidence of androgen excess).

 A total of 220 women met the inclusion criteria for the study. 80.5 % of patients had patchy alopecia areata, (177 of 200),  4.1 % had alopecia totalis, (9 of 220), 23 had alopecia universalis (23 of 220) and 5 % had ophiasis (11 of 220).

 Irregular menstrual cycles were noted in 25.5 % of patients (56 of 220) and 9.6 % had trouble conceiving (21 of 220). Polycystic ovarian syndrome was a diagnosis in 11.4 % of patients and ovarian failure was noted in 2.7 % of patients.

Overall, the researchers noted that androgen excess/PCOS was the most common dysfunction identified in 220 patients with AA and all subtypes 42.5% (n=96) (p<0.001).

Obesity was a comorbidity in 39.1 % (86 of 202). 22.7 % were overweight.  Hirsutism was noted in 37.7 %, acne in 31.8 %. 5.9 % of patients had metabolic syndrome, and 13.2 % had seborrheic dermatitis. 8.6 % of patients had diabetes.

Conclusion

The authors concluded that there was a significant association between alopecia areata and hyperandrogenism. As with all types of hair loss, testing for androgens (testosterone, free testosterone, DHEAS +/- androstenedione) is appropriate in women with acne and hirsutism and testing a fuller panel is appropriate for women with irregular periods. Polycystic ovarian syndrome must be ruled out in all pre-menopausal women with irregular periods but may be particularly relevant to consider in the setting of alopecia areata. Of course, not all women with alopecia areata have PCOS, but women with alopecia areata who present with acne, hirsutism, irregular periods, androgenetic aloepcia, infertility and elevated androgens must have this diagnosis properly evaluated. To review the topic of PCOS in further detail, please see prior articles on the topic.

REFERENCE

Ranasinghe GC, Piliang M, Bergfeld W (2017) Androgen Excess in Alopecia Areata, an Unexpected Finding. Med J Obstet Gynecol 5(3): 1104.