Do I need testosterone levels in order to have a complete set of blood tests for androgenetic alopecia?

Should I have my doctor order testosterone levels to better evaluate my hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to measuring testosterone levels in women.

Question

I am a 32 year old female. I have recently been diagnosed with androgenetic alopecia (female pattern hair loss). My ferritin is 38 and my TSH is 2.31. I see that my doctor did not order testosterone levels! How important is that? My understanding is that these are very important to complement all the tests that are needed.

Answer

For women with androgenetic alopecia, tests such as CBC, ferritin, TSH, fasting cholesterol levels (LDL, HDL, triglycerides), 25 hydroxyvitamin D and hemoglobin A1c/glucose are routinely important. The other tests to order will depend on the information obtained at the appointment and the clinical examination findings.

No, testosterone levels are not always needed!

For androgenetic alopecia, 85 % of women with AGA have normal levels so one can have AGA with normal levels. Put another way… you have have AGA if your levels are low, if your levels are normal and if your levels are high. Your testosterone levels do no influence whether you will be given a diagnosis of AGA or not. It’s the pattern of hair loss and the finding of miniaturization in certain areas of the scalp that determine if you have AGA - not the testosterone levels!

I would need to know more about your story to really know if testosterone levels are needed in your case … or not.

Generally speaking, I often order testosterone levels for my own pre-menopausal female patients with androgenetic alopecia to try to better evaluate if the patient has one of the known underlying causes of elevated testosterone. You may wish to see the prior article for the top 10 causes of elevated testosterone levels in women with hair loss.

I generally order serum testosterone for my own pre-menopausal female patients with androgenetic alopecia if ONE or MORE of the following situations are true :

1. The patient also has acne

2. The patient also has hair growth on the face, or body (i.e. hirsutism)

3. the patient has also experienced a deepening of the voice

4. the patients also has irregular menstrual cycles

5. The patient has been diagnosed with polycystic ovarian syndrome (PCOS)

6. The patient has clinical signs of high androgens (enlargement of clitoris, markedly increased muscle mass)

7. The patient has possible, suspected or known congential andrenal hyperplasia (CAH)

8. The patient has possible, suspected or known or possible Cushing syndrome

9. The patient has known ovarian cancer

10. The patient uses androgen replacement (DHEA, testosterone, anabolic steroids)

11. The patient has experienced infertility

12. The patient has obesity

13. The patient has type 2 diabetes

14. The patient had elevated testosterone levels before

15. The patient has thyroid disease

16. The patient has known pituitary disease (prolactinomas, and other pituitary diseases)

In general, I prefer that patients have these tests done in the morning between 6 am and 10 am. I prefer that testosterone levels be ordered on day 3-8 of the menstrual cycle but timing of testosterone is really less important for evaluating hair loss that other tests. Getting the test is the morning is far more important if there are concerns about high testosterone. I often order sex hormone binding globulin (SHBG) so that I can calculate the free androgen index and often order DHEAS too. In some cases, I order free testosterone, but total testosterone is far more important for evaluating hair related issues. Other androgen hormones includes androstenedione and other hormones such as estradiol, progesterone day (21), 17 hydroxyprogesterone (day 3-5) may be ordered depending on the exact story.

One needs to to keep in mind that oral contraceptives reduce testosterone levels and so patients who use OCPs will not have accurate testosterone readings.

Conclusion

Thanks again for the question. Testosterone is not really all that helpful to order for most premenopausal women with androgenetic alopecia and regular periods who do not have acne and who do not have hirsutism. Generally speaking, one can determine if order testosterone levels is worth doing with a series of simple questions and a good examination. There are many question to ask but the 4 most helpful are:

a) Are your periods regular when not on birth control?

b) Do you experience acne?

c) Do you experience hair growth on the face, chest, body, abdomen?

d) Do you have any medical issues or would you say you feel quite healthy?

Many thanks again.