“We are proud to pull together this Clinical Practice Guideline on the investigation of androgen excess in women, drawing on expertise from endocrinology, gynaecology and clinical biochemistry. This breadth of experience reflects the complexity of androgen excess in women and the multidisciplinary approach required to dissect challenging cases.” Michael O’Reilly, Lead Author
The first Society for Endocrinology Clinical Practice Guideline for the Evaluation of Androgen Excess in Women1 provides a structured, evidence-based approach to identifying hyperandrogenism, as well as understanding its origins and its metabolic consequences.
Androgen excess is often dismissed as merely cosmetic, yet it affects millions of women. The inaugural guidelines from the Society for Endocrinology on female androgen excess offer an essential framework for assessment. These guidelines encourage clinicians to look beyond reproductive symptoms to identify underlying health issues and address the significant, lifelong metabolic risks associated with hyperandrogenism.
AN UNDER-RECOGNISED EPIDEMIC
Androgen excess is a common, yet under-appreciated, condition in women’s health, defined by clinical or biochemical evidence of increased androgen production.2 It affects up to one in ten women of reproductive age and, less frequently, those who are postmenopausal. Hyperandrogenism most often presents with hirsutism, acne or female-pattern hair loss and, in more severe or prolonged cases, can progress to overt virilisation, including clitoromegaly, deepening of the voice and erythrocytosis.3
Despite its prevalence and lifelong impact, androgen excess may often be dismissed as a cosmetic or fertility-related concern. This reductive perspective contributes to prolonged diagnostic delays and fragmented care, with many women never investigated beyond reproductive symptoms. In a minority of cases, overlooking key red-flag features – such as rapid progression, severe biochemical disturbance or postmenopausal onset – can mean missing serious underlying pathologies, including malignancy.
PCOS IS NOT THE FULL PICTURE
Polycystic ovary syndrome (PCOS) is rightly identified as the predominant cause of androgen excess, affecting up to 13% of women globally and imposing a substantial healthcare and economic burden, estimated at upwards of $15 billion annually.4 However, its high prevalence can lead to a diagnostic shortcut. Not every woman with hyperandrogenism has PCOS, and it is essential to identify those patients with non-PCOS pathology.
Other aetiologies, including non-classic congenital adrenal hyperplasia, hormone-secreting adrenal or ovarian tumours, Cushing’s syndrome and severe insulin resistance syndromes, can mimic the clinical and biochemical phenotype of PCOS. An automatic assumption of PCOS, without a structured workup, risks overlooking these rarer but critical diagnoses, delaying appropriate management and, in some cases, life-saving intervention.
BEYOND APPEARANCE: THE METABOLIC ICEBERG
The dermatological and reproductive features of hyperandrogenism often prompt clinical presentation. However, beyond their immediate impact, they indicate a broader risk of systemic metabolic burden. Androgen excess has profound, and frequently direct, effects on metabolic health, as follows.
Insulin resistance
Profound insulin resistance, present in up to 70% of women with PCOS, is a key driver of the associated dysglycaemia and markedly increases the lifetime risk of type 2 diabetes.5
Adiposity
Approximately two-thirds of women with hyperandrogenism live with overweight or obesity.6 This is a bidirectional relationship, where excess adiposity amplifies metabolic strain, while androgens themselves promote visceral fat accumulation.
Cardiovascular disease
Growing evidence demonstrates a direct link between androgen excess, hypertension and a higher incidence of adverse cardiovascular events, independent of obesity.7
Liver disease
Metabolic fatty liver disease (MASLD) is not only more prevalent in women with androgen excess, but its severity often correlates directly with androgen levels, suggesting a causal role.8
Psychological health
The prevalence of anxiety and depression is higher than in the general population, reflecting both the psychosocial impact of the clinical features and potential neuroendocrine effects of the hormonal imbalance.9
These findings firmly position androgen excess as a systemic metabolic disorder, intricately linked to the core drivers of cardiometabolic disease. Yet it continues to be under-recognised in mainstream metabolic care.
NEW GUIDELINE: A TURNING POINT
'Viewing hyperandrogenism through a metabolic lens, rather than a purely reproductive one, is essential for improving long-term health outcomes.'
In this context, the new Society for Endocrinology Clinical Practice Guideline for the Evaluation of Androgen Excess in Women represents a critical intervention.1 Developed by a multidisciplinary expert panel, it provides a much-needed, evidence-based and pragmatic framework for clinical practice.
Key contributions include:
• A structured diagnostic pathway for women presenting with common features such as acne, alopecia, hirsutism or menstrual irregularities
• Clear guidance on biochemical investigations and imaging, clarifying which tests are appropriate and when
• Suggested referral criteria for specialist and multidisciplinary care
• Emphasis on the lifespan relevance of androgen excess, from adolescence through to the postmenopausal phase of life.
By standardising the assessment process, this guideline is designed to shorten diagnostic delays, improve the patient experience and ensure that serious endocrine pathologies are not missed.
METABOLIC IMPLICATIONS: CLOSING THE LOOP
The relationship between hyperandrogenism and adiposity is bidirectional and self-perpetuating. Excess adipose tissue increases peripheral androgen production and alters hormone metabolism, while androgens, in turn, exacerbate insulin resistance and promote the accumulation of metabolically harmful visceral fat. This vicious cycle is a powerful driver of metabolic dysfunction.
Early recognition and intervention aimed at breaking this cycle have the potential to mitigate not only reproductive complications, but also the long-term sequelae of type 2 diabetes, cardiovascular disease, and MASLD. Viewing hyperandrogenism through a metabolic lens, rather than a purely reproductive one, is essential for improving long-term health outcomes.
LEANNE CUSSEN AND MICHAEL O’REILLY
Department of Endocrinology, Androgens in Health and Disease Research Group; RCSI University of Medicine and Health Sciences; and Beaumont Hospital, Dublin, Ireland
REFERENCES
1. Elhassan YS et al. 2025 Clinical Endocrinology https://doi.org/10.1111/cen.15265.
2. Elhassan YS et al. 2018 Journal of Clinical Endocrinology & Metabolism https://doi.org/10.1210/jc.2017-02426.
3. Cussen L et al. 2022 Clinical Endocrinology https://doi.org/10.1111/cen.14710.
4. Yadav S et al. 2023 Elife https://doi.org/10.7554/elife.85338.
5. Dunaif A 1999 Endocrinology & Metabolism Clinics of North America https://doi.org/10.1016/s0889-8529(05)70073-6.
6. Kujanpää L et al. 2022 Acta Obstetricia et Gynecologica Scandinavica https://doi.org/10.1111/aogs.14382.
7. Righi B et al. 2023 Endocrine https://doi.org/10.1007/s12020-023-03330-w.
8. Song MJ & Choi JY 2022 Frontiers in Endocrinology https://doi.org/10.3389/fendo.2022.1053709.
9. Tay CT et al. 2020 Psychoneuroendocrinology https://doi.org/10.1016/j.psyneuen.2020.104678.
