In the past, testing for androgen conjugates (e.g., 3α-androstenediol G [3α-diol G] and androsterone G [AOG] as markers for 5α-reductase activity in the skin) was advocated. Routine ≥9 Adult onset adrenal hyperplasia >1000 <10,000 ng/dL Hirsutism Ferriman – Gallwey score ≤8 24-hour urinary cortisol Trial of OCPs, cosmetic, and dermatologic treatments >45 g/day ACTH stimulation test >300 ng/dL Cushing evaluation Plus: Moon facies, plethora, striae, dorsoclavicular or supraclavicular fat pads, proximal muscular weakness Assess for PCOS, AOAH, HAIR-AN, ovarian or adrenocortical tumor or other* 17-OH progesterone bioavailable testosterone (total and free included) No response 48-hour low-dose dexamethasone suppression: 40% suppression of T  11-desoxycortisol >7 ng/mL,  24-hour urinary cortisol >45 g/day,  DHEAS >360 g/dL Total T >200 ng/dL Elevated values consistent with Ovarian Tumor or Adrenocortical Tumor Total T >80 <150 ng/dL, bioavailable or free T mildly elevated, endocrine consultation PCOS, hyperthecosis, HAIR-AN Radiologic consultation on current imaging techniques Total T >200 ng/dL  bioavailable or free T >6.85 pg/mL  Or free endocrine consultation Total T normal or mildly elevated, bioavailable T normal or mildly elevated PCOS, idiopathic hirsutism Adrenal androgen secreting tumor  usually >1.5 cm and detectable by CT (sensitivity 70%–90%).  Ovarian androgen-secreting tumors usually <2 cm.  Selective venous sampling may be required.
Figure 31.3 Evaluation of hirsute women for hyperandrogenism. Evaluation includes more than the assessment of the degree of hirsutism. When hirsutism is moderate (>9) or severe or if mild hirsutism is accompanied by features that suggest an underlying disorder, elevated androgen levels should be ruled out. Disorders to be considered include endocrinopathies, of which PCOS is the most common, and neoplasms. Plasma testosterone is best assessed in the early morning on day 4 to 10 in regularly cycling women. A 17-hydroxyprogesterone is also indicated when symptoms warrant a bioavailable testosterone measurement. *3β-hydroxysteroid dehydrogenase deficiency in severe forms presents with mineralocorticoid and cortisol deficiency. Mild forms are diagnosed with a mean post-ACTH(1-24) stimulation: 17-hydroxypregnenolone/17-hydroxyprogesterone ratio of 11 compared to 3.4 in normals. 11β-hydroxylase deficiency presents with hypertension in the first years of life in two thirds of patients. The mild form presents with vitalization or precocious puberty without hypertension. Undiagnosed adults demonstrate hirsutism, acne, and amenorrhea. Diagnosis is confirmed with an 11-desoxycortisol level >25 ng/mL 60 minutes after ACTH(1-24) stimulation. ACTH, adrenocorticotropic hormone; AOAH, adult-onset adrenal hyperplasia; DHEAS, dehydroepiandrosterone sulfate; HAIR-AN, hyperandrogenemia, insulin resistance-acanthosis nigricans. (See references 2–11,15.)